Niek Exalto

Predicting adverse obstetric outcome after early pregnancy events and complications: a review

BACKGROUND The aim was to evaluate the impact of early pregnancy events and complications as predictors of adverse obstetric outcome. METHODS We conducted a literature review on the impact of first trimester complications in previous and index pregnancies using Medline and Cochrane databases covering the period 1980-2008. RESULTS Clinically relevant associations of adverse outcome in the subsequent pregnancy with an odds ratio (OR) > 2.0 after complications in a previous pregnancy are the risk of perinatal death after a single previous miscarriage, the risk of very preterm delivery (VPTD) after two or more miscarriages, the risk of placenta praevia, premature preterm rupture of membranes, VPTD and low birthweight (LBW) after recurrent miscarriage and the risk of VPTD after two or more termination of pregnancy. Clinically relevant associations of adverse obstetric outcome in the ongoing pregnancy with an OR > 2.0 after complications in the index pregnancy are the risk of LBW and very low birthweight (VLBW) after a threatened miscarriage, the risk of pregnancy-induced hypertension, pre-eclampsia, placental abruption, preterm delivery (PTD), small for gestational age and low 5-min Apgar score after detection of an intrauterine haematoma, the risk of VPTD and intrauterine growth restriction after a crown-rump length discrepancy, the risk of VPTD, LBW and VLBW after a vanishing twin phenomenon and the risk of PTD, LBW and low 5-min Apgar score in a pregnancy complicated by severe hyperemesis gravidarum. CONCLUSIONS Data from our literature review indicate, by finding significant associations, that specific early pregnancy events and complications are predictors for subsequent adverse obstetric and perinatal outcome. Though, some of these associations are based on limited or small uncontrolled studies. Larger population-based controlled studies are needed to confirm these findings. Nevertheless, identification of these risks will improve obstetric care.

Human embryonic growth and development of the cerebellum using 3-dimensional ultrasound and virtual reality.

The aim of our study was to evaluate the first trimester cerebellar growth and development using 2 different measuring techniques: 3-dimensional (3D) and virtual reality (VR) ultrasound visualization. The cerebellum measurements were related to gestational age (GA) and crown-rump length (CRL). Finally, the reproducibility of both the methods was tested. In a prospective cohort study, we collected 630 first trimester, serially obtained, 3D ultrasound scans of 112 uncomplicated pregnancies between 7 + 0 and 12 + 6 weeks of GA. Only scans with high-quality images of the fossa posterior were selected for the analysis. Measurements were performed offline in the coronal plane using 3D (4D view) and VR (V-Scope) software. The VR enables the observer to use all available dimensions in a data set by visualizing the volume as a “hologram.” Total cerebellar diameter, left, and right hemispheric diameter, and thickness were measured using both the techniques. All measurements were performed 3 times and means were used in repeated measurements analysis. After exclusion criteria were applied 177 (28%) 3D data sets were available for further analysis. The median GA was 10 + 0 weeks and the median CRL was 31.4 mm (range: 5.2-79.0 mm). The cerebellar parameters could be measured from 7 gestational weeks onward. The total cerebellar diameter increased from 2.2 mm at 7 weeks of GA to 13.9 mm at 12 weeks of GA using VR and from 2.2 to 13.8 mm using 3D ultrasound. The reproducibility, established in a subset of 35 data sets, resulted in intraclass correlation coefficient values ≥0.98. It can be concluded that cerebellar measurements performed by the 2 methods proved to be reproducible and comparable with each other. However, VR—using all three dimensions—provides a superior method for the visualization of the cerebellum. The constructed reference values can be used to study normal and abnormal cerebellar growth and development.

Early pregnancy - models of healthcare

Introduction pregnancy problems form a major part of all gynecological emergencies. In the past, patients were admitted to the emergency receiving ward and waited for a considerable length of time before undergoing ultrasound scan and clinical assessment. With the appearance of early pregnancy assessment units (EPU), an increasing number of women are being assessed and managed as outpatient or office attenders. The advent of high-resolution transvaginal ultrasound coupled with the improved access to hCG measurements has allowed the development of models of care and improved delivery of care. Within the UK the growth of EPU numbers has increased to the extent that over 200 active units are registered with the Association of Early Pregnancy Units (AEPU). The AEPU has set out, since it’s inception in 2001, to improve the standards of early pregnancy care and to provide a clearer pathway for the patient’s journey (earlypregnancy.org.uk). In recent years ultrasound diagnosis and improved understanding of problems related to early pregnancy have led to the introduction of medical and expectant management of miscarriage and selected cases of ectopic pregnancy. Randomized controlled trials have provided evidence-based practice (rcog.org.uk/guidelines). Patient choice has emerged as a powerful selector for treatment. The mission statement from the Association of Early Pregnancy Units has the patient at the center of all activity and the multidisciplinary care structure reflects the multitasking approach of care providers.

