J. Bello-Muñoz

The prevalence of congenital varicella syndrome after a maternal infection, but before 20 weeks of pregnancy: a prospective cohort study

Objective. To describe the prevalence of congenital varicella syndrome (CVS) within the population of presumably infected pregnant women. Methods. From 1993 to 2006, all women who presented vesicular rash or a suspicious contact were referred and evaluated in a special unit at our center. Those with residual immunity or were serologically negative were precluded from this study. Positive IgM cases underwent monthly ultrasound scans (US), fetal blood (FB) sampling (including IgM anti VZV and virus culture). Amniotic fluid sample for PCR was added to the diagnosis of positive IgM cases after 1997. Results. A total of 276, of the 566 consulted women, tested positive for IgM anti VZV. Seventeen (6%) were excluded because of an unadvised termination of pregnancy and seven (2.55%) miscarried. Only seven (2.7%) were considered highly likely to have a VZV fetal infection. One case showed positive IgM in FB but developed normally. Another fetus showed positive PCR and infection was confirmed post TOP. Four cases that underwent TOP and histochemistry confirmed no more cases. Complete post-natal follow-up was carried out. The asymptomatic infected child grew healthy until the completion of screening tests when it reached 5 years old. Conclusion. The fetal infection rate in this cohort was 0.8%, but the best expected prevalence of CVS, according to our findings, should be 0.39% among infected women. This data should be considered and used during parental counselling.

Use of 3-Dimensional Sonography for Prenatal Evaluation and Follow-up of Fetal Goitrous Hypothyroidism

Objective. Fetal goitrous hypothyroidism is a rare and potentially lethal condition. Consequently, its early diagnosis and treatment improve prognosis. Thyroid hormone measurement in either fetal serum or amniotic fluid implies important risks. Here we present a fetal goiter and the follow‐up procedure, both done by the traditional method and by using 3‐dimensional power Doppler (3DPD) imaging and virtual organ computer‐aided analysis (VOCAL). Methods. A single well‐documented case of fetal goiter was followed weekly from 22 weeks until delivery. Amniocentesis for thyrotropin (TSH) and free thyroxine (T4) measurement as well as levothyroxine injections were performed at every control. In addition to amniocentesis, every control involved a sonographic evaluation, which included standard measurements of the gland and the capture of volume image sets in gray scale and 3DPD. Volume calculation of the gland was done using VOCAL software. Vascularization of the gland was evaluated by the vascularization index (VI) included in the software. Results. With treatment, TSH levels decreased progressively until normalization. Free T4 levels increased toward the end of gestation. Sonographic measurements of the gland volume to estimated fetal weight ratio decreased across treatment as levels of TSH did. The VI clearly depicted the vascular regression of the goiter, decreasing throughout treatment in a consistent way until 24 hours before delivery. Conclusions. Gray scale and 3DPD evaluations of the thyroid gland have been validated under similar circumstances and might be reliable complements to the invasive methods used in the management of this fetal condition.

Amniocentesis and the risk of second trimester fetal loss in twin pregnancies: results from a prospective observational study

Abstract Aim: To compare the rate of pregnancy loss between twin pregnancies undergoing a genetic amniocentesis (AC) and a control group with similar characteristics. Methods: Prospective observational study on a population of twin pregnancies referred to our prenatal diagnosis unit for screening from 1990 to 2010. Those women referred for an AC were compared with those without indication for the procedure. Primary outcomes were pregnancy loss within the 4 weeks after procedure and pregnancy loss before 24 weeks. Secondary outcome included neonatal morbidity, gestational age at delivery and birth weight. Results: Maternal characteristics were similar for both groups, except for maternal age. There was neither difference in the pregnancy loss rate within 4 weeks (2.7 versus 2.6%) nor in the loss rate before 24 weeks of gestation (1.2 versus 1.1%). Gestational age at birth was 36 weeks for both groups. Chorionicity and gestational age at procedure played no role in modifying the risk. Conclusion: Based on our results, there is no difference in the pregnancy loss rate in twin gestations, regardless of chorionicity or gestational age at procedure, either within 4 weeks after the procedure or before 24 weeks, in patients who undergo AC when compared with patients who do not.

