D. Borowski

Doppler study of the embryonic heart in normal pregnant women

Objective. To describe normal fetal cardiac and hemodynamic development in normal early first trimester pregnancies. Materials and methods. Eighty-eight women with singleton, uncomplicated pregnancies were prospectively studied with transvaginal ultrasound, pulsed and color Doppler. Heart diameter, heart rate, and inflow and outflow waveforms with valve signals were documented. The proportion of the cardiac cycle of isovolumetric relaxation time (IRT%) and isovolumetric contraction time (ICT%) as well as Tei index were calculated. Results. Ninety-one percent of studies were successful. Heart diameter and the fetal heart rate showed a positive correlation with increasing gestational age: R = 0.80 (p < 0.000001), R = 0.76 (p < 0.000001), respectively. Mean heart diameter at 6 weeks was 1.28 ± 0.26 mm and mean fetal heart rate was 117 ± 6 bpm compared to 3.88 ± 0.54 mm and 171 ± 6 bpm at 10 weeks. The inflow waveform was monophasic (atrial contraction) in all cases from 6 to 9 weeks. Eight pregnancies (9%) miscarried between 6 and 12 weeks of gestation and the heart exams were characterized by increased IRT% compared with the survivors. In survivors, IRT% decreased between 7 and 8 weeks, from 32.9 ± 10.7% to 20.8 ± 5.7% (p < 0.0001). ICT% decreased from 18.6 ± 4.4% of the cardiac cycle at 8 weeks to 12.6 ± 4.4% at 9 weeks (p < 0.0008) (after heart development period). Conclusions. Doppler examination of the fetal cardiac function is possible after 5 weeks of gestation. After 8 weeks of gestation, the fetal heart is morphologically mature but has not yet achieved effective myocardial compliance. The embryonic human heart is dependent on the atrial contraction for ventricular filling throughout the period of cardiac development. Non-survivors manifest myocardial dysfunction.

OP02.08: Non immune hydrops fetalis (270 cases)—optimization of diagnosis and therapy

our series of fetuses with pleural effusion treated with thoracoamniotic shunting. Methods: Between 1992 and 2005, 53 fetuses with pleural effusion were referred to our unit and underwent thoraco-amniotic shunting. In all cases a detailed fetal anatomy scan and karyotyping were performed. A search for maternal infection was done in every case. A double pigtail catheter (Rocket, London, UK) was inserted by one operator under ultrasound guidance using local anesthesia when a complication like hydrops or polyhydramnios was found. Results: There were 35 bilateral and 18 unilateral shunt placements. In all 53 cases the procedure was successful. In two cases there was termination of pregnancy because of abnormal karyotype. There were 12 neonatal deaths. There were 34 survivors, with a follow-up at 1–7 years for 45% of cases. Survival rate was 90% for fetuses without hydrops and 58% for those which were hydropic, compared with an overall survival rate of 59% and 35%, respectively, as reported in untreated cases. Conclusions: Thoraco-amniotic shunt may improve outcome for fetuses with pleural effusion expecially if complicated with hydrops.

OP10.11: Polish experience with fetoscopic laser surgery for TTTS

Objectives: To study the impact of treatment with endoscopic laser ablation for twin–twin transfusion syndrome (TTTS) on the CHOP cardiovascular score. Methods: Retrospective review of patients undergoing laser ablation for TTTS with both preoperative and postoperative fetal echocardiograms. Results: Between June 2005 and February 2007, 41 patients underwent laser ablation therapy for TTTS. Quintero staging was Stage 2 for 19, Stage 3 for 19 and Stage 4 for three. The preoperative CHOP scoring was Grade I (0–5) = 22; Grade II (6–10) = 7; Grade III (11–15) = 8; Grade IV (16–20) = 4. The mean gestational age at treatment was 20.6 ± 2.07 weeks. Fifteen patients underwent both preoperative and postoperative fetal echocardiography with an average of 3 days between the preoperative evaluation and treatment and an average of 10 days between treatment and post-op evaluation. The mean preoperative CHOP score was 9.9 ± 1.4 and the mean postoperative CHOP score was 4.8 ± 0.9 (P = 0.0002). Conclusions: The CHOP cardiovascular score measures physiologic perturbations that underlie the clinical findings in TTTS. Following treatment with laser ablation, clinical resolution is associated with a significant decrease in the CHOP cardiovascular score. This provides further validation of the CHOP cardiovascular score as a tool for the evaluation of pregnancies complicated by TTTS.

