E. Anastasakis

A Case of Heterotopic Pregnancy in the Absence of Risk Factors

Objective: To reinforce the risk of heterotopic pregnancy in a natural cycle when intrauterine pregnancy and abdominal pain co-exist. Method: A single case report with a literature review. Results: Our case was associated with significant haemorrhage, laparotomy and salpingectomy. The obstetric outcome was favourable in this case. The literature review demonstrates the diagnostic difficulties as well as treatment options. Conclusions: Sonographic diagnosis of a heterotopic pregnancy is not always possible. Patients with abdominal pain and intrauterine pregnancy should heighten the clinician’s suspicion of a heterotopic pregnancy.

Increasing the noninvasive management of rhesus isoimmunization

To determine the clinical outcome of isoimmunized pregnancies managed by middle cerebral artery peak systolic velocity (MCA‐PSV) in an intention‐to‐treat study.

P03.09: 2D or off-line 3D ultrasound during the 1st trimester scan

accuracy according to the initial, lower and higher angle was calculated. Cases with wrong fetal assignment were individually analyzed. Results: Overall, 95 cases were included in the analysis. Following online genital angle calculation fetal gender assignment was possible in all but one woman (98.9%) in which the angle fell inside the cut-off (28◦). The assigned gender was correct in 90 of the 95 cases (94.7%). Among the 5 cases with wrong fetal gender assignment 2 cases were < 12 weeks and two cases had an angle calculated from the second volume which fell inside the cut-off (undetermined gender). Using the narrower and higher angle the accuracy of fetal gender determination was 93.7% and 96.8% respectively. Conclusions: 3DUS is a highly accurate tool for fetal gender assignment in the first trimester. A second look may have a role in reducing the margin of error in fetal gender determination. In case of discrepancy the wider angle seems to perform better.

P04.18: First trimester placental volume, uterine arteries Doppler, and biochemical markers for the prediction of preeclampsia

Objectives: To evaluate the incidence, combined anomaly, and outcome of prenatal diagnosis of single umbilical artery (SUA) in the first trimester ultrasound. Methods: From April 2008 to July 2009, 59 cases of single umbilical artery (SUA) of 3879 unselected pregnancies was observed, during 11–13+6 weeks scan, with Voluson Expert in Puerta de Hierro Hospital from Madrid. Results: The incidence of SUA in our population resulted 1.55%. In 42 cases were isolated SUA diagnosed in the first ultrasound at 11–12 weeks, and was confirmed again at 16 weeks scan. 36 normal pregnancies at birth and 6 cases presented growth retardation at delivery. The other 16 cases had associated ultrasound finds: 8 with congenital heart diseases; 3 skeletal anomalies, 3 central nervous system malformations, 1 kidney anomaly, and 1 cleft palate. Conclusions: During the prenatal period, the fetus with isolated SUA by 11–12 weeks ultrasound examination must be carefully monitored, if no other malformations were found normal pregnancy or growth retardation can be expected.

OP20.10: Evaluation of the nuchal translucency and fetal anatomy in 1st trimester using the 2D and 3D ultrasonography

three risks was used to calculate detection and false positive rates by taking the proportions with risks above a given risk threshold. Results: In the study population of 57,119 pregnancies, there were 44 (0.08%) cases with holoprosencephaly, 150 (0.3%) cases with exomphalos and 35 (0.06%) cases with megacystis. Of the fetuses with holoprosencephaly, 29 (65.9%) were chromosomally abnormal. Of those with exomphalos and megacystis the karypype was abnormal in 83 (55.3%) and 11 (31.4%), respectively. Applying a risk cut off of 1 : 100 would detect 96.7%, 96.4% and 100% of the aneuploid fetuses with holoprosencephaly, exomphalos and megacystis for respective false positive rates of 6.7%, 16.4% and 4.2%. Conclusion: In fetuses with holoprosencephaly, exomphalos and megacystis, the combined risk for trisomies can help to distinguish between euploid and aneuploid fetuses. However, in view of the following pregnancy, karyotyping is still recommended.

P17.09: Prenatal diagnosis of atraumatic fetal subdural hematoma in the second trimester

Introduction: Fetal subdural hematoma (SDH) is a rare event. With advances in obstetric ultrasound however it has been recognized that SDH may occur in utero before the onset of labor. We present a unique case of atraumatic SDH diagnosed in the second trimester. Case Report: A 31-year-old woman was referred to our institution for the investigation of a brain anomaly detected in an anomaly scan, at 22 weeks and 4 days of gestation. The woman had an uneventful pregnancy so far. A rounded hyperechogenic mass was detected in the posterior fossa, measuring about 2 cm, between the skull and the brain producing only a mild midline shift to the right. A strong suspicion of a fetal subdural hematoma was brought to mind among others. We suggested fetal brain MRI and this confirmed our suspicion of atraumatic spontaneous subdural hematoma of the posterior fossa. Medical consultation was given to the parents stating the scarcity of the condition and the poor prognosis that is referred to the literature. The parents chose the termination of the pregnancy, which took place with misoprostol leading to the delivery of a dead female fetus weighing 596 gr. The pathology report, confirmed the ultrasonographic and MRI diagnosis. Conclusion: Spontaneous fetal subdural hematoma is an extremely rare condition with a poor prognosis and it has never been reported before in literature to occur and be diagnosed at the time of the midtrimester scan. Ultrasound and other imaging techniques such as CT and MRI, and use of Doppler techniques for detecting cerebral hemodynamic abnormalities, might help in earlier diagnosis and perhaps lead to more accurate management and prognosis.

