Ultrasound Obstet Gynecol 2001; 18 (Suppl. 1): 32–61
Posters
POSTER SESSION 1: OBSTETRICS – FIRST TRIMESTER, GYNECOLOGY
P01
Early diagnosis in ovarian cancer: role of transvaginal
ultrasound
M. A. Pascual, F. Tresserra, P. J. Grases & S. Dexeus
Purpose: To evaluate the efficiency of transvaginal ultrasound in the
early diagnosis of ovarian cancer.
Methods: Screening transvaginal ultrasound has been annually performed during the last 2 years in asymptomatic women without familial history of ovarian cancer. When abnormalities were detected, the
procedure was repeated after 4–6 weeks. If the findings disappeared,
the study was repeated after 1 year. If the abnormality persisted, study
was complemented with tumor markers, computed tomography and
laparoscopic surgery. The findings were compared with a control
group of women in whom ovarian transvaginal ultrasonography was
formally indicated.
Results: A total of 26007 transvaginal ultrasound were performed:
8813 (33.8%) belonged to the screening group and 17194 (66.2%)
to the control group. In 14 patients of the screening group, a malignant
tumor was diagnosed and histologically confirmed. The mean age of
these patients was 45 years old (SD 12). Eleven of these tumors were
stage I (seven Ia, and four Ic), two stage IIIc and one was a metastatic
melanoma in both ovaries. Six lesions were borderline tumors (five serous and one mucinous). In the control group, 27 ovarian cancers were
diagnosed in patients with a mean age of 48 years (SD 17). In this
group, 11 tumors were in stage I, and six were borderline.
Conclusions: Although consensus about the benefits of using transvaginal ultrasound as a screening procedure is not conclusive, our data
reveals that tumors detected in patients screened with transvaginal
ultrasound are in earlier stages when compared with those diagnosed
in the control group. No differences were found in age and number of
borderline tumors between both groups. Additional studies are needed
to support this preliminary findings.
P02
Endometrial sampling during sonohysterography
(SHGes)
E. Ferrazzi, C. Lanzani, N. Ciminera & V. Conserva
Purpose: To assess the diagnostic accuracy of sonohysterography
(SHG) and endometrial sampling during SHG (SHGes) compared to
traditional hysteroscopy and biopsy.
Methods: Seventy-two consecutive patients with irregular bleeding
and/or intracavitary abnormalities underwent transvaginal sonography (TVS) and SHG. SHG was performed with a 4.7-mm intrauterine
catheter. In all patients, an endometrial biopsy was performed by a syringe vacuum aspiration at the end of SHG. Procedure-related pain was
assessed. Sonographic findings at SHG were defined as normal, focal
lesions or diffuse endometrial abnormality. In patients with diffuse
endometrial abnormality, hysteroscopy and hysteroscopic guided
biopsy were performed. In patients with focal lesions, an operative
hysteroscopy was performed. Pathologic report was the gold standard.
Results: Mean age was 48 years (interquartile range 38–54). At SHG,
no pain, mild, and severe discomfort was reported by 75, 18 and 7% of
patients, respectively. Fifty patients underwent hysteroscopic guided
biopsy, 22 operative hysteroscopy. Hysteroscopic findings were compared to SHG–SHGes finding. (A) Benign lesions: in 56 cases SHG
and SHG sampling was concordant with pathologic report, in five
cases SHG and SHG sampling over diagnosed the endometrial lesion.
In five cases, simple hyperplasia was missed by SHG endoemetrial sampling. (B) (pre)Malignant lesions (six cases): in five cases SHG–SHGes
was correct. One case of adenocarcinoma was intepreted as atypical
hyperplasia at SHG–SHGes. Sensitivity, specificity, positive and
32
negative values of SHG and SHGes for intracavitary abnormalities
were 100, 64, 94 and 100%, respectively.
Conclusions: SHG and SHGes should be considered a reliable office
triage in the management of patients with intracavitary uterine
abnormalities, as adequate as hysteroscopic endometrial biopsies.
P03
Factors associated with endometrial thickness and uterine
size in a random sample of postmenopausal women
B. E. Gull, B. Karlsson, I. Milsom & S. Granberg
Objective: To investigate factors possibly associated with endometrial
thickness and uterine size in a random sample of postmenopausal
women.
Study design: A random sample (n ¼ 1000) of the total population of
women aged 45–80 years resident in the city of Göteborg was invited
to attend for a transvaginal sonography examination. Eight hundred
and twenty-seven women accepted the invitation and underwent a
gynecological and a transvaginal sonographic examination with measurement of endometrial thickness and uterine size. The women’s
height and weight were measured and a blood sample for analysis of
serum estradiol and follicle stimulating hormone was taken. The
women also provided information regarding previous medical and
gynecological history, possible medication and smoking habits.
Results: Five-hundred and fifty-nine women were postmenopausal
and 183 of them were taking some form of hormonal substitution
(33%). Factors associated with endometrial thickness and uterine size
were analyzed using univariate and stepwise multiple regression analyses. The current use of hormone replacement treatment was the most
important factor associated with both endometrial thickness and all
the uterine size parameters studied. The presence of fibroids was also
associated with endometrial thickness. Other factors shown to be associated with uterine size were age, parity, smoking, hypertension and
diabetes mellitus.
Conclusions: Several of the known risk factors for endometrial cancer
were shown to be associated with endometrial thickness and uterine
size parameters.
P04
Morphological and color Doppler velocimetry ultrasound
evaluation of breast solid lumps – a malignancy S-score
proposition
E. F. Marussi, J. G. Cecatti, M. Alvarenga, M. R. M. Machado,
C. M. M. O. Franzin & E. C. Martinez
The purpose was to evaluate the sensitivity, specificity and predictives
values for each morphological or CDV ultrasound criteria, alone or
associated, for the prediction of breast’s solid lumps malignancy and
to create a malignancy’s score. We studied 430 women with 502 breast
lumps (359 benign and 143 malignant). They were cared at CAISMUNICAMP from May 1998 to November 1999 when a US examination of the breast were performed and the results compared with the
pathological diagnosis, the gold standard. They had been evaluated
through US morphological criteria such as borders, posterior wall, ecotexture, ecogenic halo, Cooper ligaments, diameters, volume, skin,
compressibility, ratio between width and depth and CDV criteria such
venous flow, color index, maximum systolic velocity, resistance index,
pulsatility index and A/B ratio intra- and peritumoral. For data analysis, the groups of benign and malignant tumors were compared regarding control variables adjusted by age via logistic regression. The best
individual performance among the morphologic criteria, were borders,
ecogenic halo, Cooper ligaments, ecotexture, width/depth ratio and
biggest diameter and among the CDV criteria, they were the color
23–28 October 2001, Melbourne, Australia
index, maximum systolic velocity, pulsatility and resistance index
inside tumor. In the logistic regression analysis, the criteria identified
as statistically associated to the malignancy were the borders, ecogenic
halo, the largest diameter and the woman’s age. They compound
the equation of the malignancy’s score, whose performance was of
95.2%. No one CDV criteria improved the global performance of
the score. Excluding subjective criteria, the logistic regression analysis
selected, for compound another equation of malignancy’s score, the
woman’s age, the lump’s largest diameter, the measure of the Cooper
ligament and the VSmx inside the lump. This second score had a
slightly lower performance than the first one (92% against 95.2%).
P05
Three-dimensional ultrasound and treatment of choice in
cervical cancer
A. Babinszki, A. Artner, J. Szalay, L. Palfalvi & L. Ungar
Purpose: Tumor volume, parametrial involvement, lymph nodal status, urinary bladder and rectum involvement are essential parameters
in the treatment planning of early stage cervical cancer. Fertility sparing trachelectomy criteria has become a new diagnostic challenge
within the last years. We assumed that three-dimensional (3D) ultrasound may add useful information for the oncologists in planning
the treatment of cervical cancer patients.
Methods: Three-dimentional transvaginal sonography was performed
in all cases to assess tumor volume, parametrial involvement, local and
distant spread of the tumor. Tumor vascularization was also examined
by 3D power Doppler.
Results: In the last 5 months, 15 patients with early stage cervical cancer, considered for primary surgical treatment, have been examined
with 3D sonography prior to surgery. Two out of 15 patients have
undergone abdominal radical trachelectomy, 13 were surgically
explored with the intention of Wertheim hysterectomy. In one patient,
paraaortal tumor spread was suspected on our 3D examination, surgical finding at exploration has proven lymphatic spread extending
above the renal blood vessels, that has made the surgeon to abandon
first line surgery as a curative intent treatment.
Conclusions: Tumor volume was difficult to measure since most of the
early stage patients underwent cone biopsy prior to referral for radical
surgery. Macroscopic pelvic lymph node involvement was assessed
accurately in all of our patients. Our impression was, that parametrium
involvement, especially the caudal third of the parametrium, and the
urinary bladder wall could be visualized and assessed more accurately
than it was possible with 2D method. Involvement of the upper part of
the cervical canal could be examined accurately in candidates for radical trachelectomy. Early experience suggest, that 3D examination of
the macroscopic lymph node involvement, parametrial, urinary bladder and rectal wall tumor spread can be helpful for treatment planning
of early stage cervical cancer patients.
Poster Session 1: Obstetrics – First Trimester, Gynecology
benign tumors. A wash-out time >170 s showed a 91% sensitivity
and 75% specificity for the diagnosis of ovarian malignancy, and the
accuracy was 78%.
Conclusions: After microbubble contrast agent injection, malignant
and benign adnexal lesions behave differently in degree, onset, and
duration of Doppler ultrasound enhancement.
P07
Value of texture analysis in ultrasonographic examination
of exised specimens of breast masses
W. Bader, G. Westhof, J. Hackmann, S. Dieterle, W. Hatzmann
& S. Boehmer
Purpose: Specimen sonography is necessary for successful surgical
excision of non-palpable breast masses, discovered only in breast ultrasound. But is there any difference in echogenicity and echostructure
between native and in vitro sonography?
Methods: The ultrasound images from 46 benign and malignant
breast tumors were documented under standardized conditions preand postoperative, using a linear array machine (Shimadzu, US device
SDU-490) and 7.5 MHz transducer with a water path interposed
between the transducer and skin or the plastic bag, containing the fresh
specimens after surgical excision. Two images of each tumor were
documented on a 3/4 in. Sony high-band video device (U-matic BVU800-P), and the recordings were digitized with an 8-bit resolution in
384 288 pixels (frame grabber band, Ing. Büro Fa. Fricke, Berlin).
In each sonographic image, the maximum area of the region of interest
of the tumor was marked and then subjected to consecutive texture
analysis and correlation to the histological findings. For evaluation
of tumor status eight parameters of first and second order texture statistics (grey level histogram, Fourier analysis, co-occurrence matrix)
were applied.
Results: In all cases, the mass was clearly identified on sonograms
obtained in the operating room. Fibroadenomas (n ¼ 11), fibrocystic
diseases (n ¼ 5) and ductal carcinomas (n ¼ 26) showed comparable
results in texture analysis. On the other hand, lobular carcinomas
(n ¼ 4) were clearly different in all parameters, in especially mean
of grey level, homogeneity and contrast (P < 0.001 on the basis of
Wilcoxon and Student’s t-test).
Conclusions: In vitro examination is a rapid and efficient method
of localizing impalpable breast masses in excised specimens, but
differences in echostructure and echogenicity are possible.
P08
Which is the role of color Doppler sonography in the
diagnoses of malignancy in postmenopause ovaries
carcinomas?
S. Speca, V. Summaria, A. M. Costantini & P. Marano
P06
Transit-time study of an ultrasound contrast agent in benign
and malignant adnexal tumors
M.-R. Ordén, J. S. Jurvelin & P. P. Kirkinen
Purpose: To evaluate objectively the effects of a microbubble contrast
agent on the power Doppler ultrasonographic examination of adnexal
tumors specially focusing in timing of the transit of the microbubble
bolus.
Methods: Seventy patients with suspected ovarian tumors were examined pre-operatively using contrast-enhanced ultrasonography. A
5 min examination was stored digitally and the behavior of the contrast agent was evaluated objectively by measuring the time-dependent
image intensity at the region of interest with a computer program. A
time–intensity curve of each case was derived and analyzed.
Results: Both the baseline and maximum power Doppler intensities as
well as the absolute and relative (%) rise in intensity were significantly
higher (P < 0.001) in malignant as compared to benign tumors. The
arrival time was shorter (17.5 s vs. 22.5 s; P ¼ 0.005) and the washout time longer (219 s vs. 128 s; P ¼ 0.000) in malignant than in
Aim: To assess the reliability of B-mode sonography signs in association with color Doppler (CDS) flow analysis in diagnosing the ovaries
cancer in postmenopause women.
Material and methods: We studied by sovrapubic and transvaginal
sonography 400 consecutive female patients (age 48–64) from January
1996 to September 2000. All the patients were asymptomatic and
under estro-progestinic therapy (postmenopause). We evaluated the
morphological, volumetric and sonography changes of the ovaries, in
association with the angioarchitecture (absence or presence of a neovascularization; low impedence arterial flow with PI < 0.8 and
RI < 0.4).
Results: In the 710 ovaries studied, we diagnosed 37 benign lesions
(25 cystis, eight cystic teratomas, and 14 unilateral hydrosalpinxes),
all with no flow signal at CDS and four carcinomas (one bilateral
ovaries adenocarcinoma, one endometrial adenocarcinomas, one
hidrosalpinx with Walthard’s nidus); all these last lesions showed a
neovascularization with a RI < 0.4 and a PI < 0.8.
Conclusion: Our study confirmed the validity of the CDS in the diagnoses of ovaries malignant lesions, above all if associated to high flow
speed and low impedence flow rate.
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11th World Congress on Ultrasound in Obstetrics and Gynecology
P09
Abnormal ductus venosus blood flow in fetuses with normal
nuchal translucency (NT)
A. A. Yamasaki & D. Pares
Objective: To assess the incidence of reverse flow during atrial contraction at ductus venosus in fetuses with normal nuchal translucency
and correlation with cardiac abnormalities.
Methods: Ductus venosus Doppler ultrasound blood flow velocity
waveform were obtained in 932 fetuses with 11–14 weeks’ gestation
during measurement of nuchal translucency.
Results: Among 932 fetuses, NT was increased in 43 (4.6%). The incidence of reverse flow was observed in 5.4% of fetuses with normal NT
(2.5 mm) and 13.9% of fetuses with increased NT (>2.5 mm). Among
fetuses with normal NT, there was no cardiac abnormalities observed.
Conclusion: Reversed flow in fetuses with normal NT is not associated
with cardiac abnormalities.
P10
Color Doppler in the assessment of cervical cancer
M. Ciampelli, C. Mastromarino, R. Lopez, D. Basso, M. Distefano,
A. Poerio & G. Scambia
The treatment and prognosis of cervical cancer depends on the clinical
stage based on the FIGO classification and the presence of lymph node
metastases. Clinical staging of cervical cancer does not attain a good
diagnostic performance, since it is incorrect in approximately one-third
of patients who undergo surgical staging. Magnetic resonance (MR)
imaging resulted to be superior to clinical evaluation and computed
tomography (CT) in parametrial evaluation and in the staging of uterine cervical carcinoma. Endoluminal ultrasound was introduced to
analyse the cervix but no improvement in the diagnostic accuracy with
respect to clinical staging was obtained. Color Doppler velocimetry
was proposed as a non-invasive tool in the examination of cervical cancer. Cervical cancers with detectable intratumoral blood flow were
associated with larger size, invasion of parametrium, pelvic lymph
node metastases and greater microvessel density. A ‘vascularity index’
resulted to be correlated with staging and lymph node metastases. The
aims of our study were to assess color Doppler characteristics of 48 cervical cancers at different stages and to analyse the correlation between
Doppler parameters and clinical–pathological features of the tumors.
Three-dimensional color power Doppler technique was used to
investigate the vascular architecture of the neoplastic tissue. Threedimensional vascular images were compared to magnetic resonance
results. The actual clinical application of the three-dimensional vascular analysis in the evaluation of cervical cancers remains still to be
defined.
P11
Doppler evaluation in gynecological tumor recurrences
M. Ciampelli, C. Mastromarino, R. Lopez, D. Lorusso,
C. F. Filidi & G. Scambia
Diagnosis of recurrent malignant disease in the abdomen and in the
pelvis is a challenging problem. Because the survival of patients with
disease recurrence is improved only in patients with small recurrent
lesions, the detection of recurrences at a very early stage is of great
importance. Clinical examination and tumor markers are used for
the follow up of oncological patients; however, their diagnostic value
is not very reliable. Computed tomography (CT) and magnetic resonance (MR) have been studied extensively and their diagnostic accuracy varies from 50 to 84%. Transrectal ultrasound has been used in
monitoring recurrent female cancer with a diagnostic accuracy of
90.5% for pelvic lesions. However the ultrasound approach cannot
be used to differentiate between radiation fibrosis and recurrent malignancy on the basis of tissue appearance. Color Doppler examination
was proposed in the management of patients treated for rectal tumor.
The aim of our study was to evaluate the ultrasound diagnostic accuracy in the detection of recurrent gynecological disease in a group of
350 patients, followed up every 3–6 months at our Department
after surgical treatment of a pelvic gynecological malignancy. The
34
Poster Session 1: Obstetrics – First Trimester, Gynecology
ultrasound data have been compared to clinical examination, tumor
markers and instrumental tools such as CT and MR. The usefulness
of color Doppler velocimetry in the examination of recurrent malignant lesions has been analyzed. In a selected group of patients with
small-sized pelvic masses located in the central region of the pelvis,
color Doppler analysis was able to differentiate recurrent vs. benign
lesions.
P12
Ductus venosus blood flow assessment at 10–16 weeks’
gestation and chromosomal abnormalities
E. Antolı́n, C. Comas, M. Echevarrı́a, M. Torrents, A. Muñoz,
F. Figueras, M. Cararach & J. M. Carrera
Background: Enlarged fetal nuchal translucency (NT) is a well established ultrasonographic marker for aneuploidy screening, especially
during the first trimester of gestation. Nuchal translucency screening
combined with maternal age at early mid-trimester can identify about
75–80% of chromosomal abnormalities with a false–positive rate of
5%. Recently, Doppler parameters have been included in fetal aneuploidy screening, in order to improve the test performance. Changes
in the ductus venosus (DV) blood flow velocity waveforms have been
reported in a significant proportion of chromosomally abnormal
fetuses at first and early mid-trimester of pregnancy.
Objective: The aim of our study was to evaluate the role of the DV
blood flow assessment at 10–16 weeks’ gestation in the screening for
chromosomal abnormalities.
Methods: From December 1998 to June 2001, DV blood flow was
prospectively evaluated in 5067 consecutive pregnancies between 10
and 16 weeks of gestation. Pulsatility index for the DV (DVPI) was calculated. All cases were screened for chromosomal defects combining
maternal age and fetal NT thickness.
Results: The average maternal age was 32 years (range 22–47).
Seventy-four percent of the women were younger than 35. The incidence of chromosomal abnormalities was 1.06% (n ¼ 54), including
trisomy 21 (n ¼ 25), trisomy 18 (n ¼ 6), trisomy 13 (n ¼ 2) and others
(n ¼ 21). The incidence of chromosomal abnormalities was 13.8% in
those cases where DVPI was greater than the 95th centile, compared
with an incidence of 0.3% in the remaining cases with a DVPI below
this cut-off. This fact gives and odds ratio (OR) of 48 (95% IC: 26–87).
The overall detection rate (DR), specificity (S), positive predictive
value (PPV) and negative predictive value (NPV) for chromosomal
abnormalities were 70.4, 95.3, 13.8, and 99.7%, respectively, when
using the 95th centile DVPI as a cut-off. According to gestational
age, all the statistical parameters were increased in early gestational
age (10–13 weeks) when comparing with late gestational age (14–
16 weeks), the corresponding DR and OR being 76.3% and 64
(95% CI: 30–138) compared with 56.3% and 26 (95% CI: 9–72),
respectively. Moreover, when only autosomal trisomies were considered, a DR of 87.9% was reached with an S, PPV, NPV and OR of
95.3, 10.9, and 99.9% and 146 (95% CI: 51–418).
Conclusions: Our results suggest that the evaluation of DVPI at
10–16 weeks’ gestation is a useful tool in the screening for chromosomal defects, especially in detecting autosomal trisomies and when
it is assessed in early gestational age.
P13
Abnormal umbilical vein blood flow in trisomy 9 fetus
during early pregnancy
C. C. V. Murta, A. F. Moron, M. A. P. Ávila & F. A. P. Vasques
We describe a case of reversed flow in the umbilical vein and in the ductus venosus during atrial contraction of one fetus at 12 weeks’ gestation with increased nuchal translucency (9.1 mm). In addition,
Doppler velocimetry detected high retrograde flow in the inferior vena
cava. Cytogenetic analysis of chorionic villi revealed trisomy 9. We
suggest that these findings can be an early sign of chromosomal
abnormalities and cardiac defects in the first trimester. To the best of
our knowledge, this is the second report of reverse umbilical venous
blood flow described in the literature and the earliest case reported
in pregnancy.
23–28 October 2001, Melbourne, Australia
P14
Correlation between ductus venosus, gestational age
and nuchal translucency at 11–14 weeks scan:
preliminary study
H. Munoz, M. Parra, D. Pedraza, P. Jimenez, S. Villa
& M. Puga
Background/objective: Fetal ductus venosus assessment at 11–
14 weeks’ gestation is one of the best tests to identify fetuses with cardiac malformation. Negative blood flow during atrial contraction has
been used as qualitative sign in this cases. The aim of this study is to
describe normal ranges for Doppler velocimetry of ductus venosus
at 11–14 weeks’ gestation and correlate it with nuchal translucency
thickness.
Material and methods: We performed a prospective study, 88
patients were examined at 11–14 weeks of pregnancy. Crown rump
length, nuchal translucency, fetal anatomy and uterine artery Doppler
velocimetry were evaluated transabdominally. Ductus venosus was
identified using longitudinal plane and Doppler velocimetry index
was measured using Doppler duplex ultrasound. An average of
three waveforms were analyzed and pulsatility index venousus was
measured. For statistical analysis mean values and 95% CI for pulsatility index of ductus venosus was established for each crown
rump length, Spearman regression and normal centile distribution
was performed.
Results: The 77 out of 88 patients with nuchal translucency
below 95th centile were used for calculating normal ranges for
each gestational age. Mean maternal age was 29 6.5 years old
(range ¼ 15–42), and 20% was over 35 years old. Mean pulsatility
index was 1.02, 0.99, 0.95 and 0.92 at 11, 12, 13 and 14 weeks,
respectively. Although ductus venosus pulsatility index was not modified according to gestational age, there was a significant positive
correlation with nuchal translucency thickness (r ¼ 0.59, P 0.001).
Conclusion: Ductus venousus pulsatility index is correlated positively
with nuchal translucency at 11–14 weeks’ gestation.
P15
Abstract withdrawn
Poster Session 1: Obstetrics – First Trimester, Gynecology
P16
Diagnosis and management of low segment Cesarean
section scar pregnancies
B. Woelfer, R. Salim, J. Elson, A. C. Lawrence & D. Jurkovic
Background: Rising Cesarean section rates have led to an increasing
number of pregnancies implanted into postoperative uterine scars.
We report a large series of Cesarean scar pregnancies treated in a single
tertiary referral center.
Methods: The diagnosis of Cesarean scar pregnancy was made on
ultrasound scan when trophoblast was seen covering the lower segment uterine scar. Pregnancies <14 weeks size were treated either
medically (local injection of methotrexate KCl) or with conservative
surgery (dilatation and curettage insertion of Foley catheter). Surgical treatment was used for smaller, non-viable pregnancies and in cases
complicated by heavy bleeding or infection. Clinically stable patients
with larger, viable pregnancies were treated medically. A single viable
pregnancy >14 weeks required total abdominal hysterectomy.
Results: In a 4-year period, 14 Cesarean section scar pregnancies were
diagnosed. Out of 13 women who were <14 weeks pregnant, seven
were treated surgically (54%), five medically (38%) and one expectantly (8%). Surgery was successful in all cases. Three women (43%)
required insertion of Foley catheter into the cervix to arrest the bleeding and one (14%) required blood transfusion. Three out of five (60%)
women who received medical treatment were cured. Two women
required surgery because of prolonged and heavy bleeding, one of them
was transfused (20%). A case managed expectantly resolved spontaneously without any intervention. Five women tried to conceive again
after treatment. All three women who succeeded (60%) had normal
singleton intrauterine pregnancies.
Conclusion: Early Cesarean scar pregnancies can be safely treated both medically and by conservative surgery. Although surgical
treatment was more effective, this may be due to the selection
criteria, which favored use of surgery in cases of smaller, non-viable
pregnancies.
P17
Experience with fetal nuchal translucency in a private
clinic in São Paulo
S. C. Cha, P. A. Chinen & D. Pares
The fetal nuchal translucency (NT) has been used since 1995 as screening exam for abnormal karyo-type and structural malformations. Fetal
nuchal translucency measurements were performed in 1877 pregnancies, during the period from 1995 to 2000, between 11 weeks to
13 weeks and 6 days. From the 1877 exams, we obtained 29 (1.4%)
with abnormal NT and these data are the object of our study. Nineteen
pregnancies (65.5%) had no structural malformation and/or karyotype abnormalities. We had one (3.4%) case of congenital heart disease
with hypoplasia of left ventricle (death in the third day of life), one
(3.4%) case of fetal dead for true knots of the cord, without other morphological disturb. Others three (10.3%) cases had spontaneous abortion (one case of 46 XX; one case of 69 XXY and the other case does
not have karyo-type). In two (6.9%) cases induced abortion happened,
without karyo-type study.
