Manuela Cunha

Screening for twin–twin transfusion syndrome at 11–14 weeks of pregnancy: the key role of ductus venosus blood flow assessment

A discrepancy in crown–rump length (CRL) and/or nuchal translucency thickness (NT) between monochorionic twins has been found to be associated with an increased risk of twin–twin transfusion syndrome (TTTS). As one of the most plausible mechanisms for increased NT is hemodynamic imbalance and cardiac dysfunction, indirectly manifested by abnormal blood flow in the ductus venosus (DV), we aimed to clarify the role of DV blood flow assessment in identifying those monochorionic twins more prone to develop TTTS.

Phenotypic Expression in the First Case of Complete Trisomy 12: Combination of Prenatal Ultrasound and Necropsic Examination

The authors report the first case of a complete trisomy 12 detected antenatally at 16 weeks of gestation. The ultrasonographic features (craniofacial abnormalities) correlated well with postmortem findings. The absence of the hypophysis gland, olfactory pathways and both adrenal glands, as well as developmental anomalies of the central nervous system, were additional findings at autopsy. The recognition of complete trisomy 12 phenotype can be helpful in the pre- and postnatal diagnosis of future similar cases and parental counseling.

Recipient's vascular doppler pattern immediately following death of the donor in a case of untreated severe twin-to-twin transfusion syndrome.

In a stage III twin-to-twin transfusion syndrome, death of the donor at 31 weeks was followed by unusual umbilical artery (UA) doppler findings in the recipient, with a high diastolic peak velocity and a low S/D ratio. Besides, middle cerebral artery waveforms could not be obtained in the recipient. The recipient was delivered by emergency cesarean section, weighed 1,230 g, was strikingly pale and had a cord hemoglobin concentration of 15 g/dl. Neonatal blood average pressure was of 29 mm Hg, immediately after delivery, and ranged from 33 to 43 mm Hg in the first 12 h of life. Neonatal heart function returned to normal on day 2. We hypothesize that death of the donor twin induced an acute decrease in placental resistance. This phenomenon, combined with decreased systolic blood flow due to the recipient’s systolic function impairment, could account for the umbilical artery flow pattern we observed. The acute decrease in volemia and the presence of systemic hypertension and cardiomyopathy may explain the inability to obtain middle cerebral artery doppler. This complex hemodynamic disturbance in the recipient may be responsible for morbidity unrelated to anemia in case of donor’s demise, as acute fetal distress.

Non-viable cervico-isthmic pregnancy: the importance of an accurate sonographic diagnosis to preserve fertility

Background: Cervico-isthmic pregnancy is a rare occurrence and until the use of current ultrasonographic techniques was associated with a disastrous outcome for women desiring to maintain their fertility. Case Report: A 39-year-old woman was diagnosed at 12 weeks of amenorrhoea with an intra-uterine non-viable pregnancy and a low implantation of the gestational sac. Medical management of this situation with a regimen of intravaginal misoprostol was unsuccessful. At introduction of a cervical expander severe vaginal bleeding ensued, leading to an emergency curettage followed by a life-saving hysterectomy. Pathologic examination confirmed the peroperative impression of an isthmic implantation of the gestational sac. Conclusion: Early ultrasonographic diagnosis is essential to make conservative management of cervico-isthmic pregnancy possible.

OC273 Prenatal prediction of pulmonary hypoplasia in prolonged oligohydramnios before 26 weeks: clinical, biometric and pulmonary artery Doppler velocimetry correlates

Methods: Included were fetuses with isolated CDH that were liveborn after 30 weeks’ gestation and had postnatal follow-up until discharge from the hospital. Regression analysis was used to investigate the effect on survival of gestation at diagnosis, o/e total FLV, intrathoracic herniation of the liver, side of CDH and gestation at MRI, institution, year and gestational age at delivery. Results: Some 144 fetuses were evaluated between 22 and 38 weeks. Significant predictors of survival (univariate regression analysis) were the presence or absence of intrathoracic herniation of the liver, side of CDH and o/e total FLV. Multiple regression analysis demonstrated that liver herniation and o/e total FLV provided significant independent prediction of survival. Conclusions: In fetuses with isolated CDH, measurement of o/e total FLV and assessment of intrathoracic herniation of the liver by MRI at 22–38 weeks of gestation provide independent prediction of subsequent postnatal survival at discharge from the hospital.

P49.09: Prospective sonographic diagnosis of accreta in patients with placenta previa

Introduction: The most frequent indication for intra-operatory ultrasound is dilation and curettage procedure and this may be difficult by extreme flexion or version of the uterus. Curet can be guided and with a monitored path between the cervix and endometrial cavity and completely uterine evacuation can be assessed. Methods: Three women with pregnancy complicated by trophoblastic gestational disease were included in this study. All patients showed a typical ultrasound images of trophoblastic gestational disease diagnosed at others hospitals and uterine curettage was done. However, all women persisted with vaginal bleeding and ultrasound showed the permanence of material in uterine cavity after the procedure and so these patients were led to our hospital. The ultrasound showed uterine volume above 300 mL and two patients had retroversion position of the uterus. Curettage was guided by transabdominal ultrasound with fluid-filled bladder appropriate and was performed by a senior obstetric ultrasonographer (transducer of 3–5-Mhz). There was continuous communication between the ultrasonographer and the obstetric surgeon. Ultrasound showed the dilation of cervix and the correct position of the canula of the vacuoextractor in the uterine, monitoring all the procedure and observing the complete evacuation of the uterine material. Ultrasound performed one day after the procedure demonstrated the absence of images of trophoblastic gestational disease. Conclusion: In difficult cases of uterine curettage, ultrasound can be used to help the obstetrician in order to make a safe procedure and total evacuation of uterine cavity in cases of trophoblastic gestational disease.

Clinical impact of ultrasonography between the 10th and the 13th week of pregnancy.

The authors aimed to assess the impact of a routine ultrasound examination performed between 10 and 13 weeks of pregnancy. During a thirty month period, 778 ultrasound examinations between 10 and 13 weeks of pregnancy were performed, in women referred to our hospital. Transvaginal ultrasound was systematically adopted and the parameters obtained were introduced in a computerized data base. Biographic data, first day of menses (whenever possible), menstrual cycle characteristics, eventual use of hormonal contraception in the three months before last menses, antecedents of chromosomal abnormalities, number of foetuses and chorionicity, foetal vitality, crown-rump length, nuchal translucency and foetal heart rate were registered in all examinations. The median gestational age at the time of examination was 12.5 weeks (9-14.3). The median of maternal age was 29 years (14-44), maternal age prevalence higher or equal to 35 years was 17%. Fifty two per cent of women had usually regular menstrual cycles and 11% ignored last menses. In 74% of cases discrepancy between amenorrhea and ultrasound derived gestational age was inferior to one week and in 19% superior. The median of nuchal translucency was 1.4 mm (0.5-10), 7% of all cases had a nuchal translucency higher or equal to 2.5 mm. If maternal age criteria had been decisive for diagnostic invasive procedures, they would have been made in 135 cases. Considering nuchal translucency value combined with maternal age, it should have been done in 63 cases. In our series, invasive testing was performed in 31 (5%) cases. Eight women with fetuses with abnormal karyotypes decided for termination of pregnancy. The importance of ultrasound examination between 10 and 13 weeks seems unquestionable, allowing the correction of gestational age, multiple pregnancy characterisation and chromosomal abnormalities screening.