P. Dürig

Perinatal outcome of fetuses with a birth weight greater than 4500 g: an analysis of 3356 cases

OBJECTIVE To assess the perinatal outcome in a series of macrosomic fetuses according to the intended mode of delivery, and to estimate the individual risk of shoulder dystocia and brachial plexus injury upon information available either prior the onset of labor or at delivery. STUDY DESIGN Perinatal and postnatal information of 3356 women who delivered during a 10-year period a macrosomic fetus (>4500 g) in vertex presentation were analyzed. After the exclusion of cases with extraneous factors that may have affected the health of the neonate, patient and neonatal characteristics were compared according to the intended mode of delivery. The contribution of factors known prior labor and at the time of deliver on the occurrence of shoulder dystocia and brachial plexus injury was analyzed using multiple logistic regression analysis. RESULTS During the study period, 2371 women were admitted to spontaneous labor, 778 underwent an induction of labor, and 207 had an elective cesarean section. All cases of shoulder dystocia (n=310), and brachial plexus injury (n=94) occurred among women who delivered vaginally. The rate of brachial plexus injury was higher in cases who had shoulder dystocia than in those who did not (58/310 versus 36/2329, P<0.001). The incidence of brachial plexus injury increases steadily from 0.8 in fetuses weighing 4500-4599 g to 2.86% in those weighing more than 5000 g (P<0.01) and from 2.1 in women taller than 180 cm to 12.5% in those shorter than 155 cm (P<0.05). After adjustment for confounding variables shoulder dystocia (OR 9.2, 95% C.I. 5.38; 15.59), operative vaginal delivery (OR 1.96, 95% C.I. 1.10; 3.49) and clavicular fracture (OR 2.9, 95% C.I. 1.31; 6.44) remained predictors of brachial plexus injury. CONCLUSION Since some of these risk factors are known prior to delivery, each woman whose fetus is suspected to weight more than 4500 g should be counseled on her individual risk of severe perinatal morbidity before a decision on the mode of delivery is taken.

Single and multiple umbilical cord cysts in early gestation: two different entities

To investigate the prevalence of single and multiple umbilical cord cysts in the first trimester and to assess whether there is a difference in the pregnancy outcome between them.

Posterior sacculation of the uterus in a patient presenting with flank pain at 29 weeks of gestation.

BACKGROUND: Uterine sacculation is a rare complication of pregnancy and may cause substantial peripartal morbidity. CASE: A possible diagnosis of posterior uterine sacculation was raised when a 34-year-old Gravida 1 Para 1 presented with bilateral flank pain at 29 weeks. Sonographic and magnetic resonance imaging findings confirmed the diagnosis and demonstrated bilateral dilated renal pelvises. Bilateral nephrostomas were placed, offering the patient considerable relief. A healthy female newborn was delivered by cesarean at 34 1/7 weeks. Operative findings confirmed the posterior sacculation of the uterus. CONCLUSION: Early diagnosis of sacculation of the uterus is necessary to limit maternal and fetal morbidity and mortality. For a detailed evaluation of the pelvic anatomy, we recommend the use of magnetic resonance imaging in the third trimester.

Ductus venosus blood flow velocity characteristics of fetuses with single umbilical artery

Sonographic Doppler evaluation of the fetal ductus venosus has been proved to be useful in the evaluation of fetal cardiac function. The aim of this study was to investigate the ductus venosus blood flow profile in fetuses with single umbilical artery and to correlate it with the umbilical cord morphology.

P12.12: Relationship between single umbilical artery in twin pregnancies and pregnancy outcome

manifestations of the underlying hemodynamic imbalance may be present as early as the first trimester of gestation and may have a profound impact on the development of the UC angioarchitecture. Methods: Twenty four consecutive monochorionic twins with TTTS were included into the study. The length of one complete umbilical vascular coil (distance between the right outer surface of consecutive arterial coils) was measured in a longitudinal section of the UC. The coiling index (CI), defined as the reciprocal value of that measurement, was calculated. The UC coiling pattern was classified as normal or abnormal [uncoiled, hypocoiled (CI 90th centile)] according to local reference ranges. Atypical (uncoordinated, supercoiling) coiling was classified according to Raio et al. (ISUOG 2003, OC 205). Results: Nine (37.5%) and 8 (33.3%) cases were treated with endoscopic laser coagulation and amnionreduction, respectively. In the remaining 7 (29.2%) cases, no treatment was undertaken. The surviving rate was 72.2%, 56.3%, and 21.4% in the laser, amnioreduction and no treatment group, respectively. The donor twin showed in 22 (91.7%) cases a less twisted UC than the recipient twin. Of these, 12 (54.5%) were uncoiled and 5 (22.7%) hypocoiled. On the other hand, the UCs of recipient twins were characterized by a high percentage of atypical [4 (16.7%) with supercoiling, and 8 (33.3%) with uncoordinated coiling], and abnormal coiling patterns [4 (16.7%) with hypercoiling, 2 (8.3%) hypocoiling]. Only 13 (27.1%) cases had a CI within normal ranges for gestational age. In one case informations on UC angioarchitecture was available from the first trimester and the UCs were uncoiled and atypical, respectively. Conclusions: Monochorionic twins with TTTS have different UC coiling patterns.