P18
Fetus with osteogenesis imperfecta presenting as increased
nuchal translucency thickness in the first trimester:
a case report
T.-C. Hsieh & G.-P. Yeh
Background: Nuchal translucency (NT) has been used successfully
in screening for chromosomal abnormalities at 11–14 weeks of gestation. Increased NT thickness is also associated with lots of fetal anomalies in chromosomally normal fetuses. We report a case of osteogenesis
imperfecta (OI), type II, presenting with increased NT thickness. A 26year-old Taiwanese woman, gravida 2, para 1, without medical or
family history was scanned for confirmation of menstrual gestational
35
11th World Congress on Ultrasound in Obstetrics and Gynecology
age at 13 weeks of gestation. Crown-rump length was compatible
with menstrual age. Increased NT thickness was noted (3.6 mm).
Follow up scan 2 weeks later revealed hypomineralization of skull,
multiple fractures of long bones and ribs and severe micromelia. A
presumptive diagnosis of OI type II was made based on sonographic
findings. After counseling, the parents decided to terminate the pregnancy. A stillborn weighing 70 g was delivered after intravaginal
misoprostol application. Postmortem radiograph and autopsy
confirmed the diagnosis of OI.
Discussion: NT screening for chromosomal and structural abnormalities at 11–14 weeks of gestation was proposed by Nicolaides in the
1990s. It has gained worldwide popularity due to early screening and
high detection rate. Distorted and narrow thoracic cage due to rib fractures or altered composition of the extracelluar matrix has been
thought to be the possible mechanisms of increased NT thickness in
fetuses with OI. In our opinion, the characteristic of hypomineralization in OI enables clear visualization of intracranial structures which
may resemble the sonographic features of increased NT thickness in
some cases. This finding should prompt the sonographer to measure
NT thickness and scan for possible anomalies.
P19
First trimester Down syndrome screening by nuchal
translucency in Thai population
S. Ajjimakorn, P. Tungkajiwangoon & A. Jaowisidha
Purpose: To examine the significance of the fetal nuchal translucency
(NT) at 10–13 þ 6 weeks’ gestation in the prediction of DS in a Thai
population.
Methods: Total 2353 pregnant women were recruited from January
1996 to June 1999. Almost all women underwent transabdominal
scanning (TAS) (Toshiba 140, TAS probe 5.0 MHz Toshiba PVF5.00 MT). When the result showed an increased risk for DS
(>2.5 mm NT), the pregnant woman was counseled and the invasive
test was optional. All the newborns were physically examined thoroughly by pediatricians to detect the markers for major chromosomal
anomalies such as DS, trisomy 18 and 13. For the suspected DS or
other chromosomal abnormalities, the newborn’s blood was sent for
the chromosome study.
Results: The mean maternal age was 28.71 þ 0.13 years and 2037
pregnant women (86.57%) were <35 years old. The mean gestational
age was 11.94 þ 1.07 weeks. Sixty-five pregnant women who had
NT > 2.5 mm decided to have the invasive tests. Sixty had normal
karyo-types while five had abnormal chromosome abnormalities (one
trisomy 13, two trisomy 18 and two trisomy 21). All of them were
>35 years old. Sixty pregnant women with normal chromosome
fetuses had detailed ultrasound scanning at 18–20 weeks’ gestation
and screening for maternal toxoplasmosis, cytomegalovirus, rubella
virus, and herpes virus. The infection screen was negative in all cases.
There were 20 congenital heart diseases, four fetal deaths in utero at
28–30 weeks, one Bart’s hydrops fetalis and 10 abortion. The rest
had normal pregnancy outcomes and NT resolved by 20 weeks. There
were 316 (13.43%) cases with maternal age >35 years. Twenty-three
had >2.5 mm. NT and all of them had the invasive tests which revealed
five abnormal chromosomes (as mentioned above). However, no DS
fetuses were detected in <35 years pregnant women. Two hundred
pregnant women with normal NT decided to have the invasive tests
due to advanced maternal age and all of them had normal karyo-types.
The sensitivity, specificity, positive predictive values and negative predictive values for trisomy 21, 18 or 13 with different cut-off values for
fetal NT were studied. This is the first report of the first trimester NT
screening for DS in Thai people. The cut-off of >2.5 mm NT was used
to increase sensitivity. We can detect all the cases of DS with this cutoff value but one case of DS will be missed if we use the cut-off of
>3.0 mm.
Conclusions: This study revealed the feasibility in NT measurement
for DS screening in the first trimester of pregnancy in Thai population.
This test can increase detection rate of DS in the high-risk pregnant
women, who did not accept the invasive prenatal diagnosis procedures,
as well as in the low risk pregnancy.
36
Poster Session 1: Obstetrics – First Trimester, Gynecology
P20
First trimester determination of fetal gender by
ultrasound
M. Podobnik & M. Podgajski
Objective: To determine the feasibility of correctly identifying fetal
gender from 11 to 13 weeks of gestation.
Methods: Fetal gender assessment by ultrasound was prospectively
carried out in 425 singleton pregnancies at 11–13 weeks of gestation
(confirmed by crown-rump length or biparietal diameter) immediately
before chorionic villus sampling for karyo-typing. A total of 425
women underwent a detailed assessment of fetal anatomy at 11–
13 weeks of gestation by means of transabdominal and transvaginal
sonography. Fetal gender was identified in transverse and sagital
planes, and was confirmed by chorionic villus sampling.
Results: The accuracy of sex determination increased with gestation
from 91.7% at 11 weeks, to 97.2% at 12 weeks and 100% at
13 weeks. Male fetus were wrongly assigned as female in 5.5% of cases
in 11 weeks, 2.4% at 12 weeks and 0% at 13 weeks. The accuracy of
correctly identifying fetal gender increased with gestational age.
Conclusion: Whilst the accuracy of sonographic determination of
fetal gender at 11–13 weeks is good, our decision on invasive testing
for sex-linked conditions should be undertaken only after 12 weeks
of gestation.
P21
Heart activity visualization in embryos with crown-rump
length shorter than 5 mm
A. A. Yamasaki & D. Pares
Introduction: In the past, heart activity was only visualized by ultrasound in embryos with a crown-rump length (CRL) of 5 mm or more.
When CRL was shorter than 5 mm, non-visualization of heart activity
was considered normal. However, improvement in ultrasound equipment resolution has made it possible to diagnose viability in embryos
with CRL as small as 2 mm.
Objective: The aims of this study were to determine: (a) how often
heart activity is visualized in embryos with CRL between 2 and
5 mm; (b) outcome when CRL is shorter than 5 mm and heart activity
is not visualized.
Methods: Presence or absence of heart activity was examined in
embryos with CRL between 2 and 5 mm by vaginal ultrasound (Medison Model Voluson 530 and Aloka Model 1700), 4–7 MHz; B- and
M-mode). Follow up scans were carried out one-week later when the
initial scan did not demonstrate heart activity.
Results: Two hundred and forty-four embryos were examined and
heart activity was demonstrated in 210 (86%) cases. Follow up scans
demonstrated heart activity in six (17.5%) of the 34 embryos in which
heart activity was not initially visualized.
Conclusion: This study has demonstrated that visualization of heart
activity is possible in most embryos with CRL between 2 and 5 mm
nowadays. Non-visualization at this stage is associated with embryonic
demise in about 80% of cases.
P22
How to discriminate between normal and abnormal
early pregnancy
S. A. Jun & M. O. Ahn
Early fetal growth delay and early oligohydramnios have been suspected as signs of embryonal jeopardy. Sonographic examinations of
100 early pregnancies between the sixth and ninth gestational week
were performed to investigate predictable sonographic findings of early
abortion. Sonographic measurements of the gestational sac (G-SAC),
Crown-rump length (CRL) and fetal heart rate (FHR) were performed
using a transvaginal transducer with Doppler. All measurement of 11
early abortions were compared to those of 89 normal pregnancies to
investigate the objective rules for the screening of early abortion.
Most of the early aborted pregnancies were classified correctly by
discriminant analysis with G-SAC and CRL (G-SAC ¼ 0.5222
CRL þ 14.6673 ¼ 0.5 CRL þ 15). In conclusion, early fetal growth
23–28 October 2001, Melbourne, Australia
retardation and oligohydramnios could discriminate the poor prognosis of early pregnancies.
P23
Nuchal translucency screening and antenatal maternal
serum screening for Down syndrome: results
of a project
C. E. Benavides, C. C. Garcia, N. C. Lagos, X. C. Melgarejo
& M. I. C. Ferres
Objectives: To asses the implementation of antenatal screening for
Down syndrome using individual risk estimates based on maternal
age, nuchal translucency and three serum markers; alpha fetoprotein,
unconjugated estriol and human chorionic gonadotrophin (hCG) in
maternal blood. Women with an estimated risk of 1 in 250 or greater
were classified as screen positive and offered diagnostic amniocentesis.
Subjects: A total of 1956 women of all ages with singleton pregnancies
seen between June 1999 and March 2001.
Results: The screening result of combination of first trimester ultrasonographic and serum screening was 85% Down syndrome detection
and the false positive rate was 3%. The median gestational age of
nuchal translucency was 11 weeks and the time of serum screening
was 16 weeks.
Conclusion: The combination of nuchal translucency and serum
screening increases the Down syndrome detection and decreases the
false positive rate. Is very important because the amniocentesis is associated with a risk of pregnancy loss from 0.5 to 1%. Besides, it is costeffective and performs better than the selection for amniocentesis on
the basis of maternal age only, nuchal translucency only or serum
screening.
P24
Reduction of complications during first trimester abortion
with the use of sonography
A. Malvasi, A. Losito, D. Baldini, A. Mudoni & V. Traina
Background: In our reproductive medicine service, more than 3000
abortions have been practised every year, since 1978. The standard
operation for legal abortion is executed, according to law 194/78
within 90 days. The technique in voluntary or spontaneous abortion
provides D&C as well as hysterosuction with the patients in general
anesthesia. In order to reduce the possible complications for this operation and the increasing legal cases, routine perioperative sonography
has been used to evaluate sudden abortion complications.
Methods: Besides ordinary preoperative sonography assessing gestational age, evolution of pregnancy, pelvic disease, etc. the use of intraoperative sonography has been shown to be necessary. A permanent
team of four operators performs the operation under sonographic
guide by using an R–T 36600 General Electric apparatus owned by
our medicine service. In a lapse of time of five years, 16804 abortions
under sonographic guide were practised and in a retrospective way
there was a statistically significant reduction of complications according to literature. The 16118 cases in the previous 5 years and within the
two homogeneous groups.
Results: We registered 11 complete and 13 incomplete uterine perforations vs. 4 and 7 (P < 0.01), 18 cases of retention of ovule remainders
vs. 6 (P < 0.05), which required hospital readmission for a further
examination of uterine cavity. In addition, the group under sonographic guide has shown a lower rate of failures in operations, antibiotics administrations (P < 0.001), endovaginal prostaglandin use
(P < 0.005), anesthetics use (P < 0.05) and hospital stay (P < 0.01).
If for the 24 previous uterine perforations in 19 cases the operation
was delayed (11 days later) 13, when intraoperative sonography
was used, it occurred only in three cases, for the other patients under
sonographic guide, the uterine cavity was completely cleared with no
complications at all (P < 0.001).
Conclusions: In our service, as well as according to literature, intraoperative sonography during abortions, led to a great reduction of
complications with a better compliance for the patient and a significant
reduction of costs. In particular, thanks to the use of sonography,
complete and incomplete uterine perforations descreased, in 91% cases
Poster Session 1: Obstetrics – First Trimester, Gynecology
under sonographic guide the uterine cavity was emptied with no
complications for the patients. Because of the favorable relationship
between costs and benefits, the intervention can be performed under
sonographic guide.
P25
The combination of uterine artery Doppler and placental
volume measurement in the first trimester for the prediction
of high risk pregnancies
K. Schuchter, M. Metzenbauer, E. Hafner & K. Philipp
Purpose: To evaluate the combination of placental volume measurement and uterine artery Doppler in the first trimester for the prediction
of pregnancies complicated by preeclampsia, pregnancy induced
hypertension, preterm placental abruption or fetal growth retardation.
Methods: At the booking scan in the first trimester one single operator
was performing Doppler examinations of both uterine arteries on 380
women with singleton pregnancies. Both the pulsatility index (PI) and
the criteria of notching or not notching were recorded. Another operator was recording and afterwards calculating the placental volume at
the same visit. In order to correct the placental volume measurement
for the gestational age a placenta quotient was calculated (placental
volume/crown-rump length).
Results: Uterine artery PI above the 90th centile could be recorded in
38 pregnant women. Three of these pregnancies were complicated with
placental abruption, two of these were preterm placental abruptions
with additional PIH. Six of the 38 pregnancies ended with SGA babies.
On 39 women, the calculated placental quotient was below the 10th
centile. Two of these women developed PIH in addition to the occurance of placental abruption. Six babies had a birth weight below the
10th centile and one of these had PIH. Only eight pregnancies met
the criteria of uterine artery PI above the 90th centile and placenta quotient below the 10th centile. Two of these ended with placental abruption and PIH before 37 weeks of gestation, four of these babies had a
birth weight below the 10th centile and none of these had a birth
weight above the 50th centile.
Conclusion: Regarding our results we think that the combination of
placental volume measurement and uterine artery Doppler might be
a possible way for the evaluation of high risk pregnancies.
P26
Transvaginal ultrasound and induced abortion
A. N. Balic, D. B. Balic, B. Balic & I. Zukic
Background: The aim of this study was to audit prospectively the
value of preabortion ultrasonography.
Methods: All women who came to our center because of doubt
unplanned pregnancy in first trimester from March 1994 to July
2001 underwent an exam by vaginal ultrasound before abortion. We
analyzed these data and compared them with complications after legal
induced abortion.
Results: During 2 years a total of 334 women were surveyed. Fiftythree women (8.04%) were not pregnant. In 65 cases (9.86%), the
pregnancy was greater by 2 weeks than we expected on the basis of
last menstrual period. Also we found: 41 (6.22%) myoma uteri, 10
(1.51%) ovarian cysts, 15 (2.27%) multiple pregnancy, 8 (1.21%)
anomaly of the uterus, 4 (0.61%) missed abortions and 5 (0.76%)
embrionic abnormality (anencephalus, abdominal cyst, nuchal
translucency).
Conclusion: Preabortion ultrasonography increases security of this
intervention by eliminating some problems linked induced abortion.
Since the examination is simple, fast and cheap, we recommended
it for routine use. We hope that it is one way for decreasing late
complications after abortion, like infertility.
P27
Twin cervical ectopic pregnancy
M. P. Bethune & A. Sampson
A 40-year-old woman presented for IVF treatment due to 8 years
of secondary infertility. Two embryos were transferred without
37
11th World Congress on Ultrasound in Obstetrics and Gynecology
Poster Session 1: Obstetrics – First Trimester, Gynecology
ultrasound guidance. The patient presented at 6.5 weeks gestation with
heavy vaginal bleeding. A transvaginal ultrasound revealed twin cervical ectopic pregnancies, lying side by side in the cervical canal and
within 6 mm of the external os. One contained a 9-mm embryo with
a normal fetal heart rate. The other sac was anembryonic. The bHCG
level was 129 000 IU/L. The patient was treated with the same regimen
of methotrexate as used for persistent trophoblast disease: second daily
methotrexate with folinic acid rescue after each dose. Complete
resolution of the twin pregnancy occurred, bleeding was however,
recurrently heavy over the next 6 weeks.
Discussion: Cervical ectopic pregnancy is a rare event, accounting for
less than 1% of ectopic pregnancies. The incidence is increasing due to
the increased use of in vitro fertilization. Prior to the advent of conservative treatments most patients required hysterectomy due to severe,
uncontrollable bleeding. Conservative measures include dilatation
and curettage (usually combined with uterine artery embolization, ligation or cervical balloon tamponade); local injection of methotrexate or
potassium chloride (ultrasound guided); or systemic methotrexate.
Twin cervical pregnancy is an extremely rare event with only two previous case reports in the literature [1]. Due to the large size of this twin
pregnancy mass, the high bHCG level and the large volume of vascular
trophoblast; we decided to treat this patient in a similar manner to a
patient with gestational trophoblast disease. This mode of treatment
should be considered with cervical ectopic pregnancies where the
bHCG level is abnormally elevated.
Reference
1 Pascual MA, Ruiz J, Tresserra F, Sanuy C, Grases PJ, Tur R, Barri
PN. Cervical ectopic twin pregnancy diagnosis and conservative
treatment. Human Reproduction 2001; 16, 584–6
the values were 0.106 for the F-test and 0.956 for the P-value and
for week 38 the values were 0.102 (F-test) and 0.904 (P-value). We
conclude that the measurement of the UCCSA as proposed by
Raio et al. 1999 is reproductible and can be adopted as a new obstetric
ultrasound parameter.
P28
Ultrasonographically measured umbilical cord cross-sectional
area – reproducibility of the method
F. A. P. Vasques, A. F. Moron, C. G. V. Murta, F. H. C. Carvalho,
H. Cattini, T. R. Gonçalves, M. M. Barbosa & W. J. Hishaba
A prospective cross-sectional study was developed in order to determine the reproducibility of the measurement of the umbilical cord
cross-sectional area (UCCSA) during normal pregnancies (patients
with known dates of LMP and an ultrasound examination before the
20th week, without any pathologic condition), measured by different
and trained examiners. The measurements of the umbilical cord
cross-sectional area were obtained in a plane adjacent to the insertion
of the cord abdomen, as proposed by Raio et al. 1999, after the different examiners were trained by the author. The inclusion criteria were:
(1) singleton pregnancy; (2) gestation age >20 weeks; (3) intact membranes (4) normal umbilical Doppler flow velocimetry. The exclusion
criteria, in the presence of any of those were: (1) congenital and/or
chromosomal abnormalities; (2) pregnancy complications (any type);
(3) inadequate size for gestational age with when the examination
was performed, i.e. the weight below the 10th percentile or above
the 90th; (4) abnormal AFI for the gestational age. The patients were
examined and included only once. During the period of the study
(February 2000–May 2001), 545 patients were examined, after meeting the inclusion criteria determined for the present study. The age of
the patients ranged from 15 to 42 years (mean ¼ 26.7 4.8), 242
patients (44.4%) had two gestations, 135 patients (28.1%) were at
their first gestation, 129 patients (23.7%) were at their third gestation
and 39 patients had four or more gestations (3.8%). The ultrasound
machine used was the Synergy Multi Sync M 500. The statistical program used was the statistical package for social sciences (SPSS). The
first examiner collected 22% of the data, the second examiner collected
45% of the data, the third examiner collected 24% of the data and
the fourth one collected 9% of the data. According to the analysis of
variance (ANOVA), we performed, comparing the data obtained by the
different examiners, no significance was found and this fact was
also showed by the comparison of the data among them and verifying
that the data had a dispersion inside tolerable limits. The ANOVA
showed the following data (example for 3 weeks): At 25 weeks, the
F-test showed a value of 0.930 and a P-value of 0.454; at 32 weeks
38
P29
A comparison of the uterine and intraovarian arterial
flows in women having a history of recurrent
spontaneous miscarriage associated with
antiphospholipid syndrome
J. Jirous, M. E. Diejomaoh, F. Al-Abdulhadi & M. H. Boland
Purpose: To study the relationship between values of Doppler indices
characterizing the uterine and intraovarian arterial flows in the presence of antiphospholipid syndrome in women with history of recurrent spontaneous miscarriage (RSM). We are not aware of any
previous study undertaken on this specific topic.
Methods: Sixty-two women attending our recurrent spontaneous miscarriage clinic were recruited for this prospective study and subsequently divided to group A (n ¼ 35) involving RSM women with
normal anticardiolipin antibodies values (ACL IgM, ACL IgG) and
group B (n ¼ 27) for those with antiphospholipid syndrome (abnormal
ACL IgM, ACL IgG values). ACL IgM and ACL IgG antibodies
were measured in the blood using the standardized enzyme linked
immunosorbent assay (ELISA). Color and power Doppler transvaginal
ultrasonography was used to estimate the uterine artery pulsatility
index (UTAPI), spiral artery resistance index (SARI) and intraovarian
resistance index (IOARI) in the 21st day of a regular 28-day unstimulated menstrual cycle. The data were analyzed using the statistical
software SPSS 9.0 Windows. Statistical significance was defined as
P < 0.05.
Results: There was no statistically significant difference in the mean
age in group A (33.67 5.52 years) and group B (32.70 5.85 years),
the mean UTAPI values (3.14 1.16 for group A and 3.44 0.88 for
group B), the mean SARI values (0.73 0.13 for group A and
0.73 0.07 for group B). The incidence of the first trimester miscarriages in women over 30 years was significantly higher in group B compared with group A (P < 0.01).
Conclusions: Our preliminary study has revealed that there was no
significant difference in UTAPI, SARI and IOARI values of RSM
women with normal and abnormal ACL IgM and ACL IgG values.
This fact could be explained by the predominantly mild form of antiphospholipid syndrome in Kuwait confirmed in our previous studies.
We could hypothesise that such mild disease will have minimal/mild
vascular effects in the non-pregnant uterus and subsequently in the placental bed.
P30
Vascularity index of the testis: a guiding technique for
testicular sperm extraction (TESE)
J. Har-Toov, O. Eitan, R. Hauser, A. Butchan, I. Gull, I. Wolman,
H. Yavez & A. J. Jaffa
Aim: To develop a non-invasive computerized technique that predicts
the presence of spermatogenic sites within the testes of non-obstructive
azoospermic (NOA) patients.
Material and methods: Power Doppler ultrasound images of the
testes of seven NOA patients and six fertile men were acquired. Three
sagittal, three transverse and one coronal cross-sections of the testis
were scanned by a linear 7.5 MHz transducer. Three-dimensional
(3D) matrix of 32 elements was generated from all images of each testis. Each element carried information (a vascularity index, VI) about
the blood vessels that crossed its volume. The matrix (4 4 2) was
divided into regions of 16 elements which were classified as ‘positive’,
‘negative’ and ‘undetermined’ according to the VI values in the anterior
and posterior layers of a region. The NOA patients underwent testicular biopsies at three locations along the midline of the testis. The results
of the biopsies were correlated to the appropriate regions in the 3D
matrix.
23–28 October 2001, Melbourne, Australia
Results: Of the seven NOA patients, 12 testes were scanned, however,
only 27 biopsies were performed. Accordingly, only 27 regions were
considered. Thirteen regions were ‘positive’, 12 regions were ‘negative’, and two were ‘undetermined’. Motile spermatozoa were found
in nine out of 12 ‘positive’ regions (69.2%). No sperm was found in
10 of the 12 ‘negative’ region (83.3%). In the control group of six
patients, there were 12 testes, which divided into 36 regions.
Twenty-four regions were ‘negative’ (66.7%), one was ‘positive’
(2.7%) and 11 were ‘undetermined’ (30.6%).
Conclusion: The results yielded that positive/negative region predict
the presence or absence of spermatozoa, and thus, this method appears
to be a promising non-invasive guiding tool for TESE in NOA patients.
TESE will be more effective, less biopsies will be needed, and testicular
damage will significantly be lowered. However, this method is not suitable to identify spermatozoa in fertile men.
P31
Lower abdomen cystic masses diagnosed in female
infants in fetoneonatal period: diagnosis and
management
M. Hrehorcak, D. Smetanova, K. Pycha, A. Zuntova,
J. Horejsi & M. Holemarova
Cystic masses in female fetuses and neonates are in waste majority of
cases identified in screening ultrasound during pregnancy. Often they
are detected as early as in second trimester screening sonography (18–
22 weeks). When they are identified, problems with differential diagnosis and management modalities arise. In majority of cases, the cystic
formation is simple ovarian cyst. It might be misinterpreted with other
conditions such as: hydronephrosis, bowel obstruction, mesenterial
cysts, etc. We attempt to identify US criteria for reliable prenatal diagnosis of simple not complicated ovarian cysts. Define treatment possibilities and recommendations. Forty-three cases of such formation in
lower abdomen were reported in our hospital either in pediatric gynecology or pediatric surgery departments. Thirty-three were diagnosed
prenataly, nine diagnosed postnataly. Cysts were unilateral in all cases.
Twenty-two cases were treated surgically by ovarectomy. Nine of the
treated cases were cysts larger than 60 mm, in four cases the diameter
was less than 40 mm, Nine cases were cyst between 40 and 60 mm.
Histological examination proved 18 cases with hemorrhagic necrosis
of the ovarian cyst, four cases were diagnosed as follicular cysts and
one case of malignant retroperitoneal sarcoma. Twenty cases of cystic
formation were observed and expectation management was applied.
All of them were smaller than 40 mm in largest diameter and they
resolved spontaneously within 1 year of age. We conclude that basic
criteria for accurate diagnosis include mandatory visualization of the
kidneys and stomach in the time of diagnosis. Simple ovarian cyst
has following features on ultrasound: one chamber cystic formation
in lower abdomen, smooth walls, anechogenic. Expectation management with serial follow up is recommended for cysts smaller than
40 mm in diameter, Surgical treatment should be instituted only in case
of ovarian torsion (cyst diameter seems to be of good predictive value)
or rupture with bleeding. Simple cysts with diameter larger than
40 mm remains controversial. Should we treat them to prevent torsion?
We conclude that conservative approach is adequate in certain cases,
when risk of acute abdomen is low and spontaneous disappearance is
presumable in respect to preservation of future reproductive function
of female infant.
