G. R. Lobo

Alterações ultra-sonográficas na gravidez Rh negativo sensibilizada avaliada pela espectrofotometria do líquido amniótico e pela dopplervelocimetria da artéria cerebral média

OBJECTIVE: To evaluate and compare existing ultrasound findings in women with Rh-alloimmunized pregnancies with diagnosis of fetal anemia by spectrophotometric analysis of amniotic fluid or Doppler ultrasound of the fetal middle cerebral artery. MATERIALS AND METHODS: This was an observational descriptive study involving 99 patients evaluated between January 1995 and January 2004. Patients were divided into two groups: 74 Rh-isoimmunized women submitted to spectrophotometry of the amniotic fluid (group S) and 25 Rh-isoimmunized women submitted to Doppler ultrasound of fetal middle cerebral artery (group D) to evaluate fetal anemia. Ultrasound findings in the two groups were compared. RESULTS: Placental anomalies, mainly placentomegaly and textural irregularities were more frequently seen in pregnant women followed up with spectrophotometry of the amniotic fluid compared to those followed up with Doppler ultrasound (64% X 32%, p = 6,294). CONCLUSION: The frequency of abnormal ultrasound findings was 2-fold higher in pregnancies evaluated with spectrophotometry of the amniotic fluid compared to those followed up with Doppler ultrasound.

Validation of Fetal Medicine Foundation algorithm for prediction of pre-eclampsia in the first trimester in an unselected Brazilian population

Abstract Objective: The objective of this study is to evaluate the predictive performance of the Fetal Medicine Foundation (FMF) algorithm for prediction of preeclampsia (PE) between 11 and 14 weeks of gestation in an unselected Brazilian population. Methods: We conducted a prospective cohort study with 617 singleton pregnancies of unselected risk. Biophysical markers (mean pulsatility index, mean arterial pressure) and biochemical markers (placental growth factor (PLGF) and PAPP-A) were inserted into the FMF software and converted into multiples of the median (MoM). The subjects were divided into five groups: early-onset PE, parturition <34 weeks’ gestation; preterm PE, parturition <37 weeks; PE, parturition at any gestational age; gestational hypertension (GH); and control group. Areas under the receiver operating characteristics curve (AUC) were calculated for the outcomes. Results: Among 617 patients, seven developed early-onset PE, 18 developed preterm PE (seven early PE plus 11 delivered between 34 and 36 + 6 weeks gestation), 34 developed PE (18 preterm PE plus 16 delivered after 37-week gestation), 12 pregnant women developed GH, and 517 women comprised the control group. The best predictive performance using the FMF algorithm occurred in the early-onset PE group, with AUC = 0.946 (95% CI 0.919–0.973) and the detection rate of 28.6% and 85.7% for 5% and 10% false-positive (FP), respectively. Conclusions: The FMF algorithm to predict PE was effective in a Brazilian population, mainly in the early-onset form of the disease at 10% FP.

Anti-Diego alloimmunization: report of two cases

Red cell alloimmunization is an immune disorder caused by incompatibility between maternal and fetal red blood cell antigens [1]. Due to its high prevalence and immunogenicity, D-antigen incompatibility is the most frequent cause of signiWcant perinatal hemolytic disease (PHD). However, red blood cells have over 300 other surface antigens and at least 43 of these are capable of producing hemolytic disease [2]. The following blood group system (and antigens) are the most frequently associated with PHD: Rh (D, C, E, c, e, f, Cw), Kell (K, k-celano, Kpa, Kpb, Jsa, Jsb), MNS (M, N, s, S), Kidd (JKa, JKb), DuVy (Fya, Fyb) and Lutheran [3]. Since most species of anti-Lewis antibodies are exclusively immunoglobulin M (IgM), which cannot cross the placenta, they rarely cause perinatal hemolytic disease (PHD) [4]. In Brazilian laboratories, when the indirect Coombs test is positive, the patient’s serum is routinely tested using a panel of antigens which include the following systems: Rh: (D, C, E, c, e, f, Cw, variants), Lewis (Lea, Leb), Kell (K, k (celano), Kpa, Kpb, Jsa, Jsb), MNS (M, N, s, S), Kidd (JKa, JKb), DuVy (Fya, Fyb), Diego (DI, Dia, Dib). While it is scientiWcally correct to try to identify exactly the speciWc antibodies present in the maternal blood, for clinical practice, only the detection of antibodies capable of producing hemolysis would be relevant. Motivated by the economic aspects of this question, we decided to study the prevalence of women sensitized to the Diego system in our obstetric population and review the perinatal results of these pregnancies.

