M. Suto

Differences in insulin sensitivity in pregnant women with overweight and gestational diabetes mellitus

Aim. The purpose of the present study was to investigate changes in insulin sensitivity using homeostasis model assessment (HOMA) and the quantitative insulin sensitivity check index (QUICKI) in normal-weight and overweight women with normal glucose tolerance (NGT) and gestational diabetes mellitus (GDM) during pregnancy. Methods. Ninety-two pregnant women in the first trimester, 202 in the second trimester and 154 in the third trimester were enrolled in this study. Fasting plasma glucose and insulin concentrations were measured in all women in the first, second and third trimesters. HOMA indices (insulin resistance, HOMA-IR and β-cell function, HOMA-β) and QUICKI were calculated from fasting glucose and insulin concentrations. Results. HOMA-IR values in overweight women with NGT and in women with GDM were significantly (p < 0.01) higher than those in normal-weight women with NGT. HOMA-IR in women with GDM increased significantly (p < 0.05) during pregnancy, but HOMA-IR values in normal-weight and overweight women with NGT did not change significantly with advance of gestation. QUICKI values in overweight women with NGT and in women with GDM were also significantly (p < 0.01) lower than those in normal-weight women with NGT, and QUICKI in women with GDM decreased significantly (p < 0.05) during pregnancy. HOMA-β in normal-weight women with NGT increased significantly (p < 0.01) during pregnancy. Conclusion. We showed that insulin sensitivities determined by using HOMA-IR and QUICKI in overweight women with NGT and women with GDM were lower than those in normal-weight women with NGT, and that insulin sensitivity in women with GDM declined with advance of gestation.

Differences in bone metabolism between singleton pregnancy and twin pregnancy

OBJECTIVE The objective of this study was to examine the influence of twin pregnancy on calcium metabolism, including bone turnover markers and calcium-regulating factors, by comparison between singleton pregnancy and twin pregnancy in women during pregnancy and puerperium in cross-sectional and longitudinal studies. METHODS Women with singleton and twin pregnancies were recruited from the outpatient clinic of Tokushima University Hospital. In both cross-sectional and longitudinal studies, bone formation and resorption markers, mineral metabolism and calcium-regulating factors were measured at 10, 25, 30 and 36 weeks of pregnancy and at 4 days and 1 month postpartum in women with singleton and twin pregnancies. RESULTS Urinary levels of cross-linked type I collagen N-telopeptides and C-terminal telopeptides of type I collagen in women with twin pregnancy were significantly higher than those in women with singleton pregnancy and those high levels were observed earlier than those in women with singleton pregnancy. In the cross-sectional study, serum levels of bone-specific alkaline phosphatase, calcium and phosphate in women with twin pregnancy were higher and the levels of 1,25-(OH)2 vitamin D and 25-(OH) vitamin D in women with twin pregnancy were lower than those in women with singleton pregnancy. CONCLUSION Changes in bone metabolism in women with twin pregnancy are different from those in women with singleton pregnancy. Early and large increases in bone turnover markers allow women with twin pregnancy to meet high fetal demand for calcium during pregnancy.

Simultaneous recordings of pulsed wave Doppler signals in hepatic vein and descending aorta using dual Doppler: a novel method for evaluating fetal arrhythmias

Fetal arrhythmias, which affect 1–2% of pregnancies, are common1. Cardiac-rhythm analysis involves recording atrial and ventricular contractions simultaneously. Fouron and Reed introduced simultaneous pulsed Doppler interrogation of flow in the superior vena cava (SVC) and the ascending aorta (AAo) to assess fetal cardiac rhythms2,3. The SVC-AAo method is widely used to analyze fetal arrhythmias. A-wave reversal in the SVC during atrial systole, and forward flow in the AAo, indirectly define the mechanical relationship between atria and ventricles. However, numerous factors can influence success with this method. Doppler interrogation of low-velocity SVC atrial systolic flow depends on an optimal angle of insonation and a low set wall-motion filter, rendering the signal susceptible to contamination. Furthermore, the A-wave in the SVC might be hidden within the arterial systolic flow spectrum in the AAo and thus be difficult to interpret. When atrial systole coincides with ventricular systole in arrhythmias, the Awave may not be distinguished from the arterial systolic flow spectrum, or vice versa. The Doppler gate can be placed simultaneously over other arteries and veins (e.g. pulmonary and renal arteries and veins)4–6. These techniques are less limited by the fetal position than is the SVC-AAo method. However, as with the SVC-AAo method, the venous A-wave might be hidden within the arterial systolic flow spectrum when atrial systole coincides with ventricular systole. To evaluate fetal arrhythmias, we simultaneously recorded pulsed wave Doppler signals in the hepatic vein and the descending aorta (DAo) using dual Doppler. Dual Doppler has two separate sample gates, thus allowing simultaneous recording of signals from two locations. We obtained dual Doppler recordings using a Preirus or a EUB-7500 (Hitachi Aloka Medical, Ltd., Tokyo, Japan) ultrasound device. Hepatic veins were visualized in color flow mode in a transverse section of the fetal abdomen, spreading out from the inferior vena cava (IVC) between