P32
A large pedunculated leiomyoma with unusual
features – a case report
S.-L. Lee & S.-K. Tay
Introduction: Leiomyoma, a benign tumour arising from smooth muscle, is a common finding on gynecological ultrasound examination. It
usually presents as a heterogeneous, hypoechoic mass with ill-defined
borders. According to its location, it may be described as submucous,
subserosal, and intraligamentous. With the new generation ultrasound
units, its perfusion may be mapped with accuracy.
Poster Session 1: Obstetrics – First Trimester, Gynecology
Case report: The patient is a 39-year-old lady who was first seen in our
department in October 1998. She just had a delivery by cesarean section in August 1998. Her pregnancy was looked after by a different
hospital, where she was told to have a fibroid. No follow up was
arranged for her after her delivery. When she came to our department,
she was complaining of occasional lower abdominal pain. An ultrasound scan that was performed revealed some small intramural and
subserous leiomyomata of 1–2.6 cm. A predominantly cystic, loculated
mass with an irregular contour was seen in the POD. It had some echogenic components and its measurements were 10.7 cm 7.5 cm
11 cm. Power Doppler detected some intratumoral venous flow.
Impression was that it was not of ovarian origin. The patient was
scheduled for a myomectomy/frozen section for fibroid on 9 November
1998.
Histopathology report: Leiomyomas with edema, hyalinization and
infarction.
Discussion: The ultrasonic features in this case are not typical of a leiomyoma. Although cystic degeneration are sometimes seen in myomata,
it is usually not so predominant. Although the state-of-the-art ultrasound units, with color and power Doppler facilities, are supposed to
be capable of producing very accurate assessment of pelvic masses, it
was found to be inadequate in this instance. Firstly, the classification
according to its location was not possible as the stalk was not seen,
probably as a result of tumor size. Secondly, the blood flow results
were not helpful as this is a predominantly cystic mass. Hence,
not much useful information could be derived for the planning of the
surgery.
P33
Asymptomatic endometrial polyps in postmenopausal
women: are they an indication for surgical
removal?
E. Ferrazzi, C. Lanzani, V. Conserva & A. Padoan
Purpose: To compare demographic, sonographic, and outcome data
of postmenopausal patients with asymptomatic endometrial polyp,
surgically treated or not treated.
Methods: Ninety postmenopausal women with sonographic/sonohysterographic diagnosis of asymptomatic endometrial polyp were prospectively enrolled in this study. All patients underwent transvaginal
sonography with color Doppler evaluation (Voluson 5300, KRETZ),
and sonohysterography in selected cases. Patients were counseled on
the risk of malignancy (estimated risk < 1/200). Sonographic follow
up at 3, 6 and 12 months was proposed as an option to standard hysteroscopic polipectomy. Surgery was considered in case of bleeding,
polyp enlargement, or Doppler PI < 0.6. Demographic and sonographic data of both groups were recorded. Surgical complications in
group B patients were considered as abnormal outcome.
Results: Sonographic follow up was chosen by 42 women (group A)
and surgical removal by 47 patients (group B). Forty-three patients
underwent operative hysteroscopy, and four patients hysterectomy
(group B). One major (uterine perforation not requiring surgery)
and three minor complications (two cervical lacerations requiring
hemostatic suturing, one false entry) (9%). Demographic (age, years
of menopause, blood hypertension/diabetes, BMI, nulligravidity, hormonal replacement therapy assumption, tamoxifen assumption) and
sonographic data) Endometrial thickness mean (interquartile range) ¼
8 (5–10) vs. 11 mm (7–13); volume (cc): 3 (1–4) vs. 4 (1–5); PI: 0.48
(0.44–0.51) vs. 0.49 (0.45–0.53) were not significantly different
between group A and B. Pathologic findings were glandulocystic and
hyperplastic polyp in 45 and in two patients, respectively. All group
A patients remained asymptomatic in the follow up period (mean
10 months, interquartile range 5–16).
Conclusions: Demographic and sonographic data were not significantly different in the two groups. No untreated patient became symptomatic during follow up period. Benign lesions only were found in
treated patients, at the cost of one uterine perforation. A large multicentre study is needed to understand the exact prevalence of endometrial cancer in asymptomatic endometrial polyp, and verify the safety
of conservative management.
39
11th World Congress on Ultrasound in Obstetrics and Gynecology
P34
Sonographic based triage – transvaginal sonography (TVS)
and sonohysterography (SHG) – for benign uterine
lesions and surgical management
F. P. G. Leone, A. Tonta, C. Lanzani, M. Di Grandi
& C. Mastromatteo
Purpose: To assess the reduction of clinical indications to hysterectomy as a consequence of sonographic based triage – transvaginal
sonography (TVS) and sonohysterography (SHG) – in the surgical
management of benign uterine lesions.
Methods: All women undergoing surgery for symptomatic (methrorragia) benign uterine lesions were included. Women with prolapse, cervical lesions and malignant lesions were excluded. Data from 180 and
154 patients treated during 1998–99 (group A) and the year 2000
(group B), respectively, were analyzed.
Diagnostic triage: All patients had complete history collected and pelvic examination performed. Group A. Patients were evaluated by TVS
– not mandatory – VABRA curettage and/or D&C and/or diagnostic
histeroscopy with biopsy. Group B. All patients were evaluated by
TVS and in case of endometrial thickness >4 mm, a SHG was performed to distinguish focal lesions (polyps, myomas, focal hyperplasia)
and diffuse lesions (hyperplasia). Theraputic protocol (in group A) was
decided in each single case by the medical-equipe; in group B: patients
with focal endocavitary lesions underwent operative hysteroscopy.
Patients with diffuse lesions underwent hysteroscopy and endometrial
guided biopsy. Indications to abdominal miomectomy were: submucous myomas (G0–G1) > 5 cm, G2 or subserous myomas in women
asking to preserve the uterus. Indications to hysterectomy (vaginal/
abdominal) were large miometrial lesions non-responding to medical
therapy.
Results: Median age of group A and B patients was not significantly
different (46 years, interquartile range 40–56). The frequency of
abdominal/vaginal hysterectomy was significantly lower in group B
(28%) than in group A (54%) (P < 0.01). Laparotomic myomectomy
were not significantly different in the two series (24% vs. 22%). The
frequency of operative hysteroscopy was significantly higher group B
63%) than in group A (9%) (P < 0.01).
Conclusions: The introduction of sonographic based triage and therapeutic protocols for benign uterine lesions determined a dramatic
reduction of demolitive uterine surgery, even in the same medical
equipe. This involves a significant reduction of economic cost and an
improvement in health care for the same abnormal conditions.
Poster Session 1: Obstetrics – First Trimester, Gynecology
P35
Sonohysterographic staging of submucous
myomas
E. Ferrazzi, C. Lanzani, M. Digrandi, A. Padoan
& C. Mastromatteo
Purpose: To assess the diagnostic accuracy of sonohysterography in
preoperative assessment of submucous myomas.
Methods: Twenty premenopausal patients with submucous myomas
and irregular uterine bleeding and/or infertility were consecutively collected in 12 months. Before surgery, all patients underwent transvaginal sonography (TVS) (Voluson, KRETZ, 5300), with color Doppler
evaluation, and sonohysterography (SHG). Number and site of myomas and the myoma–perimetrium distance were considered at TVS.
SHG was performed with a 4.7-mm (14F) intrauterine catheter. Patient
compliance to SHG was evaluated by a subjective pain scale. Duration
from TVS to completion of the procedure, and volume of saline solution instilled for SHG, were evaluated. Sonographic findings at TVS
and SHG were classified as submucous myoma G0, G1 and G2 and
compared to hysteroscopic finding. Depending on myoma grading
and volume, selected patients underwent preoperative medical treatment with triptorelin (decapeptyl-ipsen). Hysteroscopic myomectomy
was the standard surgical approach. Diagnostic accuracy of TVS and
SHG was evaluated.
Results: Mean age was 41 years (interquartile range 34–47). Mean
BMI was 24 kg/m2 (interquartile range 21–28). Twelve patients
reported irregular bleeding, eight infertility. Eleven patients had additional intramural and or subserous myomas. Mean duration time of
SHG was 12 min (interquartile range 9–16). Mean volume of sterile
solution instilled for SHG was 16 mL (interquartile range 8–24). In
all cases, a successful SHG was performed, with no and mild discomfort in 16 (80%) and 3 (11%) patients, respectively. Hysteroscopic
findings were compared to TVS and SHG considering the submucous
myoma grading. SHG correctly classified all miomas (five cases of
G0, 11 cases of G1, five cases of G2). TVS correctly classified all G0
cases, over classified two G1 cases as G2, correctly classified five cases
of G2.
Conclusions: Sonohysterography was a simple and well tolerated imaging technique, with a diagnostic accuracy comparable to hysteroscopy. We speculate that endometrial sampling performed during
SHG could help to exclude coexisting endometrial abnormalities
which are likely to occur in larger series.
POSTER SESSION 2: OBSTETRICS – DOPPLER AND MISCELLANEOUS
P36
Weekly and 2-week Doppler investigations to avoid
misunderstanding compromised fetal conditions?
SGA fetuses management in our experience
L. Solerte, A. Ragusa & S. Garsia
Fetal surveillance in adequate for gestational age (AGA) and small for
gestational age (SGA) allows to predict distress conditions and improve
neonatal outcome. Doppler velocimetry (DV), fetal heart rate monitoring (CTG), biophysical profile with amniotic fluid index, are the common tools used to have fetal direct–indirect signs of well-being. Several
clinical studies stressed DV and CTG-like reliable evidences of fetal
conditions, despite their known limitations, connected with gestational
age and compensatory mechanisms. In order to establish the best follow up time for fetal health, we analyzed two different groups of 20
non-selected pregnant women with SGA 10–30 percentile. Intrauterine
growth retardation were excluded for different role of DV in prediction
and screening in placental disorders. From January to July 2001 we
observed our two groups divided by maternal history; women were
homogeneous for age and weight, with SGA.
Diagnosis: Made at 20–24 weeks scan, according to most common
used biometry diagrams. DV was performed on the main arterial
40
districts by pulsatility index, in umbilical and middle cerebral artery,
and peak velocity in intracardiac aorta, to estimate changes in blood
flow velocity and cardiac out-put, to compare with Apgar index in neonatal outcome, including cesarean section rate. We closed our assessment with a precise definition of utility and applicability of weekly and
2-week follow up, in order to improve fetal conditions at delivery time,
avoid misunderstanding fetal distress organize better work-time.
P37
Cardiac function in fetuses of poorly controlled
pregestational (pre-existing) diabetic pregnancies
S.-F. Wong, F.-Y. Chan, R. Cincotta & C. Ward
Background: Cardiac impairment is frequently found in fetuses of diabetic mothers. Poor diabetic control has been implicated as one of the
cause for cardiac dysfunction, but it is still controversial.
Aim: To assess the cardiac function in fetuses of well-controlled and
poorly controlled pregestational (pre-existing) diabetic pregnancy in
the third trimester.
Methods: Women with pregestational diabetes (Type 1 and 2)
were enrolled at 30–36 weeks. Right-, left-ventricular septal wall and
interventricular septal wall thickness were measured by M-mode at
23–28 October 2001, Melbourne, Australia
end-diastolic phase. At the mitral and tricuspid valves inflow, the
ratio between early ventricular filling and active atrial filling (E/A) at
both atrioventricular valves were measured by Doppler echocardiography. Peak velocities of ascending aorta and pulmonary artery were
assessed. Angle of isolation was kept at less than 208. Results from
women with poorly controlled diabetes (HbA1c > 6.5%) were compared with those whose diabetes were satisfactorily controlled
(HbA1c 6.5%).
Results: A total of 15 women were included in this study. Six had wellcontrolled diabetes and the other seven had poorly controlled diabetes.
HbA1c in the poorly controlled group was 7.3% and in the well-controlled group was 5.4% (P < 0.001). There was no difference between
the groups in cardiac size, interventricular septal wall thickness, ejection fraction, aorta and pulmonary artery peak flow velocities. The
right atrioventricular E/A ratio was significantly lower among the
poorly controlled DM pregnancies (0.71 vs. 0.54; P < 0.05). This
reflected an impaired right ventricular compliance in fetuses of poorly
controlled diabetic mothers.
Conclusion: Fetuses of poorly controlled diabetic mothers had
lower atrioventricular E/A ratio. This may be due to impaired right
ventricular compliance.
P38
Changes in fetal blood flow in hypoxemia during labor
M. Ropacka, M. Dubiel, K. Marsal, S. Gudmundsson
& G. H. Breborowicz
Objective: The aim of this study was evaluation of intrapartum
Doppler velocimetry changes in fetuses with signs of fetal hypoxemia
in fetal pulse oximetry (arterial hemoglobin saturation <30%).
Study design: Examinations were performed on 44 women in labor
with singleton pregnancies. The subject of analysis was Doppler blood
flow velocimetry in umbilical cord, fetal brain and lung. In all cases the
following examinations were performed: blood flow velocimetry in
middle cerebral artery (MCA), umbilical artery (UA), and pulmonary
vein (PV). Among fetuses with normal Doppler velocimetry at the time
of admission, we selected those with cephalic presentation and nonreassuring fetal heart rate pattern during labor. The fetuses were
included to the group of fetal pulse oximetry monitoring. All cases with
signs of fetal distress in ctg and intrapartum fetal arterial oxygen
saturation <30% for at least 5 min were included to the study group.
Fetuses with abnormal ctg and fetal oxygen saturation >30% constituted the control group.
Results: Doppler indices (PI, RI) in MCA were significantly lower in
the presence of reduced oxygen saturation. Pulsatility and resistance
index in UA in the study group were higher, comparing to the control
group. But, there was no statistically significant difference between
both groups in analyzing parameters. There were no statistically significant changes in parameters describing blood flow in pulmonary veins
in both studied groups.
Comments: The combined intrapartum fetal monitoring, including
pulse oximetry and Doppler blood flow velocimetry, proved that the
reduction of fetal arterial oxygen saturation (<30%) is associated with
changes in hemodynamics of fetal cerebral circulation. It has been not
observed any changes in blood flow in umbilical artery and pulmonary
vein in the presence of decreased fetal saturation.
P39
Comparison of power Doppler and velocimetry in
predicting outcome of high-risk pregnancy
M. A. Dubiel, G. H. Breborowicz, K. Marsal & S. Gudmundsson
Purpose: To prospectively evaluate semiquantitative computer analysis of power Doppler (PD) signals in the placenta, fetal brain, lung,
liver, kidney and spleen in high-risk pregnancies in relationship to perinatal outcome and also to compare tissue blood flow in the fetal brain
and placenta with Doppler velocimetry.
Methods: PD signals were recorded in 180 high-risk pregnancies
between 27 and 41 weeks of gestation. Images from PD scans angiographics were transmitted for computer analysis of pixel intensity.
Mean flow signal intensity was recorded for each organ. The PD
Poster Session 2: Obstetrics – Doppler and Miscellaneous
brain/lung ratio was calculated. The PD results were plotted on
reference values and related to perinatal outcome. Middle cerebral
(MCA), umbilical (UA) and uterine artery (Ut. A) velocimetry was also
performed.
Results: High-risk pregnancies displayed lower PD signal intensity
from the placenta, fetal lung, liver and kidney as compared to normal.
However, the brain and spleen signals showed higher intensities suggesting increased tissue perfusion. PD signals from the fetal brain, lung,
placenta and PD brain/lung ratio were correlated with perinatal outcome. The PD signal intensity from the fetal liver, kidney and spleen
showed poor correlation with perinatal outcome. Fetal brain tissue
blood flow showed better correlation with the outcome than MCA
velocimetry. Placental tissue blood flow results were similar in predicting outcome to those obtained by means of UA and Ut. A velocimetry.
Conclusions: In comparison with conventional Doppler velocimetry,
computer analysis of PD signals, give similar results in the prediction
of adverse perinatal outcome.
P40
Diagnosis and prognostic value Doppler flow velocity
waveform in high risk pregnancies
M. R. Ghoneim, H. Megahed, M. Habba, M. M. El-Biely
& G. L. Lotfy
Objective: To determine whether Doppler umbilical artery flow velocity waveforms (FVW) would improve the clinical management and
reduce the prenatal morbidity or not, in cases of high risk pregnancies.
Methods: A total of 160 pregnant women of 28 weeks or more gestational age were included in this study. The age of the cases were from
20- to 30-year-old and their gravidity ranged from gravida 1 to 5. The
cases were classified into two groups. Low risk group, not associated
with medical or obstetric complications and includes 70 cases. High
risk groups include, the other 90 cases, such as the following: mild
pre-eclampsia (20), severe pre-eclampsia (15), diabetes mellitus (10),
postdated pregnancy (15), previous one or more cesarean section
(15), rheumatic heart (4), decreased perception of fetal movement
(3), bronchial asthma (2), Rh incompatibility (2) and previous IUFD.
All of them were subjected to thorough general and obstetric examination, investigations, ultrasonic examination, biophysical profile scoring
and Doppler umbilical artery FVW study. The cases of low risk group
were examined every 2 weeks, while high risk ones, were examined
every week or twice weekly according to the results of the previous
examination.
Results: There is a highly significant difference between values of
umbilical artery FVW indices in low and high risk group. Doppler
has specificity 92.8% in cases of low risk group while has sensitivity
52.8% and specificity 55.6% in cases of high risk group and it is more
sensitive than biophysical profile. Doppler of umbilical artery is very
beneficial in cases of pre-eclampsia, where its sensitivity 78.5% and
its specificity 52%.
Conclusion: There is a strong association between abnormal FVW and
adverse fetal outcome. The Doppler will identify a group of fetuses
truly at risk, where intensive fetal monitoring or delivery will be
required.
P41
Differentiated evaluation of blood flow middle cerebral
artery in relation to the fetal well-being
P. Rozpravka & A. Ostro
Objective: To state clinical signification of differentiated evaluation
Doppler velocimetry middle cerebral artery (MCA) of ultrasonographically detected intrauterine growth retarded (IUGR) fetuses, during
pregnancies complicated hypertension (PIH) and pre-eclampsia.
Methods: In prospective, comparative clinical studies evaluated Doppler velocimetric curve MCA separately in proximal (basal) segment
(PS) and distal (cortical) anatomical segment (DS). Values of pulsatility
index (PI) were compared in proximal and distal segment MCA. Corticocerebral index (CCI) was stated as ratio PIPS/PIDS. Results were
compared in the group-A with IUGR detected and in control groupB with normal growth of the fetuses. Period of measurements complex
41
11th World Congress on Ultrasound in Obstetrics and Gynecology
Poster Session 2: Obstetrics – Doppler and Miscellaneous
biometry was l week, fetal flowmetry minimally 24 h, maximally
l week.
Results: Values of PI in PS and DS MCA were significantly different.
Resistance of MCA in cortical direction decrease. Values of PIPS were
higher comparing PIDS. We found statistically significant correlation
CCI and >1 and chronical fetal hypoxy resulted in IUGR. Differentiated flow analysis of MCA did not show statistically significant differences of PIPS and PIDS. Calculated CCI ¼ 1. MCA resistance does not
show changes in cortical direction. We found significantly higher statistical occurrence of perinatal complications of the fetuses, elective
cesarean sections for fetal intrauterine hypoxy, when values of CCI
and >1. This is the fact concluded worse prognosis of the fetuses
with cortical sparing effect in utero, but also worse postnatal adaptation. Main outcome – corticocerebral index is simple parameter
for detection of different saturation of the brain of the fetus under
hypoxemia. Fetal prosperity in utero has coming worse during cortical
preservation. There is significantly higher occurrence of perinatal
complications.
specific and positive predictive values, but equal negative predictive
value to comprise adverse pregnancy outcomes.
Conclusion: For routine clinical practice, it seems justified to use
singleton nomograms to assess uterine circulation in twin gestation.
However, as the negative predictive value of uterine Doppler studies
is slightly lower when compared to singletons, maternal and fetal
complications might occur despite normal uterine waveforms.
P42
Does cigarette smoking causes periodic decreases in blood
flow to the fetus of mothers with hypertensive disorders
and/or impaired fetal growth?
T. A. Lawrie, F. Rosier-van Dünne, K. Norman & H. J. Odendaal
Aim: To evaluate the acute effect of maternal cigarette smoking on
umbilical and middle cerebral artery blood flow in the fetus of women
with and without pre-eclampsia and/or intrauterine growth restriction.
Methods: Pregnant women and 24 weeks gestation were recruited
from the antenatal ward at Tygerberg Hospital, South Africa. Doppler
studies of the umbilical and middle cerebral arteries were performed
before and at 10, 20 and 30 min after the mother had smoked a cigarette.
The same studies were performed in the non-smoking controls.
Results: There were 13 smoking mothers with hypertension and/or a
fetus with growth restriction (group A), 15 non-smoking mothers with
hypertension and/or a growth restricted fetus (group C) and 24 normotensive smoking mothers and an appropriately grown fetus (group B).
There was a significant difference in the mean umbilical artery RI and
PI values in group A vs. group C (P ¼ 0.03 and 0.004, respectively).
There was a significant difference in the mean middle cerebral artery
PI between group B and group C (P ¼ 0.004).
Conclusions: Smoking significantly reduces the feto-placental perfusion in pregnancies compromised by hypertension and/or intrauterine
growth restriction and should be actively discouraged in these patients.
P43
Doppler assessment of the uterine circulation in the second
trimester in twin pregnancies: prediction of hypertensive
disorders, small-for-gestational age and weight discordance
A. Geipel, C. Berg, U. Germer, S. Gröger, M. Krapp, A. Katalinic
& U. Gembruch
Objective: To compare singleton nomograms of the uterine circulation
with previously established twin nomograms in the prediction of
hypertensive disorders, small-for-gestational age (SGA) and birth
weight discordance >20%.
Methods: This was an analysis of maternal and perinatal data
obtained from 256 diamniotic–dichorionic twin pregnancies. The uterine artery resistance and pulsatility index were calculated as a mean
from both sides and the presence and absence of notching was
recorded. Cut-off levels for abnormal flow parameters were the 95th
centile of reference ranges using singleton and twin nomograms.
Results: As mean uterine artery indices are lower in twin gestation, a
higher number of patients (n ¼ 73; 28.5%) was screen positive according to twin reference values when compared to those of singletons
(n ¼ 51; 19.9%). However, singleton reference ranges or recording
of notches only proved to be more efficient than twin reference ranges
to correctly predict SGA (17.6, 19, 13.7%), birth weight discordance
>20% (30.6, 37.5, 23.9%), and hypertensive disorders (23.5, 21.4,
16.4%), respectively. Compared to singleton nomograms of uterine
artery Doppler, twin nomograms had higher sensitivities, lower
42
P44
Doppler velocimetry of uterine arteries between 12 and 16
weeks of gestation
A. A. Yamasaki, G. Braia & O. Toma
Introduction: The aim of prenatal care is to identify high risk pregnant in order to adopt preventive and/or therapeutic treatments. The
presence of an end diastolic ‘notch’ at uterine Doppler velocimetry
has been considered a predictor to pre-eclampsia and intrauterine
reduced growth. It reflects an answer expressed by a wave of
high amplitude representing vascular bed with high resistance (uteroplacental circulation).
Objective: To identify high risk patients by analysis of uterine Doppler
velocimetry between 12 and 16 weeks of gestation when occurs the
second wave of trophoblastic invasion.
Patients and methods: Between June 1999 and June 2001, we did a
longitudinal study with 127 pregnant from 12 to 16 weeks. This study
analyzed uterine Doppler velocimetry using two types of equipment:
Aloka Model 1700 and Medison Model Voluson 530. We determined
the incidence of end diastolic ‘notch’ between 12 and 16 weeks and its
evaluation during pregnancy.
Results: The incidence of end diastolic ‘notch’ was 26% (33 patients).
Among these patients only nine (7%) still had notch at 16–24 weeks.
Among patients with normal uterine Doppler velocimetry at 12–
16 weeks, none developed pre-eclampsia or intrauterine reduced
growth.
Conclusion: It is possible to identify low risk patients (74%) to preeclampsia and intrauterine reduced growth at the end of first trimester
of pregnancy by uterine Doppler velocimetry. At the end of first trimester, 26% of patients can be identified as high risk for pre-eclampsia or
intrauterine reduced growth. The advantage of this early screening
method is the possibility to give aspirin (100 mg/day) at time of second
wave of trophoblastic invasion as prophylactic treatment.
P45
Evaluation of placental Doppler velocimetry in pregnancies
complicated with oligohydramnios
K. Blaszczyk, A. Lukasik, K. Swadzba, M. Stokowacka & R. Poreba
Objective: The objective of the study was to evaluate intraplacental
Doppler indices in pregnancies complicated with oligohydramnios.
Methods: Thirty-six singleton pregnancies between 32 and 39 weeks
complicated with oligohydramnios (cases of premature rupture of
the membranes and fetal malformations were excluded from the study)
and 40 normal pregnancies were examined by real time ultrasonography, color and pulse Doppler. Placental Doppler velocity waveforms
were estimated in the placental cord insertion (umbilical artery velocimetry) and in three different pulsatile intraplacental vessels (the mean
value). Placental Doppler velocity waveforms analysis was performed
on the base of Haberman and Friedman method. The ratios between
intraplacental and umbilical artery pulsatility index values were
calculated. Fetal well-being was evaluated by means of non-stress test
analyzed according to Fischer method.