P34.02: Placental dimensions in the early 2nd trimester for the prediction of fetal birth weight

can result in considerable morbidity and mortality. Undiagnosed; a choledochal cyst can lead to development of serious complications such as hepatic fibrosis, pancreatitis, cholangitis, and liver failure in infants. Prenatal diagnosis, postnatal ultrasound evaluation and early surgical treatment can reduce the development of serious complications. We report a case of a choledochal cyst diagnosed prenatally by ultrasound. A 24 year old woman, gravida2, para1, presented at 29 weeks gestation to our hospital for a routine ultrasound evaluation. Ultrasound examination revealed a singleton fetus with normal amniotic fluid volume and measurements consistent with 29 weeks. Assessment of the fetal abdomen demonstrated an ovoid shaped well defined anechoic mass measuring 1.2 × 1.2 cm. in the right upper quadrant, located medially and communicating with the gall bladder. The postnatal ultrasound confirmed the diagnosis and it was classified as Type 1 choledochal cyst.

P32.01: Uterine arteries doppler in the early second trimester for the prediction of fetal birth weight

In utero exposure to antiepileptic drugs such as carbamazepine can result in several different major malformations, mainly cardiac and facial anomalies. We report prenatal diagnosis of a case with ostium primum type ASD and another case with muscular VSD associated with preconceptional and antenatal exposure to carbamazepine. A 27 years old woman was referred for anomaly scan due to carbamazepine exposure at 20 weeks of gestation. A careful sonographic examination revealed isolated ostium primum type ASD. Amniocentesis revealed normal karyotype. The patient delivered at term and the anomaly was confirmed by echocardiography after the birth. The second case was referred to routine anomaly scan at 21 weeks of gestation because of carbamazepine use. A delicate scan revealed isolated, large, muscular VSD. Fetal blood sampling revealed normal karyotype. The patient was delivered by caesarean section at term due to previous caesarean operation. The anomaly was confirmed by echocardiography after the birth. As the risk of cardiac anomalies is increased, fetal echocardiography should be performed in patients with antenatal antiepileptic drugs such as carbamazepine use. Fetal echocardiography allowed us to identify most of the cardiac anomalies even primum type ASD, whose parental diagnosis is difficult.

P02.43: Congenital diaphragmatic hernia diagnosed in the first trimester

decided to follow up the pregnancy during two weeks and perform the cordocentesis in this time, karyotópe was normal. At 26 weeks we found progressive changes in fetal anatomy: heart herniation became larger, left lobe of liver began to protruse, the absence of the sternum and cartilaginous parts of the ribs was confirmed. Patient was offered pregnancy termination because of the impossibility of surgical correction. Radiography, CT and morphology of abortus confirmed ultrasound diagnosis of isolated absence of the sternum and cartilaginous parts of the ribs.

P11.09: Nuchal cord at term and the risk of Cesarean section

Objective: External cephalic version (ECV) is an effective tool for reducing the rate of Cesarean in patients with breech presentation at term. While amniotic fluid index has been showed to be associated with successful ECV, there is still uncertainty about which measure should be used to counsel mothers about the likelihood of success. The purpose of this study was to assess the association between the amniotic fluid index (AFI), maximal vertical pocket (MVP), as continuous, categorical and dichotomic variable, and the success rate of ECV. Methods: A prospective observational study was performed including all patients undergoing a trial of ECV between 1988 and 2001 in our center. The association between the different amniotic fluid (AF) measurements and the success of the ECV was calculated using linear and dichotomic logistic regression analyses. Multiple regression analyses with stepwise were performed to adjust for confounding variables including parity, and maternal body mass index (mBMI). Results: Data was available for 1219 patients who underwent a trial of ECV. The rate of successful ECV was 43% in nulliparous and 60% in parous women. A high level of both the AFI and the MVP preprocedure was associated with a successful ECV (Pearson’s R: 0.176 and 0.151, p < 0.001). While there is no cut-off value that preclude a trial of ECV, these levels where strongly associated with successful ECV: an AFI ≥ 12 cm (OR 2.0 95%CI 1.6–2.6), and a MVP ≥ 5 cm (OR 1.9 95%CI 1.5–2.4). After adjustment for confounding factors, an AFI ≥ 12 cm (OR 2.3, 95%CI 1.7–3.0) remained most predictive of successful ECV, after parity ≥ 1 (OR 2.5, 95%CI 1.8–3.3) and mBMI < 35 kg/m2 (OR 3.7 95%CI 1.8–7.8). Conclusion: Both AFI and MVP can be used in combination with parity and mBMI to counsel women prior a trial of ECV. However, an AFI equal or greater than 12 cm seems to be the best AF-related variable associated with successful ECV.