E. Gratacós

OC111: Placental sharing, birth weight discordance and vascular anastomoses in monochorionic diamniotic twin placenta

lead to CA vasodilatation, manifesting as easy visualization on FE. We reviewed our experience with visualization of prominent CA and outcome of these fetuses. Methods: We reviewed all cases between 2001 and 2007 in which there was unusual prominence and easy visualization of CA. Fetuses with ventricular hypoplasia or fistulous connections as a cause for coronary dilatation were excluded. CA prominence was defined as easy visualization via CD imaging starting at the origin of the aorta, with an ability to trace descent of the vessel through the ventricular septum to at least 2/3 of the length towards the apex of the heart. Results: Eleven cases were identified. FE was performed at a median of 27 (range, 20–32) weeks’ gestation. Underlying disorders included: high-output cardiac failure due to anemia (two) or chorionagioma (one), tachyarrhythmia (one), truncus arteriosus with severe outflow obstruction (one), severe intrauterine growth retardation (one), lower urinary tract obstruction with massively dilated bladder (one), CMV infection (one), amniotic band with umbilical obstruction (one), porencephaly (one) and cystic hygroma (one). Hydrops fetalis was present in four. Of the 11, two are still unborn; five had intrauterine fetal demise within 2 h to 7 days after FE; two died immediately after birth, both delivered at < 35 weeks; two are currently alive – one with pulmonary hypertension that has resolved and one with neurological insult. All four fetuses identified at < 24 weeks gestation died in utero. Conclusions: Visualization of prominent CA in the fetus is a marker of severe myocardial insufficiency and predicts poor outcome.

OP20.05: Anterior cerebral artery improves the prediction of adverse perinatal outcome in small-for-gestational age fetuses with normal umbilical artery

Objectives: Previous studies suggested that in intrauterine growth restricted (IUGR) fetuses there might be an early vasodilatation of the anterior cerebral artery (ACA). The aim of this study was to assess longitudinally changes in the two segments of the ACA and in the middle cerebral artery (MCA) in IUGR fetuses in relation to changes in the umbilical artery pulsatility index (UA-PI). Methods: A longitudinal Doppler evaluation of 67 IUGR fetuses was performed. IUGR was defined as an estimated fetal weight (EFW) 95th centile). ACA was evaluated in its two segments: S1 just after its origin from the internal carotid artery, and segment 2 (S2) after the junction with the anterior communicating artery. MCA was evaluated after its origin from the circle of Willis. Results: A total of 189 examinations were performed (median per case 2 (range, 1–8)). In IUGR fetuses with normal UA-PI, the proportion of fetuses with a PI below the 5th centile in ACA S1, ACA S2 and MCA-PI was 60.9% 55.5% and 39% respectively (P 95th centile), the proportion of fetuses with reduced PI values in the ACA S1, ACA S2 and MCA was similar (77.5% vs. 70% and 66.6% vs. 70%, respectively). Conclusions: Brain vasodilation seems to start before the umbilical artery PI becomes abnormal, and is earlier expressed in ACA, with no apparent differences between S1 and S2. Therefore, a subgroup of IUGR fetuses with normal PI values in the UA and the MCA already have brain vasodilatation which is not detected with current techniques.

THE PRENATAL MANAGEMENT OF NEURAL TUBE DEFECTS: TIME FOR A RE-APPRAISAL

The prevalence of neural tube defects (NTD) in Europe is around 9 per 10,000 births making it one of the most frequent congential anomalies affecting the central nervous system. NTD encompass all anomalies that are secondary to failure of closure of the neural tube. In this review, we will first summarize the embryology and some epidemiologic aspects related to NTDs. The review focuses on myelomeningocele (MMC), which is the most common distal closure defect. We will describe the secondary pathologic changes in the central and peripheral nervous system that appear later on in pregnancy and contribute to the conditions morbidity. The postnatal impact of MMC mainly depends on the upper level of the lesion. In Europe, the vast majority of parents with a fetus with prenatally diagnosed NTDs, including MMC, opt for termination of pregnancy, as they are apparently perceived as very debilitating conditions. Animal experiments have shown that prenatal surgery can reverse this sequence. This paved the way for clinical fetal surgery resulting in an apparent improvement in outcome. The results of a recent randomized trial confirmed better outcomes after fetal repair compared to postnatal repair; with follow up for 30 months. This should prompt fetal medicine specialists to reconsider their position towards this condition as well as its prenatal repair. The fetal surgery centre in Leuven did not have a clinical programme for fetal NTD repair until the publication of the MOMS trial. In order to offer this procedure safely and effectively, we allied to a high volume centre willing to share its expertise and assist us in the first procedures. Given the maternal side effects of current open fetal surgical techniques, we have intensified our research programmes to explore minimally invasive alternatives. Below we will describe how we are implementing this.