P25.06: Structural congenital heart disease in twins, report from a large cohort of twin pregnancies

nor functional cardiac anomalies were taken into account for this purpose. Results: A total of 57 (3.8%) cases of sCHD were found in the entire population, the incidence of sCHD was 3.25% in DC, 4.35% in MC and in TTTS cases was about 8%. 34 (59.6%) of cases underwent selective feticide because of either associated anomalies or severity of CHD. 7 (12.3%) died spontaneously in-utero and 16 were followed until birth, 75% of which was preterm (mean gestational age 29 +/− 2 weeks). 4 (25%) of cases were severe pulmonary stenosis (all of them in previous TTTS cases), two of which underwent pulmonary valvuloplasty at 4th and 7th day of life. 4 (25%) presented anomalous vein drainage systemic (3) and pulmonary (1). 3 (18.7%) fulfilled criteria for Fallot tetralogy. 3 (18.7%) had aortic coarctation. 2 (12.5%) presented cono-truncal anomalies (TGA and truncus). Neonatal intensive care stay was very long (mean of 74 +/− 23 days) because of prematurity and surgical interventions. Conclusions: sCHD have a higher incidence among twins, in TTTS the incidence of pulmonary stenosis is even higher than in other twins. Cardiac thorough screening is mandatory in all TP, particularly in MC.

OC18.02: Inter-observer agreement on cardiac defects using spatio temporal image correlation and volume computer aided diagnosis

ng/ml, 49.4 (7-264) pg/ml, 6.8 (3.0–11.9) IU/L and 165 (42373) pmol/L respectively. The median (range) total AFC was 12 (2–39). The total AFC was significantly correlated with serum AMH (r=0.43; P 6.0 mm. Conclusions: The total AFC is significantly correlated with serum AMH levels but not with inhibin-B, FSH or oestradiol. The number of antral follicles measuring 2–6 mm is most closely related to AMH levels and this follicular cohort is most reflective of the quantitative status of ovarian reserve.

OP08.11: Clinical outcome of chromosomically normal fetuses with increased nucal thickness at 11 to 13 + 6 scan, a large prospective case series

for relationships with gestational age (GA), maternal age, race, body mass index (BMI), mean arterial blood pressure (MAP), nicotine/caffeine use, measures of uterine and umbilical artery blood flow resistance. Results: 111 consecutive patients had a complete multi-analyte screen. ANG-2 correlated with PIGF and pp-13 (Pearson 0.484, 0,326). PP-13 correlated with free beta HCG (Pearson 0.386, all p<0.0001). ANG-2 and pp-13 were the only factors related to BMI, while ANG-2 showed the stronger relationships MAP than PIGF. Smoking had a significant impact on pp-13 levels and only PIGF was related to placental Doppler studies (* =p<0.05, ** =p<0.001, table). PTX-3 had no significant relationships with any study parameter. Conclusion: Of the maternal serum analytes that reflect placental angiogenesis ANG-2 has a closer relationship with maternal vascular risk factors while PIGF relates more strongly to the placental circulation. PP-13 acts as a marker of placental mass illustrating the effects of smoking in the first trimester. These independent relationships support the use of multiple analytes for first trimester screening for placental dysfunction.

P26.04: Limb ischemia in the recipient twin, a form of intrinsic amniotic band sequence?

constrictive sheet of detached or ruptured amniotic membranes, but the actual cause of this rare phenomenon still remains unknown. Report: Two cases of severe TTTS: a 29 weeks monocorial twin gestation which finished at 32 weeks, obtaining a former recipient twin born with a severely compromised left leg, and a case of severe TTTS treated with laser photocoagulation on 17 weeks, finished at 35 weeks, with female newborn with major ischemic injury on left leg. In both cases, histology showed a fusion of ‘‘chorion-nodosumlike’’ cells as well as amnion cells within the fetal dermis, as an imbricated layer, deep inside the granulation chronic inflammatory tissue. Our theory about the cause of this complication is that close contact between a previously compromised, badly perfused limb and mechanically ameliorated chorionic and/or amniotic tissue which stick together early in gestation, giving rise to slow growing amniotic cells inside dermal tissue with a much higher growth rate. This process leads to an inner constriction region secondary to tissue fusion deeply underneath fetal dermis, due to the relatively slower growth of chorionic mesenchyme inside normal tissue of the fetal limb, which eventually restricts circulation and thus, distal perfusion. Conclusion: This pathology may be related to an amnion disruption sequence rather than a thrombotic event. This clinical opinion is offered as a suggestion to encourage fetal medicine groups to collect peri-lesional tissue whenever this complication appears, and so as to look for similar or contradictory findings in order to correctly elucidate the real ethiology of this entity.