OP02.01: Early first trimester 3D‐US trophoblast volume measurements using VOCAL technique

centile) 2) Control group (n = 88) included patients whose infants were appropriate for gestational age (birth weight >10th centile). Poor neurodevelopmental outcome was defined as the presence of hearing impairment or severe developmental delay and was compared between the two groups. Results: Primary CMV infection occurred during the first trimester in 5 (33%) of the IUGR cases and 26 (29%) of the control cases (P = 0.8). The mean birth weight in the study group was 2460 gr compared to 3180 gr among the control patients (P < 0.01). The median age of children at follow-up was 2 years (range 3 months–8 years). The rate of poor neurodevelopmental outcome was similar among the two groups: Two (13%) infants in the study group had hearing impairment whereas 8 (9%) of the infants in the control group were diagnosed with hearing impairment (7) or developmental delay (1) on post-natal follow-up (P = 0.6). Conclusions: The outcome of congenital CMV infection does not seem to be affected by the presence of isolated IUGR. Therefore, the prognostic value of IUGR as a sole finding in fetuses infected by CMV is limited.

OP21.01: Early pregnancy placental bed and foetal vascular volume measurements using three dimensional virtual reality

A 15 year old female diagnosed with Klippel Trenaunay Syndrome, a congenital vascular disorder, initially presented with continuous bleeding following menarche at age 11. Her symptoms were controlled with Depoprovera for 2.5 years. The patient returned with 6 month duration of dysfunctional uterine bleeding. MRI and ultrasound were performed prior to hysteroscopy with removal of clot from the uterus. She was placed on a GnRh agonist with no improvement in her bleeding pattern. She required blood transfusions prior to undergoing definitive therapy. Following further imaging evaluation with MRI, CT, and serial ultrasounds for identification of abnormal vasculature in the pelvis and uterus, a total abdominal hysterectomy was performed. MRI, CT, and ultrasound demonstrated the abnormal vasculature in the pelvis and associated with the uterus. Ultrasound and MRI were excellent at evaluating myometrial thickness. Ultrasound was a safe, noninvasive, and less expensive imaging modality for monitoring and preoperative evaluation of this patient compared to MRI and CT as ultrasound does not require intravenous contrast administration or utilize radiation. Additionally, serial imaging studies are necessary in these patients as myometrial compression by endometrial contents appears to alter visualization and localization of small venous abnormalities associated with this disease process.

OP38.02: Diagnostic techniques and criteria for first trimester conjoined twin evaluation

Normal first-trimester fetuses display a characteristic gap between the right and left body of the mandible in this view (the ‘‘mandibular gap’’). The presence or absence of this gap was evaluated and measured prospectively during real-time scanning (n = 100) and retrospectively by analyzing three-dimensional (3D) volume datasets (n = 50) in normal first-trimester fetuses undergoing screening for aneuploidy at 11–13 weeks of gestation. 3D volume datasets from 12 fetuses with suspected micrognathia were also collected and examined retrospectively for the same features. Results: The mandibular gap was identified in all 150 normal fetuses and measured between 2.2–3.7 mm (mean, 2.8) with no significant differences between measurements obtained by two-dimensional ultrasound and 3D off-line analysis. Among fetuses with suspected micrognathia, 3 3D volume datasets were excluded from analysis because of poor image quality in 1 and the diagnosis of a normal chin in 2. In the remaining 9 fetuses, the mandibular gap was absent and was replaced by a bony structure representing the receding chin in 7 (78%) cases and not visualized due to severe retrognathia in the remaining 2 (22%) cases. All fetuses with micrognathia had associated anomalies, including 5 with aneuploidy, 2 with skeletal dysplasias, and 2 with a genetic syndrome. Conclusions: The RNT view may be a helpful technique to detect severe micrognathia in the first trimester. The absence of the mandibular gap or failure to identify the mandible in this view is highly suggestive of micrognathia and should prompt a targeted ultrasound to assess for other anomalies. Further research is needed to determine the false positive and negative rates of this technique.