OP20.08: The use of a cardiac profile improves detection of heart dysfunction and prediction of poor perinatal outcome as compared with ductus venosus alone

n 75 37 48 68 23 Echocardiography Aortic isthmus flow index −0.5 (1.3) −0.9 (1.5) −1.3 (4) −2.5 (6.5)** −11.8 (4.2)** Aortic peak velocity −0.04 (1.3) −0.9 (1.3)* −0.8 (1.7)* −0.9 (1.4)* −1.3 (1.8)** Pulmonary peak velocity −0.6 (1.1) −1.3 (1.7)* −1.5 (1.1)* −1.3 (1.4)* −1.5 (1.2)* Aortic valve diameter 0.8 (1.6) 0.1 (1.9)* 0.2 (2.5) 0.7 (2.4) 0.3 (2) Pulmonary valve diameter 0.1 (1.4) −0.3 (2.4) −1.5 (2.4)* 0.1 (1.6) −1.4 (1.1)* Left shortening fraction −1.5 (1.2) −2 (1.6) −1.2 (1.6) −1.7 (3.1) 0.03 (4.3)* Right shortening fraction −0.8 (3) −2.7 (4.3)* −1.2 (3.8) −1.2 (4.7) −0.3 (7.5) Isovolumetric contraction time −0.05 (1.3) 0 (1.9) 0 (1.7) 0.3 (1.8) 0.5 (2.5) Ejection time 0 (1.3) −0.8 (1.8)* −1.3 (1.4)* −1.5 (1.7)* −1.6 (1.2)* Cardiothoracic ratio 0.4 (1.2) 0.3 (1.5) 0.6 (1.8) 1.1 (1)* 2.2 (1)** Left E/A ratio −0.3 (1.4) −0.1 (1.8) 0.4 (1.4)* 0.5 (2.2)* 1.6 (2.7)** Right E/A ratio 0.2 (0.9) 0.3 (1.7) 0.7 (1.5)* 0.6 (1.9)* 1.2 (2.2)* Isovolumetric relaxation time 0.05 (1.3) 0.3 (1.7) 0.5 (2.1) 0.5 (2.6) 1.2 (3.4)** Modified-myocardial performance index −0.1 (1.2) 0.6 (2.3)* 1.1 (2.1)* 1.1 (2.4)* 1.9 (2.1)** Normalized left cardiac output 235 (147) 295 (67)* 344 (155)* 351 (219)* 298 (184)* Normalized right cardiac output 343 (113) 308 (162) 429 (212)* 463 (245)* 554 (119)** Normalized combined cardiac output 570 (166) 512 (180) 749 (318)* 881 (289)* 722 (225)* Biochemical evaluation Cord blood BNP (pg/mL) 20 (26) 48 (51)* 92 (164)* 70 (83)* 410 (340)**

P07.07: Predictive value of peak systolic velocity in the middle cerebral artery to detect fetal anemia in red‐cell alloimmunized pregnancies beyond 35 weeks

Results: The colour Doppler derived mean velocity of 59 (SD ± 10.8) mm/s is significantly (P = 0.04) higher than the spectral Doppler derived velocity of 54 (SD ± 9.5) mm/s. Umbilical blood flow derived from the mean flow multiplied by the cross sectional area is 114 ml/min (SD ± 69) and 104 ml/min (SD ± 58), respectively (P = 0.01) (student t test). Conclusion: These preliminary data suggests that colour Doppler derived umbilical venous volume flow is approximately 10% higher than spectral Doppler derived volume flow. This can be explained by less angle dependency of colour Doppler derived velocity.

Added value of website based parent information about intrauterine treatment for severe congenital diaphragmatic hernia

We aimed to measure whether website‐provided information about congenital diaphragmatic hernia (CDH) and fetal therapy for severe cases provides added value compared with clinical counseling of parents.

OC246: Selective ligature of uteroplacental vessels in the pregnant rabbit: a novel experimental model of intrauterine growth restriction

fetuses was found to have a chromosomal aberration. 3D evaluation of the fetal spine was performed in all cases, and it did not add significant information to the 2D examination. Conclusions: Isolated hemivertebra(e) with an intact neural tube might be associated with a good postnatal outcome. Associated anomalies are frequent but, in our experience, prenatal ultrasonography was accurate in identifying them.

OC15.03: Changes in cardiac tissue Doppler imaging in fetuses with congenital diaphragmatic hernia and association with the risk of severe neonatal pulmonary hypertension

