M. Comas

Assessment of fetal cardiac function using tissue Doppler techniques.

Objective: Tissue Doppler echocardiography is being increasingly used in fetal medicine as a clinical and research tool. The objective of this study was to review the current status of tissue Doppler imaging (TDI) techniques applied to the fetus. Methods: Fetal cardiac function was evaluated using spectral and color TDI modes in normal fetuses and in several clinical conditions. Results: Annular peak velocities and their ratios as well as the myocardial performance index were evaluated using spectral TDI, and changes throughout gestation were described. Color TDI has several limitations in fetal life, particularly the use of low frame rates with current methods of acquisition and the lack of normal references for deformation parameters. Conclusions: Despite its limitations, TDI is a sensitive and promising method to evaluate fetal cardiac function.

Does pre-eclampsia influence fetal cardiovascular function in early-onset intrauterine growth restriction?

Increasing evidence shows that intrauterine growth restriction (IUGR) is associated with fetal cardiac dysfunction. Most studies group IUGR with and without pre‐eclampsia (PE) altogether. Our objective was to evaluate whether the association with PE has any impact on cardiac function in IUGR fetuses

OC03.03: Cardiac dysfunction is present in small‐for‐gestational age fetuses with normal umbilical artery Doppler

Objectives: Tissue Doppler imaging (TDI) echocardiography is a novel imaging tool that allows quantification of a modified fetal myocardial performance index (MPI) in transversal four chamber view in fetuses with intrauterine growth restriction (IUGR). The aim of this study was to compare fetal cardiac function in pregnancies complicated by IUGR with normal controls. Methods: A prospective study was performed on fetuses with IUGR (n = 37, group 1) and normal fetuses (n = 60, group 2) between the 20th and 40th week of gestation by transversal four chamber view colour TDI raw data. Isovolemic contraction time (ICT), isovolemic relaxation time (IRT) and ejection time (ET) were measured offline with TDIQ-Software (Toshiba Medical Systems). The MPI was calculated by the formula (ICT + IRT)/ET for the left (LV) and right ventricle (RV). Results: The measurements were feasible in all cases. The MPI of group 1 was significant elevated in both ventricles (LV: group 1 0.59 ± 0.21/group 2 0.46 ± 0.13, P < 0.0001; RV: group 1 0.68 ± 0.15/group 2 0.47 ± 0.15, P < 0.0001). We identified cut off values for a suspected significant elevated MPI in IUGR fetuses (LV 0.55, specificity 70%, sensitivity 70%, ROC: area under curve 0.73/RV 0.60, specificity 83%, sensitivity 71%, ROC: area under curve 0.85). Conclusions: This is the first report of quantification of radial modified MPI by TDI in IUGR fetuses and normal controls. IUGR fetuses showed signs of fetal myocardial dysfunction. TDI is a useful new ultrasound tool for quantification and monitoring of abnormal myocardial function in high-risk pregnancies.

P12.01: Reference ranges for fetal myocardial velocities and performance indexa using tissue Doppler at 24–41 weeks of gestation

Objectives: To construct gestational age-based reference ranges for tissue Doppler parameters in fetuses from 24 to 41 weeks of gestation. Methods: A prospective cross-sectional observational study involving 207 uncomplicated singleton pregnancies between 24 and 41 weeks of gestation. Myocardial peak velocities and myocardial performance index (MPI’) were measured by tissue Doppler in left and right annulus. Left and right atrioventricular flows were also measured by conventional Doppler and E/E′ ratios calculated. Regression analysis was used to determine gestational-age specific reference ranges and to construct normograms for tissue Doppler parameters. Results: All myocardial peak velocities showed a progressive increase with advancing gestation as well as left MPI’ (Table 1). Right MPI’ remained constant. In contrast, left and right E/E′ showed a progressive decline. Conclusions: Normal data of fetal tissue Doppler parameters during second half of pregnancy are provided. The reported reference values may be useful in future research or clinical studies of fetal cardiac function.

