D. C. Wood

Venous Doppler ultrasonography in the fetus with nonimmune hydrops

Eighteen pregnancies with nonimmune hydrops fetalis were referred for fetal echocardiography to rule out congenital heart disease. In 14 of these cases, pulsating blood velocities were recorded in the umbilical vein, which in a normal population had a nonpulsatile blood velocity pattern. The four cases without pulsations in the umbilical vein were found to have intrauterine viral infections. In the last 10 cases examined, the umbilical venous pulsations were found to reflect abnormal central venous pulsations during atrial systole suggesting increased fetal central venous pressure. Right ventricular shortening fraction was significantly decreased in the group with umbilical venous pulsations compared with those without (0.18 versus 0.32, p less than 0.05). All the fetuses without venous pulsations survived, but only four of the 14 with pulsations survived (p less than 0.05). The results suggest that blood velocity recordings in the umbilical and central veins of the fetus can give valuable clinical information with regard to the presence of fetal congestive heart failure and differentiate between this physiologic state and other causes of nonimmune hydrops fetalis. This may have implications for fetal diagnostic work-up and prognosis.

Fetal branch pulmonary arterial vascular impedance during the second half of pregnancy

OBJECTIVE Our purpose was to establish normal physiologic parameters in the fetal proximal and distal branch pulmonary arterial vascular impedance during the second half of pregnancy and to analyze relationships between proximal and distal pulmonary arterial blood velocity waveforms. STUDY DESIGN In this cross-sectional study 100 uncomplicated singleton pregnancies were studied by pulsed color Doppler techniques between 18 and 41 weeks of gestation (median 30 weeks). Both right and left proximal (immediately after the bifurcation of the main pulmonary artery) and distal (beyond the first bifurcation of the branch pulmonary artery) pulmonary artery blood velocity waveforms were recorded and pulsatility index values were calculated. Peak systolic velocities and time-to-peak-velocity intervals were measured. Time-to-peak-velocity intervals were also analyzed at the level of aortic and pulmonary valves and at the ductus arteriosus. Right and left pulmonary artery diameters and right lung length were measured. RESULTS In both right and left proximal and distal pulmonary arteries pulsatility index values decreased (p < 0.0001) and the peak systolic velocities (p < 0.003) and time-to-peak-velocity intervals (p < 0.0001) increased during the second half of pregnancy. In the proximal pulmonary arteries the pulsatility index values decreased linearly until 34 to 35 weeks of gestation and in the distal pulmonary arteries until 31 weeks of gestation. Thereafter they remained unchanged. In pulmonary arteries time-to-peak-velocity intervals were shorter (p < 0.01) than at the pulmonary valve level. There were no significant differences between the right or left pulmonary arteries in the pulsatility index values, peak systolic velocities, time-to-peak-velocity intervals, or pulmonary artery diameters. In the proximal pulmonary arteries the pulsatility index values (p < 0.02) and peak systolic velocities (p < 0.0001) were higher and time-to-peak-velocity intervals (p < 0.0001) were longer than in the distal pulmonary arteries. There was a 2.5-fold increase in pulmonary artery diameters and right lung length. CONCLUSIONS Fetal branch pulmonary arterial vascular impedance decreases significantly during the second half of pregnancy. The linear decrease in vascular impedance during the second trimester and in the beginning of the third trimester may be related to the growth of the lung and the increase in the number of resistance vessels. During the latter part of the third trimester pulmonary vascular impedance does not decrease further.

Perinatal echocardiography: protocols for evaluating the fetal and neonatal heart.

Abstract This Protocol for Evaluating the Fetal and Neonatal Heart details the indications, views, and measurements to be obtained for both (1) the basic screening examination of the fetal heart (a necessary component of all complete fetal anatomy evaluations) and the specialty study called (2) echocardiography as applied to either the fetus or neonate, using 2D and Doppler ultrasound. While the purpose of the screening study is to detect or exclude the possibility of a cardiac abnormality, echocardiography attempts to diagnose the specific anatomic and physiologic disruption. Also emphasized is the value of a collaborative team approach to management of the fetus and its parents when a cardiovascular anomaly is present, in an effort to achieve a smoother transition from fetus to neonate across the continuum of perinatal care.

Massive Fetal Ileal Duplication Requiring Antenatal Intervention

Enteric duplication is a rare congenital anomaly that is typically diagnosed during infancy or childhood and is seen in approximately 1 per 10,000 live births. 1 Although a number of case reports of prenatal identification of abdominal cystic masses have been confirmed to be enteric duplications after delivery, 2-14 no prenatal interventions or complications related to the mass have been reported. We present a case of large cystic ileal duplication that underwent transabdominal decompression with eventual fetal cardiovascular impairment that required emergency preterm delivery.

P26.01: Fetal cardiovascular functional parameters across gestation

ossified metacarpals with two digits with ossified phalanges in both hands. X-ray of the feet demonstrated a claw-like deformity in both and no ossified metatarsals were identified. To our knowledge this is the first report on diagnosis of SHFM in first trimester. In agreement with others, the observation of a more severe phenotype in the offspring of a mildly affected parent suggests anticipation. First trimester diagnosis of SHFM is feasible and may provide the couple with early knowledge of recurrence and severity.