Objectives: The application of RFA to complicated cases involving monochorionic twins offers the potential of a less invasive option when compared to BCC. The purpose of this study was to compare outcomes between these two techniques. Methods: A retrospective review was undertaken of all cases of complicated monochorionic twin gestations treated from July 1996 to December 2010. Cases were identified from the fetal treatment database and data extracted in a uniform fashion from the patient’s charts. Results: A total of 149 cases were identified with procedures performed on 146. Indications for selective termination on one fetus were twin reversed arterial perfusion (TRAP) sequence in 53, severe twin-to-twin transfusion syndrome (TTTS) in 43, discordance for fetal anomalies in 26 and severe IUGR in 24. Eighty-eight cases were managed with bipolar cord cautery (BCC) and 58 with RFA. All cases were technically successful in achieving selective termination. The mean gestational age at the time of the procedure was 20.9 ± 2.7 weeks in the BCC group vs. 20.2 weeks ± 2.2 weeks in the RFA group (P = 0.1). The median gestational age at delivery was 34.7 [29.2–38.6] weeks for the BCC group vs. 33.0 [23.4–38.3] weeks in the RFA group (P = 0.073). Mean birthweights did not differ between the two groups. The procedure to delivery interval was 87 ± 42 days for the BCC group vs. 73.9 ± 747.6 days for the RFA group (P = 0.1). Overall survival was 86.8% in the BCC group vs. 71.9% in the RFA group (P = 0.021). Premature rupture of the membranes (PROM) occurred in 28.1% of BCC cases and 29% of RFA cases and was the most common complication. Conclusions: Despite the smaller caliber of the instrument, RFA is not associated with a decrease in the overall complication rate for selective termination procedures. The technique used for selective termination should still be determined by technical considerations but patients should be informed of the survival associated with each technique.

OC01.04: Analysis of brain structure by MRI voxel based morphometry (VBM) and neurodevelopment in preterm born infants with and without IUGR

tumors (BOT), to determine the ability of ultrasound (US) to diagnose new and recurring BOT, and to assess differences in US variables between new and recurrent BOT. Methods: The cohort involved a subgroup of participants in an international multi-center ultrasound study on ovarian masses (IOTA phase 2). Patients with a history of BOT with a further ovarian tumor or a first diagnosis of BOT were included. The gold standard was the histological diagnosis of the ovarian mass. Results: 20 patients with a history of BOT and an ovarian mass and 93 patients with newly diagnosed BOTs were included. In 17 (85%) patients with a previous BOT, a recurrent BOT was found. In the remaining 3 cases (15%) the recurrent tumor was benign. All recurrent BOT histotypes matched the primary BOT. No BOT recurred as invasive primary tumor or with invasive peritoneal implants. Subjective assessment of US findings was a better method for identifying BOT in patients with a history of BOT than in patients with newly diagnosed BOT (sensitivity 76% [13/17] vs. 41% [38/93]). Patients with BOT recurrence were younger (median 35 years vs. 53) and had smaller tumors (median 41 mL vs. 548) with more papillations (mean 2.06 vs. 1.44) than patients with newly diagnosed BOT. Recurrent tumors were more often anechoic and less often homogeneous with low-level echogenicity, reflecting the higher percentage of serous BOT among the recurrent BOTs than among newly diagnosed BOTs (71% vs. 56%). The early ultrasound diagnosis of recurrence permitted conservative treatment of recurrence in 65% [11/17] patients. Conclusions: BOT history is a strong predictor of BOT in a recurrent ovarian mass. US is highly accurate in diagnosing BOT recurrence and so can be used for follow up after fertility sparing procedures where early diagnosis of recurrence is essential for conservative re-treatment.

OC22.02: Combination of the aortic isthmus with ductus venosus improves the prediction of neurological damage in early-onset intrauterine growth restricted fetuses

Objectives: To evaluate the neurobehavioral outcome of earlyonset intrauterine growth restricted (IUGR) fetuses with abnormal umbilical artery (UA) Doppler and to compare the groups with and without brain sparing. Methods: A cohort of consecutive IUGR fetuses (birth weight < 10th centile) with abnormal UA Doppler (pulsatility index > 95th centile) and requiring delivery before 34 weeks was created and compared to a group of appropriate-for-gestational age (AGA) infants matched with cases by gestational age at delivery. Middle cerebral artery (MCA) was assessed by Doppler in all cases within 72 hours of delivery. Neonatal behavior was evaluated at 40-week corrected age with the Neonatal Behavioral Assessment Scale (NBAS). The effects of the study group and brain sparing (MCA pulsatility index < 5th centile) on each NBAS area were adjusted by multiple analysis of covariance or logistic regression for smoking during pregnancy, socioeconomic level, mode of delivery and gender. Results: A total of 126 fetuses (64 IUGR and 62 AGA) were included. Among IUGR fetuses, the proportion with abnormal MCA was 55%. All the neurobehavioral areas studied were poorer in the IUGR group, significantly in habituation, motor and socialinteractive. Abnormal habituation (36.2 vs. 16.3%; P = 0.027), motor (40.3 vs. 15.6%; P = 0.002) and social-interactive (25.8 vs. 8.2%; P = 0.009) scores were more frequent in IUGR than in AGA newborns. All the neurobehavioral areas studied were poorer in IUGR fetuses with brain sparing, significantly in habituation, motor, social-interactive and attention. Abnormal MCA identified IUGR fetuses with the highest risks of abnormal NBAS in motor (odds ratio 3.6; P = 0.011), social-interactive (odds ratio 4.1; P = 0.019) and attention (odds ratio 3.7; P = 0.011) areas. Conclusions: Early-onset IUGR with abnormal umbilical artery Doppler have poorer neurobehavioral competencies, which suggest a delayed neurological maturation. Abnormal MCA Doppler discriminates those cases at highest risk for abnormal neurobehavior.