OC09.06: Semiautomatic endocardium deformation analysis to assess fetal cardiac function: clinical feasibility and comparison with tissue Doppler imaging

A STIC volume was also acquired and saved. In post-processing, the volume was rotated to show an apical 4CV. M-mode was applied to the tricuspid annulus, and the amplitude of the resulting wave was measured (mm). Three TAPSE measures were taken and results averaged. Measurements were performed by two observers and interand intra-observer variations were calculated. Results: 50 women were recruited at 20 to 38 wks. STIC-TAPSE values were plotted against GA and estimated fetal weight, and these scatterplots compared to those obtained from conventional M-mode TAPSE. Good correlation was found between the two methods. Interand intra-observer variation in STIC-TAPSE were < 15%. Length of post-processing measurement was 30–60 seconds, and decreased following a learning curve. Conclusions: STIC-TAPSE is easy to perform and can be measured even on archival cases. We suggest that this measure may be added to the basket of tests of right heart function, such as ventricular volume, ventricular mass, ejection fraction, etc.

OP23.01: Cardiac function assessed by tissue Doppler myocardial velocities in fetuses with growth restriction

gestation who underwent fetoscopic laser surgery at four centers in Japan. We assessed perinatal survival, survival at 6 months of age, and neurological complications. A conditional logistic regression was performed using preoperative ultrasonographic variables to estimate adjusted odds ratios (OR) for fetal or neonatal death. Results: Survival of at least one twin at 28 days and 6 months of age were 91.2% and 90.1%, respectively. Survival at 6 months of age without major neurological complications was 72.4%. There were no differences in at least one survivor at 28 days of gestation between Quintero stage 1 or 2 (90.9%) and 3 or 4 (91.2%). However, two survivors at 28 days of gestation were significantly lower in Quintero stage 3 or 4 (59.1%) than 1 or 2 (81.8%). The significant independent variables of the preoperative ultrasound findings for fetal or neonatal death of the donor were reversed (OR: 9.29, 95% confidence interval (CI): 2.86–30.14) or absent (OR: 3.87, CI: 1.81–8.29) end-diastolic velocity in the umbilical artery, and reversed blood flow in the ductus venosus (OR: 2.45, CI: 0.41–14.64) of the donor. Those for neonatal death of the recipient were reversed blood flow in the ductus venosus (OR: 2.25, CI: 0.95–5.34) and hydrops of the recipient (OR: 2.14, CI: 0.76–6.05). Conclusions: Survival of at least one twin after fetoscopic laser surgery reached 90%, regardless of the stage. Two survivors were decreased in Quintero stage 3 or 4. Reversed or absent end-diastolic velocity in the umbilical artery of the donor, reversed blood flow in the ductus venosus of the donor or recipient, and hydrops of the recipient were associated with one fetal and one neonatal death.

OP19.13: Intra‐ and interobserver reliability of tissue Doppler for measurement of fetal myocardial velocities

Objective: To compare fetal umbilical vein flow measurement on free-floating (FF) and intra-abdominal (IA) portions. Methods: Prospective measurement of the umbilical venous volume flow (UVVF) in 13 normal pregnancies during routine antenatal ultrasounds. Umbilical vein cross-sectional diameter was measured in the IA umbilical vein, and in perpendicular views of FF portions of the cord. Velocity measurements were obtained using angle correction. Means were compared using Student T-test for related measures and intra-class correlation coefficient (ICC) was calculated by a two-way ANOVA model. Results: All measurements were done by two operators, blind to each other (MY and JC). For FF, mean vessel diameter showed an inter-observer ICC of 0.96. Mean blood velocity showed an interobserver ICC of 0.88. Mean angle correction used for Operator 1 was of 25,5◦, and for Operator 2 the mean correction reached 22.38◦, with an inter-observer ICC of 0.48. Vessel area and UVVF displayed an inter-observer ICC of 0.96 and 0.93, respectively. For IA, mean vessel diameter measurement showed an inter-observer ICC of 0.91. Mean blood velocity inter-observer ICC was of 0.45. Mean angle correction used was of 32.15◦ and 27.80◦, a non significant difference (p = 0.47), but with a poor inter-observer ICC (slight to none correlation, −0.98). Regarding vessel area and UVVF results, inter-observer ICC resulted of 0.91 and 0.74, respectively. Conclusions: When comparing UV blood flow between free-floating and intra-abdominal portions, our study shows a difference in UVVF calculations (inter-observer ICC 0.93 versus 0.74), attributable to the significant difference in the reliability of insonation angles for measuring IA portions (inter-observer ICC −0.98). These results validate the special attention to be addressed for a correct insonation angle for obtaining the blood velocity.