OP02.02: The global myocardial performance (Tei) Index in fetuses of mothers with well controlled gestational diabetes mellitus

fetuses and 1040 fetuses with Down syndrome were included in the analysis. Data Extraction: Articles were independently selected, reviewed, and abstracted by 2 reviewers. For each study, the positive likelihood ratio (LR), negative LR, sensitivity, and specificity were calculated. Overall estimates of pooled positive LR, negative LR, sensitivity, specificity, and pooled odds ratio with 95% confidence intervals were calculated for absent nasal bone. Data Synthesis: When the absence of nasal bone was observed in the first trimester, the odds of Down syndrome increased 48-fold (positive LR, 48; 95% CI 29–79). When the nasal bone was seen, the risk of a fetus having Down syndrome was halved (negative LR, 0.44; 95%CI 0.33–0.59). The pooled estimates of sensitivity for detecting fetuses with Down syndrome was 65% (95% CI 61%–69%) and specificity was 99% (95% CI 98%–99%). The diagnostic odds ratio for absent nasal bone was 112 (95% CI 66–187). Conclusions: The absence of nasal bone when observed in the first trimester is a useful tool in distinguishing Down syndrome fetuses. The overall sensitivity of absent nasal bone allows us to use it as a practical marker for Down syndrome.

OP02.11: Comparison of cardiovascular functional parameters and Doppler flow waveforms in fetuses with two‐vessel cord versus three‐vessel cord at 20–23 weeks gestational age

−3.47 for those without coarctation. Difference between means in the two groups was −0.18 (95%CI = −1.56 to 1.2). In sagittal views, mean Z-scores were −2.97 and −3.45 for those with and without coarctation, respectively. Difference between the means was 0.49 (95%CI = −0.95 to 1.93). Conclusions: In this small case series of prenatally suspected coarctation of the aorta, the use of aortic isthmus Z-scores did not allow prompt identification of affected fetuses.

Fetal myocardial index during labor

Abstract BACKGROUND: The Myocardial Performance Index (MPI) is a Doppler derived myocardial function tool and can be used to evaluate systolic and diastolic function in fetuses. The objectives of this study were to investigate the MPI during labor and compare it to values in non-laboring women. METHODOLOGY: 40 women with uncomplicated, term, singleton pregnancies were recruited to this prospective observational study at Thomas Jefferson University Hospital. Controls were a retrospective cohort of women > 34 weeks who underwent third trimester fetal echocardiography. Fetal left and right sided isovolumic contraction time, isovolumic relaxation time and ejection time were recorded before, during and after contractions. Right and left sided MPI was then calculated. RESULTS: Laboring patients and non-laboring patients were comparable for age, race, gravidity and parity. During labor the average left MPI was 0.63 ± 0.17 and the average right MPI was 0.62 ± 0.20. The coefficient of correlation between MPI and cervical dilation was 0.15 for left MPI Index and 0.14 for right MPI. When comparing non-laboring to laboring women, the average left MPI for non-laboring women was 0.34 ± 0.04, p = <0.001. CONCLUSIONS: Myocardial Performance Index is a non-invasive, easily attainable measure of cardiac function that can be obtained during labor and does not change with cervical dilation. MPI is significantly different between laboring and non-laboring women. The fetal MPI may help define fetal status in labor.

OP36.05: Isolated intra-abdominal umbilical vein (IAUV) varix in 163 fetuses: antenatal management and postnatal outcomes

Y. Mivelaz1, K. I. Lim2, C. Templeton1, C. I. Andrew3, J. E. Potts1, G. G. Sandor1 1Division of Cardiology, Department of Pediatrics, BC Children’s Hospital, The University of British Columbia, Vancouver, BC, Canada; 2Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, BC Women’s Hospital, The University of British Columbia, Vancouver, BC, Canada; 3Division of Cardiac Surgery, Department of Surgery, BC Children’s Hospital, The University of British Columbia, Vancouver, BC, Canada

OC06.06: Fetal myocardial performance (Tei) index and left ventricular shortening fraction (LVSF)

Methods: Routine two dimensional fetal scans were performed in 123 consecutives singleton pregnancies during the second half of pregnancy. General Electric E8 ultrasound equipment was used in all cases. Mechanical PR interval was measured from the onset of the mitral A wave to the onset of the aortic ejection flow, using previously described technique for standard and modified Tei index. All measurements were taken twice by two different operators. For statistical analysis mean and standard deviation was used position measurement. For comparison between two groups and the inter observer agreement Least square analysis was performed. Results: The mechanical PR interval was easily obtained in all 123 cases. The mean gestational age was 25.5 weeks (18–38 weeks). The PR interval was 117,97ms (SD: 9.49 mseg), in standard Tei index group, and 119,11ms. (SD: 10.71 m seg) in modified Tei index group. There was a positive correlation between PR interval and gestational age (COV 2.48). There was no significant difference between both groups (t student 99%:261 > t calculated −0,068). Difference between Inter observer was not significant (t student 99%: 2,61 > t calculated −0.087). Conclusion: The pulsed Doppler assessment using standard and modified Tei index approach of the mechanical PR interval in the fetus, is a feasible and could be used to explore the fetal atrio ventricular conduction abnormalities. It is reproducible and easily obtained during the routine second half of gestation and the normal range is similar to that described with other methods.