Results: In normal pregnancies group all Doppler velocity waveforms
values were between 10 and 90th percentile of the normal for gestational age values based on Doppler indices nomograms, as well as all
patients had the normal (<1) intraplacental to umbilical artery pulsatility index ratio. In the group complicated with oligohydramnios in 15
patients abnormal (>1) intraplacental to umbilical pulsatility index
ratio were observed (P < 0.05, sensitivity 42%, specificity 100%, positive predictive value 100%, negative predictive value 65%). In that
group the results of non-stress test analysis according to Fisher method
were pathological (Fisher <5) significantly more often (P < 0.05).
23–28 October 2001, Melbourne, Australia
Conclusion: The results of the study demonstrate, that in pregnancies
complicated with oligohydramnios the evaluation of intraplacental to
umbilical pulsatility index ratio is a valuable method for estimation
the fetoplacental circulation and is an important complement of fetal
well-being assessment.
P46
Influence of maternal cigarette smoking on maternal
weight gain, uterine and umbilical flow velocities
and fetal growth
C. A. Albuquerque, K. Smith, C. Johnson & R. Harding
Objective: To investigate the effects of cigarette smoking during pregnancy on maternal body mass index, maternal weight gain, uterine and
umbilical artery flow velocities and fetal growth.
Methods: We studied 37 pregnant women (17 cigarette smokers
[>10/day] and 20 non-smokers) using an ATL HDI 5000 scanner
for fetal anatomic survey and measurement of uterine and umbilical
artery flow velocities. Maternal BMI change and weight gain during
pregnancy, uterine and umbilical cord flow velocities, and fetal weight
at delivery were measured in all patients.
Results: There were no differences between the smoking and nonsmoking groups in gestational age at scanning (23.7 1.5 vs.
26.5 1.3 week), gravid (2.3 0.3 vs. 2.1 0.3) and parity (0.9
0.2 vs. 0.6 0.2). The median maternal BMI was less in smokers
than non-smokers both pre-pregnancy (19 vs. 24) and at delivery
(27.5 1.3 vs. 32.3 1.3). Maternal weight gain was less in smokers
than non-smokers (10.2 1.6 vs. 14.7 1.5 kg, P < 0.05). In the uterine artery, there was no significant difference in the systolic/diastolic
ratio between smokers and non-smokers (1.9 0.1 vs. 1.8 0.1).
The umbilical artery systolic/diastolic ratio was greater in smokers
than non-smokers (3.25 0.2 vs. 2.31 0.07, P < 0.05) and fetal
weight at delivery was lower in smokers (2.7 0.2 vs. 3.3 0.2 kg,
P < 0.05).
Conclusions: Decreased BMI and lower weight gain of women who
smoke suggest that their nutritional intake may be lower than in
non-smokers. Decreased maternal weight gain in smokers and
increased umbilico–placental resistance may both contribute to fetal
growth restriction. Smoking appears not to affect utero-placental
resistance.
P47
Intrapartum umbilical artery, fetal aorta and middle
cerebral artery Doppler velocimetry as a predictor
of poor perinatal outcome in growth retarded
fetuses
N. Klep, H. Concin & A. Kurjak
Background: The aim of the study was to evaluate the diagnostic prediction of the Doppler waveform analysis during active labor for
adverse perinatal outcome in a group at significant risk of intrapartum
hypoxia.
Materials and methods: The study population consisted of 33 pregnant women at high-risk and ultrasonographic diagnosis of IUGR
between 28 and 35 weeks of gestation. On the basis of the flow velocity
changes in the fetal vessels during pregnancy, patients were divided
into two study groups A, with physiological Doppler waveforms (12
women) and B, with pathological Doppler waveforms (21 women).
The percentage of the changes of the index values during active labor
were correlated with pH values of the blood from the umbilical artery.
Results: In group A, no statistically significant correlation was found.
In group B, following was established: high negative correlation
between the changes of the index values and pH values of the blood
from the umbilical artery: dPAU 24%, r ¼ 0.531, t ¼ 2.179,
P < 0.05. dPIAFD 26%, r ¼ 0.655, t ¼ 3.0, P < 0.05; dPIACM
10%, r ¼ 0. 699, t ¼ 3.1, P < 0.01.
Conclusions: The study revealed a significant correlation between the
changes of index values of the Doppler waveform analysis during
active labor and pH values of the blood from the umbilical artery in
the process of intrapartum aggravation of already antepartum from
chronic hypoxemia suffering fetuses.
Poster Session 2: Obstetrics – Doppler and Miscellaneous
P48
The association between the Doppler hypoxia index
and arterial umbilical cord pH in multiple gestation
pregnancies complicated by intrauterine growth
restriction
U. Musser, E. P. Gaziano & P. H. Arbeille
Purpose: To study the relationship between the Doppler hypoxia
index and umbilical cord pH in multiple gestation pregnancies complicated by fetal growth restriction.
Methods: Seventeen fetuses were studied from 12 multiple gestation
pregnancies (11 twins and 1 triplet). Each pregnancy had at least one
growth-restricted fetus from which middle cerebral artery and umbilical artery Doppler values were collected, the last value of which was
within 3 weeks of delivery. For each fetus, we calculated the cerebral
umbilical ratio and the hypoxia index, which reflects the duration
and degree of Doppler determined fetal blood flow redistribution.
Umbilical arterial cord blood was obtained for blood gas analysis
immediately after the births. Excluded were fetuses with major
congenital anomalies and those with reverse end diastolic flow in the
umbilical artery.
Results: There is a significant correlation at the 0.05 level, one-tailed,
between the hypoxia index and arterial umbilical cord pH. A linear
regression model suggests that gestational age and birth weights are
not cofounders in the relationship between the hypoxia index and
arterial pH. While the hypoxia index has the same sensitivity (75%)
as the cerebral umbilical ratio for identifying fetuses who will have
an arterial cord pH of less than 7.20, the hypoxia index has a better
specificity (85 vs. 69%), positive predictive value (50 vs. 38%) and
negative predictive value (92 vs. 90%).
Conclusions: There is a significant correlation between the non-invasive hypoxia index and arterial umbilical cord pH in the growthrestricted fetus from multiple gestation pregnancies.
P49
The evaluation of Doppler indices in renal vessels in
normal fetuses and in fetuses with obstructive
uropathy
D. Wyrwas, K. Szaflik, D. Borowski & M. Kozarzewski
Purpose: The aim of the study was an evaluation of Doppler indices in
renal vessels in normal fetuses and in fetuses with diagnosed obstructive uropathy.
Methods: In the study, there were included 106 normal fetuses and 21
fetuses with signs of the obstructive uropathy. In pregnancies complicated by the uropathy, the measurements of Doppler flow in renal
arteries were performed twice: in the ahydramnion settings and after
the diagnostic amnioinfusion. The analyzed indices included the pulsatility index and the resistance index.
Results: The diagnosis of uropathy was set-up at the mean gestational
age of 20.3 2.0 weeks. The control group consisted of 106 healthy
fetuses from normal pregnancies at the mean gestational age
(28 weeks). The physiological absence of an end-diastolic flow in renal
arteries was found in normal pregnancies and that parameter was
excluded from further analysis. The PI values in normal pregnancies
decreased with the gestational age from the mean value of 3.16 at
15 weeks to 2.19 at 40 weeks of gestation. In pregnancies at gestational age below 26 weeks complicated by the uropathy, the PI was significantly lower with the mean value of 1.57. However, there were no
statistical difference in PI values for pregnancies above 30 weeks of
gestation, the mean values of PI were 2.39 and 2.33 for normal and
pathological pregnancies, respectively. There were also no differences
for PI values among pregnancies with the uropathy before and after
amnioinfusion.
Conclusions: There is a physiological linear decrease in the PI values in
fetal renal arteries with the gestational age. The RI cannot be used for
the evaluation of renal function due to the physiological absence of an
end-diastolic flow in renal arteries. The PI was significantly lower in
pregnancies complicated by obstructive uropathy at the gestational
age below 26 weeks.
43
11th World Congress on Ultrasound in Obstetrics and Gynecology
P50
The role of thromboelastography in conjunction with
second trimester uterine artery Doppler velocimetry in
the prediction of adverse pregnancy outcome
C. Karidas, P. Anastassopoulos, D. Perry & D. L. Economides
Poster Session 2: Obstetrics – Doppler and Miscellaneous
the sensitivity dropped down. It is not advisable to wait for both to
happen before taking a decision for induction of labor.
P52
Abstract withdrawn
Purpose: A pilot, prospective study to evaluate the use of thromboelastography in conjunction with uterine artery Doppler in the second
trimester as predictors of pre-eclampsia and IUGR (intrauterine
growth restriction defined as birth weight below the 5th centile for
gestational age).
Methods: Two-hundred and forty-nine (249) unselected pregnant
women were recruited at their booking appointment in the Royal Free
Hospital. They underwent thromboelastography assessment and color
flow/pulsed Doppler imaging of both uterine arteries at 20–24 weeks
gestation. Standard parameters were measured from each thromboelastography tracing (R, reaction time; K, clot formation time; A, angle;
MA, maximum amplitude). The presence or absence of notches in the
flow velocity waveform was noted and the resistance index measured.
The main outcome measures were pre-eclampsia and IUGR.
Results: Twenty-three pregnancies (9.2%) were complicated by IUGR
and 10 (4%) by pre-eclampsia. Assessment using abnormal Doppler
velocimetry, defined as bilateral notches/mean RI 0.55 (27 cases)
or unilateral notch/mean RI 0.65 (5 cases), demonstrated 52%
(95% CI 33–71%) sensitivity for IUGR and 40% (CI 17–69%) for
pre-eclampsia with positive predictive values 37.5% (23–55%) and
12.5% (5–28%), respectively. Furthermore, in the pregnancies complicated by an adverse outcome, the groups with normal (14 cases) and
abnormal (15 cases) Doppler velocimetry did not differ significantly
in any of the thromboelastography parameters (Mann–Whitney test
for comparisons).
Conclusion: Pulsed Doppler velocimetry of the uterine arteries in
the second trimester is an established predictor of adverse pregnancy
outcome. The additional use of thromboelastography assessment
does not appear to contribute significantly in providing further information. As this is a pilot study, larger trials are required to delineate
its role.
P51
The sensitivity of Doppler studies vs. biochemical indices
in predicting fetal outcome in cases of pregnancy
induced hypertension
M. R. Ghoneim, K. Nicolaides, M. A. Abd-El Moneim,
H. E. Megahid & M. S. Hafez
Location: The Outpatient Clinic of Obstetrics and Gynecology,
Faculty of Medicine, Suez Canal University, Ismailia, Egypt and the
High Risk Pregnancy Unit of King’s College University Hospital,
London, UK.
Aim of the work: To compare the sensitivity and specificity of the
Doppler studies vs. the biochemical indices in predicting fetal outcome
in cases of pregnancy induced hypertension.
Material and methods: A total of 252 cases were the subject of this
study 192 cases from King’s College Hospital and 60 from Suez Canal
University Hospital. All cases were selected as having pregnancyinduced hypertension, 226 cases with proteinuric hypertension and
26 cases with non-proteinuric pregnancy induced hypertension. All
cases were monitored weekly from 28th gestational week till delivery
whereby all Doppler studies were carried out on a free loop of umbilical artery. Serum uric acid, liver enzyme aspartate-aminotransferase,
and platelet count were estimated weekly.
Results: Out of 252 patients with PIH, 136 patients (54%) had abnormal Doppler flow velocimetry associated with abnormal higher mean
AST proteinuria, serum urate >350 mm/L, lower platelet count and
higher perinatal mortality. The sensitivity and specificity of abnormal
Doppler velocimetry in the prediction of intrauterine growth retardation (IUGR) were 80 and 52.6%. These were raised to 94 and 88%,
respectively, with higher mean serum urate and lower platelet counts.
However, the specificity of the abnormal Doppler with abnormal all
biochemical indices for the prediction of adverse neonatal outcome
and IUGR was 100%, but this was a late event in cases of PIH as
44
P53
The use of umbilical artery Doppler velocimetry in the
monitoring of pregestational diabetic pregnancy
S.-F. Wong, F.-Y. Chan, R. Cincotta, J. Oats & D. McIntyre
Purpose: To assess whether umbilical artery Doppler velocity waveform analysis can predict adverse perinatal outcomes for pregnancies
complicated with pre-existing diabetes mellitus (types 1 and 2 diabetes
mellitus).
Methods: All diabetic pregnancies (types 1 and 2) delivered at Mater
Mothers’ Hospital, Australia, between 1st January 1995 and 31st
December 1999, were included. All pregnant diabetic women were
monitored with umbilical artery Doppler velocimetry at 28, 32, 36,
and 38 weeks gestation. Umbilical artery Doppler study was repeated
on weekly basis for pregnancies complicated by macrosomia, polyhydramnios, or fetal growth restriction. Adverse perinatal outcome was
defined as pregnancies with one or more of the following: small-forgestational age (birth weight <10th centile), cesarean section for
non-reassuring cardiotocography, fetal acidemia at delivery (cord
blood arterial pH < 7.2), 1-min Apgar of 3, 5-min Apgar of <7,
hypoxic ischaemic encephalopathy, stillbirth and perinatal deaths.
Abnormal umbilical artery Doppler index was defined as systolic/diastolic ratio of 95th centile or higher for gestation (including absent
or reversed end-diastolic flow). The incidence of adverse perinatal
outcomes was compared between those with normal umbilical artery
Doppler and those with elevated systolic/diastolic (S/D) ratio.
Results: One hundred and four pregnancies had umbilical arterial
Doppler studies performed during the study period. Twenty-three
pregnancies (22.1%) had elevated S/D ratio of the umbilical artery
Doppler velocimetry. If the scans were performed within 2 weeks of
delivery, 71% of pregnancy with abnormal umbilical Doppler study
have adverse outcome. For umbilical artery Doppler studies performed
23–28 October 2001, Melbourne, Australia
within 1 week of delivery, the sensitivity was 35%; specificity was
94%; positive predictive value was 80%; and negative predictive
value was 68%. However, only 30% of women with adverse perinatal
outcomes had abnormal umbilical Doppler flow.
Conclusion: Elevated umbilical arterial Doppler S/D ratio is associated
with adverse perinatal outcomes. However, the majority of diabetic
pregnancies with adverse perinatal outcomes have normal umbilical
artery Doppler velocimetry. Thus, this could be a useful test for
monitoring, but is not a good predictor of adverse perinatal outcomes.
P54
Ultrasonic fetal and placental tissue characterization
and the role of Doppler ultrasound in lung maturity
M. Podobnik, M. Podgajski, B. Gebauer & B. Breyer
Background: The aim of this study is to confirm the relationship
between the gestational age and quantitative assessment of ultrasonic
signs of placental tissue, fetal lungs and liver tissue and to correlate
Doppler parameters from main stems of the pulmonary arteries for
determining fetal lung maturity in normal pregnancy and pregnancy
with pre-eclampsia and diabetes.
Methods: The placenta, fetal lungs and fetal liver in 300 normal pregnancies, 100 pre-eclamptic pregnancies and 100 diabetic pregnancy
were examined by ultrasound at 30–41 weeks of gestation. The coefficients of variation (the standard deviation divided by the mean
value) were used to characterize the tissue in different groups during
pregnancy. Doppler velocimetry was performed in the main stems of
pulmonary arteries in normal pregnancies and pregnancies with
pre-eclampsia and diabetes.
Results: The coefficients of variation in mature fetuses were greater
than 29% for placentas in vivo, greater than 34% for placentas
in vitro, greater than 28% for liver tissue and greater than 30% for
lung tissue. Placental, lung and liver tissue of diabetic pregnancy tended
to have lower coefficients of variation throughout their pregnancies.
We found in mature fetuses mean peak systolic velocity higher than
40 cm/s and PI lower than 3.00. In mature fetuses with pre-eclampsia,
we found higher mean peak systolic velocity in compared with
normotensive patients.
Conclusions: The coefficient of variation values for placentas in vivo
and in vitro, and fetal lungs and liver increase during pregnancy in normal and pre-eclamptic patients with increasing gestational age and
decrease in diabetic patients.
P55
Uterine artery Doppler blood flow resistance indices
in the second half of pregnancy: measures of central
tendency, distribution, inter-ratio dependency,
and explanation of variation
M. O. Thompson, K. S. Vines, J. Aqualina & K. F. Harrington
Study objectives: To evaluate the three commonly used indices of
Doppler blood flow resistance in clinical practice for the uterine
artery. By assessing the measures of central tendency, dispersion, and
variation, to determine the most appropriate index for clinical use
transabdominally in the second half of pregnancy.
Methods: A prospective study of uterine artery Doppler measurement
in singleton pregnancies between 18 and 32 weeks gestation. Using
previously described methods, two independent measurements
were obtained transabdominally from each side in all subjects. The
systolic/diastolic ratio (SD ratio), pulsatility index (PI), and resistance
index (RI) were recorded from both the right and left uterine artery in
turn. All measurements were obtained by a single operator (MOT)
using the same machine (Philips SD 800). The results were analyzed
statistically for the measures of dispersion, distribution, and the
variation explained.
Results: There were 1796 observations from 449 subjects in total,
with the SD ratio showing the widest dispersion. The PI measurements
were intermediate with respect to both, while the RI showed the least
dispersion. The RI distribution was the closest to a naturally distributed (Gaussian) pattern, followed by the PI. The SD ratio did not appear
to conform to a normal distribution. The interquartile ranges (IRQ) for
Poster Session 2: Obstetrics – Doppler and Miscellaneous
the SD ratio were 0.71, 0.73 (left- and right-uterine artery, respectively); PI: 0.42, 0.41; and RI: 0.15, 0.17. The mean of three derived
measurements of the RI was sufficient to account for over 99% of
the observed variation.
Conclusions: Differences reported between the different resistance and
pulsatility Doppler indices could be due to either random or systematic
error, or a combination of both. The observations from this study
suggest that when the RI is used, these are kept to a minimum. These
findings may be helpful in selecting the appropriate index for uterine
artery Doppler screening and clinical applications in the second half
of pregnancy.
P56
Uterine artery Doppler ultrasonography and pregnancy
outcome in women with a history of early onset
pre-eclampsia and thrombophilia
J. van Eyck, B. Arabin & B. Wibbens
Purpose: To assess the relationship between persistence after
22 weeks’ gestation of the notch in the uterine artery and pregnancy
outcome in pregnant women with a history of early onset (<32 weeks)
pre-eclampsia, were tested for thrombophilia and subsequently
received medication according to the disorder.
Methods: Between 1995 and 2000, Doppler ultrasonography of both
uterine arteries was performed between 18 and 24 weeks, in 80 pregnant women with a history of early onset pre-eclampsia, were tested for
thrombophilia. A total of 34 women had no thrombophilia and had
received only low-dose aspirin as from 12 weeks’ gestation. Forty-six
women had thrombophilic disorders like: protein S deficiency (N ¼
10), APC-resistance (N ¼ 11), anticardiolipin antibodies (N ¼ 15)
and had received low-dose aspirin as from 12 weeks gestation in combination with low-molecular heparin as from 7 weeks’ gestation.
Seventeen women from this group of 46 women also suffered from
hyperhomocysteinemia. Next to their treatment with folic acid and
pyridoxin, they had received low-dose aspirin as from 12 week gestation. Five women had a combination of two disorders and one woman
had three disorders.
Results: In 29 women with single hit thrombophilia (protein S deficiency, APC-resistance or anticardiolipin antibodies), notches persisted
in only one woman, who subsequently developed pre-eclampsia (PE) at
31 weeks. Of the remaining 28 women, four developed PE at 31, 31, 35
and 39 weeks despite disappearance of notches. In 12 women with single hit hyperhomocysteinemia, notches persisted in three women, one
of them developing PE at 33 weeks. From the remaining nine women,
two developed PE at 31 and 35 weeks. In 34 women without thrombophilia, notches persisted in four, one of them developing PE at
36 weeks. From the remaining 30 women, 3 developed PE at 29, 29
and 38 weeks.
Conclusions: The percentage of persistence of uterine notch in women
with ‘treated’ thrombophilia is comparable to women without thrombophilia (11 vs. 12%), whereas recurrence rate of PE is, respectively,
19 and 12%. In both groups averaged gestational age at which PE
developed was 3 weeks later than in the index pregnancy. Whether
these observations can be contributed to the described medication is
currently evaluated in a large prospective, randomized, multicenter
study in The Netherlands (FRUIT study).
P57
Uterine Doppler evaluation in 12 women with
pregnancy-induced hypertension: correlation with
fetal Doppler study and perinatal outcome
O. Gómez, M. Del Rı́o, J. M. Martı́nez, M. Palacio,
B. Puerto & V. Cararach
Introduction: Classification of hypertensive disorders of pregnancy is
problematic due to variable clinical presentation and confusing terminology. Management is based on severity of clinical and laboratory
criteria, which, unfortunately, do not select pregnancies that will be
delivered because of maternal or fetal indication.
Objective: To evaluate whether maternal uterine Doppler evaluation
correlates with fetal Doppler study and maternal and perinatal results.
45
11th World Congress on Ultrasound in Obstetrics and Gynecology
Poster Session 2: Obstetrics – Doppler and Miscellaneous
Design: Twelve women with pregnancy-induced hypertension (ISSHP
criteria) between 26 and 38 weeks of gestation were divided into
two groups based on uterine Doppler examination (presence – group
A, or absence – group B, of a bilateral protodiastolic uterine notch)
at diagnosis.
Results: There were seven patients in group A (four severe and three
mild pre-eclampsia) and five patients in group B (one severe and one
mild pre-eclampsia, two severe gestational hypertension, one Hellp
syndrome). The mean gestational age at delivery (weeks gestation),
the mean birth weight (grams) and the mean umbilical artery pH in
groups A and B were, respectively, 31.1 vs. 36.1, 1256 vs. 2428, and
7.20 vs. 7.25. Doppler evaluation showed statistically significant
higher pulsatility index of the right and left uterine artery, as well as
in the umbilical artery, in group A vs. group B. Fetal vascular redistribution or a ductus venosus PI >1 were detected only in group A (5/7
and 3/7, respectively), whereas in none of the group B. Indication for
delivery was always for fetal risk (four cases) or maternal risk (three
cases) among group A, whereas for maternal indication was only in
one case of the group B.
Comments: We suggest that uterine Doppler examination at the time
of diagnosis in patients with hypertensive disorders of pregnancy may
help to identify pregnancies at serious maternal and fetal risks better
than classical clinical and laboratory criteria.
Hadlock, Merz, Osaka and Shepard for weight estimation are in common use in our institution, but none of them has been devised specifically for Filipinos. It is the objective of the study to determine which
among these formulas is accurate in diagnosing the fetus weighing
4000 g or more among Filipinos.
Methods: The accuracy of in utero fetal weight estimations were evaluated prospectively in 74 Filipino patients during the study period.
Sonographic estimate was performed by a single sonologist within
24–48 h of delivery. Estimates of fetal weight were calculated using
the Hadlock, Merz, Osaka and Shepard. The newborn birth weight
were measured within 30 min of delivery. The results were then
compared with the actual birth weight.
Results: Of the 74 patients seen, 62 patients were included. Eighteen
(29%) had a birth weight less than 3000 g, 40 (65%) weighed between
3000 and 3999 g and six (10%) had a birth weight of 4000 g or more.
When birth weight is less than 3000 g, Osaka and Merz conferred the
same diagnostic accuracy but the former had a significantly higher
negative predictive (88%). For birth weight ranging from 3000 to
3999 g, Hadlock had the highest diagnostic accuracy (100%). This
report confirms that the best in utero weight estimations among fetuses
weighing 4000 g or more result from the use of Shepard formula which
has sensitivity, specificity, positive and negative predictive values and
diagnostic accuracy of 100%.
Conclusion: Since the accuracy of Shepard formula in estimating
fetal weight 4000 g or more is significantly better than those based
on Hadlock, Merz and Osaka, we recommend the use of such formula
in intrapartum fetal weight estimations among Filipinos. This estimated weights can offer guidance in predicting fetal macrosomia,
and therefore, aid in obstetric management.
P58
Abstract withdrawn
P60
A nomogram for the umbilical cord cross-sectional area
in normal pregnancies
F. A. P. Vasques, A. F. Moron, C. G. V. Murta,
F. H. C. Carvalho, T. R. Gonçalves, H. Cattini,
W. J. Hisaba & M. M. Barbosa
P59
Accuracy of ultrasonographic determination of fetal
weight at term among Filipinos
M. R. S. Vitug, R. P. Rivera & L. R. Clemente
Background: The birth weight of an infant is one of the most important factors affecting its survival. Four computer-generated formulas,
46
A prospective cross-sectional study was developed in order to determine reference ranges for the umbilical cord cross-sectional area
(UCCSA) during normal pregnancies (patients with known dates of
LMP and an ultrasound examination before the 20th week, without
any pathologic condition). The measurements of the UCCSA were
obtained in a plane adjacent to the insertion of the cord abdomen, as
proposed by Raio et al, 1999. The inclusion criteria were: (1) singleton
pregnancy, (2) gestation age >20 weeks, (3) intact membranes, (4) normal umbilical Doppler flow velocimetry. The exclusion criteria, in the
presence of any of those, were: (1) congenital and/or chromosomal
abnormalities; (2) pregnancy complications (any type); (3) inadequate
size for gestational age when the examination was performed, i.e. the
weight below the 10th percentile or above the 90th; (4) abnormal AFI
for the gestational age. The patients were examined and included only
once. During the period of the study (February 2000–May 2001), 545
patients were examined, after meeting the inclusion criteria determined
for the present study. The age of the patients ranged from 15 to
42 years (mean ¼ 26.7 4.8), 242 patients (44.4%) had two gestations, 135 patients (28.1%) were at their first gestation, 129 patients
(23.7%) were at their third gestation and 39 patients had four or more
gestations (3.8%). The ultrasound machine used was the Synergy
Multi Sync M 500 and the statistical analysis was performed by the
program called Statistical Package for Social Sciences (SPSS). Our data
were considered normally by the Kolmogorov–Smirnov test and then
we figured the nomogram by linear regression analysis. The analysis
of variance obtained through the F-test (value ¼ 356.27) showed that
our regression model was significant at the level of P < 0.001, showing
that the curve represented well the studied population and that the
confidence interval (95%) contained the real value of the UCCSA. The
regression equation was: y ¼ 532.27 þ 44.358x 0.6555x2. We
conclude that, there is a progressive increase in the UCCSA up to the
32nd week of gestation, followed by a stabilization until the 34th week
and a fall of the values from the 35th week of gestation.