OP08.03: Chromosomal anomalies spectrum in missed miscarriages in relation to embryo appearance

Mean z-score, 95% CI and centile corresponding to the mean were calculated. One-sample t tests were carried out to verify if z-score distribution is equal to zero. Finally, we compared z-scores of male and female fetuses with Down syndrome (DS) by the means of two sample t test. Results: 132 CHA pregnancies was eligible for designed analysis, of which 80 cases with DS, 20 with Edwards syndrome (ES), 7 with Patau syndrome (PS), 17 with Turner syndrome (TS) and 8 with triploidy. The results are summarized in table. We proved no difference in growth pattern of fetuses with DS. The separate comparison of female and male fetuses with DS also revealed no significant difference (p>0,2). Otherwise, we observed significant growth restriction – similar in PS and TS (around 5th centile), severe in ES (0,5th centile) and the most striking in triploidies (<0,003th centile). Conclusions: Statistical analyses showed no significant difference in growth pattern of DS fetuses, regardless of their sex. By contrast, in TS, PS, ES and triploidy there was growth restriction of various extent, deepening in mentioned order.

OP21.01: Congenital heart disease in fetuses with abnormal ductus venosus blood flow and normal karyotype

Objectives: To prospectively investigate the correlation between maternal distress after prenatal diagnosis of fetal malformations and the feto-maternal circulation. Methods: A cohort of women (group A, n = 30) carrying a fetus with a non-cardiac malformation underwent Doppler blood flow measurements and psychometric evaluation at fixed points from the time of diagnosis throughout pregnancy. The same protocol was used in controls (group B, n = 29) with presumably healthy fetuses. At 29–31 weeks gestational age (GA), mean uterine artery (UtA) pulsatility index (PI), umbilical artery (UA) PI, middle cerebral artery (MCA) PI, and ductus venosus (DV) PI for veins (PIV) were measured. MCA/UA PI ratio (MCA/UA) was calculated. Psychological distress was measured by Impact of Event Scale (IES) self-report questionnaire. IES subscores for intrusion, avoidance, and arousal were calculated. Results: There were no significant differences in GA or parity between the groups. Median maternal age was significantly lower in group A (31.0 yrs (19–40) vs. 33.0 (23–39), P = 0.034), but this was not correlated with either parity or any of the outcome measures. Doppler findings did not differ significantly between the groups except UtA PI (A: 0.63 ± 0.13 vs. B: 0.74 ± 0.15, P = 0.006). IES scores were significantly higher in group A (IESsum P = 0.003, intrusion P = 0.002, avoidance P < 0.001, arousal P = 0.015). In the overall group, the only correlation between Doppler results and psychometric scores was found between UA PI and avoidance (r = 0.281, P = 0.034). In group A there was a correlation between both MCA PI and MCA/UA, and IESsum (r = −0.456, P = 0.011; r = −0.380, P = 0.038), intrusion (r = −0.475, P = 0.008; r = −0.436, P = 0.016), and avoidance (r = −0.368, P = 0.045; r = −0.375, P = 0.041), respectively. Conclusions: In women carrying a fetus with known malformation there may be a correlation between maternal distress and the fetal cerebral circulation at 30 weeks of GA.

OC212: Risk assessment of pre-eclampsia and IUGR in patients with normalization of the uterine artery Doppler study between 20 and 24 weeks

although the NDI was defined as zero in the absence of a notch. The averaged values of resistance index (RI) and NDI from the right and left uterine artery were used for statistical analysis. We measured the serum levels of PlGF and sFlt-1 during both 16–23 and 27–29 weeks of gestation. The cut-off values for RI, NDI, sFlt-1 and sFlt-1/PlGF ratio were set at the 90th percentile, and the cut-off value for PlGF at the 10th percentile. Results: Pre-eclampsia occurred in 5.0%. The area under the curve (AUC) of NDI for pre-eclampsia was larger than that of RI (0.777 vs. 0.687), and the AUC of PlGF was larger than that of sFlt-1 in the second trimester (0.672 vs. 0.561). Therefore, we selected the NDI and PlGF as the appropriate risk factors for the occurrence of pre-eclampsia. In women with both normal (Group 1, n = 221), only abnormal PlGF (Group 2, n = 14), only abnormal NDI (Group 3, n = 16), and both abnormal (Group 4, n = 9), the frequencies of high sFlt-1/PlGF ratio in the early third trimester were 6.8%, 21.4%, 0%, and 100%, respectively (P < 0.001), and the frequencies of pre-eclampsia were 2.7%, 0%, 6.3% and 66.7%, respectively (P < 0.001). Conclusions: A high sFlt-1/PlGF ratio in the early third trimester and pre-eclampsia may frequently occur in women with both a high NDI and low PlGF levels in the second trimester.