OP21.10: Agenesis of the ductus venosus: what is the real clinical relevance?

and the right ventricle, presence and absence of holosystolic tricuspid regurgitation and VCC, and the pulsatility of blood flow pattern in the ductus venosus were analyzed. Results: Six pregnancies were terminated, 1 intrauterine death occurred, 1 ongoing pregnancy and 7 fetuses were lost to follow-up, leaving 28 patients for the analysis. One child died preoperatively. Biventricular repair was performed in 18 cases by interventional opening of the pulmonary valve and in 3 cases by surgical valvolotomy; one of these children died postoperatively. Single ventricle palliation (starting with Blalock-Taussig-Shunt) was performed the other 6 cases. Size of the right ventricle, tricuspid valve size, presence or absence of VCC were correlated with the possibility of biventricular repair and outcome. Tricuspid regurgitation was correlated with absence of VCC and sufficient size of right ventricle and tricuspid valve for biventricular repair. Conclusions: Prenatal echocardiography can accurately diagnose right ventricular outflow tract obstructions. Size of right heart structures and presence or absence of VCC are important for selecting the postnatal treatment and to therefore for prognosis and prenatal counselling.

P05.02: Ultrasound vs. magnetic resonance in fetal central nervous system anomalies, a Markov's chain cost effectiveness analysis

Objective: The objective of this study was to analyze the reasons of fetal cardiomegaly and prenatal and neonatal outcome. Material and methods: Between 2000 and 2008 over 10.000 pregnancies were referred to our department for fetal echocardiography and detailed anomaly scan. All examinations were performed with Voluson 730 Expert and Philips HDI 5500. We measured heart size dividing heart area by chest area (HA/CA). An inclusion criteria was HA/CA ratio 0,45 or more. There were 3 study groups in our series: 1. Cardiomegaly with normal heart anatomy (NHA), and no extracardiac malformations (ECM) 2. Cardiomegaly with congenital heart disease (CHD) without or with ECM, 3. Cardiomegaly and ECM with NHA. Results: Cardiomegaly was identified in 99 fetuses. Of the 99 fetuses we lost follow up in 21 fetuses. Of 78 fetuses 31 hearts were normal with no ECM (Group 1). In this group the most common reason of cardiomegaly were: intrauterine infection (n=10), 40% of demise, twin-twin transfusion syndrome (n=10), 67% of demise, intrauterine growth restriction (n=7) 43% of demise, and arrhythmias (n=5) 60% of demise. Total fetal and neonatal demises in group 1 was 52%. Group 2 (n=28): 12 fetuses had aortic stenosis (42% of demises), 8 fetuses had Ebstein anomaly (75% of demises), 2 fetuses had pulmonary stenosis (100% of demises), and 6 fetuses had complex CHD (67% of demises). The total demises in group 2 was 53%. Group 3: n= 19. There was renal agenesis in 8 fetuses (100% of demises), skeletal malformations in 5 fetuses (80% of demises), 6 fetuses with another fetal malformations including 4 fetuses with urinary tract disease (100% of demises). Conclusion: Cardiomegaly is a serious problem and it’s connected with high rate of demises, independently of the reason of cardiomegaly. All fetuses with cardiomegaly should be referred as soon as possible for fetal cardiology centre for haemodynamic assessment.

OP29.07: Early and late selective intrauterine growth restriction in monochorionic twins: Hospital Vall d'Hebron seven years experience

LCN between twins, first trimester discrepancy identified 3 cases and only one of them was discordant at delivery. So, LCN discrepancy was not a predictor of birthweight discordance by any of these methods (p = 0.72 and p = 0.63 for chi-squared tests respectively). ROC curve using FHTV discrepancy (in %) suggested a significant prediction on birthweight discrepancy. The area under curve was 0.76 and the analysis suggested that the best cut-off was between 15 and 20% of discrepancy reaching sensitivity and specificity around 80%. With a cut-off of 15% 13 cases of first trimester discrepancy were identified. From them, 8 were discordant at delivery (61.5%). So, the identification of 88.9% of cases of birthweight discrepancy (8/9). Conclusions: Measurements of first trimester FHTV can be useful for predicting birthweight discordance.