Jena Miller

Fetal Growth Restriction

Normal fetal growth is determined by the genetically predetermined growth potential and further modulated by maternal, fetal, placental, and external factors. Fetal growth restriction (FGR) is a failure to reach this potential and is clinically suspected if sonographic estimates of fetal weight, size, or symmetry are abnormal. Integration of fetal anatomy assessment, amniotic fluid dynamics, uterine, umbilical, and fetal middle cerebral artery Doppler is the most effective approach to differentiate potentially manageable placenta-based FGR from aneuploidy, nonaneuploid syndromes, and viral infection. Although placental dysfunction results in a multisystem fetal syndrome with impacts on short- and long-term outcome, only cardiovascular and behavioral responses are helpful to guide surveillance and intervention. Early-onset FGR before 34 weeks gestation is readily recognized but challenging to manage as questions about optimal delivery timing remain unanswered. In contrast, near-term FGR provides less of a management challenge but is often missed as clinical findings are more subtle. Once placenta-based FGR is diagnosed, integrating multivessel Doppler and biophysical profile score provides information on longitudinal progression of placental dysfunction and degree of fetal acidemia, respectively. Choosing appropriate monitoring intervals based on anticipated disease acceleration and intervention when fetal risks exceed neonatal risks are the prevailing current management approaches.

Discordant twins: diagnosis, evaluation and management.

Approximately 16% of twin gestations have discordance of at least 20%. We identified 14 risk factors for divergent growth that can be categorized as maternal, fetal, or placental. Determination of chorionicity and serial ultrasound evaluation with a high index of suspicion for divergent growth is required for the diagnosis and stratification of risk. The highest reported likelihood ratio for detection of discordance was 5.9 during the first trimester examination and 6.0 for the second trimester. Although our ability to identify discordant twins is limited, once suspected and at viable gestational age, these pregnancies should have antepartum testing. Discordant growth alone is not an indication for preterm birth. Although there are multiple publications on the increased morbidity and mortality rates with discordant growth, there is a paucity of reports on how to manage them optimally and deliver them in a timely manner.

Integrated Testing and Management in Fetal Growth Restriction

Growth-restricted fetuses are at higher risk for poor perinatal and long-term outcome than those who are appropriately grown. Multiple antenatal testing modalities can help document the sequence of fetal deterioration. The full extent of this compromise is best identified by a combination of fetal biometry, biophysical profile scoring, and arterial and venous Doppler. In the preterm growth-restricted fetus, timing of delivery is critically determined by the balance of fetal versus neonatal risks. In the near-term fetus, accurate diagnosis continues to be a challenge as unrecognized growth restriction contributes to a significant proportion of unexplained stillbirths. In this review, we present an integrated diagnostic and surveillance approach that accounts for these factors.

Decreased fetal cardiac performance in the first trimester correlates with hyperglycemia in pregestational maternal diabetes

In‐vitro animal studies suggest that high glucose levels impair fetal cardiac function early in gestation. We aimed to study whether evidence of first‐trimester myocardial dysfunction can be detected in fetuses of women with pregestational diabetes mellitus.

Perinatal outcomes after second trimester detection of amniotic fluid viral genome in asymptomatic patients.

Abstract Objective: Symptomatic fetal viral infection can affect placental and fetal development and may lead to non-immune hydrops or fetal death. All infections are not detectable by clinical history or ultrasound and a background positivity rate exists in asymptomatic patients. We investigated if intraamniotic presence of viral genome at the time of genetic amniocentesis in asypmtomatic patients affects perinatal outcome. Study design: Six-hundred and eighty-six pregnancies referred for second trimester genetic amniocentesis with a normal ultrasound and fetal karyotype had amniotic fluid multiplex polymerase chain reaction for adeno-, cytomegalo-, Ebstein-Barr-, entero- and parvovirus. Forty asymptomatic patients that were positive for viral genome were matched 2:1 with negative controls. Perinatal outcomes were compared between these groups. Results: Pregnancy complications and perinatal outcomes were similar in the two groups. Conclusion: Asymptomatic fetal viral infection at the time of second trimester amniocentesis does not increase the risk for adverse perinatal outcome.

Maternal body mass index does not affect performance of fetal electrocardiography.

The obesity epidemic challenges traditional antenatal fetal heart rate (FHR) monitoring technologies. Doppler signals in particular are attenuated. We sought to evaluate whether the performance of a novel transabdominal fetal electrocardiogram (fECG) device (AN24, Monica Healthcare) is influenced by body mass index (BMI). We performed a prospective observational study of singleton pregnancies (gestational age [GA] 20 to 41 weeks) monitored overnight with fECG. Recording quality ([RQ] %) of both the best hour and the total recording time of the FHR record were related to BMI. Two hundred four women were monitored. BMI ranged from 16.0 to 50.7 (median BMI 26.9). The correlation coefficient (with 95% confidence interval [CI]) between BMI and RQ was -0.35 (CI -0.60; -0.03) for the gestational age group 20(+0) to 25(+6) weeks, -0.08 (CI -0.28; 0.13) for GA 26(+0) to 33(+6) weeks, and -0.20 (CI -0.40; 0.03) for GA group > or =34(+0) weeks. Median RQ in obese women (BMI > or =30 kg/m(2)) was 97.4, 98.9, and 100%, respectively. BMI has no clinically significant influence on recording quality of FHR monitored with fECG. It can therefore be considered a good method for monitoring the fetal condition in pregnancies of obese women.

First-trimester detection of fetal anomalies in pregestational diabetes using nuchal translucency, ductus venosus Doppler, and maternal glycosylated hemoglobin.