23–28 October 2001, Melbourne, Australia
P61
Can sonography represent a marker of dystocia in epidural
analgesia? A prospective randomized study
A. Malvasi, A. Brizzi, A. Cecinati, L. Liaci, P. Totaro & V. Traina
Purpose: An association between epidural analgesia and dystocia in
the second stage of labor remains controversial. To compare severe
labor pain and dystocia at the time of epidural placement for predicting
cesarean section (c.s.) risk. We hypothesized, the dystocia causes severe
labor pain, such that more epidural medication is required to maintain
comfort.
Methods: We examined the relationship between labor outcome and
severe labor pain defined by the number of supplemental anesthetic
boluses, by cervical dilatation, clinical evaluation of pelvic dimension,
sonographic fetal weight and ultrasonographic examination of fetal
axis in cephalic presenting deliveries. This prospective study included
375 women in labor with have singleton fetuses at term in vertex presentations. We excluded women with pre-eclampsia, placenta previa,
repeat c.s.
Results: Seventy-nine of the 375 patients receiving early epidural
analgesia were delivered by c.s. (68 due to dystocia, 11 due to fetal
distress). A multiple logistic regression model evaluated demographic
and labor-related variables associations with cesarean risk. By using
multivariate analysis, the odds ratio of c.s. among patients who
required at least three boluses was 2.4 compared with those who
required two boluses or less (P < 0.001). Variables that proved to be
statistically significant in increasing the likelihood of c.s. were station
at time epidural placement (P < 0.01) and severe labor pain associated
with dystocia (P < 0.01). The relationship between severe labor paindystocia and labor arrest (persistent occipito-posterior or occipitotransverse position in labor progress) we confirmed with sonography
examination during the first and second stage of labor (82% of cases)
(P < 0.01).
Conclusions: This is a prospective study demonstrating an association
between severe labor pain and c.s. The abnormality of fetal axis exists
and it can affect the progress of epidural analgesia labors. The sonographic examination in labor reducing the time of labor failure, the
possibility of fetal and maternal complications. Furthermore it reduces
forensis implications because of the possibility to give evidence of the
intrapartum head fetal axis.
P62
Computerized cardiotocography: predictive value of
instant variability
A. A. Yamasaki & O. T. Toma
Introduction: Computerized cardiotocography differs from classic
method in measurement of instant variability, also named short-term
variation (STV) which is an important parameter of evaluation of fetal
condition. While classic cardiotocography considers an active fetus
when in the presence of two transitory accelerations (TA), in computerized method, value of STV is the most important parameter and it
must be higher than 4 ms.
Objective: Correlation between STV and TA.
Methods: Two hundred and forty traces of computerized cardiotocography were analyzed (SYS 8002), in normal pregnant, between 30 and
36 weeks of gestation. They were divided into two groups: group I
(n ¼ 200) represented by pregnant whose exam did not show any TA
but STV > 4 ms after 10 min; group II (n ¼ 40) represented by pregnant with no TA and STV < 4 ms after 10 min. In all cases traces were
continued until presence of TA, and the longest trace was 60 min of
duration.
Results: In group I, all cases showed TA while in group II in 60% cases
initial STV < 4 ms have become more than 4 ms and with presence of
TA, showing fetal in good conditions. In the other hand, in 40% cases
even after keeping trace until complete 60 min there were not changes
in STV or presence of TA.
Conclusion: Fetuses with STV > 4 ms are related to active fetuses
(presence of TA) and the ones with STV < 4 ms does ever not mean
altered result as when prolonging trace until 60 min, 60% of these
fetuses become active.
Poster Session 2: Obstetrics – Doppler and Miscellaneous
P63
Computerized cardiotocography: correlation between
STV > 4 ms and response of fetal cardiac frequency to
vibroacoustic stimulation test
A. A. Yamasaki, G. Braia & O. Toma
Introduction: In classic cardiotocography, a fetus is considered active
when there are two transitory accelerations (TA) or elevation of
20 bpm in cardiac frequency after vibroacoustic stimulation test. In
computerized cardiotocography there must an instant variability, also
named short-term variation (STV), higher than 4 ms.
Objective: Comparison between STV > 4 ms and fetal response to
acoustic stimulus.
Patients and methods: Twenty-four normal pregnant were analyzed
between 30 and 36 weeks by computerized cardiotocography (SYS
8002). If STV > 4 ms, but TA is absent after 10 min, a vibroacoustic
stimulation test was done for 3 s. The fetus was considered reactive
when heart rate increased by 20 bpm for 3 min. The fetus was considered hyper-reactive when heart rate increased less than 20 bpm or
duration of response less than 3 min.
Results: Among 24 fetuses, 20 (87%) were considered reactive after
vibroacoustic stimulation test (elevation of 20 bpm for 3 min or more).
Only four fetuses (13%) were hyperactive.
Conclusion: When STV > 4 ms fetuses are reactive in 87% cases and
hyperactive in 13%. The STV can be used as isolated parameter for
assessment of fetal well-being.
P64
Correlation between the umbilical cord cross-sectional
area and fetal anthropometric parameters
F. A. P. Vasques, A. F. Moron, C. G. V. Murta, H. Cattini,
M. M. Barbosa, T. R. Gonçalves, W. J. Hisaba & F. H. C. Carvalho
A prospective cross-sectional study was developed to determine the
correlation between the umbilical cord cross-sectional (UCCSA) and
fetal anthropometric parameters during normal pregnancies (patients
with known dates of LMP and an ultrasound examination before the
20th week, without any pathologic condition). The measurements of
the umbilical cord cross-sectional area were obtained in a plane adjacent to the insertion of the cord in the abdomen, as proposed by Raio
et al., 1999, and compared to the biparietal diameter (BPD), head
circumference (HC), abdominal circumference (AC) and femur length
(FL) by the non-parametric correlation of Spearman. The inclusion
criteria were: (1) singleton pregnancy; (2) gestational week >20 weeks;
(3) intact membranes; (4) normal umbilical Doppler flow velocimetry.
The exclusion criteria, in the presence of any of those were: (1) congenital and/or chromosomal abnormalities; (2) pregnancy complications
(any type); (3) inadequate size for gestational agent the time the ultrasound examination was performed, i.e. the weight below the 10th or
above the 90th percentile; (4) abnormal AFI. The patients were examined and included only once. The statistical analysis was performed by
the program called Statistical Package for Social Sciences (SPSS) and we
used a Toshiba 140 with a transabdominal transducer of 3.5 MHz.
Our results showed a strong correlation (Spearman rank ¼ 0.610, significant at the level of P < 0.01) between the UCCSA and the estimated
fetal weight by ultrasound examination and also with the fetal anthropometric parameters (UCCSA BPD ¼ 0.622; UCCSA HC ¼
0.617; UCCSA AC ¼ 0.625; UCCSA FL ¼ 0.604, all of them
significant at the level of P < 0.01). We concluded that the UCCSA
is a parameter that can be included at the routine of obstetrical
ultrasound examinations.
P65
Does amniocentesis (AC) influence fetal growth?
T. huu Nguyen & T. Larsen
Purpose: To examine the relationship between AC and birth weight.
Methods: A cohort of singleton pregnancies with AC carried out in
Denmark (n ¼ 96893) was compared to the total population of singleton pregnancies without AC or CVS (chorionic villus sampling)
(n ¼ 873254) for infants born in years between 1980 and 1996.
47
11th World Congress on Ultrasound in Obstetrics and Gynecology
Poster Session 2: Obstetrics – Doppler and Miscellaneous
Exclusion criteria were multiple pregnancies, infants with malformations, chromosomal abnormalities, stillbirths, and death within the
first living year. The pregnancies with AC were grouped according to
gestational age (14–19th week of gestation) at the time of AC, and
mean birth weight was calculated for each group. Maternal age, parity
and previous abortions were taken into account when comparing mean
birth weights. To exclude social status as a confounder, the overall
mean birth weight (pregnancies without CVS or AC) was also compared to the mean birth weight of a subgroup of infants (also without
CVS or AC) born to women who undergo AC in some other pregnancy.
Results: The mean birth weight of the AC cohort was found to be significantly higher than that of the total population and inversely related
to the gestational age at AC.
Conclusion: The invasive procedure seems to stimulate growth. No
known potential cofounders can explain the higher birth weight after
pregnancies with AC.
development requires further study. Breathing movements may
provide important information on fetal health and outcome.
P66
Effect of income on fetal biometry by ultrasound
M. A. Taher
Objective: To compare gestational age corrected fetal biometry among
rich and poor women.
Methods: An ultrasound database from August 2000 to January 2001
was used for the purpose of this study. One hundred and seventy-five
patients with certain menstrual history were included. Patient’s income
was assigned based on their report during the initial evaluation. There
were 137 rich and 38 poor women. All data were enter into Statistix
7.0 statistical package, and analyzed using appropriate statistical tests.
Probability values less than 5% were considered significant.
Results: Multiple regression analysis using a second-order model for
gestational age a S function of fetal biometry, income, and fetal biometry–income interaction did not show income to alter the relationship
between gestational age and fetal biometry except for femur lengths.
Ninety-five percent prediction intervals for gestational age did not
show clinically significant difference between rich and poor.
Conclusion: There does not appear to be a significant difference in
ultrasound measured fetal biometry among different income groups.
P67
Fetal breathing: a clinically useful paradox
P. G. Hepper, A. Shannon & J. C. Dornan
Purpose: To examine fetal breathing movements in fetuses with congenital diaphragmatic hernia and compare this to unaffected fetuses
and with their outcome after birth.
Methods: Twenty women with normal singleton pregnancies and four
cases of congenital diaphragmatic hernia were studied. All fetuses were
observed for 60 min at 36 weeks of gestation. Fetal breathing movements were observed by scan taking a cross-sectional view across the
abdomen. The scan was recorded and breathing movements analyzed
off-line. All sessions occurred at the same time of the day and two
hours after a light meal. No patients were cigarette smokers. Bouts
of fetal breathing activity were defined as the length in seconds of each
series of successive individual breathing movements bracketed by periods of apnea. The absence of fetal breathing movements for more than
3 s was called the apnea period. Total duration of breathing was the
sum of all bouts.
Results: The normal fetuses exhibited a breath to breath interval of
1.3 s and displayed breathing movements for around 30–35% of the
observation period. Of the four fetuses with congenital diaphragmatic
hernia, three died during the neonatal period due to lung hypoplasia,
one survived following surgical repair. All four fetuses exhibited a similar breath to breath interval as unaffected fetuses but the three fetuses
who died spent 80% (range 70–90%) of the time breathing whereas
the fetus that survived spent 32% of its time breathing. Increased
yawning was also observed in the fetuses who died.
Conclusions: It has been speculated that the inhibition of fetal breathing movements may result in pulmonary hypoplasia, yet fetuses with
lung hypoplasia spend more time breathing than those without lung
hypoplasia. The relationship between breathing movements and lung
48
P68
Fetal responses to invasive procedures
B. M. Petrikovsky, E. Schneider & N. Holsten
Objective: To study fetal responses to invasive procedures.
Study design: Seven fetuses underwent invasive procedures between
23 and 38 weeks of pregnancy for accepted clinical indications. Two
ultrasound machines were used simultaneously; one to provide
guidance, and one to register FHR and respiratory rate (RR). A pairedtest was used for statistical analysis.
Results: Three patients had bladder centesis, two placements of the
bladder shunts and two placements of pleuro-amniotic shunts. FHR
changed from 128 6 bpm prior to the procedure to 168 8 after it
(P < 0.05). RR also increased from 26 12 to 32 8 (P < 0.1).
Conclusion: Invasive fetal procedures are accompanied by an
increased FHR and RR which are likely to represent pain response.
P69
Predicting neonatal outcome after prolonged preterm
membrane rupture by ultrasound measurement of
fetal lung length
P. R. Stone, L. Sadler, M. Battin, S. Grant, J. Mitchell & A. Roberts
Purpose of study: To assess the ability of ultrasound measurements
of fetal lung length to predict neonatal respiratory outcome after
prolonged membrane rupture and oligohydramnios.
Methods: From the database of all cases of spontaneous membrane
rupture <28 weeks gestation, normal singleton pregnancies with membrane rupture for at least 7 days and delivery after 24 weeks gestation,
where lung length measurements were available, were studied. At least
one lung length measurement 7 days after membrane rupture needed to
be available. The last lung length prior to delivery was used to predict
the likelihood of pulmonary hypoplasia. Complete neonatal follow up
was available on all babies. Neonatal outcome measures included, survival, bronchopulmonary dysplasia defined as an oxygen requirement
at 36 weeks gestation and in non-survivors a neonatal respiratory
death. Two groups, good and poor outcomes were defined. A comparison between the last lung length before delivery corrected for gestation
between the good and poor outcome groups was made to determine
whether lung length could predict neonatal outcome. The trends in
serial measures of lung length were also examined and compared with
neonatal respiratory outcomes.
Results: There were 43 live births eligible for study from the database
of 57 babies. All had received antenatal corticosteroids as part of the
management of prematurity. There were no differences in maternal
age, ethnicity, parity and the incidence of antepartum hemorrhage
between the good and poor outcome groups. Parameters significantly
associated with a good outcome included gestation at membrane rupture, largest pool of amniotic fluid and gestation at delivery. The last
fetal lung length did not predict adverse neonatal respiratory outcome
in the 28 babies, in which membrane rupture was >21 days the findings were the same. Serial lung growth data also did not predict outcomes (figures are presented to illustrate the results).
Conclusions: Fetal lung length determined by antenatal ultrasound
does not predict adverse neonatal respiratory outcome and the prediction of pulmonary hypoplasia remains an elusive goal.
P70
Pregnancy in women with Marfan syndrome
C. G. Garcı́a, N. P. Lagos, C. E. Benavides, I. F. Hoffmann,
G. A. Castillo, M. A. Astorga, X. Melgarejo & I. Ferres
Background: The Marfan syndrome is inherited as an autosomal
dominant trait, and the fetus has a 50% risk of inheriting the mutant
gene. It is caused by an abnormal fibrin gene located on chromosome
15q. The prevalence of the syndrome is 717/100 000. The symptoms and complications usually affect ocular, skeletal and cardiovascular systems. Pregnancy in the Marfan syndrome is associated with
23–28 October 2001, Melbourne, Australia
major problems: the first are maternal catastrophic cardiovascular
complications which include aortic dissection, aortic rupture, or
cardiac failure, due to mitral and aortic valve regurgitation. These
conditions are responsible for 90% of the maternal deaths. The
second problem is the risk of having a child with the syndrome
(50%).
Case report: An 18-year-old patient with a Marfan syndrome and
with mental retardation. She had long limbs, slenderness of hands
and feet, marked hyperextensible joints, kyphoscoliosis, narrow chest
with pectum excavatum, an high arched palate with malocclusion. On
first evaluation by US, she was 18 weeks pregnant. A maternal echocardiography was done, showing that all four chambers, and the valvular
structures were normal, and the aortic root measured 26 mm, which
was normal. The echocardiography was repeated at weeks 29 and
36, and showed no change in the aortic root or in the rest of the parameters. Study of the fetus showed normal anatomy, without morphotype of Marfan in utero. Fetal echocardiography was normal. There
was moderate IUGR. At 39th week, there was a vaginal delivery, without complications, of a male newborn, 2910 g, 49 cm, Apgar 9–9, on a
normal physical examination.
Conclusions: Maternal and fetal outcomes were monitored with systematic echocardiography, which is the best and safest method available for the follow up of the severe cardiovascular complications.
Patients with Marfan syndrome with aortic root of <40 mm, usually
tolerate pregnancy well and can undergo vaginal delivery with epidural
anesthesia, with favorable maternal and fetal outcomes.
P71
Sonographic examination of puerperal uterus after repeat
cesarean section with traditional and Misgav Ladach
methods
A. Malvasi, P. Totaro, L. Liaci, M. D’Ambrosio & V. Traina
Purpose: In our Department of Obstetrics, where 1600 deliveries are
carried out on average every year, cesarean section (c.s.) with Misgav
Ladach methods has been practiced since November 1995, for 2078
cases in all. In our study, we have examined sonographically 309 repeat
c.s. with Misgav Ladach methods compared to 318 traditional repeat
c.s. The aim of our investigation is the sonographic examination of
patients with open peritoneum and those with closed peritoneum to
discriminate the frequency of bladder flap hematomas and other complications in the two techniques.
Methods: The patients were examined by transvaginal and transabdominal sonography, on the third and 10th postoperative day, to
demonstrate the presence of a fluid or mixed mass on the loweruterine-segment (LUS) of 3 cm or more, clean wall, with reinforcement
of distal echoes.
Results: It has been observed that, in the group open peritoneum c.s.,
there were masses of mixed echostructure referring to hematomas on
the 12th day in nine cases, while in the group closed visceral peritoneum in 51 cases (P < 0.05). In 39 cases, they were collection on the
LUS from 3 to 4.2 cm in six from 4.2 to 5 cm and only in one case it
was a lateral collection of 6 cm which did not require surgical treatment anyway. Besides in 22 patients, the bladder-flap hematoma was
associated with puerperal fever (values >38.5 8C). In Misgav Ladach
method, only seven women had adhesion of light-medium importance
so that uterine exteriorization was not necessary, and not significant
(NS) in comparison with the reference of nine women.
Conclusion: Peritoneum closure in repeat c.s. lengthens operative time
and in some cases favors bladder-flap hematomas which increase postoperative morbidity (P < 0.05), antibiotics use 2.6 and 4.8%
(P < 0.01), length of hospital 3 1 vs. 7 2 days staying (P < 0.01)
and costs (P < 0.05). In conclusion, follow up has shown no intraperitoneal compare to repeat c.s. with closed and open peritoneum.
P72
Third trimester abdominal pregnancy
A. Salim, P. Handaya, G. H. Wiknjosastro & B. Karsono
Introduction: Surviving of the fetus of the third trimester abdominal
pregnancy is possible although very rare. The high fetal and maternal
Poster Session 2: Obstetrics – Doppler and Miscellaneous
mortality rates is associated with it. We report four cases which
succeed in having two living healthy babies. The subsequent problem
is about the placenta which is left in the abdomen.
Methods: Four women suspected of late abdominal pregnancy were
referred to our center for further management. All of them underwent
abdominal ultrasound and vaginal if necessary. Blood flow of the
umbilical artery also studied. They were treated until the fetus is viable
according to our pediatrician prior to be delivered abdominally.
Results: From April 1994 until October 2000, we have four cases of
third trimester abdominal pregnancy. Two cases of 30 and 32 weeks
gestational age with fetal death intra-abdominally. Another two cases
of 33 and 31 weeks with living fetus intra-abdominally and placenta
implanted at the superior and posterior side of the uterus. Umbilical
artery RIs were 0.67 and 0.71. The interval between time of admission
till the delivery were 19 and 33 days. Female babies 2400 g Apgar score
9/10 and 1680 g Apgar score 6/8 for 1 and 5 min. They are growing
and developing well except the first one has a slight club-feet.
Conclusion: We report four cases of third trimester abdominal
pregnancies, two of which succeed in delivering healthy babies.
P73
Thromboelastography in the second trimester of pregnancy
in the prediction of adverse pregnancy outcome
C. Karidas, P. Anastassopoulos, D. Perry & D. L. Economides
Thromboelastography (TEG) is a method of monitoring global homeostatic function as a dynamic process, involving the interaction between
the protein coagulation cascade and platelets, as opposed to the isolated end points measured by conventional coagulation screens. The
purpose of this study is to determine whether TEG variables can be
used in the second trimester to predict the development of adverse
pregnancy outcomes such as pre-eclampsia and intrauterine growth
restriction (IUGR defined as birth weight below the 5th centile for
gestational age).
Methods: A prospective study of a cohort of 273 pregnant women
who underwent TEG assessment at 18–24 weeks gestation. Standard
parameters were measured from each TEG tracing (R is the reaction
time, K the clot formation time, A the angle, and MA the maximum
amplitude). Pregnancy outcomes were obtained from the case
notes of 251 participants. Twenty-two patients were lost at follow
up. The Mann–Whitney test was employed for analysis, as the above
parameters did not follow normal distribution.
Results: Twenty-three pregnancies (9.2%) were complicated by IUGR
and 10 (4%) by pre-eclampsia. In the IUGR group, no significant difference was observed in any of the TEG parameters in comparison to
the normal pregnancies (for R time: Mann–Whitney U ¼ 2296, for K
time: U ¼ 2556, for MA: U ¼ 2514.5, for A-angle: U ¼ 2433, 95% CI
(1972, 3273)). Similarly, TEG parameters did not differ significantly in
the pregnancies complicated by pre-eclampsia (for R time: Mann–
Whitney U ¼ 971.5, for K time: U ¼ 1063.5, for MA: U ¼ 1199.5
and for A-angle: U ¼ 1183, 95% CI (765, 1646)). Comparisons after
logarithmic transformation, did not reveal any significant differences
between the two groups.
Conclusion: Thromboelastography parameters in the second trimester
of pregnancy did not differ in normally developed and complicated
pregnancies. Therefore, they cannot be used as a single predictor of
adverse pregnancy outcome. This is a pilot study, therefore, further studies are required to evaluate their use in conjunction with established
predictive tests.
P74
Ultrasound during breast-feeding in normal term infants
L. A. Jacobs
The primary objective of this pilot study of infant feeding mechanisms
on ultrasound was to develop local ultrasound techniques to assess the
infant oral cavity during breast-feeding.
Study methods: A convenience sample of 32 volunteers with term
babies were invited for ultrasound during a breast-feed in week 1
49
11th World Congress on Ultrasound in Obstetrics and Gynecology
Poster Session 2: Obstetrics – Doppler and Miscellaneous
and 4 of life. Useable data was obtained in 22 participants but not all
attended for both scans yielding 36/44. The whole breast-feeding
scan was videotaped for analysis later. Conventionally, accepted
positioning and attachment criteria were used. The infant was weighed
before and after feeding to satisfaction from one breast. A submental
approach was used to obtain a median sagittal view of the nipple
position, hard and soft palate, tongue movements and the
relationship between these intraoral structures. Various designs and
frequency of transducers were tested. The optimal transducer is an
EC-7 endocavity transducer with a 1358 end-firing 7 MHz small radius
curved array on a long, thin handle that does not interfere with feeding
positioning.
Conclusions: The relationship of nipple to hard palate/soft palate
junction is shown to be variable with distances from 3 to 11 mm.
The participants had previous and present history of breast-feeding
success. They were not specifically directed to attach in a particular
way since their current infants were recruited as thriving, contented
examples of the appearances of ‘normal breast-feeding’. It is unknown,
whether the participants in the landmark study by Woolridge et al.
(1986), were instructed in feeding attachment prior to ultrasound
imaging thus influencing the nipple position. Further data analysis will
detect any infant maturation or learning differences between weeks 1
and 4. This simple ultrasound technique can be applied to the assessment of infant feeding problems and preterm infant feeding behavior.
POSTER SESSION 3: OBSTETRICS – 3D, FETAL ANOMALIES, FETAL THERAPY
AND CERVIX
P75
Fetal magnetic resonance imaging
S. J. Sinnott, D. Traves, T. Ryan, K. Frawley, T. Wood
& R. B. Cincotta
Fetal magnetic resonance imaging (MRI) is rapidly establishing a key
role in the diagnostic evaluation of fetal central nervous system (CNS)
anomalies. We present, a pictorial essay of the effectiveness of fetal
MRI in the assessment of cerebral anomalies and ventriculomegaly.
High resolution neurosonography remains the cornerstone in antenatal
CNS screening. When cerebral anomalies are diagnosed or suspected
by ultrasound examination, MRI clearly has a role and often adds useful information or can increase the level of diagnostic confidence and
may alter patient counseling and management. MRI examinations also
can be used to obtain further opinions from different subspecialists,
such as neuroradiologists, neurosurgeons, neurologists and intervention radiologists. Subtleties that may not be distinguishable on ultrasound can be seen on MRI. The MRI should not be seen as a
competitor to ultrasound, rather a complementary study from which
the imaging specialists can improve their working knowledge in CNS
anatomy and pathology.
P76
Prenatal diagnosis of congenital cardiac tumors:
two cases reports
G. Rodrigues & E. Castela
Introduction: Congenital cardiac tumors are rare. Among the pediatric population, more than 90% of cardiac neoplasms are histologically
benign. However, they have the potential for serious consequences, if
not detected in a timely manner, usually because of their conspicuous
location. Rhabdomyomas are the most common tumors of both
infancy and childhood, occurring in 62% of cases.
Case report: Cardiac rhabdomyomas were diagnosed in two patients
at 33 and 34 weeks with support of pediatric cardiology through telemedicine. The first patient had multiple tumors, in right atrium, atrial
septum, ventricular septum and mitral valve, with variable size and
without cardiac arrythmia or stigmata of the tuberous sclerosis. This
patient had unilateral ventriculomegaly due to cerebral ischemy probably linked to tumor embolization. The second patient had a single
tumor, localized in ventricular septum without other ultrasounds findings. The two patients had not obstructed valvular inflow or outflow.