P05.16: Incidence of hypertensive pregnancy disorders according to the severity of umbilical artery Doppler waveforms

were beneath the 3rd centile. The patient was counselled regarding the poor prognosis for this fetus. The patient elected to continue with the pregnancy. Repeated scans at 20, 21, 24, 26, and 27 weeks showed persistent oligohydramnios with the mean pool depth decreasing from 17 mm to 15 mm. From 20 weeks umbilical artery Doppler showed absent end-diastolic flow, although this never reversed. At 28 + 1 weeks’ gestation, the patient presented with antepartum haemorrhage, and uterine contractions. Ultrasound confirmed fetal viability. Labour progressed spontaneously, a female infant with a birthweight of 355 g was delivered with APGAR scores of 3 at 1 minute, and 8 at 5 minutes. The infants abdominal circumference was 24.5 cm and head circumference was 21.5 cm, both beneath the 3rd centile for gestation age and gender. The placenta was noted to be extremely small and gritty. The infant had an uneventful neonatal period with no evidence of respiratory distress, necrotising enterocolitis, intracranial damage or infection. Chromosomal analysis was normal. She was discharged at 95 days of age. Despite severe placental insufficiency as diagnosed by Doppler ultrasound this fetus survived to extra-uterine life. It is hypothesised that the second wave of trophoblastic invasion failed, leading to a period of chronic physiological stress in the fetus allowing it to survive.

P12.11: Discordant sonographic umbilical cord coiling pattern in twins with twin‐to‐twin transfusion syndrome

of amnioinfusion was 658 ± 220 cc. The mean pre-op MVP was significantly different between the SP and NSP groups (8.7 ± 0.6 vs. 11.0 ± 0.2 cm, p < 0.05). The mean gestational age (GA) was not different (20.3 ± 1.9 vs. 19.7 ± 6.5 weeks). There was no correlation between MVP and GA (r = .03, p = .72). There was no difference in Stage (p = .08), with 11/16 (68%) SP patients being Stage III or IV. Conclusion: An SP is present in 12% of patients with TTTS, despite polyhydramnios. Amnioinfusion is required for SLPCV in patients with SP to disclose all anastomotic vessels. As a corollary, therapeutic amniocenteses prior to laser surgery may result in iatrogenic development of SP, requiring intraoperative amnioinfusion.

P12.10: Incidence of sonographic lean and large umbilical cords in twin pregnancies

of amnioinfusion was 658 ± 220 cc. The mean pre-op MVP was significantly different between the SP and NSP groups (8.7 ± 0.6 vs. 11.0 ± 0.2 cm, p < 0.05). The mean gestational age (GA) was not different (20.3 ± 1.9 vs. 19.7 ± 6.5 weeks). There was no correlation between MVP and GA (r = .03, p = .72). There was no difference in Stage (p = .08), with 11/16 (68%) SP patients being Stage III or IV. Conclusion: An SP is present in 12% of patients with TTTS, despite polyhydramnios. Amnioinfusion is required for SLPCV in patients with SP to disclose all anastomotic vessels. As a corollary, therapeutic amniocenteses prior to laser surgery may result in iatrogenic development of SP, requiring intraoperative amnioinfusion.

OC058: Conservative management of cervical ectopic pregnancies

combined with antibiotics given i.v. or orally. Successful treatment we defined as a patient in good health after 3 months, without clinical symptoms or laboratory signs of infection. Unsuccessful treatment we defined as relapse of TOA in less than 3 months or patients that had surgery in the form of laparoscopy or laparatomy for abscess/organ removal in less than 3 months. Results: The immediate success rate according to our definition was 94% for the whole material. If however, we compare the period 1986 to 1990 (5 years) with 2000 to 2002 (3 years) we see an improved success rate from 88 % to 97 %. The rate of success was not influenced by age, parity, earlier PID, size of abscess or universus bilateral abscess. As for the longterm outcome, 8% have had a new episode of TOA, which in almost all cases have been successfully treated in the same way as the first. In patients operated on more than 3 months after successful treatment, no rest of abscess was found. 25% of patients under 40 years have become pregnant after treatment. Conclusion: This method of treating TOA is simple, cheap and safe. We have had no major complications. With respect to the immediate success and longterm outcome, we recommend this as the method of choice for treatment of TOA.

P05.27: Abnormal end-diastolic flow pattern in the umbilical artery and perinatal mortality

Objective: to evaluate the morbidity and mortality rate of IUGR fetuses correlated to Doppler velocimetry, FHR tracing, BPP and AFI. Methods: a multicenter prospective study of 246 fetuses with ultrasound diagnosis of IUGR. Among them 186 met the study entry criteria. The study group underwent Doppler velocimetry study of UA, MCA, DV and UV twice weekly, BPP and AFI twice weekly and FHR tracing daily. IUGR fetuses were divided into two groups: Group 1 IUGR fetuses with Doppler velocimetry abnormality; Group 2 with normal Doppler velocimetry. In Group 1 the type and time passing from Doppler alteration to birth were documented. Apgar score, pH at birth, need of intubation, RDS, IVH, PVL, days of NICU hospitalization were available and related to neonatal outcome. Results: Gestational age at time of admission ranged from 16.1 to 40 weeks. One hundred IUGR fetuses showed Doppler velocimetry alteration while sixty-eight fetuses did not show Doppler alteration (Group 2). In Group 1 morbidity and mortality rate were significantly correlated with the type of Doppler velocimetry abnormality and with time passing from the latter finding and delivery being higher in fetuses with AEDF, RF in UA with a time >72 hours from the Doppler abnormality and delivery. Conclusions: Doppler velocimetry should be performed in IUGR fetuses as its findings help to reduce morbidity and mortality rate. There is a significant correlation between the type of alteration and time passing from alteration to birth.