OBJECTIVE The frequency of fetal anomalies in women with pregestational diabetes correlates with their glycemic control. This study aimed to assess the predictive performance of first-trimester fetal nuchal translucency (NT), ductus venosus (DV) Doppler, and hemoglobin A1c (HbA1c) to predict fetal anomalies in women with pregestational diabetes. STUDY DESIGN This was a prospective observational study of patients undergoing first-trimester NT with DV Doppler. Screening performance was tested for first-trimester parameters to detect fetal anomalies. RESULTS Of 293 patients, 17 had fetal anomalies (11 cardiac, 7 major, 3 multisystem). All anomalous fetuses were suspected prenatally. One had NT >95th centile, 2 had reversed DV a-wave, and 13 had HbA1c >7.0%. The HbA1c was the primary determinant of anomalies (r(2), 0.15; P < .001) and >8.35% was the optimal cutoff for prediction of anomalies with an area under the curve of 0.72 (95% confidence interval, 0.57-0.88). Therefore, first-trimester prediction of anomalies was best in women with increased NT or HbA1c >8.3% (sensitivity 70.6%, specificity 77.4%, positive predictive value 16.2%, negative predictive value 97.7%, P < .001). CONCLUSION In women with pregestational diabetes and poor glycemic control, an increased NT increases risks for major fetal anomalies. Second-trimester follow-up is required to achieve accurate prenatal diagnosis.

OC01.02: A step towards standardization in sonographic assessment of fetal venous system: sequential analysis of five‐transverse views

L. Rode1,2, K. Klein3, K. Nicolaides4, E. Krampl-Bettelheim3, I. Vogel5, H. Larsen6, A. Holmskov7, K. Riis Andreasen8, N. Uldbjerg9, J. Ramb10, B. Bødker11, L. Skibsted12,2, L. Sperling13, S. Hinterberger14, L. Krebs15, H. Zingenberg16, E. Weiss17, I. Strobl18, L. Laursen19, J. Tranberg Christensen20, B. M. Hansen21, A. Lando21, A. Tabor1,2 1Department of Fetal Medicine 4002, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; 2Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark; 3Department of Obstetrics & Gynecology, Medical University of Vienna, Vienna, Austria; 4Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, United Kingdom; 5Department of Clinical Genetics, Aarhus University Hospital Skejby, Aarhus, Denmark; 6Department of Obstetrics & Gynecology, Aalborg Hospital, Aalborg, Denmark; 7Department of Obstetrics & Gynecology, Viborg Hospital, Viborg, Denmark; 8Department of Obstetrics & Gynecology, Hvidovre Hospital, Hvidovre, Denmark; 9Department of Obstetrics & Gynecology, Aarhus University Hospital Skejby, Aarhus, Denmark; 10Department of Obstetrics & Gynecology, Sønderborg Hospital, Sønderborg, Denmark; 11Department of Obstetrics & Gynecology, Hillerød Hospital, Hillerød, Denmark; 12Department of Obstetrics & Gynecology, Roskilde University Hospital, Roskilde, Denmark; 13Department of Obstetrics & Gynecology, Herlev Hospital, Herlev, Denmark; 14Department of Obstetrics & Gynecology, General Hospital of Klagenfurt, Klagenfurt, Austria; 15Department of Obstetrics & Gynecology, Holbæk Hospital, Holbæk, Denmark; 16Department of Obstetrics & Gynecology, Glostrup Hospital, Glostrup, Denmark; 17Department of Obstetrics & Gynecology, Medical University of Graz, Graz, Austria; 18Department of Obstetrics & Gynecology, Medical University of Innsbruck, Innsbruck, Austria; 19Department of Obstetrics & Gynecology, Odense University Hospital, Odense, Denmark; 20Department of Obstetrics & Gynecology, Gentofte Hospital, Gentofte, Denmark; 21Department of Neonatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark

OC26.02: Maternal hyperglycemia affects first trimester fetal cardiac function in normal hearts

Objectives: Non invasive measurement of fetal vascular flow remains an elusive matter, accuracy of current tools is very limited and relies mainly in operator skills. The aim of our study was to develop a tool for indirect flow measurement, accurate and repeatable, by using power Doppler signal, Real time three dimensional ultrasound (4DPD) and mathematical image data simulation and adjustment tools based on artificial neural networks (ANN). Methods: Six pregnant sheep with adequately controlled gestational age of 125 days (near term) were surgically instrumented to access fetal ascending aorta by transventricular catheterization. Cardiac output was measured by Fick thermodilution, as well as by pulsed Doppler. Several sets of 4DPD volumes were taken during the procedure. Measurements were stored in an electronic datasheet. Pearson’s correlation coefficient and simple linear regression were obtained. Linear equation matrix were generated and obtained data was evaluated through an error adjustment process by employing an artificial neural network software (ANN). Results: A total of 30 sets of measurements in controlled conditions were collected during the study period. A mean of six measurements by cardiac cycle were digitally obtained from the velocity curve. A six by six matrix of data was designed for every measurement. Mean velocity at every time was calculated and compared to actual data, intraclass correlation coefficient (95% CI) was 0.9 (0.73–0.99). ANN predicted calculated measurements in 99% of cases. Conclusions: 4DPD might be a reliable, accurate, non invasive tool for fetal vascular flow measurement.

171 – Doppler Ultrasound Evaluation of the Fetus and Placenta

Abstract Doppler ultrasound can be used to assess vascular beds in the maternal, fetal, and placental circulation. The vessels most frequently evaluated in clinical practice are the uterine, umbilical and (fetal) middle cerebral arteries, and the ductus venosus. Evaluation of blood flow in various vascular beds, combined with clinical information, provides insight into maternal adaptation to pregnancy, placental resistance, and fetal cardiovascular status, and may therefore guide pregnancy management.