Plasma adipokine concentrations in overweight/obese pregnant women: a longitudinal study

Abstract The purpose of this study was to investigate the differences in plasma concentrations of adipokines in pregnant women with varying body mass indices (BMIs) with every trimester. In this study, 89 pregnant women were recruited. These women were divided into lean, normal, and overweight/obese groups. Serum levels of adiponectin, resistin, leptin, and visfatin were measured in the first, second, and third trimesters. In the overweight/obese group, adiponectin, resistin, and visfatin concentrations were not significantly affected by advanced gestational age. Leptin concentrations in the third trimester were significantly higher than those in the first and second trimesters. Adiponectin concentrations in the overweight/obese group were significantly lower than those in the lean group in the first and second trimesters. Visfatin concentrations in the overweight/obese group were significantly higher than those in the normal group in the first trimester. Leptin concentrations in the overweight/obese group were significantly higher than those in the lean and normal groups in all trimesters. In the first trimester, the largest differences were observed between the overweight/obese group compared to the lean and normal group. The changes in adipokines in overweight/obese groups are different from those in lean and normal groups.

OP27.03: Evaluation of fetal arrhythmia from simultaneous recordings of pulsed wave Doppler signals in hepatic vein and descending aorta using Dual Doppler

Objectives: Echocardiography is the most commonly used modality for diagnosing fetal arrhythmias. Although simultaneous Doppler recording at the superior vena-cava (SVC) and the ascending aorta (aAo) is thought to be the most reliable method for analyzing the relation between the atrial and ventricular contraction, the relatively difficult technic and unclear interpretation are often problem for this method. In this study, we evaluated the relation between a small diastolic flow in the aAo (SDFAo) and an atrial contraction, and assessed the usefulness of making analyzing fetal heart rhythms using the SDFAo. Methods: First, to find the cause of the SDFAo, we obtained simultaneous recording of electrocardiogram, Doppler echocardiographic wave form at the aAo, color Doppler mapping, and color M-mode in neonates. Next, we measured AV interval in 83 fetal echocardiographic examinations using the two methods, the simultaneous SVC-aAo Doppler waveform and the SDFAo, and compared. Finally, we assessed fetal arrhythmias in SDFAo method and assessed the usefulness for assessing the heart rhythms. Results: In the neonatal examination, SDFAo is found to be created by posterior movement of the aAo due to atrial contraction. The interval between SDFAo and systolic flow at the aAo is the same as the PR interval by ECG. Next, in the fetal examination, AV interval measured using the SDFAo method is well correlated to that with the SVC-aAo method (r2 = 0.322, P < 0.001). Finally, in the case with fetal heart block, the SDFAo method was much easier and clearer for assessing atrial contraction than the SVC-aAo method. However, the SDFAo method can not detect atrial contraction during fetal tachycardia and paroxysmal contraction. Conclusions: The SDFAo method can be used to detect atrial contraction for measuring AV interval, and for analyzing fetal bradyarrhythmias. This method is much easier and more practical for analyzing fetal heart rhythms than SVC-aAo method.

OP30.09: Assessment of fetal atrioventicular time intervals by dual Doppler in hepatic vein and descending aorta

achieve > 250 fps. For each acquisition, 15s of non compressed data were stored in cine-loop format and analyzed offline. Aortic valve closure was marked from aortic flow and the onset of each cardiac cycle was manually indicated in the 2D images. Sample volume and area length were standardized at the minimum size. Two observers measured peak systolic left ventricular strain and strain-rate. Results: Strain and strain-rate measurements were feasible in 93% of the acquisitions. Mean time spent for 2D strain was 9 min with intraclass agreement coefficient of 0.89 (95% CI 0.76–0.95) and 0.89 (95% CI 0.78–0.94) for strain and strain-rate respectively. Agreement between observers using 2D strain showed a mean difference of 0 with 95% limits of agreement −8.1 to +8.1 for strain and 0 (−1.2 to 1.1) for strain-rate. Mean time for TDI was 14 min with an intraclass agreement of 0.65 (95% CI 0.41–0.83) and 0.63 (95% CI 0.36–0.82) for strain and strain-rate respectively. Agreement between observers using TDI showed a mean difference of 3.2 (−14 to 21) for strain and 0.1 (−5.6 to 5.8) for strain-rate. Conclusions: Evaluation of strain and strain-rate of the fetal heart is feasible by 2D strain or TDI and has reproducibility similar to previous data in adults.