OP23.04: First trimester evaluation of the ductus venosus: influence of body mass index and gestational age

late samples. Age standardised detection and false positive rates for different screening protocols were produced. Results: We collected two blood samples in 27 pregnancies affected by trisomy 21 and in 3891 control pregnancies. The early samples were taken between gestational week 8+0 up to week 13+6, and the late samples between week 11+3 up to week 14+6. The median interval between the samples was 17 days (range 1–40 days). We found a significantly better (P < 0.05) estimated screening performance when using early sampling vs. late sampling. With a risk cut-off of 1 in 100, at the time of the risk assessment, the estimated detection and false positive rates were 91% (95% CI: 81–98%) and 1.6% (95% CI: 1.3–2.0%) respectively. Better estimated performance was achieved with the use of the double set of markers; detection rate 93% (95% CI: 85–99%) and false positive rate 1.7% (95% CI 1.4–2.0%), but this was not significantly different from the early sample protocol (P > 0.05). Conclusions: Using early sampling with measurement of PAPPA and free β-hCG in the combined first trimester screening can optimise screening performance for trisomy 21. Using a double set of the maternal serum markers has the potential to further improve screening performance.

P13.23: Fetal malformations features in the Fetal Medicine Department of the Federal University of São Paulo

landmarks for a standardized and reproducible measurement of BPD and HC. Methods: A 3D volume of 21 fetuses was acquired either transvaginaly or transabdominaly by a single operator using the same machine. The volumes were treated offline with the 3D static mode to measure different BPD and HC at different levels. We analyzed first 3 axial sections, from up to down: (i) an axial section passing through the lateral ventricles (ii) one passing through the third ventricle, the thalami and the cerebral fissures of Bichat (defined as the reference plane) (iii) one passing through the posterior cerebral fossa. We studied then a coronal section passing through the posterior fossa and an oblique section between the reference plane and the coronal section. These biometric data were converted into Z-scores. A BlandAltman analysis was used to assess the level of agreement between the reference plane and the 4 deviant planes. Results: The results of the Bland-Altman analysis are shown in the table. The 4 deviant planes do not consistently provide similar measures with respect to the reference plane. Conclusions: The study put into relief the necessity of standardizing the measurement of the BPD and HC to increase the sensitivity of a screening test for neural tube defects. We suggest to measure the BPD and the HC in the reference plane.

P07.08: First trimester evaluation of the tricuspid flow: influence of body mass index and gestational age

Objectives: To estimate whether body mass index (BMI) and gestational age (GA) affects the evaluation of the tricuspid flow (TF) during first-trimester ultrasound examination for aneuploidy risk assessment. Methods: Using a Medison SA-8000Live system and an abdominal probe, we evaluated 519 women with singleton pregnancies undergoing first-trimester aneuploidy risk assessment ultrasound examinations. Weight categories were defined as normal (BMI less than 25), overweight (25–29.9), obese (30–34.9) and severely obese (more than 35). Gestational age categories were defined in week intervals from 11 to 14 weeks. The evaluation of the TF was considered inadequate when after 20 minutes a waveform displaying the Fetal Medicine Foundation criteria was not obtained. Results: Increasing BMI was associated with inadequate TF assessment. Table 1 displays the percentage of patients where the TF assessment was inadequate. As to GA, the percentage of patients with inadequate TF assessment decreased in higher GA groups, as displayed in Table 2. Conclusions: In singleton pregnancies, increased BMI was associated with a lower likelihood of obtaining an adequate TF waveform. Gestation age also affects the assessment of the TF. Exams performed with GA ≥ 12 weeks were associated with a higher likelihood of obtaining an adequate TF waveform.