P05.25: A cardiovascular profile score assessment of cardiac dysfunction in the recipient and donor twins in severe twin–twin transfusion syndrome

our centre, at between 26 to 33 weeks of gestation in order to screen for subtle fetal cerebral lesions. Gestational age was established according to crown-rump length. Fetal cerebral maturation was characterized according to gyration for gestational age in both twins. One donor presented a delay in fetal cerebral maturation at 28 weeks of gestation. This fetus had growth retardation < 3th percentile. Delayed gyration consisted of a 2 week-delay as compared to that of its co-twin. Neurological development was normal in both twins at 3, 6 and 12 months of age. In conclusion, delay in fetal brain maturation may occur in TTTS even in cases with two survivors and a normal outcome. This should be accounted for in the follow-up of these cases.

OP05.09: Preliminary experience in Poland with fetoscopic laser surgery for severe TTTS

Objective: To compare the transfer of technetium-99m labelled red blood cells (99mTc RBCs) in monochorionic (MC) placentas, MC placentas after laser coagulation of the vascular anastomoses for TTTS and fused dichorionic (DC) placentas. Methods: Placental perfusion study with 99mTc O Rh – RBCs in 5 MC, 5 lasered MC and 5 fused DC placentas. The arteries of twin 1 were injected with 20–30.10 × 9 99mTc RBCs diluted in 100 mL NaCl, whereas the vessels of twin 2 were rinsed with 200 mL NaCl. The % of transferred 99mTc RBCs was calculated by dividing the radioactivity measured in the rinsing solution of twin 2 by the initial radioactivity injected in twin 1. Afterwards, each placenta was injected with dyed barium sulphate to document the angioarchitecture. Results: GA at birth was similar in the 3 groups. None of the lasered MC and fused DC placentas had visible anastomoses, whereas all 5 MC placentas had visible anastomoses-1 had only small arteriovenous (AV)-venoarterial anastomoses (VA) without an arterioarterial (AA) anastomosis, 4 had an AA with AV/VA. The % of transferred 99mTc RBCs in lasered MC placentas (0, range: 0–000012) was similar to fused DC placentas (0, range: 0–001760) (NS), but significantly lower than in MC placentas (8.5, range: 1–66) (p < 0.01). In MC placentas, the larger the AA, the higher the % of transferred 99mTc RBCs. Conclusion: In MC placentas successfully separated by laser coagulation of the vascular anastomoses, the transfer of 99mTc RBCs was not significant and similar to fused DC twin placentas. Therefore, laser seems to functionally separate the 2 fetal circulations.

P01.24: Multicenter study of nuchal translucency (NT) in Poland. A prospective study of 1650 low‐risk women

ultrasound scans in high-risk pregnancy and to investigate its value of the nasal bone hypoplasia in second-trimester ultrasound screening of chromosomal aneuploidy. Methods: The prospective study to measure the length of nasal bone was conducted from June 2003 to March 2005. The study population included 191 singleton pregnancies undergoing the genetic amniocentesis at 15–21 weeks’ gestation. Nasal bone hypoplasia was defined as nasal bone less than 5th percentile for the gestational age using the chart by Sonek et al. Results: The nasal bone length showed to a linear correlation with advanced gestation (R2 = 0.183, p < 0.01)). Thirteen had an aneuploidy (3 trisomy21, 5 trisomy18, 3 inversions, 1 translocation and 1 duplication). The nasal bone was either absent or hypoplastic in 5/13 (38.5%) fetuses. But no statistical difference was found between chromosomally normal and abnormal fetuses in the incidences of the nasal bone hypoplasia (p = 0.066). Conclusion: The nasal bone hypoplasia had some limitation for the mid-trimester ultrasound-screening marker of fetal aneuploidy in high-risk pregnancy. Larger studies are needed to determine the role of nasal bone hypoplasia either as an isolated marker or in combination with other sonographic marker in chromosomal aneuploidy.