Conclusion: Prenatal diagnosis of congenital cardiac tumors is possible in the hands of an expert, although it is impossible to make a
histological diagnosis in utero, several ultrasonographic criteria,
including tumor number, size, location and echogenicity, may help narrow the differential diagnosis. Thrombosis of cerebral venous circulation can occur antenatally. Accurate diagnosis can be made using fetal
real time and color Doppler ultrasound. At the date of preparation of
this abstract, the pregnancies are in course and delivery is expected in
short-term in a center of pediatric cardiology.
50
P77
Prenatal sonographic appearance of Beare–Stevenson cutis
gyrata syndrome
C.-C. Tsai, T.-Y. Hsu, S.-Y. Chang, T.-J. Wang, C.-Y. Ou,
Z.-H. Chen & P.-U. Hsu
Background: Beare first described a 2-year-old boy who had abnormal physical feature including hypertelorism, cutis gyratum,
acanthosis nigrican, cleft palate, functional pyloric obstruction and
abnormal genitalia. Ten cases of Beare–Stevenson cutis gyrata syndrome have been reported. Here, we present, the first case of antenatal
ultrasound image of this rare syndrome. A 31-year-old Taiwanese,
gravida 2, para 1, was referred for fetal evaluation at 32 weeks gestation because of polyhydramnios and fetal head anomaly. Conventional
sonography revealed a single fetus with amniotic index of 27.3 cm,
cover leaf skull, and a skin fold-like umbilical cord. Three-dimensional
sonography of the face of the fetus showed, high wide forehead, ocular
proptosis, and depressed nasal bridge. The patient delivered a male
infant weighing 2980 g at 39 weeks gestation. Physical examination
of the infant showed furrows of corrugated appearance of the
skin, craniofacial anomalies, particularly craniosynosis, displaced
ears, prominent umbilical stump and hypospadia. Computer tomography and magnetic resonance image were performed and revealed
fronto-ethmoid-nasal, cephalocele, pansynostosis and frontal base
defect.
Conclusion: A total of 10 cases of Beare–Stevenson cutis gyrata syndrome have been previously reported. All of the previously reported
cases of the syndrome were diagnosed postnatally. Our patient presented with ocular hypertelorism, low-set and creased ears, ocular
proptosis, choanal atresia, cloverleaf skull, craniosynosis, cutis gyrata,
acanthosis nirican, prominent umbilical stump and bifida scrotum.
Here we present the first case of antenatal ultrasound image of this rare
syndrome.
P78
The post-exercise cervix
M. Gun & D. Gluis
Measurement of the cervix via transvaginal ultrasound is now recognized as reproducible and accurate. The length of the cervix as determined by transvaginal ultrasound has an inverse relationship to the risk
of preterm delivery. Studies utilizing transfundal pressure to elicit
changes in the cervix have been reported [1,2]. This poster will illustrate the use of ‘post-exercise’ transvaginal scanning in an attempt to
identify those patients at risk for preterm delivery both pre- and postcerclage placement.
References
1 Iams JK, Goldenberg RL, Meis PJ, Mercer BM, Moawad A, Da A et
al. The length of the cervix and the risk of spontaneous premature
delivery. N Engl J Med1996; 334: 567–72.
23–28 October 2001, Melbourne, Australia
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
2 Guzman ER, Vintzileos AM, McLean DA, Martins ME, Genito CW,
Hanley ML. The natural history of a positive response to transfundal
pressure in women at risk for cervical incompetence. Am J Obstet
Gynaecol 1997; 176: 634–8.
P79
Warfarin embryonopathy
S. J. Sinnott, C. McDonald, D. Traves & G. Pritchard
Warfarin sodium readily crosses the placenta due to its low molecular
weight and intrauterine exposure to this oral anticoagulant has
multiple recognized complications. Complication outcomes seem to
be dependent on the timing of exposure. Exposure during the first
trimester between the 6 and 12 weeks of gestation is associated with
warfarin embryonopathy: characterized by nasal hypoplasia, stippled
epiphyses or vertebrae and digital hypoplasia. Warfarin embryonapathy has been identified in up to 25 fetuses with known exposure
to warfarin sodium during the first trimester. Exposure during the
second and third trimesters is thought to lead to a number of central
nervous system abnormalities. The authors report a rare case with
images of the prenatal ultrasound and postnatal X-rays and clinical
photos. A discussion of the pathogenesis and literature review is
included.
P80
2D/3D sonographic imaging of thanatophoric dysplasia
type I at 19 weeks of gestation
R. K. Pooh, S. Nishida & Y. Ohno
Thanatophoric dysplasia is a sporadic, lethal congenital skeletal dysplasia. There are two major subtypes: (1) a short, curved femur characterizes type I; and (2) a straighter femur with cloverleaf skull
characterizes type II. We, here, present a case of type I disease. A
30-year-old pregnant woman was referred to the ultrasound unit due to
fetal short extremities at 19 weeks and 4 days of gestation. Ultrasound
revealed short limbs and a severely small thorax. Every limb bone was
markedly short, and the femur, tibia, fibula and humerus were remarkably curved. 3D ultrasound demonstrated the abnormal appearance of
extremities. Cranial and intracranial structures were normal. One
week later, no growth of limb bones was seen. Thanatophoric dysplasia type I was strongly suspected and counseling of the couple was
done. Pregnancy was terminated at 21 weeks of gestation and a female
fetus was aborted. Short and curved limb bones were confirmed by
postnatal X-ray. Genomic DNA obtained by cord blood showed a
point mutation in the fibroblast growth factor receptor 3 (FGFR3)
gene; a C to T substitution at position 742 in the FGFR3 gene, resulting
in a Arg248Cys substitution, known to be associated with type I
disease. By ultrasound in the second trimester, prenatal diagnosis
of skeletal dysplasia can be feasible. However, differentiating this
lethal disease from non-lethal skeletal disorders should be done
prudently.
P81
A critical evaluation of three-dimensional and
two-dimensional sonographic studies, and color Doppler
ultrasound in detecting nuchal cord in utero
U. Hanaoka, T. Yanagihara, A. Kuno, H. Tanaka
& T. Hata
Objective: To evaluate whether three-dimensional sonography is more
valid than two-dimensional sonography, and color Doppler ultrasound
in diagnosing nuchal cord in utero.
Methods: Eighty-five singleton pregnancies without nuchal cord
and 35 with nuchal cord (30 single nuchal cord, four double nuchal
cords, and one triple nuchal cords) were studied within 1 week before
delivery using a transabdominal three-dimensional sonography.
Two-dimensional sonography and color Doppler ultrasound were also
conducted.
Results: Three-dimensional sonography identified in utero 22 (73.3%)
single and 3 (60%) multiple nuchal cords found at birth. There were no
significant differences in overall diagnostic indices of each diagnostic
modality for detecting nuchal cord. However, the ability to view
nuchal cord was better with three-dimensional sonography than with
two-dimensional sonography or color Doppler ultrasound.
Conclusions: Three-dimensional surface imaging does not provide
more useful diagnostic information than two-dimensional sonography
and color Doppler ultrasound for detecting nuchal cord in utero.
P82
Fetal renal blood flow assessment by three-dimensional
power Doppler ultrasound: preliminary results of a
three-dimensional histogram study
F.-M. Chang, C.-H. Chang, C.-H. Yu, T.-P. Liao
& H.-C. J. Ko
Purpose: To assess the fetal renal blood flow in normal gestation using
three-dimensional (3D) power Doppler ultrasound.
Methods: The study was under a prospective, consecutive and crosssectional design. Normal pregnancies that attended the prenatal clinic
were included. We used a three-dimensional power ultrasound scanner, Voluson 530D MT (Kretz, Zipf, Austria) to assess the total blood
flow of fetal kidney. First, we used the 3D transabdominal probe to
scan the whole fetal kidney under the 3D power Doppler mode at a
fixed condition. Second, we used the VOCAL software (Kretz, Zipf,
Austria) to calculate the histogram indices of fetal renal blood flow
obtained from the 3D power Doppler scanning. The histogram indices
included vascularization index (VI), flow index (FI) and vascularization-flow index (VFI).
Results: In total, 81 fetuses ranging from 20 to 39 weeks of gestation
were included for final analysis. Our results showed that VI had a high
correlation with gestational age (r ¼ 0.90, n ¼ 81, P < 0.001). In
addition, FI was positively correlated with gestational age (r ¼ 0.35,
n ¼ 81, P < 0.05), and VFI also presented a high correlation with
gestational age (r ¼ 0.88, n ¼ 81, P < 0.001). Furthermore, the VI,
FI, and VFI of fetal kidney in the third trimester were all higher than
those indices of fetal kidney in the second trimester (all P < 0.01).
Conclusion: The 3D power Doppler ultrasound can assess the total
blood flow of fetal kidney, which is superior to the previous methods
of blood flow assessment. Our study indicates that fetal renal flow
increases with the advancement of gestational age, and our data may
be a useful reference for further studies of fetal renal flow in abnormal
conditions.
P83
Prenatal neuroimaging of progressive ventriculomegaly
at 20–21 weeks of gestation – a case report
R. K. Pooh, M. Tanemura, M. Yamasaki & K. Pooh
Intrauterine course of genetic hydrocephalus has not been revealed. We
had a case with progressive ventriculomegaly between 20 and
21 weeks of gestation. A pregnant woman was referred to the ultrasound unit at 20 weeks of gestation. Her 8-year-old son had congenital
hydrocephalus, gait disturbance, mental retardation and adducted
thumbs, but genetic examination was not done. The male fetus had
grown normally with normal BPD. However, 2D/3D sonography
and fetal magnetic resonance imaging (MRI) demonstrated partial
agenesis of the corpus callosum, moderate ventriculomegaly and a
small inter-hemispheric cyst. Ventricular volume by 3D volumetry
was estimated as 4.89 mL, which was more than twice as large as
normal ventricle size. Subarachnoid space appeared normally. At
21 weeks of gestation, ventricular volume markedly increased to
8.29 mL within 7 days. Furthermore, 2D/3D ultrasound revealed the
bilateral adducted thumbs. Genetic hydrocephalus, such as corpus callosum agenesis, retardation, adducted thumbs, spastic paraparesis, and
hydrocephalus (CRASH) syndrome was strongly suspected from those
sonographic findings. Pregnancy was terminated at the end of 21 weeks
of gestation. Genetic examination by direct sequenced PCR resulted in
a point mutation at Intron 6 of L1CAM located at Xp28. In our case,
prodromic sign of progressive hydrocephalus was suspected by USG
and MRI at the middle of gestation. Especially, 3D volumetry was useful for the assessment of the objective evaluation of the progressive
ventriculomegaly.
51
11th World Congress on Ultrasound in Obstetrics and Gynecology
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
P84
The assessment of placental blood flow by
three-dimensional color power Doppler ultrasound:
preliminary result of a three-dimensional histogram study
three-dimensional transducer. The fetal nutrition score values were
determined from a qualitative assessment of the amount of subcutaneous tissue present at three locations (face, ribs, and buttocks) on
the antenatal three-dimensional ultrasonograms. Fetal nutritional status, using fetal nutrition score, was compared with those by modified
neonatal nutrition score and ponderal index, respectively.
Results: There was a significant linear correlation between fetal nutrition score and modified neonatal nutrition score. Fetal or neonatal
nutrition score correlated well with birth weight and neonatal
crown-heel length, respectively. However, no significant correlation
between ponderal index and fetal nutrition score or modified neonatal
nutrition score was evident. Ponderal index also did not correlate with
birth weight and neonatal crown-heel length, respectively.
Conclusion: We do cast doubt on the usefulness of the ponderal index
for measurement of neonatal soft tissue and muscle mass. Fetal nutrition score using three-dimensional ultrasonography provides a novel
means of evaluating the nutritional status of the fetus in utero, and
should be useful for predicting the extreme in fetal growth earlier.
C.-H. Yu, C.-H. Chang, F.-M. Chang, T.-P. Liao & H.-C. Ko
Objective: To assess the placenta blood flow in normal gestation by
three-dimensional color power Doppler ultrasound.
Methods: We collected normal pregnant women with gestational age
between 20 and 40 weeks prospectively, consecutively and crosssectionally. Three-dimensional ultrasound scanner, Voluson, 530D MT
(Kretz, Zipf, Austria) was used to assess the placental blood flow in
each case. First, we used the 3D transabdominal probe to scan the placenta under the 3D power Doppler mode at a fixed condition. Second,
we used the VOCAL software (Kretz, Zipf, Austria) to calculate the
histogram indices of fetal placental blood flow obtained from the 3D
power Doppler scanning. The histogram indices included vascularization index (VI), flow index (FI), and vascularization-flow index (VFI).
Results: One-hundred singleton pregnant women were enrolled
into the program. The best-fit equations for VI, FI, and VFI are
0.27107 G 4.02743, 0.56115 G þ 34.28945, and 0.15663
GA 2.53810, respectively. All the P-values are less than 0.05. All
the indices were positively correlated with the fetal gestational age.
Besides, The VI, FI, VFI of fetal placenta in third trimester were all
higher than those indices of fetal placenta in the second trimester.
Conclusion: The fetal placental blood flow increases with the advancement of gestational age. Our data may be a useful reference for further
studies of fetal placental flow in abnormal gestations.
P85
Three-dimensional color power angiography of an
aneurysm of the vein of Galen
R. Ximenes, D. S. Ximenes, A. Ximenes, J. Szejnfeld, S. Ajzen,
G. D’Hippolitto, S. M. Goldman & R. Sandoval
Description of the case: A 26-year-old, gravida 1, para 0, female.
The first scan was at 16 weeks, with normal fetal biometry and development. At 25 weeks’ gestation, a cystic area at the level of the
biparietal-diameter, measuring 25 mm of diameter, ventricles has
normal sizes, the cystic area was interrogated with color Doppler
and showed a typical ‘turbulent flow’. The transvaginal probe was performed for evaluation of the fetal brain. Color Doppler energy was used
to evaluate the cystic area and their communications – ‘angiography’, followed by tri-dimensional reconstruction of the brain vessels, especially
the venous drainage and the arterial communications. This pathology
is referred as a complex arterio-venous malformation (AVM). Antenatal MRI was performed to evaluate the central nervous system. The
parents were counseled about the prognosis. At 34 weeks’ gestation,
the shunts of the arteriovenous malformation were more prominent,
ventriculomegaly, tricuspid regurgitation and polyhydramnios.
Proof of diagnosis: At 35–36 weeks’ gestation, she delivered a female
baby, weighing 2900 g, with Apgar score 4 and 8. The baby was transferred for the neonatal intensive care, but after 24 h died because of
renal failure.
Relevance: This report demonstrated that 3D color Doppler energy
mode is useful in prenatal diagnosis and a more detailed angio-architecture of the aneurysm of the vein of Galen, with a excellent correlation with MRI. We hope, in the near future this technique could guide
the identification of the fetus at increased risk for intrauterine and
neonatal cardiac failure and therefore poor prognosis.
P86
Three-dimensional sonographic evaluation of fetal soft
tissue deposition
T. Yanagihara, M. Matsumoto, U. Hanaoka, A. Kuno & T. Hata
Objectives: To evaluate fetal nutritional status in utero and to detect
intrauterine growth restriction and macrosomia by use of threedimensional ultrasonography.
Methods: Fifty-two fetuses from 28 to 41 weeks gestation were
studied within 1 week before delivery using a transabdominal
52
P87
Three-dimensional volumetry in fetal weight estimation,
cerebral ventricle measurements, and cardiac function
S. Yagel
Objectives: To examine the applicability and efficacy of 3-D volumetry in three discrete areas: fetal weight estimation, cerebral ventricle
measurements, and 3-D echocardiographic studies of fetal cardiac
function.
Materials and methods: Group 1: fetal weight estimation: 250 gravidae with uncomplicated singleton gestations and first-trimester confirmation of gestational age were examined up to 48 h before delivery
using both standard 2-D fetal weight estimation and 3-D volumetry.
Group 2: fetal cerebral ventricle measurements: 40 gravidae with
first-trimester confirmation of dates were examined at 15–25 weeks
gestation. Fetal lateral ventricles were measured by 3-D volumetry.
Group 3: 3-D echocardiography: 40 gravidae with 1st-trimester confirmation of dates were examined at 15–25 weeks gestation. End-systolic
and -diastolic ventricular volumes were studied to evaluate fetal
cardiac function.
Results: In these preliminary groups 3-D volumetry for fetal weight
estimation was shown to have a considerable advantage over standard
2-D methods. Three-dimensional volumetry of the fetal cerebral lateral
ventricles is a simple method of measuring the fetal brain, and may
prove to be a more intelligent method of evaluating cerebral ventricular
volume. Three-dimensional echocardiographic volumetry of the endsystolic and -diastolic ventricular volumes is a new method for evaluating fetal cardiac function, and has considerable potential in heart
scanning in cases of suspected fetal heart failure.
Conclusions: Three-dimensional ultrasonography shows great potential in the evaluation and volumetric measurement of many fetal organ
systems.
P88
Cervical cerclage after hysteroscopic metroplasty
G. Ragusa, C. Lanzani, M. Digrandi & E. Ferrazzi
Purpose: The objective of the study is to evaluate the role of cervical
cerclage after hysteroscopic metroplasty.
Methods: Forty-six women, previously treated by hysteroscopic
metroplasty for subseptate uteri, were prospectively recruited for this
observational study. A total of 34 patients conceived 46 pregnancies.
Miscarriages, ectopic pregnancies, and live births rate were 34, 7,
59%, respectively. Elective or ultrasound indicated cervical cerclage
was proposed to these latter 27 patients. After discussing an informed
consent form patients were asked to choose the elective cerclage or the
ultrasound indicated cerclage. Cervical length was checked every
3 weeks, from 12 weeks of gestation. Indications for cervical cerclage
were: cervical funneling or shortening <25 mm. In symptomatic
patients, or when cerclage was indicated, a cervicovaginal swab
was performed, and, if necessary, antibiotic therapy was started. The
Shirodkar technique was adopted for cerclage.
23–28 October 2001, Melbourne, Australia
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
Results: Eleven of 27 patients underwent cervical cerclage: seven on
ultrasound indication, four electively. Mean gestational age at the time
of indicated cervical cerclage was 20 2 weeks. Three patients, in the
US-indicated group, had a pathologic cervicovaginal swab. All no cervical cerclage delivered at term (39 2 weeks). Mean gestational age
at delivery in patients who underwent indicated cervical cerclage was
significantly lower (P < 0.05) than in patients with no sonographic
indication (37 2 vs. 39 1 weeks).
Conclusions: Ultrasound cervical assessment is a useful tool to select
patients for therapeutical cerclage. According to our data cervical cerclage should be performed only in cases of cervical changes diagnosed
by transvaginal sonography.
P89
Comparison of two methods of cervical stress testing
P ¼ 0.18, and saline 2.5 0.9 vs. 2.6 0.6 cm, P ¼ 0.45). Intravaginal contrast did not alter the identification of funneling in either group.
Conclusion: Intravaginal contrast allows for easier identification of
cervical/vaginal anatomy in some patients undergoing ultrasonographic examination by transperineal scanning but did not significantly
alter assessment of cervical length. Intravaginal soluble methylcellulose gel is the superior cervical contrast agent to normal saline.
This methodology may also be useful in other settings, such as with
a transabdominal approach.
P91
Evaluation of the effects of cervical properties
K. Kepkep, H. Gurpinar & E. Kar
Purpose: Cervical ultrasonography provides useful information on
the prediction of preterm delivery. However, the cervix in natural
state evaluated by sonography does not always show the predicting
signs of preterm delivery. Some insist on the usefulness of the
cervical stress testing like transfundal pressure or Valsalva maneuver,
which provoke cervical shortening or funneling by increasing intrauterine pressure. Our object was to compare the efficiency of the transfundal pressure with that of the Valsalva maneuver as cervical stress
testing.
Methods: Normal pregnant women visiting our outpatient department for routine check up underwent transvaginal ultrasonography.
Cervical length was measured and the shape of the internal os were
evaluated. When the shape of internal os was flat or mildly depressed,
these women were regarded as candidates for the stress testing. First,
Valsalva maneuver, second, transfundal pressure were applied. Cervical shortening ratio was calculated in comparison with the natural
state, and appearance of funneling was evaluated.
Results: Twenty-five examinations were performed on 20 pregnant
women. The shortening ratio in transfundal pressure was 9.8%, which
was greater than that in Valsalva maneuver, 6.5%. However, the number in which cervical length became 25 mm or less was same in each
test. On the other hand, funneling was induced in two cases only by
transfundal pressure.
Conclusion: Although transfundal pressure seemed better testing than
Valsalva maneuver, further examinations is required to conclude
which test is superior.
Introduction: Preterm delivery has been faced in all delivery with a
7–11% and it keeps its importance by causing perinatal mortality
and morbidity. Therefore it is important to define preterm delivery risk
during the earlier period of the delivery.
Objective: The aim of our work is evaluating the influence of the
cervical length and funneling which are measured by transvaginal
ultrasonography (TVUSG) in the asymptotic singleton pregnant
women, to predefine preterm delivery.
Material and methods: The cervical length at 16th, 20th, 24th, 28th,
32nd and 36th week of the pregnancy has been measured by TVUSG
within a sample of 60 pregnant women who do not have any risk about
the preterm delivery or who have already had a preterm delivery or an
abortus case before. Also, the funneling has been observed within the
same sample. The relation of a cervical length less than or equal 30 mm
and the existence of the funneling with a preterm delivery risk before
the 37th week of the delivery has been evaluated statistically.
Results: We have observed the preterm delivery in the seven of the 60
pregnant women which were controlled until the delivery (11.7%). In
this group, the relation between the preterm delivery and a cervix
which is less than or equal 30 mm has been found to be statistically
reasonable with the cervical length value at the 28th and 32nd week
(P ¼ 0.0001; P ¼ 0.00001). A cervical funneling has been found in
one patient and it has been not defined as meaningful with regard to
the preterm delivery risk (P > 0.05).
Conclusions: In order to define the risk of the preterm delivery, it is
more meaningful if the cervical length is less than 30 mm and measured
at the 28th and 32nd week of the delivery. On the other hand, funneling could not been determined during the earlier period of the delivery;
therefore it is not used as a criteria to predefine the preterm delivery.
P90
Enhancing cervical sonography with methyl-cellulose gel
P92
Prevention of preterm labor by AIWA’s score
J. M. O’Brien, B. A. Houseman, A. A. Allen & J. R. Barton
H. Yoshitake, Y. Koyama, J. Fukuda, K. Uehira, S. Amiya
& S. Yano
O. Okitsu, H. Niki & T. Mimura
Purpose: Our purpose was to evaluate the performance of two different contrast agents for cervical sonography in obstetrical patients. In
addition, we sought to evaluate this technique in a setting other than
with transvaginal sonography, such as utilizing a transperineal or
transabdominal approach.
Methods: Women with an indication for cervical sonography without
premature rupture of the membranes underwent placement of 10 mL
of normal saline or water-soluble methyl-cellulose gel. Assessment of
cervical dimensions and contour was performed via transperineal
sonography prior to and after contrast placement. Two authors independently evaluated, the adequacy of visualization of the cervical
canal, external os, and vaginal fornices. When an improvement in
visualization after contrast placement was noted by both observers,
the attribute was counted.
Results: Twenty-five patients were enrolled into two groups. The
mean gestational age at examination was 26.6 6.2 weeks in the saline group, and 27.5 5.2 weeks in the methyl-cellulose gel group,
P ¼ 0.58. Administration of contrast improved visualization in 18
women in the gel group vs. six in the saline group, P ¼ 0.002. Seventeen patients in the gel group had easier identification of the external os
and enhanced visualization of the fornices was noted in 13 patients (12
patients had both). The mean cervical length was similar prior to and
after administration of contrast (gel 2.8 0.9 vs. 2.9 1.0 cm,
Purpose: To elucidate the availability of ‘AIWA’s scoring’ in prevention of preterm labor.
Patients: We retrospectively studied the 6434 deliveries after 22 weeks
of gestation, managed at AIWA-Maternity Hospital from 1986 to
1990, and from 1995 to 2000.
C-stage: deliveries from 1986 to 1990: 1786 (control stage
without AIWA’s scoring);
P-stage: deliveries from 1995 to 1997: 2190 (prototype stage
without AIWA’s scoring);
A-stage: deliveries from 1998 to 2000: 2458 (applied stage with
AIWA’s scoring).
Nine twins and seven cases of pregnant mother transportation (MT)
in (C) 1786, 25 twins and 3 MT in (P) 2190, and 17 twins, 2 triplets, 6
MT in (A) 2458, were involved, respectively.
Methods: The ‘AIWA’s score’ of risk assessment for premature delivery consists of cervical consistency, insertion resistance to external os
of uterus by internal examination, and cervical length and funneling of
internal os of uterus measured by transvaginal ultrasonography. The
full AIWA’s score is 12 point, which means extremely high risk of
premature labor. On the other hand, 0 point means no risk of it. Then,
P-score (0–3) consists of the history of early delivery, abortion after
18 weeks of gestation, present multiplicity and so forth. AIWA’s score
53
11th World Congress on Ultrasound in Obstetrics and Gynecology
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
þ P-score ¼ AP-score. (A) From 1998 to 2000, in case with AP-score
>8, before 26 weeks of gestation, patients had cervical cerclage if
they wanted after severely informed consent. We compared some
parameters between C- and A-stage.