P07.09: First trimester evaluation of the facial angle: influence of body mass index and gestational age

Objectives: To estimate whether body mass index (BMI) and gestational age (GA) affects the evaluation of the tricuspid flow (TF) during first-trimester ultrasound examination for aneuploidy risk assessment. Methods: Using a Medison SA-8000Live system and an abdominal probe, we evaluated 519 women with singleton pregnancies undergoing first-trimester aneuploidy risk assessment ultrasound examinations. Weight categories were defined as normal (BMI less than 25), overweight (25–29.9), obese (30–34.9) and severely obese (more than 35). Gestational age categories were defined in week intervals from 11 to 14 weeks. The evaluation of the TF was considered inadequate when after 20 minutes a waveform displaying the Fetal Medicine Foundation criteria was not obtained. Results: Increasing BMI was associated with inadequate TF assessment. Table 1 displays the percentage of patients where the TF assessment was inadequate. As to GA, the percentage of patients with inadequate TF assessment decreased in higher GA groups, as displayed in Table 2. Conclusions: In singleton pregnancies, increased BMI was associated with a lower likelihood of obtaining an adequate TF waveform. Gestation age also affects the assessment of the TF. Exams performed with GA ≥ 12 weeks were associated with a higher likelihood of obtaining an adequate TF waveform.

P04.08: Cesarean scar pregnancy managed conservatively: case series

CT chest abdomen pelvis revealed right pleural effusion, bilateral multicystic ovaries and large ascites. 2.7 litres peritoneal fluid was drained with no malignant cells on cytology. She responded well to supportive measures. Histopathology of product of conception demonstrated oedematous appearance of chorionic villi, normal trophoblast proliferation and no evidence of molar changes. Recent identification of FSH receptor gene mutations which increased FSH receptors sensitivity to structurally similar HCG is responsible for spontaneous OHSS. It induces follicular growth, activates LH receptors on granulosa cells and causes the release of vasoactive molecules. Clinical presentation, biochemical tests and ultrasound findings strongly supported the diagnosis of molar pregnancy but it was a non-molar miscarriage. This case would create awareness of this unusual presentation of spontaneous OHSS mimicking a partial molar pregnancy as it could cause major emotional impact on the patient and financial impact on the healthcare system.

P25.09: Reproducibility of three‐dimensional power Doppler for the assessment of the fetal brain blood flow in the anterior cerebral artery territory

volumetry by VOCAL 30o was performed in an ACCUVIX XQ device (Medison, Seoul, Korea) and MRI in Sonata Maestro Class system in a Leonardo workstation using ARGUS VA60C software. (Siemens, Erlangen, Germany). Reliability and agreement of the two techniques were evaluated with intraclass correlation coefficients (ICCs), and proportionate Bland-Altman plots were constructed. Results: A high degree of reliability was observed between VOCAL and MRI (ICC 0.879 [95% CI: 0.794; 0.929]). Bland-Altman tests showed no clinically significant mean percent differences between measurements (MD: 21.92 [95% LA: ±29.32; SD: ±14.96]). Conclusions: Three-dimensional volumetry of fetal lateral ventricles by VOCAL method has good agreement with fetal MRI in fetuses with ventriculomegaly.

P08.06: Identification of the outflow tracts of the fetal heart in the first trimester using the method STIC: preliminary results

Objectives: To identify the outflow tracts of the fetal heart using the STIC method (spatiotemporal image correlation) in the 11–13 week scan. Methods: We performed 30 ultrasound examinations of pregnant women between 11 and 13 weeks from november 2009 to february 2010 at the Center for Fetal Medicine of Campinas (CENTRUS), according to the screening protocol in the first trimester traced by the Fetal Medicine Foundation using the HD11 (Philips). After the morphological analysis it was assessed the fetal heart following the methodology described by Paladini in 2008. We identified the heart through the four-chamber view and after activation of the color Doppler the STIC method was performed. It was then carried out post-processing, making it possible to identify the cardiac atria and the position of the aorta and pulmonary arteries, and the relationships among these structures. Results: A total of 30 women between 11 and 13 weeks. Six women (20.0%) had a gestational age of 11 weeks, 13 (43.3%) 12 weeks and the remaining 11 (36.7%) women had 13 weeks of gestation. The crow rump length averaged 64.3 mm (47.3 to 82.3 mm), with standard deviation of 9.4 mm. The mean nuchal translucency thickness was 1.9 mm (1.2 to 5.0 mm) with a standard deviation of 0.7 mm. Examination showed no regurgitation of the tricuspid valve. The nasal bone was present in 25 (83.3%) samples. The visualization of the outflow tract and their relationship to the cardiac atria occurred in 19 (63.3%) women. Inappropriate positioning of the fetus (7 cases), Doppler acquisition of poor quality (2 cases) and the impossibility of assessing the aorta (2 cases) were the reasons for not identifying the correct exit routes. Conclusions: The application of ultrasound examination suggested by the methodology described by Paladini proved to be feasible within the screening period of the first trimester, antecipating the identification of the outflow tract of the fetal heart.