P01.19: Prenatal diagnosis of Down's syndrome in II and III trimester of pregnancy using ultrasound and echocardiography examination

Objective: To determine whether isolated choroid plexus cysts are a risk factor for trisomy 18 Methods: The cases with isolated choroid plexus cyst(s) were retrieved from our database from January 2001 to December 2004. Detailed ultrasonographic examination, maternal serum screening or genetic karyotyping was provided at the discretion of obstetricians who care for the pregnant women. All women were followed up through delivery. A retrospective chart review of the prenatal sonograms in the cases of trisomy 18 during the same period was also conducted. Results: One hundred fifty-six women had fetuses with isolated choroid plexus cyst(s). All fetuses with isolated choroid plexus cyst(s) either the normal karyotypes or the normal postnatal pediatric examination. There are 8 fetuses with trisomy 18 during the same period. Thirty-three percent of fetuses with trisomy 18 had choroid plexus cyst(s). All fetuses with trisomy 18 had structural anomalies. Conclusion: Isolated choroid plexus cyst was not associated with trisomy 18 in this study. All fetuses with trisomy 18 had structural anomalies which are obvious in antenatal scanning. These results indicate that the karyotyping of fetuses with isolated choroid plexus cyst(s) is not warranted.

P12.09: 3D sonography in gestational and placental volume measurements in women with first trimester bleeding

Objective: The aim of this pilot study was to evaluate the safety and efficacy of ultrasound guided surgical evacuation of uterus compared to the conventional blind method of evacuation of retained products of conception (ERPC) currently being practised. It is not known whether routine use of intraoperative transvaginal ultrasound (TVS) improves the outcome of surgical management of first trimester miscarriage and surgical termination of pregnancy (TOP) in both primary as well as repeat procedures. Methods: A retrospective analysis over a six-month period was performed in a teaching hospital in London, UK in women who had either undergone surgical, medical or conservative management of miscarriage or TOP in the first trimester. The inclusion criteria were women who had retained products of conception (RPOC) after initial treatment of first trimester miscarriage or TOP and needed subsequent surgical evacuation of uterus. Outcome measures were the incidence of incomplete evacuation requiring further treatment and persistent vaginal bleeding. Results: Of 240 women, 30 had RPOC after initial treatment. 27% (8/30) opted for conservative management with weekly TVS, 33% (10/30) had repeat ERPC under TVS guidance and 40% (12/30) had ERPC without TVS. Amongst the TVS guided ERPC group, none required further intervention. In those who had ERPC without TVS guidance, 2 had RPOC requiring a third evacuation. Conclusion: Surgical evacuation under TVS guidance was associated with lower rate of complications compared to the conventional procedure without ultrasound. As this was a small, retrospective study, further prospective randomised controlled trials would be useful in showing further significance of these findings.

P14.83: Biochemical and Doppler parameters in evaluation of kidney function in fetuses with obstructive uropathy

Objective: To examine the underlying pathology in male fetuses with sonographic evidence of severe and isolated LUTO. Methods: Detailed postmortem examination was carried out after termination of pregnancy in 24 male fetuses presenting before 25 weeks of gestation with ultrasound evidence of isolated severe low urinary tract obstruction. Results: Gender was male in all cases. There was megacystis and hyperechogenic kidneys in all cases. There was anhydramnios/oligohydramnios and pelvicalyceal dilatation in 20 and 15 cases respectively. Prenatal diagnosis of the underlying condition was erroneous in 2/3 of the cases. Urethral atresia was never suspected antenatally. Examination of the urethra demonstrated atresia in 6 cases, severe stenosis in 8 cases, posterior urethral valves in 9 cases and an apparently normal urethra in one. Renal dysplasia was found in all cases but one. Urethral atresia was the most common urethral anomaly at 12–17 weeks. Hydronephrosis was more frequent in cases with PUV (8/9) and urethral stenosis (6/8) than with urethral atresia (1/6). In LUTO presenting before 25 weeks hyperechogenic kidneys was predictive of renal dysplasia in 95% of the cases. The association of a bladder larger diameter of more than 40 mm and hydronephrosis in a male fetus before 25 weeks was predictive of PUV with a PPV and NPV of 44% and 100% respectively. Absence of hydronephrosis and a bladder larger diameter of less (or equal) than 40 mm were predictive of urethral atresia or stenosis with a PPV and NPV of 83% and 57% respectively. Conclusion: LUTO presenting with megacystis in a male fetus in the first and second trimester can correspond to urethral atresia or stenosis more often than posterior urethral valves. Since the formers carry a poor prognosis size of the bladder and the presence of hydronephrosis could be the most discriminant association to improve prenatal counselling.

F87Transvaginal sonography in prediction of preterm delivery in patients presenting with signs and symptoms of preterm labor

Background