Giorgio Fachechi

Acute promyelocytic leukemia during pregnancy

OBJECTIVE To report our experience about a woman with acute promyelocytic leukemia (APL) during pregnancy. We focus on the obstetric treatment of our patient. DESIGN Case report. SETTING University Hospital. PATIENT(S) A 32-year-old-woman, gravida 2, para 1, at the 25th week of pregnancy with a diagnosis of APL. INTERVENTION(S) Multidisciplinary approach to the problem with the aim to ensure a good outcome for both the mother and the baby. MAIN OUTCOME MEASURE(S) Treatment of maternal malignancy and fetal outcome. RESULT(S) At discharge, after 2 months in hospital, the baby had no neurologic or sensitive deficiencies, and his general health was good. The mother is now undergoing the third and last consolidation step with good results, and APL is in remission. CONCLUSION(S) In cases of APL during the second and third trimesters, the modern chemotherapy associated with close monitoring of maternal and fetal well-being could ensure a good outcome for both the mother and the baby.

Assessment of endometrial volume and vascularization using transvaginal 3D power Doppler angiography in women with postmenopausal bleeding

To compare the usefulness of 3D power Doppler angiography (3D‐PDA) and endometrial thickness measurement by 2D Doppler ultrasound in the distinction of benign from malignant disease in postmenopausal women with abnormal uterine bleeding (AUB) and an endometrial thickness greater than 4.5 mm.

Near‐miss and maternal mortality in a tertiary care facility in Italy

multivariate analyses (Table 1). Rate and predictors (primiparous status and maternal height) for low birth weight were comparable with previous reports from eastern and central eastern Sudan and neighboring Ethiopia [2–5]. In the present study the total perinatalmortality ratewas 51 per 1000 births; most of these deaths were stillbirths and might have been laborrelated deaths. In high-resource countries, intrapartum stillbirths comprise less than 10% of all stillbirths, while in low-resource countries higher proportions of stillbirths are thought to occur in the intrapartum period. In the present study, women who had not attended prenatal care had a 2-times higher risk of low birth weight and perinatal death. This is similar to previous observations in other African countries [6]. Future efforts should emphasize improving the education, nutrition, and attendance of women at prenatal care clinics, to prepare them and their families for the delivery, and to prevent and prepare for complications. References

P34.03: Incomplete pentalogy of Cantrell during first trimester of pregnancy: case report

hospital for oligohydramnios at 24 weeks. The examination showed oligohydramnios and kidneys seemed normal shape and location in ultrasound. C-section was performed at 37 weeks. The baby was admitted to the neonatal intensive care unit instantly but despite all intensive care treatment, the respiratory distress from hypoplastic lung, hypotension and anuria worsened and the baby died on the 2 day of life. Endocrinological and Histopathological studies showed same as case 1. Conclusion: Severe oligohydraminios with normal shape kidneys since second trimester, we should add RTD in differential diagnosis.

OP33.07: Three dimensional cerebroplacental ratio (CPR 3DPDA): a new parameter for the antenatal surveillance in IUGR fetuses

Objectives: We sought to evaluate the association of small abdominal circumference (AC < 10th percentile) at third trimester ultrasound with gestational age (GA) at delivery. Methods: All women seen at our institution from 2009 through 2011 for measurements from 28 to 34 weeks’ gestation with a singleton, non-anomalous pregnancy were included in this retrospective cohort. We compared GA at delivery, with preterm defined as < 37 weeks, among three groups: fetuses with normal AC and normal estimated fetal weight (EFW; both ≥ 10th percentile; Group 1), small AC and normal EFW (AC < 10th percentile, EFW ≥ 10th percentile; Group 2), and small AC and small EFW (both < 10th percentile; Group 3). Data are presented as medians (interquartile ranges (IQR)) and risk ratios (RR) with 95% confidence intervals (CI). Results: Of the 612 eligible pregnancies, 47.7% of the women were White, 17.2% Black, 15.4% Hispanic, 14.1% Asian and 5.7% other/unknown. The median GA at ultrasound was 32.0 weeks (IQR: 30.6–33.0) and median maternal age at delivery was 32.9 years (IQR: 28.8–36.7). A small AC was found in 10.6% of the fetuses. Compared to Group 1, fetuses with a small AC (Groups 2 and 3) had a lower GA at delivery and a higher incidence of preterm delivery. Fetuses in Group 2 were more than twice as likely to be delivered preterm than fetuses in Group 1, while the risk was more than six times higher in Group 3 compared to Group 1 (See Table). The RRs did not change appreciably after adjusting for maternal age and race/ethnicity. Conclusions: Small AC is associated with a higher incidence of preterm delivery. This effect was demonstrated even in fetuses with EFW ≥ 10th percentile. Further studies should examine factors that influence this association.