P10.07: Ultrasonographic and magnetic resonance imaging (MRI) detection of placenta accreta

the study. The VCI-C method was used. Polynomial regressions with adjustments using the determination coefficient (R2) were used to assess the correlation between vertebral body area and gestational age (GA) and fetal parameters [biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (F) and estimated fetal weight (EFW)]. The mean, standard deviation, median, minimum and maximum values were calculated for each gestational age. Results: There was a high correlation between all VBA and GA. The linear regression was the model that best expressed the correlation between these variables: VBA L1 = −168.8106 + 10.0482 *GA, r2 = 0.8154 for the first lumbar vertebral body. The mean VBA L1 went from 33.55 ± 5.46 cm2 (28.09–39.02 cm2) to 181.36 ± 5.77 cm2 (175.59–187.13 cm2). There was a high correlation between all VBA and fetal biometric parameters (BPD, HC, AC, F and EFW), all P < 0.0001. Conclusions: There was a high correlation between GA and biometric parameters. Reference limits were generated for lumbar and sacral (S1 and S2) VBA between 20 and 34 weeks.

P03.12: Prenatal diagnosis of left superior vena cava draining into left atrium with absent right superior vena cava: a case report

indicative of TAPVD. A detailed scan at a tertiary care center revealed that the vessel was connected to the supra vena cava (SVC), leading to a diagnosis of type Ib TAPVD. At birth (39 weeks), the female neonate (birth weight, 2.9 kg) was in good condition with Apgar scores of 8/8. She also had hepatic hemangioma. Eleven days after birth, the infant underwent successful surgical repair. Case 2: A 38-year-old woman, G1P1, with a previous pregnancy with TAPVD, had a screening scan at 34 weeks. A relatively small LA and an abnormal vessel between the LA and dAo were detected. The right and left PVs appeared to drain into the vessel, which was connected to the vertical vein (VV) piercing the diaphragm. These findings led to a diagnosis of type III TAPVD. This diagnosis was supported by a detailed scan at a tertiary care center, which also revealed a connection of the VV to the left portal vein. At 38 weeks, the female infant (birth weight, 3.1 kg) was born with Apgar scores of 8/8. Soon after birth, she presented with severe cyanosis, which necessitated immediate surgical repair within three hours of birth. Nevertheless, the infant suffered from a critical condition, with persistent chylous pleural effusion and ascites, and died at 6 months after birth. Thus, discrepant size of the right and left heart, a common feature of TAPVD during fetal life, was not apparent in our cases. Sonographic signs of TAPVD may include presence of a wide gap and an abnormal vessel between the LA and dAo. Attention to such signs, coupled with intensive use of color Doppler imaging, should serve to detect more cases of TAPVD prenatally.

P02.83: Placental mesenchymal dysplasia concomitant with fetal abdominal lymphangioma

gestation. Postnatal evaluation confirmed: V lumbar hemivertebrae; A imperforate anus and rectovaginal fistula; C subaortic IVC; TE esophagic atresia with tracheo esophagic fistula; R Hydronephrosis L unilateral talus. Comment: Between Nov 1998 and March 2006 in our institution, this is the first case of VACTERL syndrome presented in 43 000 deliveries. The diagnosis was suspected when an association of anomalies was found in a comprehensive ultrasound; despite that the urological condition was different from the prenatal diagnosis. This case confirms the need of a thorough evaluation of the fetal anomaly as soon as one anomaly has been found.

P04.05: Atypical inferior vena cava and ductus venous blood flow velocity pattern in the fetus with Ebstein's anomaly: a case report

We present a case of Ebstein’s anomaly with tri-phasic inferior vena cava (IVC) and ductus venosus (DV) forward flow pattern. Pulsed tissue Doppler imaging (TDI) were performed to elucidate the relationship of the atypical venous flow and the ventricular wall motions. A 32 year-old nulliparous woman conceived a monochorionic-diamniotic twin pregnancy by IVF. On a routine fetal sonography at 14 weeks of gestation, Twin A showed cardiomegaly (cardio-thoracic ratio: 53%) and severe tricuspid regurgitation (TR). Another twin was sonographically unremarkable. With advance of gestation, fetal echocardiography on Twin A revealed right atrial enlargement, severe holosystolic TR (1.3m/sec), the enlarged sail-like anterior leaflet of tricuspid valve (TV), and retrograde pulmonary artery and ductal flow in the absence of pulmonary regurgitation. Posterior and septal leaflets of TV were not detected. For sonographic findings stated above, Ebstein’s anomaly and pulmonary atresia was prenatally diagnosed. Pulsed Doppler examination showed tri-phasic IVC and DV forward flow pattern. Pulsed TDI recording of the right atrioventricular valve ring showed abnormal shortening after S wave from late systolic phase to isovolumic relaxation phase of the cardiac cycle. This abnormal shortening synchronized with the second wave of IVC and DV forward flow, and the left ventricle showed the same shortening. There were no sign of fetal arrhythmia or hydrops fetalis. A Cesarean section was performed at 36 weeks of gestations. Twin A was a female infant weighing 2290g with Apgar scores of 2 and 6 at 1 and 5 minutes, respectively. Postnatal diagnosis was the same as prenatal assessment. Starnes operation was performed at 6th day after birth. But she died at the 7th day because of cardiac failure. In conclusion, we detected tri-phasic IVC and DV forward flow pattern in the fetus with Ebstein’s anomaly. We speculate that the abnormal ventricular motion caused the atypical venous flow pattern.