Results: The rate of premature delivery declined (from 4.5 to 3.2%
<37 weeks [P < 0.05]; from 2.5 to 1.3%, <36 weeks [P < 0.01]) in
A-stage using the risk assessment system. In all premature deliveries,
those before 32 weeks of gestation declined from 15.2 to 2.6%
(P < 0.01) in A-stage. The rate of preterm PROM <34 weeks in all
deliveries declined from 0.56 to 0.12% (P < 0.05), while the rate of
preterm PROM in premature labor decreased from 12.7 to 3.9%,
and the rate of emergency cervical cerclage also decreased from 13.5
to 1.2% (P < 0.05). In single baby delivery, the rate of cervical cerclage
slightly decreased from 1.1 to 0.75% in nulliparous mother, however,
it extremely increased from 2.7 to 5.3% in multipara.
Conclusions: Prevention of preterm labor by prophylactic cervical
cerclage using ‘AIWA’s score’ would be useful to decrease premature
deliveries and eventually to relieve the shortage of NICU beds in Japan.
Preterm PROM before 34 weeks of gestation has been a problem for
long years in perinatal management. Also, the success rate of emergency cervical cerclage has been poor. The rate of those two problems
would declined using AIWA’s scoring system. The rate of cervical
cerclage in multipara was two times higher than that in control
stage. The future issues is making of more appropriate indication
and contraindication of cervical cerclage with special reference to
patients QOL.
P93
Quantitative ultrasonic tissue characterization of the
cervix – a new predictor for prematurity?
I. Tekesin, M. Meyer-Wittkopf, G. Heller, B. Steinfeldt, F. Sierra
& S. Schmidt
Background: Since the incidence of premature delivery has remained
constant, despite intensive safeguard methods over the last decade,
the texture features of the uterine cervix were evaluated using quantitative sonographic gray level analysis at different gestational ages
(GA).
Materials and methods: For this purpose quantitative ultrasonic tissue densitometry of the uterine cervix was obtained from 30 asymptotic female patients (group A, mean: 30.3 GA) and compared with
values obtained from 16 symptomatic female patients (group B, mean:
29.5 GA) with uterine contractions and shortening of the cervix at
similar gestational ages. Once the two-dimensional transvaginal sonographic measurement of cervical length was completed a region of
interest of constant size was defined in the mid-section of the posterior
wall and the tissue-specific gray scale distribution was determined.
Results: Quantitative ultrasonic tissue characterization of uterine cervix was feasible in all 46 patients at all gestational ages. In patients
with premature contractions and shortening of cervix, the average gray
scale values were found to be statistically reduced in comparison with
those obtained from asymptotic patients. These results showed good
reproducibility and intraobserver variability and were found to be
independent from the measured cervical length.
Conclusion: Our results prove that quantitative ultrasonic tissue characterization of the uterine cervix might serve as a new parameter for
predicting premature delivery in the future.
P94
Transvaginal ultrasonography in detection of cervical
incompetence
M. Podobnik, M. Podgajski, B. Gebauer & S. Ciglar
Background: To examine the relationship between transvaginal ultrasound cervical changes and pregnancy outcome in women at risk of
cervical incompetence and preterm delivery.
Methods: In 100 pregnancies with clinical and ultrasonic signs of cervical incompetence, the length of the cervix, the thickness of the anterior wall of a lower uterine segment and the width of the endo-cervical
54
canal have been evaluated ultrasonically. These parameters were followed longitudinally from the 10 to 36 week gestation in the healthy
pregnancies and pregnancies at risk for cervical incompetence and preterm delivery.
Results: In patients from 10 to 14 weeks, the cervix is significantly
longer than in the 25–36 week group and the anterior wall of the lower
uterine segment in the 10–14 week group is significantly thicker than in
the 20–36 week group. In pregnancies at risk for cervical incompetence, cervical lengths and wall thickness, were significantly different
from those in comparable controls. Forty-five percent of the patients
in the at-risk group, with cervical cerclage, delivered at 37.5 weeks
and 8.5% of pregnancies ended in abortion when the amniotic
membrane herniated into the cervical canal. The frequency of preterm
delivery was 60, 38 and 15% for cervical length of <10, 10–20, and
20–30 mm.
Conclusions: A shortened cervix with decreased thickness of the anterior wall of lower uterine segment and dilated endo-cervical canal
shows a strong association with cervical incompetence and preterm
birth.
P95
Ultrasound assessment of the cervix in recognizing
preterm delivery
J. Brazert, E. Wender-Ozegowska, A. Persona-Sliwinska
& R. Biczysko
Background: Cervix is very important structure that separates the
fetus from external environment, which we can visualize very precisely
transvaginal ultrasonography. Sonographic examination allows visualization of the internal cervical os and the portion of the cervix that lies
above the vaginal fornices, providing information that is inaccessible to
digital examination. Cervical length in the pregnancy is one of the predictors of preterm delivery and diagnosis of cervical incompetence.
Materials and methods: We have investigated 57 pregnant
women: 20 diabetic pregnant women, 8 with hypertension, 14 with
cervical incompetence, and 15 in uncomplicated pregnancy. Transvaginal sonography was used to measure cervical length between 20
and 30 weeks gestation. Ultrasound examination was performed
using 2000 with 5.0 MHz transvaginal transducer. Maternal age
ranged from 19 to 39 years (mean 27.2 8.3). The following
measurements were obtained: endo-cervical canal length between the
internal and external os, funneling of the cervix, funnel width, funnel
length.
Results: The mean endo-cervical length measured in ultrasonography
was 17.3 5.2 mm in pregnancies delivered preterm (n ¼ 7) and
33.4 9.6 mm in pregnancies delivered at term (nP). The 11 pregnant
women with cervical incompetence were treated with cervical cerclage,
eight of them delivered at term and three preterm. The mean endocervical length was 10.4 mm 3.0 and in all cases we observed funneling of the cervix in this group. Endo-cervical length was 25 mm in
75% pregnant women, who delivered after 37 weeks of pregnancy.
No significant relationships were shown between length of the cervix
in pregnancy complicated by diabetes mellitus, hypertension and
uncomplicated pregnancy. The mean endocervical length in diabetic
pregnancy was 34.7 4.7 mm; pregnancy with hypertension 32.9
5.8 mm and uncomplicated pregnancy 35.6 3.8 mm.
Conclusion: Cervical length measured by ultrasonography between 20
and 30 week of pregnancy is very important predictor of preterm delivery. No significant relationships were shown between the length of the
cervix and investigated pregnancy complications.
P96
Adenomyomatosis causing an echogenic fetal
gallbladder – a new association
M. P. Bethune & M. Pahuja
Case report: A primi gravida presented for a third trimester growth
scan due to a history of SLE. Biometry was normal but a linear
echogenicity was identified in the region of the fetal gallbladder, the
23–28 October 2001, Melbourne, Australia
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
gallbladder was not separately identified. The patient delivered an
appropriately grown term baby with normal Apgar scores. Postnatal
ultrasound identified a normal-sized gallbladder with echogenic foci
in the wall demonstrating the classical ‘comet tail artifact’ seen with
adenomyomatosis.
Discussion: The fetal gallbladder can be visualized from late in the
first trimester. Previous case reports of echogenicities within the
fetal gallbladder have found a high rate of resolution by the time of
delivery [1,2]. The persistent echogenic foci in neonates were shown
to be gallstones or sludge in almost all cases. All series failed to
show any neonatal consequences of these findings [1]. Adenomyomatosis is a benign condition of the gallbladder where the lining epithelium extends as down-growth between the muscle bundles to form
gland like structures, known as Rokitansky–Aschoff sinuses. Within
these foci secondary cholesterol crystal deposition occurs. Sonographically these appear as echogenic foci within the gallbladder wall with
the classic description of ‘comet tail artefact’. A detailed medline
search failed to reveal any reported cases of neonatal diagnosis of this
condition. It has only rarely been reported in children. There have
been no previous case reports of echogenic fetal gallbladder confirmed
as adenomyomatosis in the neonatal period. Adenomyomatosis
needs to be included in differential diagnosis of the antenatal echogenic
gallbladder.
References
1 Kiserud T, Gjelland K, Bogno H, Waardal M, Reigstad H, Rosendahl K. Echogenic material in the fetal gallbladder and fetal disease.
Ultrasound Obstet Gynecol 1997; 10: 103–6
2 Brown DL, Teele RL, Doubilet PM, DiSalvo DN, Benson CB, Van
Alstyne GA. Echogenic material in the fetal gallbladder: sonographic
and clinical observations. Radiology 1992; 182: 73–6
P97
Associated anomalies and perinatal outcome in fetuses
with prenatally diagnosed single umbilical artery
M. H. Park, K. Y. Oh & J. S. Park
Objective: To evaluate pattern of associated structural anomalies,
abnormal karyotypes and perinatal outcomes of fetuses with prenatally
diagnosed single umbilical artery and to evaluate the relation of absent
side of a single umbilical artery in association with anomalies and
abnormal karyotypes.
Materials and methods: Thirty fetuses with a single umbilical
artery were detected by prenatal ultrasound examination between
March 1998 and June 2001 at Eul-Ji University Hospital. All medical
records were reviewed for maternal demographics, associated anomalies, karyotypic analysis, pregnancy complications, and neonatal
outcome.
Results: Of the 30 fetuses, 11 (36.7%) were terminated because of
severe anomalies and 1 (3.3%) experienced neonatal death. 17 fetuses
(56.7%) had an associated structural anomaly. The structural anomalies found in association with single umbilical artery were multiple malformations (seven cases, 41.2%), cardiovascular anomalies (four cases,
23.5%), urinogenital anomalies (four cases, 23.5%), CNS anomalies
(one case, 5.9%) and ectopia cordis (one case, 5.9%). Karyotype analysis was available in 25 cases and 5 of these were chromosomally
abnormal. All of the karyotypically abnormal fetuses had a structural
defect diagnosed on prenatal ultrasound examination in addition to the
single umbilical artery. Of the 13 fetuses without any associated structural or chromosomal anomalies, 3 (23.1%) demonstrated growth
restriction. Of the 26 cases identified, the absent side of a single umbilical artery, the right umbilical artery was absent in 13 (50%) and the
left in 13 (50%) fetuses. The frequency with associated structural and
chromosomal anomalies was equal on right (46.2, 15.4%) and left
(69.2, 23.1%) sides.
Conclusion: When single umbilical artery is detected, a detailed ultrasonographic examination and fetal karyotyping should be recommended for search of associated structural and chromosomal
abnormalities. In cases, where single umbilical artery is an isolated
finding on prenatal ultrasound, careful attention to fetal growth is
necessary.
P98
Case report: bradycardia in a fetus with
trisomy 21
S. C. Cha & R. Porto
Introduction: Trisomy 21 is the most common chromosomal abnormality and the risk of delivering a child with this defect increases with
maternal age. Diagnosis can only be done by invasive procedures for
fetal karyotyping. For parents who choose to avoid such tests, ultrasound scans can help identify markers of aneuploidy such as increased
nuchal translucency thickness. However, these screening methods cannot identify all abnormal cases.
Case report: V.L.F.R., 38 years-old, first pregnancy, had a 1.6-mm
nuchal translucency thickness measurement at 11 weeks and normal
anomaly scan at 20 4 weeks. On the basis of these findings, she
decided to avoid fetal karyotyping. Scan at 28 weeks showed normal
fetal biometry apart from short femur. Fetal sinusal bradycardia
(heart rate ¼ 116 bpm) was diagnosed at 33 weeks and repeat computerized fetal heart monitoring from 34 weeks onwards was always
normal apart from previously noted fetal bradycardia. Estimated
fetal weight was 2.080 g at 35 weeks (below the 10th centile for gestation) but amniotic fluid volume and fetal Doppler studies were normal.
Elective cesarean section was carried out at 38 weeks and a male
newborn weighing 2.700 g, Apgar score 7-9-10 was delivered.
Down syndrome was clinically suspected and confirmed by cytogenetic
analysis.
Discussion: Some studies have demonstrated that a silent pattern during fetal heart monitoring, with fewer accelerations and more decelerations, is more often found in trisomic fetuses than in normal ones. In
this case report, fetal bradycardia was the only abnormal finding. It
raises the possibility of considering this as a marker for aneuploidy
when fetal biophysical profile and Doppler studies are normal in the
third trimester.
P99
Choroid plexus cyst revisited – the KK Hospital
experience
J. V. K. Tan, B. H. Woo & G. S. H. Yeo
Objective: To study the clinical outcome of cases of choroid plexus
cysts (CPC), the prognostic factors that increase the risk of aneuploidy
and to formulate a counseling strategy for CPC.
Study design: Cases of CPC detected at screening ultrasonography
(between 18 and 24 weeks gestation) from 1 October 1996 to 30 September 2000 in low risk antenatal patients at KK Women’s & Children’s Hospital, Singapore, were studied. The risk of aneuploidy and
postnatal cranial ultrasonography of the cases were analyzed. Data
was stratified according to maternal age, size of CPC, unilaterality or
bilaterality and presence of concomitant structural abnormalities and/
or ultrasound markers (non-isolated).
Results: There were 485 cases with CPC among 56 746 patients (incidence 0.08%). Overall risk of aneuploidy was 6.2%. There were 30
cases of chromosomal abnormalities including 23 cases of trisomy
18; five cases of trisomy 21; one case of monosomy X and one case
of Klinefelter syndrome. Cases of non-isolated CPC were at significantly higher risk for aneuploidy (56.8%) compared to isolated CPC
(1.4%), P < 0.001. No significant difference in risk was detected
between unilateral and bilateral isolated CPC (P ¼ 0.4), and with
increasing size of isolated CPC. A near significant increase in risk
was found between the under-30 age group (0.37%) and the above30 age group. (2.3%) (P ¼ 0.07). In non-isolated CPC, the risk of
aneuploidy ranged from 14.3% at age 20–24 and 100% at age 41–
45. Likelihood ratio for trisomy 18 was 7.2 for isolated CPC, 1276
for non-isolated CPC and 0.54 for absent CPC in the whole scanned
population.
Conclusion and recommendations: Our results support the need for a
thorough ultrasound anatomic survey for all cases of diagnosed CPC.
Karyotyping should be offered to all cases of non-isolated CPC. In isolated CPC, there may be benefit from offering karyotyping when
maternal age exceeds 30.
55
11th World Congress on Ultrasound in Obstetrics and Gynecology
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
P100
Dystrophic calcification within fetal myocardium: a case
report
S. L. Rowlands, A. J. Sampson & S. Kahler
A woman presented at 19 weeks gestation for a second opinion of an
echogenic cardiac focus. The pregnancy had been complicated by 2 episodes of first trimester vaginal bleeding. She had no significant personal
or family medical history. The ultrasound reported a viable fetus with
biometry equivalent to 19 weeks gestation. Morphological examination revealed an anatomically normal heart, but there were multiple
echogenic foci present within the myocardium. These ranged in size
from 2 to 6 mm, and were within both ventricular walls and the interventricular septum. There were no abnormalities of cardiac blood flow.
The remaining morphology was normal, the amniotic fluid volume was
appropriate and the fetus was active. Rhabdomyomata were thought
to be the likely diagnosis. Their association with tuberous sclerosis
was discussed and the couple elected to terminate the pregnancy. Postmortem examination showed these echogenic foci to be multiple areas
of dystrophic calcification. These were isolated findings. There were no
features of rhabdomyomata. Dystrophic calcification within the fetal
myocardium has rarely been reported at autopsy. It is thought to represent sites of injury to the myocardium. There are few previous reports
of its antenatal detection on ultrasound later confirmed at autopsy and,
although reported in fetuses which are stillborn or miscarried, it is
rarely otherwise seen (Veldtman et al. Heart 1999; 81: 92–93).
Although generalized ischemia can lead to myocardial calcification in
older individuals, the present case and those reported by Veldtman
et al. do not show evidence of this. The extent of the myocardial calcification suggests that there would have been significant cardiac dysfunction if the pregnancy had progressed. However, we are unaware
of cases in which the pregnancy has continued. This report will discuss
the appearance, etiology and prognosis of dystrophic calcification of
the fetal myocardium and the importance of differentiating it from
rhabdomyoma on ultrasound.
P101
Echocardiography should be also performed during
the third trimester in fetuses of pregestational
diabetic mothers
B. Puerto, J. M. Martı́nez, O. Gomez, D. Moyano, M. Palacio,
S. Martı́nez, A. Borrell & V. Cararach
Objective: To assess the risk and types of congenital heart disease in
our population of insulin-dependent pregestational diabetic mothers.
Methodology: Over a 3-year period, a transabdominal echocardiography at 20–22 weeks of gestation and a second one at 32–34 weeks of
gestation was performed in 142 insulin-dependent diabetic pregnancies. In the last 30 cases, an early examination combining either the
transvaginal or the transabdominal route at 13–16 weeks was also carried out. A complete heart evaluation and measurement of the interventricular septum thickness was performed, with color and pulsed
Doppler assessment. An accurate postnatal cardiac examination was
always performed.
Results: Twelve significant cardiac defects (8.45%) were detected, but
only two of them before 22 weeks of gestation (one tetralogy of Fallot,
and another one critical aortic stenosis). Both followed early termination of pregnancy, and postmortem evaluation confirmed the diagnosis. The other 10 cases were diagnosed during the third trimester: two
coarctation of the aorta (one neonatal death because hemodynamic
disturbance), three pulmonic stenosis, five significant hypertrophic cardiomiopathy with subaortic stenosis, and a case of supraventricular
tachycardia (>240 bpm needing postnatal cardioversion). All the
babies, but one are alive and well, although most of them have needed
catheterization or pharmacological treatment. One case of a ventricular septal defect (2.5 mm, muscular) was overlooked during gestation,
but closed by the sixth month of life.
Conclusion: Our results confirm that diabetic women are at increased
risk of having a child with congenital heart disease, and therefore we
recommend conventional fetal echocardiography in all pre-gestational
diabetic pregnancies at 20–22 weeks of gestation. In view of the
56
pattern of defects we have found, we strongly suggest that a further
scan during the late trimester should always be performed.
P102
Fetal intracardiac echogenic foci: frequency of detection
with respect to maternal race and other abnormalities
E. Fitchat
Objective: To determine if there is a racial difference in the frequency
of detecting an echogenic intracardiac focus in fetuses and the
incidence of other related abnormalities.
Methods: Over a 3-month period (December 2000 to February 2001)
all fetuses scanned between 12 and 30 weeks were evaluated for the
presence of intracardiac echogenic foci. The sonographer indicated
the maternal race (black, colored, white or other), gestational age,
maternal age and the presence of other abnormalities. Amniocentesis
or cordocentesis was performed when indicated. Follow up on fetuses
and neonates were obtained from the patient records. The groups were
compared with respect to maternal race, presence or absence of foci
and other associated abnormalities.
Results: There were 725 fetuses scanned during this period where the
gestation was between 12 and 30 weeks. There were 606, 98, and 21
fetuses of colored, black and white mothers, respectively. Intracardiac
foci were present in 33 (5.4%) colored, 8 (8.1%) black and one (4.7%)
white mother, respectively. The association with other abnormalities
was 7/42 (16.6%). This was higher in the colored group 5 (15%) compared with the black group 1 (12.5%). There was only one fetus in the
white group with an intracardiac focus and this was a baby born with
congenital rubella syndrome. There were two (5%) fetuses with chromosomal abnormalities. One was a black fetus with trisomy 21 and
one colored fetus with trisomy 18. The remaining four fetuses had markers associated with normal karyotype on culture. These were polihydramnios, hyperechogenic bowel, pyelectasis, and intrauterine growth
restriction.
Conclusions: In this preliminary study the black fetus had a higher
incidence of intracardiac echogenic foci. Detection of an intracardiac
focus is associated with a 5% risk of chromosomal abnormalities
and other associated features should be evaluated.
P103
Limb body wall complex – a case series and review
of the literature
B. Luehr, J. Lipsett & J. Quinlivan
Introduction: Limb body wall complex is defined by the presence of
exencephaly and either facial clefts, thoraco- and or abdominoschisis
and limb defect. This condition is rare with an incidence of 0.83/
1000 in this case series. The aetiology is unknown but two theories best
support the evidence. These are firstly that there is early vascular disruption between the 4 and 6 week of gestational age and secondly that
there is early amnion rupture sequence in combination with a defective
folding process in the embryo [1,2]. However a similar abnormality
has been described in the mouse which is caused by the disorganization
gene and there is suggestions for the existence of a human homologue
gene [3,4].
Methods: All abortions or births coded as limb body wall defect or
fetal exencephaly between January 1996 to January 2001 were
reviewed. Those cases that fulfilled the criteria of limb body wall
complex on postmortem examination were summarized. The criteria
were: exencephaly [1] or encephalocele [2] facial cleft, thoracoand/or abdominoschisis [3], limb defect.
Results: During the 5-year period, there were 13 286 deliveries. Of
these, 11 cases met the criteria of limb body wall complex giving an
incidence of 0.83/1000 deliveries. Mean maternal age was 29 (SD
5.9) years, and the mean gravidity and parity were 3 (IQR 2–4.5)
and 0 (IQR 0–1.5). In 50% (5/10), 50% (5/10) and 30% (3/10) of
women a history of cigarette, alcohol and marijuana use, respectively,
was noted. Furthermore, 40% (4/10) of the women had a history of a
previous infant with a congenital anomaly being, respectively, amniotic band syndrome, cleft-lip, atrial septal defect and a previous affected
pregnancy with LBWC. In this latter case, two male infants with
23–28 October 2001, Melbourne, Australia
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
LBWC occurred in one patient, supporting the hypothesis that some
cases may be due to an X-linked disorganization gene. Overall, the gender of the affected infant was male. All cases were diagnosed with a
major abnormality, usually exencephaly, on ultrasound examination
between 15 and 19 weeks gestation. The specific diagnosis of LBWC
was usually not made until postmortem examination (91% of cases).
One patient had an ultrasound at 17 weeks gestation that was reported
as normal, only to have exencephaly subsequently diagnosed on
ultrasound at 19 weeks gestation. Without interruption of pregnancy,
one fetus survived for 18 h following delivery for its twin at 35 weeks
gestational age.
Conclusion: Limb body wall complex is a rare fetal anomaly. Structural components of the syndrome, ususally exencephaly, can be identified on second trimester ultrasound examination; however, the
definitive diagnosis is usually not made until postmortem examination.
Several possible mechanisms for LBWC have been discussed including
early amnion rupture sequence in combination with a defective folding
process, early vascular disruption and genetic factors. The mouse
mutant disorganization is semi dominant with 72% of heterozygotes
manifesting abnormalities, which include cranioschisis, gastro/thoracoschisis and limb defects. A human homologue for disorganization
may be the cause for at least some examples of LBWC [3,4]. The predominance of male fetuses suggests that there may be a X-linked inheritance. However, environmental teratogens such as nicotine, alcohol or
illicit drug abuse may be responsible to manifest the disorder in other
cases by impairing the uteroplacental flow during critical periods of
development as shown in mouse and rat fetuses [5–7].
References
1 Russo R, D’Armiento M, Angrisani P, Vecchione R. Limb body wall
complex: a critical and sonological proposal. Am J Med Genet 1993,
November 1; 47 (6): 893–900
2 Deruelle P, Hay R, Chauvet MP, Duroy A, Decoqu J, Puech F.
Antenatal diagnosis of limb body wall complex. J. de Ginecologie,
Obstetrique et Biologie de la Reproduction 2000, June; 29 (4):
385–91
3 Winter RM, Donnai D. A Possible human homologue for the mouse
mutant disorganization. J. Med Genet 1989, July; 26 (7): 417–20
4 Donnai D, Winter RM. Disorganization: a model for ‘‘early amnion
rupture’’? J Med Genet 1989, July; 26 (7): 421–5
5 Viscarello RR, Ferguson DD, Nores J, Hobbins JC. Limb body wall
complex associated with cocaine abuse. Further evidence of
cocaine’s teratogenicity Obstetr Gynaecol 1992, September; 80
(3Pt2): 523–6
6 Padmanabhan R, Muawad WM. Exencephaly and axial dysmorphogenesis induced by acute doses of ethanol in mouse fetuses. Drug
Alcohol Dependence 1985, December; 16 (3): 215–27.
7 Screenathan RN, Padmanbhan R, Singh S. Teratogenic effects of
acetaldehyde in the rat Drug Alcohol Dependence 1982, August; 9
(4): 339–50.
P104
Outcome of 25 pregnancies complicated with CCAM
S. P. Higgins & F. NiChuileannain
Congenital cystic adenomatoid malformation (CCAM) is a pulmonary
developmental anomaly arising from an overgrowth of the terminal
respiratory bronchioles, while the development of the alveoli is completely suppressed except at the periphery. The condition, in the vast
majority of cases is confined to a single lung (85%) or lobe. Congenital
cystic adenomatoid malformation has been classified into three subgroups according to the size of the cysts. The inheritance pattern of
the lesion appears to be sporadic, with no known teratogenic associations. The condition is usually isolated and there is no association
with chromosomal defects. The ultrasound diagnosis is based on the
finding of a solid or cystic, non-pulsatile intrathoracic tumor. Common
associated findings are polyhydramnios (65%), which is likely to be
due to decreased fetal swallowing, the consequence of esophageal
compression by the mass or decreased absorption of lung fluid by the
hypoplastic, malformed lungs, hydrops (common in microcystic form)
and placentomegaly (in cases of hydrops). Unilateral lesions are often
associated with deviation of the mediastinum in the contralateral side.