OP33.08: Evaluation of fetal cerebral blood perfusion using power Doppler ultrasound angiography (3D‐PDA) in normal and growth‐restricted fetuses (IUGR)

Objectives: The aim of the present study was to explore the possible use of 3D Power Doppler Angiography (3D PDA) using VOCALTM software (GE Healthcare, USA) assessing different fetal cerebral regions in normal and growth restricted fetuses (IUGR). Methods: 77 AGA and 55 IUGR (24–36 ws gestation). IUGR were divided in 3 groups: group 1 (n = 28): Late onset IUGR (> 34 ws) with normal bidimensional Doppler flow analysis, group 2 (n = 11): early onset IUGR (< 34 ws) with abnormal umbilical artery (UA) pulsatilty index (PI), normal middle cerebral artery (MCA) PI and normal ductus venosus (DV) PI, group 3 (n = 16): early onset IUGR (< 34 ws) with abnormal umbilical artery (UA) pulsatilty index (PI), abnormal MCA PI and pathological DV PI. Two regions of interest (ROI) were defined within the fetal brain. The first ROI (zone 1) is anterior respect the cavum septi pellucidi (CSP). The second ROI (zone 2) is obtained tracing a contour between the temporal bones as wide as the CSP. 3D-PDA vascular indexes (VI = vascularization, FI = flow, VFI = vascularization and flow) were determined in both areas for both AGA and IUGR fetuses by one operator. Results: VFI values demonstrated increased blood flow in frontal zone compared to control group (AGA) in ‘‘early onset IUGR’’ (in both groups 2–3 with and without abnormal 2D MCA findings). VI and VFI values demonstrated increased blood flow in frontal zone and decreased blood flow in temporal zone compared to control group (AGA) in ‘‘late onset IUGR’’ with preferential increment in bloody supply to the frontal region to protect general cognitive functions. Conclusions: 3DPDA analysis could be considered a valid method to identify earlier vascular redistribution in IUGR fetuses comparing to 2D velocimetry. 3DPDA could become an additional parameter to adjust the monitoring intervals in the evaluation of high risk fetuses.

OP36.10: Evaluation of fetal cerebral blood flow perfusion using power Doppler ultrasound angiography (3D-PDA) in normal and growth-restricted fetuses (IUGR): Oral poster abstracts

Objectives: The aim of this study is to evaluate three dimensional cerebroplacental ratio (CPR 3D) using 3D power Doppler angiography (3D PDA) in the intrauterine monitoring of the growth restricted fetuses (IUGR). Methods: Cerebroplacental ratio (CPR), the ratio between PI of MCA and PI of umbilical artery (UA), is a better predictor for adverse outcome than a single vessel considered alone. We defined CPR 3DPDA as the ratio between vascular indices of a region of fetal brain (ROI) and the vascular indices of the placenta using 3DPDA methodology. The ROI evaluated were a ‘frontal zone’, sprinkled mainly by anterior cerebral artery, obtained tracing a contour passing through the anterior side of cavum septum pellucido (CSP) surrounding part of temporal and frontal bone. Then a second ROI obtained tracing a contour from temporal bones of the width of CSP included (’temporal zone’) sprinkled by middle cerebral artery MCA. We considered 3DPDA vascular indexes (VI = vascularisation FI = flow, VFI = vascularisation and flow). We enrolled 33 IUGR fetuses and 81 adeguate for gestational age, as control cases (24–38 weeks). IUGR fetuses were divided into 2 groups: group 1, IUGR with normal flussimetry of umbilical artery (UA) and MCA; group 2, IUGR with abnormal UA-PI (mean > 2 SD) and abnormal MCA-PI (PI < 2 SD). We calculated the 2D CPR and the CPR 3D of the frontal and temporal cerebral zones for all vascular indexes. Results: Values of 2D CPR were in accordance with the expected ones. CPR 3D, applying VI and VFI, both in frontal and temporal zone demonstrated a statistically significant different values compared with control cases. Conclusions: CPR 3D can be considered a new parameter: it demonstrates the vascular redistribution in frontal and temporal zones during the ‘brain sparing effect’ in IUGR fetuses also in the group of IUGR fetuses without bidimensional pathological flussimetry.

OP13.07: Placenta percreta with bladder invasion

Local glandular cystitis of the urinary bladder is a rare benign disease. In its minor form, it has the same clinical features as simple cystitis, but its major pseudoneoplastic form may be mistaken for bladder tumor, even pelvic tumor. This case presented the rare ultrasonographic characteristics of local extravesical glandular cystitis mimicking pelvic neoplasm using transvaginal sonography. A 36-year-old woman patient presented with a 3-week history of gross haematuria and intermittent suprapubic discomfort. Physical examination, urinary cytology and culture including AFB were unremarkable. She was examined by transvaginal sonography within 1–3 days, 14 days and 90 days after hospitalization. Ultrasound demonstrated a 28*19*16 mm solid mass lesion between the posterior bladder wall and anterior wall of cervix like a pelvic neoplasm. The echographic features on TRUS are hypoechoic and isoechoic mixed, poorly defined mass lesion with indistinct margins. Chronic sinus tract formation was contiguous with cervix and the mass was attached to the bladder wall. CT demonstrated invasion of the adjacent structures. Eventually, the patient underwent a transvaginal biopsy of the ‘‘tumor’’. The histology demonstrated glandular cystitis with mild chronic inflammation of the lamina and no evidence of malignancy. Histological analysis of the specimen confirmed diffuse muscle infiltrating areas of glandular cystitis. The patient made an uneventful recovery and was completely asymptomatic at 3-month follow up. Glandular cystitis is a benign proliferative disorder of the von Brunn’s nests within the mucosa and the submucosa of the urinary bladder epithelium. According to its extension we can distinguish localized from widespread intestinal metaplasia of glandular cystitis. The condition masquerading as a pelvic tumor is rare. We demonstrate a rare case which may assist diagnosis especially in young patients presented with haematuria and intermittent suprapubic discomfort.

OP39.03: A new proposal of sonobiopsy of fetal brain using 3D power Doppler angiography (VOCAL) in normal and growth restricted fetuses

Objectives: To study the impact of intrauterine growth restriction (IUGR) on brain structure at 12 months of corrected age (CA) analysing the structural complexity of gray (GM) and white matter (WM) using fractal dimension (FD). Methods: 18 preterm infants with IUGR, 15 preterm infants adequate for gestational age (AGA) and 15 healthy infants born at term were recruited. MRI was performed at 12 months CA during natural sleep in a 3T scanner. Neurodevelopmental outcome was assessed at 12 months CA with Bayley Scale-III edition. Cerebral 3D FD analysis was obtained from segmented WM and GM in each subject. Results: The IUGR group showed a significant decrease of GM FD (2.797 ± 0.007) compared to preterm AGA (2.802 ± 0.008) or term (2.804 ± 0.009). A trend to lower WM FD in the IUGR group was found. We detected a trend to a significant correlation between GM FD and GM volume (r = 0.21072, P = 0.15) and a high significant correlation between WMFD and WM volume (r = 0.751557, P < 0.05). Performance of the IUGR group on Bayley-III was significantly worse than term group on motor, fine motor and adaptive behaviour. No differences were found between IUGR and preterm AGA. We did not find any correlations between FD and any of the developmental measures. After performing a principal component analysis the first three components explained the 72.26% of the data variance and so three groups of neurodevelopmental variables were obtained: The first including the language scale; the second component included the cognitive and motor scale and the socio-emotional and adaptive behaviour were associated to the third component. A correlation analysis showed a significant correlation between the second component and WM FD (r = −0.34, P < 0.05) and a nearly significant correlation with the GM FD (r = 0.27, P = 0.06). Conclusions: IUGR induces a distinct alteration on brain composition that can be featured by FD analysis at one year of life. A decreased GM and WM FD in IUGR infants could represent a characteristic phenotype of this population.

OP21.04: Ultrasound evaluation of pelvic masses using pelvic masses score system

Objectives: To assess the contribution of 3D-PDA for differential diagnosis of adnexal masses. Methods: Prospective study (June 2008–January 2010) comprising all women diagnosed as having a persistent adnexal mass and scheduled for surgery. Women were evaluated according to a predetermined protocol. First a B-mode morphologic assessment was performed (first step). Those lesions thought to be benign according to gray-scale ‘pattern recognition’ analysis were not further analyzed. Those tumors with solid components or questionable at gray-scale underwent 2D power Doppler (2D-PDA) analysis of tumor blood flow location (second step). Those lesions without flow or only peripheral blood flow were considered as benign whereas those tumors with central flow were considered as malignant. This latter group underwent 3D-PDA analysis (third step). Vascularity Index (VI) from vascularized areas of the tumor was calculated offline by a single examiner. Malignancy was considered if VI > 1.555%. Definitive histological diagnosis obtained in all cases. Sensitivity, specificity, positive (LR+) and negative (LR−) likelihood ratio and global accuracy for each step were calculated and compared. Results: 217 masses in 186 women (mean age: 44.3 years, range: 12 to 78 years) were evaluated during study period. Sixty-one masses were malignant and 156 benign. Diagnostic performance of each method is shown in Table. Conclusions: 2D-PDA and 3D-PDA increased significantly specificity of B-mode ultrasound. The probability of malignancy is significantly higher after a 3D-PDA analysis than after B-mode and 2D-PDA assessment. The Italian part of the study has been supported by a grant of Fondazione Banco di Sardegna.