In bilateral disease, the heart may be severely compressed, and this is
usually associated with ascites from venocaval obstruction or cardiac
compression. We wish to present the outcome of 25 pregnancies where
a diagnosis of congenital cystic adenomatoid malformation was made
on the basis of ultrasound findings during second and third trimester
scans. The patients were subsequently managed through the Fetal
Management Unit at the Royal Women’s Hospital over the 6-year
period from 1995 to 2001. We will present data on the progression
of the lesions through pregnancy, pregnancy outcome with shortand long-term follow up data on the babies.
P105
Prenatal detection of cardiac rhabdomyomas and
cerebral lesions in a fetus with tuberous
sclerosis: a case report
I. Dias, M. J. S. Bernardo, T. T. Kay, S. de Almeida, M. Marques
& J. Bugalho
Tuberous sclerosis is characterized by the development of hamartomatous lesions throughout many tissues, particularly the brain, the
skin, the heart and the kidneys. The authors report a case of tuberous
sclerosis suspected by prenatal ultrasound detection of cardiac rhabdomyomas and brain masses. At 20 weeks the ultrasound evaluation did
not reveal any cardiac or brain lesions. Later on, at 33 weeks, multiple
echogenic masses in the heart, located in the ventricular walls and
interventricular septum and two small cerebral echogenic masses were
diagnosed. No other abnormalities were noted. There is no previous
genetics history in the family. Sequential examination revealed a discrete increase in size of the tumors; no hemodynamic or arrhythmic
consequences were detected. A male fetus was delivered at term, with
normal weight and Apgar score. Postnatal magnetic resonance imaging
confirmed the small brain tumors. The baby had some seizures that
were controlled with anti-epileptic therapy. Cardiac tumors spontaneously decreased and their regression was confirmed, a few months
later, by echocardiogram. The skin of the baby showed some depigmented spots. No other abnormalities were detected namely in
the kidneys. At 13 months, the child had normal growth and developed
appropriately. As in other cases confirmed by literature the findings
of cerebral lesions on fetal ultrasound can help in the prenatal diagnosis of tuberous sclerosis, but does not necessarily indicate a poor
prognosis.
P106
Prenatal diagnosis of ovarian cyst
S. C. Cha & D. Pares
Introduction: The prenatal diagnosis of a fetal abdominal cyst raises
the following possibilities: mesenteric cysts, obstructive uropathy with
dilated ureter, intestinal duplication and ovarian cysts when the fetus is
female. Ovarian cysts have been described in association with diabetes
mellitus, alloimmunization and fetal hypothyroidism, but the etiology
is often unknown. In normal pregnancies, the development of ovarian
cysts has been attributed to hormonal stimuli due to immaturity of the
neuro–endocrine axis. A possible mechanism involves gonadotropin
elevation that stimulates fetal foliculogenesis and the development of
cysts. Management is usually expectant since most cysts resolve spontaneously after birth. However, complications such as rupture or torsion of the cyst can lead to destruction of this organ. Drainage is
indicated when the diameter is greater than 5 cm or there signs suggestive of internal hemorrhage, such as internal septa or echogenic debris.
N.M.F., a 31-year-old, first pregnancy, had an ultrasound scan at 22weeks which showed no fetal abnormalities. At 30 weeks, repeat scan
showed an abdominal cyst between the bladder and the right kidney
measuring 4.3 cm 4.2 cm 3.8 cm in a female fetus. Two weeks
later, it became larger (6.3 cm 5.5 cm 5.4 cm) and drainage was
performed with aspiration of 50 mL of sero-sanguineous fluid. Progesterone levels in the aspirated fluid were 17 000 ng/dL and estrogen
levels, 1350 ng/dL; these findings confirmed the hypothesis that it
was an ovarian cyst. This case highlights the need to perform follow
57
11th World Congress on Ultrasound in Obstetrics and Gynecology
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
up scans when a fetal abdominal cyst is diagnosed and the importance
of intrauterine drainage as a diagnostic and therapeutic tool to preserve
ovarian function.
P107
Prognostic factors of non-immune hydrops fetalis
in Korean population
J. Y. Lee, S. S. Shim, J. S. Park, J. K. Jun, B. H. Yoon,
H. C. Syn & H. P. Lee
Objective: Non-immune hydrops fetalis (NIHF) is rare and carries a
grave prognosis. We undertook this study to find out prognostic factors
of NIHF in Korean population.
Material and methods: From October 1988 to February 2001, 71
pregnancies of NIHF were evaluated with antenatal testes, including
fetal karyotyping, fetal echocardiography, detailed ultrasonography,
and infection work-up. In some cases, we performed them after
delivery and included autopsy results. Twenty cases were sacrificed
due to parents’ decision before viable stage. Four cases were lost in
follow up. Sixteen cases of cystic hydroma were excluded because
they were regarded as a different entity. Thirty-one cases were retrospectively evaluated to find out prognostic factors in NIHF. We analyzed, the presumed prognostic factors, such as gestational age at
detection, gestational age at delivery, birth weight over 90th percentile,
the presence of associated conditions, 5 min Apgar score less
than 4, number of body cavities filled with fluid, and the presence of
polyhydramnios.
Results: Of 31 cases, 21 cases were expired in utero or neonatal period
(67%) and 10 cases were survived till at least 28 days after birth. Only
5 min Apgar score less than 4 was significantly associated with perinatal death (Odds ratio 6.000, CI 1.693–21.262). Other factors were not
risk factors of increased perinatal mortality.
Conclusion: On the basis of our data, we concluded that 5 min Apgar
score less than 4 was a significant risk factor for predicting increased
perinatal death in NIHF.
P108
The accuracy and indications of fetal echocardiography in
high-risk patients: a 4-year clinical experience in an
obstetric unit
J. M. Martı́nez, O. Gómez, B. Puerto, A. Borrell, M. Palacio
& V. Cararach
Objective: To evaluate the accuracy and assess the indications of fetal
echocardiography to diagnose structural heart disease in our high-risk
population, by an obstetric team.
Methodology: Over a 4-year period, a transabdominal echocardiography was performed in 912 high-risk pregnancies for congenital heart
disease at 18–38 weeks of gestation. In the last 140 cases an early
examination combining either the transvaginal or the transabdominal
route at 13–16 weeks was also carried out. Follow up was obtained
from neonatal examinations and autopsies. The main indications
for referral were: pregestational diabetes mellitus, family risk,
increased nuchal translucency, suspected cardiac anomaly at screening
ultrasound, women at high risk of chromosomal abnormality reluctant
to invasive test, suspected arrhythmia, single umbilical artery, exposure to teratogens, and pregnancies affected by a chromosomal
abnormality.
Results: There were 79 (8.6%) major congenital heart defects, and
most of them were yielded in the group of screening by ultrasound.
Seventy of them (88.6%) were diagnosed correctly as abnormal prenatally. Atrioventricular septal defects (21 cases) and hypoplastic left ventricle syndrome (12 cases) were the most prevalent heart anomalies in
the fetus. Isolated septal defects and coarctation of the aorta were the
most difficult lesions to detect, being the ones with false positive and
negative diagnosis. Another four cases of insignificant (<3 mm, no surgery nor medical treatment required) ventricular septal defects were
overlooked during gestation, but closed by the sixth month of life.
Fifteen apparently normal cases were lost to follow up.
Conclusion: Our obstetric team results, in accordance with others previously published, show a good effectiveness to diagnose congenital
58
heart anomalies. Most major detectable cardiac anomalies occur in
the group without previously known risk.
P109
The Significance of non-visualization of the fetal
gallbladder in early pregnancy
S. Blazer, E. Z. Zimmer & M. Bronshtein
Purpose: To assess the incidence of a non-visualized gallbladder in
early pregnancy and to determine its prognostic significance.
Material and methods: Transvaginal ultrasound examination was
performed in 29 749 consecutive pregnant women at 14–16 weeks
gestation. All women underwent a detailed fetal survey prospectively.
The incidence and associated risk in cases of a non-visualized fetal
gallbladder was determined.
Results: The gallbladder was not visualized in early pregnancy in 34
fetuses, giving an incidence of 0.11% (1 in 875 pregnancies). Associated malformations were detected in 14 fetuses (41%), and in 20
fetuses non-visualization of the gallbladder was an isolated finding.
All fetuses with an isolated finding had a normal outcome, in 13 fetuses
the gallbladder was detected later on in pregnancy, in five no gallbladder was found after delivery, and two patients were lost in follow up.
Of the 14 fetuses with associated anomalies, five had also an abnormal
karyotype. Termination of pregnancy was performed in nine of these
fetuses. Of the cases which continued pregnancy there was one case of
neonatal death, two cases of developmental delay and only one normal
child.
Conclusion: Non-visualization of the fetal gallbladder in the early
pregnancy is uncommon but is associated with a high incidence of associated anomalies. Fetuses with an isolated finding of a non-visualized
gallbladder have usually a favorable outcome.
P110
Ultrasonographic findings of VATER association
M. Tanemura, S. Tsukishiro & K. Suzumori
Purpose: VATER association is a combination of congenital anomalies including vertebral defects (V), anal atresia (A), tracheoesophageal
fistula (TE), esophageal atresia (E), and radial and renal anomalies (R).
This report describes the prenatal progress of four such cases and the
features of ultrasonographic findings.
Methods: Case (1): the mother was referred at 12 weeks gestation
because of a fetal abdominal cyst. Bilateral hydronephroses and an
expansive bladder were detected by ultrasonography. At 36 weeks
polyhydramnios appeared, and soon she delivered. V, A, TE, E and
R were confirmed. Case (2): the mother was referred at 14 weeks
because of a fetal abdominal cyst and oligohydramnios. Ultrasonography suggested megalocystis based on urethral atresia. An infant was
delivered at 27 weeks and died right thereafter. Autopsy confirmed
V, A, R, tracheal atresia, genital anomaly and megalocystis. Case (3):
the mother was transported at 37 weeks because of fetal distress. Polyhydamnios had been suspected on a routine office visit. The infant was
delivered by cesarean section. TE, E and limb defects were detected.
Case (4): the mother was referred at 26 weeks because of anhydramnios and mediastinal shift. Ultrasonography and fetal MRI indicated
renal agenesis and congenital diaphragmatic hernia. Autopsy on a
stillborn infant revealed V, A, TE, E, R and diaphragmatic hernia.
Results and conclusions: The features of ultrasonographic findings of
VATER association were abnormality of urinary organs and amniotic
fluid volume. However, in the cases with esophageal atresia, estimation
of renal function was difficult.
P111
Ultrasonographic normograms of the fetal chin and filtrum
during pregnancy
A. J. Jaffa, I. Wolman, J. Har-Toov, G. Fait, R. Amster,
J. B. Lessing, I. Gull & A. J. Jaffa
Introduction: Abnormal sizes of the chin and of the filtrum or their
proportions are morphological features in certain syndromes. Both
chin and filtrum can be visualized and measured from the early second
23–28 October 2001, Melbourne, Australia
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
trimester until term. As of today there are no normograms of the chin
and of the filtrum during pregnancy, and dysmorphism is evaluated
only by subjective criteria.
Purpose: To establish normograms of the fetal chin and filtrum.
Methods: We studied cross-sectioned the size of the chin and length of
the filtrum in 153 fetuses from the 13th to the 42nd week of gestation.
The chin was measured from the lower lip to the skin under the mandibular edge. The filtrum was measured from the nose to the upper lip.
Results: The growth normograms for the chin was best described by
the regression equation: Y ¼ 9.799 þ 1.312X 0.013 2; R2 ¼
0.87 (Y ¼ chin size in mm, X ¼ gestational week). The growth normograms for the filtrum was best described by the regression equation:
Y ¼ 2.672 þ 0.477X 0.005 2, R2 ¼ 0.82 (Y ¼ filtrum size in
mm, X ¼ gestational week). The ratio chin/filtrum tends to increase
from 2 at the beginning of the second trimester to 2.8 at term.
Conclusions: We present the first normograms of fetal chin and filtrum
along the pregnancy. One of the fetuses was found to have micrognatia
at 32 weeks and both his chin and filtrum were abnormal. We used the
normograms to evaluate another two past cases of face dysmorphism,
which were evaluated by subjective criteria and found abnormal chin
and filtrum sizes. These normograms can be used in consulting genetic
disorders.
P112
Antenatal transabdominal amnio-infusion for
oligo-hydramnios due to preterm premature rupture
of membranes
T.-C. Tan & A. Tan
A reduction in the amount of amniotic fluid occurs in 3–5% of all deliveries. This could be due to congenital anomalies, IUGR or premature
rupture of membranes. Preterm rupture of membranes places the fetus
at risk of cord compression and amnionitis. On the other hand, oligohydramnios has been associated with severe pulmonary hypoplasia. In
1983, Miyazaki and Nevarez first reported the effectiveness of intrauterine installation of saline solutions in relieving variable decelerations
during labor. Since then, amnio-infusion has aroused interest. To our
knowledge, there has been no conclusive study done to evaluate the use
of antenatal amnio-infusion for oligo-hydramnios diagnosed antenatally. We would like to present three case-studies of oligo-hydramnios
seen in our department in the period 1997–2001 which we performed
antenatal transabdominal amnio-infusion. Warm saline/Hartmann
solution was injected through a 22G spinal needle under ultrasound
guidance. Vaginal delivery occurred in two cases (one term and one
preterm); the third pregnancy is still on-going. There was no meconium
aspiration and no signs of fetal distress. Both cases had good maternal
and neonatal outcome except that the preterm baby was treated
with intravenous ampicillin/gentamicin for pneumonia. There was no
congenital malformation noted.
P113
Abstract withdrawn
P114
Pregnancy outcome following amnioinfusion in
oligohydroamnios
G. J. Kim, S. Y. Kim & M. S. Son
Objective: We sought to evaluate the fetal outcome following antepartum transabdominal amnioinfusion in oligohydroamanios except
membrane rupture.
Materials and methods: Twenty-six transabdomial amnioinfusion
were performed in 17 cases of singleton pregnancy with severe oligohydroamnios. We excluded premature membrane rupture cases. Transabdominal amnioinfusion was done with warmed lactate Ringer
solution.
Results: Infusion (mean volume 545 mL) of lactate Ringer’s solution
significantly increased the amniotic fluid index from 4 dm to 9.3 cm.
Mean infusion time was 56.8 min The gestational weeks were prolonged significantly from 29.4 to 36.5 weeks. There was one case of
fetal death. The mean birth weight was 2.6 kg and the mean Apgar
score at 1, 5 min was 7.6 and 8.9. Uterine contractions after infusion
were observed 3 in 21, no needle scratching marks detected at birth.
No chorioamnionitis were observed.
Conclusions: Our results show that antepartum transabdominal
amnioinfusion is a relatively safe procedure, and it can significantly
increase the amniotic fluid index and prolong the gesational age.
P115
Prenatal treatment of severe congenital erythropoetic
porphyria (CEP) – a case report
P. Calda, Z. Zizka, M. Dokoupilova, V. Sebron, L. Haakova,
V. L. Eretova & R. Plavka
Introduction: Less than 3% of porhpyhia cases affect children and
CEP is the most severe.
Case report: We report a case of a 21-year-old second digravida
whose first pregnancy terminated with intrauterine death in the
27th week of gestation due to hydrops fetalis, cause unknown. The
pathologist found organ infiltration with blastic blood elements. The
patient was referred to our unit in the 25th week of the second pregnancy with oligohydramnion, ascites, hepatosplenomegaly, and generalized hydrops. The mother was AB Rh-positive, with negative results
for irregular antibodies, CMV, toxoplasmosis, and parvovirus B19.
The initial cordocentesis showed severe anemia (Hct 7.7, Hgb 27,
RBC 0.89, WBC 2.3, Plt 72), fetal karyotype: 46XY. Virologic examination, direct Coombs test, and amniotic fluid culture were negative.
We treated the anemia with five intrauterine transfusions of O Rhnegative erythrocyte concentrate. In the 25th week the Hgb was 59,
during treatment it reached 91 (week 26), 120 (week 27), 134
(week 28), 114 (week 31), and 119 in the 33rd week, respectively. A
male fetus was delivered in the 33rd week, with sanguineous amniotic
fluid, birth weight 2370 g, APGAR 6-7-8, and arterial blood pH 7.25.
The newborn had hepatosplenomegaly, anemia, and skin suffusions.
Mild RDS was stabilized with nCPAP. From the fourth day, there
was macroscopic hematuria. The treatment of renal failure was successful, the skin changes remained as the dominating sign. Eighteen
days postpartum the diagnosis of congenital erythroid porphyria (autosomal recessive) was established based on the skin excoriation and
urine examination for porphyrins.
Discussion: This rare case of ascites, anemia and thrombocytopenia
was diagnosed postnatally, but symptomatic treatment enabled the
delivery of a fetus that could be successfully treated postnatally with
umbilical blood transfusion.
Conclusion: In all cases of unexplained ascites or hydrops the possibility of CEP should be considered.
59
11th World Congress on Ultrasound in Obstetrics and Gynecology
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
P116
Abstract withdrawn
(105 gravids) prospectively, the correlation between intra- and extracelullar magnesium deficit and uterine artery Doppler in women with
pre-eclampsia. We used bilateral early diastolic notch at 24 weeks as
the definition of an abnormal waveform (circulatory parameters: Pi,
Ri, of gravids art. uterina were excluded). For evaluation of RBC
and plasma magnesium and calcium level we used atomic absorption
spectrophotometry (AAS). According to our results, in majority of
cases, we determined significantly low level of intracellular magnesium
0.86 þ 0.22 mmol/L in group with bilateral notch, and positive correlation between bilateral notch, intercellular magnesium deficiency,
increase level of intracellular calcium (0.69 þ 0.18 mmol/L) and preeclampsia. These results support hypothesis that misbalance of intracellular electrolytes, especially, intracellular magnesium and calcium
are strong determinants of risk of pre-eclampsia because these facts
could cause grater excitability of vascular smooth muscle contraction.
P119
The importance of fluid analysis in fetal intra-abdominal
cyst aspiration
G. Fait, J. Har-Toov, I. Gull, R. Amster, I. Wolman,
J. B. Lessing & A. J. Jaffa
P117
Radiofrequency ablation of fetal cervical teratoma
F.-Y. Chan, J. Clouston, R. Cincotta & P. Borzi
Background: Highly vascular fetal tumors can lead to death before
viability as a result of vascular steal syndrome. Open fetal surgery is
associated with significant risks for prematurity and maternal morbidity. Various local ablative techniques have been tried to reduce tumor
vascularity, with variable success. Radiofrequency ablation has been
performed for sacrococcygeal teratoma, but cervical teratoma poise
further significant challenges with its proximity to vital neck structures.
Purpose: This is the first report in which percutaneous radiofrequency
ablation was used to reduce tumor vascularity in a human fetus with a
large cervical teratoma.
Methods: A partly solid, partly cystic neck tumor was first detected in
a 19-week fetus. The tumor grew rapidly and caused signs of cardiac
decompensation by 26 weeks. After extensive counseling and ethics
discussion, operation was performed at 28 weeks under general
anesthesia. Radiofrequency ablation to the solid component of the
tumor was performed with a nine-prong retractable needle electrode
with thermal couples (RITA), deployed to a maximum diameter of
5 cm. The operation was uneventful and fetal condition was monitored
throughout the procedure.
Results: Tumor growth was arrested temporarily with improvement
of the cardiac status. Re-growth of the tumor was noted after
32 weeks, necessitating delivery at 33 weeks. Postnatal investigation
showed extensive tumor infiltration into the neck tissues and probable
liver metastases. Biopsy showed immature teratoma, and chemotherapy was considered to be futile. Intensive care was withdrawn and
the baby died 6 days after delivery.
Conclusions: Radiofrequency ablation of fetal tumor in utero can
reduce blood flow sufficiently to reverse high-output fetal heart failure.
Cervical tumors poise extra challenges with its proximity to vital neck
structures. With careful and meticulous placement of the probe, ablation can be performed without injury to surrounding tissues. Experience in this area is preliminary and all such experiences should be
reported.
P118
The effect of intercellular Mg2þ in pre-eclempsia
A. P. Mitrovic & M. Djukic
Approximately 2–10% of pregnancies are complicated by preeclampsia. The pathophysiology of pre-eclampsia is general arteriolar
constriction and increased vascular sensitivity to precursor peptides
and amines. The etiology of pre-eclamsia is unknown. We examined
60
The importance of fluid analysis in the evaluation of intraperitoneal
cysts in female fetuses is demonstrated. Case 1: A 30-year-old
woman had an unremarkable pregnancy until 29 gestational weeks,
when a routine US examination revealed an anechoic cyst of 4.0 cm
in diameter located in the lower abdomen of a female fetus. At
33 weeks of gestation the cyst enlarged to 6.5 cm. Intrauterine aspiration of the cyst was performed. A volume of 75 mL of yellow
fluid was obtained and collapse of the cyst was noted. Fluid biochemistry revealed estradiol >200000 pg/mL, progesterone 1648 ng/mL,
creatinine undetectable. A fetal ovarian cyst was diagnosed. At
34 weeks of gestation the cyst enlarged again to 6 cm and 78 mL of
yellow fluid was obtained on intrauterine aspiration. Again, collapse
of the cyst was noted on US. Repeated scans until birth showed an
anechoic cyst of 4.0 cm. Postnatal abdominal US confirmed the diagnosis and a complete disappearance of the cyst after 2 weeks. Case 2: A
28-year-old woman had an unremarkable pregnancy until 34 gestational
weeks, when a routine US examination revealed an anechoic cyst
of 6.0 cm in diameter located in the lower abdomen of a female
fetus. Intrauterine aspiration of the cyst was performed. A volume of
147 mL of yellow fluid were obtained and collapse of the cyst was
noted. Fluid biochemistry revealed estradiol 781 pg/mL, progesterone
37 ng/mL, and creatinine 4 mg/dL. An unusual urinary tract malformation was diagnosed. Repeated scans until birth showed an anechoic
cyst of 6 cm. After delivery a fistula between the urinary bladder and
the upper vagina, and an imperforated hymen, were diagnosed. In
cases of prenatal needle aspiration, fluid biochemistry may be helpful
to establish the origin of intraperitoneal cysts in the female fetus, especially when recurrence occurs, and prevent unnecessary attempt of
decompression of intraperitoneal cysts.
P120
Three-dimensional magnetic resonance imaging of the fetal
brain in utero
L. Schierlitz, H. Dumanli, A. G. Schreyer, J. N. Robinson,
P. E. Burrows, R. Kikinis, F. Jolesz & C. Tempany
Background: Fetal anomalies are presently assessed predominantly by
two-dimensional imaging techniques. Three-dimensional (3D) reconstruction derived from magnetic resonance imaging (MRI) holds promise to clarify abnormalities identified in utero. We demonstrate the
application and the possible clinical use of 3D reconstruction derived
from MRI of fetal brain in utero.
Methods: We studied 10 patients who underwent clinically indicated
MRI with 17 examinations to assess fetal brain anomalies in vivo.
After image acquisition and postprocessing of the images, the anatomical anomalies were assessed on a 3D model and compared to the
two-dimensional imaging findings. Assessment of the volume of
intracranial ventricles and periventricular hemorrhage was performed.
Four of the cases have been chosen to demonstrate this technique.
23–28 October 2001, Melbourne, Australia
Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix
Results: The technique was successfully applied in six patients and 12
examinations. The demonstration of significant additional clinical
information in the assessment of anomalous anatomy was shown in
two of the cases. Serial assessment of volumetric measurement was performed in the clinical setting of hydrocephalus and periventricular
hemorrhage. Reconstruction of the cerebral vascular system with a
vein of Galen malformation and its feeding and draining vessels at
37 weeks gestation allowed the planning of the postnatal management
by the interventional radiologist.
Conclusions: 3D fetal reconstruction may be used in surgical simulation and treatment planning prior to delivery. This may become even
more relevant in the planning and performance of fetal surgical and
postpartum intervention for selected life threatening birth defects.
Further evaluation of this technique will be needed before the full
extent of its use can be determined.
P121
Assessment of normal fetal upper arm volume by
three-dimensional ultrasound
C.-H. Yu, F.-M. Chang & T.-P. Liao
Purpose: Precise assessment of the fetal organ volumes by prenatal
ultrasound (US) is very important in the evaluation of fetal well-being
and maturation. Limb volume may be a possible predictive factor of
intrauterine growth retardation. However, using two-dimensional
(2D) US to accurately estimate the fetal upper arm volume is difficult.
With the advent of three-dimensional (3D) US, the obstacle of 2DUS
can be overcome. In this study we attempt to construct a normal reference centiles of fetal upper arm volume during gestation for clinical
application using 3DUS.
Materials and methods: In total, 206 singleton fetuses ranged
between 20 and 40 weeks of gestation and fit the criteria of normal
pregnancies were enrolled in this study. Three-dimensional US was
applied to measure the fetal upper arm volume. Linear regression,
correlation analysis and polynomial regression analysis were used as
the statistical methods. A P-value of less than 0.05 was considered
statistically significant.
Results: Our results showed that fetal upper arm volume is highly correlated with the fetal gestational age (GA). Using GA as the independent variable and upper arm volume as the dependent variable, the
best-fit regression equation is upper arm volume (mL) ¼ 43.54579
4.53032 GA þ 0.13305 GA2 (r ¼ 0.91257, P < 0.0001). The
normal growth centiles of upper arm volume is established based on
this equation.
Conclusion: In conclusion, we can use the data of fetal upper arm
volume assessed by 3DUS as a reference in evaluating fetal growth.
61
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Assessment of normal fetal upper arm volume by three-dimensional ultrasound
Ultrasound in Medicine & Biology, 2002
By Huei-chen Ko
...Read more
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