Tsz-Kin Lo

Pregnancy-associated plasma protein A (PAPP-A) to predict adverse fetal outcomes in Chinese: What is the optimal cutoff value?

abstract A low level of PAPP-A predicts adverse fetal outcomes. As Chinese pregnant women have a higher level of PAPP-A, the predictive performance of PAPP-A and its optimal cutoff value might be different. This study aims to establish a PAPP-A cutoff value in the Chinese population that identifies adverse fetal outcomes. We retrospectively analysed 4936 spontaneous singleton pregnancies of Chinese women who underwent first-trimester combined Down’s screening in our unit from March 2010 to January 2014 and had delivery information available. A composite adverse fetal outcome encompassed intrauterine fetal loss (including miscarriages and stillbirths), and live births either before 32 weeks or weighing less than −2 standard deviation (SD) for gestation. The area under the curve of the receiver-operator characteristic curve for prediction of the composite adverse outcome using PAPP-A was 0.626 (95% CI =0.612–0.640, p < 0.0001). PAPP-A ≤ 0.23 multiples of median (MoM) identified 0.6% of Chinese pregnant women to be at significant risk of adverse fetal outcome (positive likelihood ratio 11.2, positive predictive value 21.4%) despite a low sensitivity (5.1%, 95% CI =1.9–10.8). The negative predictive value was high (97.7%). The commonly used cutoff of 0.4 MoM was associated with a positive likelihood ratio of 3.7 only. A prospective study is warranted.

Pregnancy-associated plasma protein A for prediction of fetal growth restriction.

Low levels of pregnancy-associated plasma protein A (PAPP-A) are correlatedwith birthweights of below the 10th percentile [1]. However, it is unknown whether levels of PAPP-A can be used to predict severe fetal growth restriction, which would be more clinically relevant. To address this issue, a retrospective analysis of singleton live births amongChinesewomen after natural conceptionwas performed. Included patients had undergone combined Down syndrome screening in Queen Mary Hospital or Tsan Yuk Hospital, Hong Kong, between March 1, 2010, and January 31, 2014. The test was performed between the start of the 11thweek of pregnancy and the end of the 13thweek. Pregnancies affected by chromosomal or structural abnormalities were excluded. Because the analysis was a review of information extracted from existing clinical database without involvement of patients or any intervention, institutional review board approval and informed consent was not needed. The screening consisted of ultrasonography and a blood test. Ultrasonography was used to measure the fetal crown–rump length and nuchal translucency according to the guidelines of the Fetal Medicine Foundation [2]. The maternal serum levels of PAPP-A and free β-human chorionic gonadotropin were measured by Delfia Xpress (PerkinElmer, Waltham, MA, USA) and converted to a multiple of the median adjusted for maternal weight for the local Chinese population. Birth weight was adjusted for fetal sex using a gestation-specific normogram for the study population [3]. Receiver operating characteristic curves were derived with MedCalc version 13.1.2 (MedCalc Software, Ostend, Belgium) to determine the performance of PAPP-A in the prediction of different degrees of growth restriction (birth weight b10th percentile and b2 standard deviations [SDs] below the mean value for gestational age). P b 0.05 was considered statistically significant. Among 4918 singleton live births included, 378 (7.7%) newborns weighed below the 10th percentile and 77 (1.6%) weighed less than two SDs below the mean value for their gestational age. The area under the receiver operating characteristic curve for prediction of birth weight less than two SDs below the mean value using PAPP-A was 0.653 (95% confidence interval [CI] 0.639–0.666) and that for birth weight below the 10th percentile was 0.595 (95% CI 0.581–0.608). Both areas were significantly above 0.5 (Pb 0.001). The performance of PAPP-Awasbetter for prediction of birthweight less than two SDs below themean than for prediction of birth weight below the 10th percentile because the area under the curve was larger and the 95% CIs do not overlap. Among the 4918 mothers, 37 (0.8%) smoked during pregnancy. Smoking status and free β-human chorionic gonadotropin level were not correlated with low birth weight by either definition used in the present analysis (data not shown). Overall, the present analysis has shown that measurements of maternal serum PAPP-A concentration in the first trimester predict severe fetal growth restriction (birthweight less than two SDs below themean value for gestational age) more effectively than they predict a birth weight below the 10th percentile among a Chinese population.

Informed choice and decision making in women offered cell-free DNA prenatal genetic screening.

Department of Obstetrics and Gynecology, Princess Margaret Hospital, Hong Kong Prenatal Diagnostic Laboratory, Tsan Yuk Hospital and Department of Obstetrics and Gynecology, Queen Mary Hospital, Hong Kong Department of Obstetrics and Gynecology, Tuen Mun Hospital, Hong Kong Department of Obstetrics and Gynecology, United Christian Hospital, Hong Kong Department of Obstetrics and Gynecology, Queen Elizabeth Hospital, Hong Kong Department of Obstetrics and Gynecology, Pamela Youde Nethersole Easten Hospital, Hong Kong *Correspondence to: Tsz-Kin Lo. E-mail: lo_tsz_kin@yahoo.com.hk

Two IUGR foetuses with maternal uniparental disomy of chromosome 6 or UPD(6)mat

Wing Cheong Leung, Wai Lam Lau, T. K. Lo, Tze Kin Lau, Y. Y. Lam, Anita Kan, Kelvin Chan, Elizabeth T. Lau and Mary H. Tang Department of Obstetrics & Gynaecology, Kwong Wah Hospital, Hong Kong Special Administrative Region, China; Department of Obstetrics & Gynaecology, Queen Mary Hospital, Hong Kong Special Administrative Region, China; Fetal Medicine Centre, Paramount Medical Centre, Hong Kong Special Administrative Region, China; Department of Paediatrics, Kwong Wah Hospital, Hong Kong Special Administrative Region, China; Department of Obstetrics & Gynaecology, The University of Hong Kong, Hong Kong Special Administrative Region, China

EP04.03: Pregnancies with reversed end-diastolic flow in uterine arteries Doppler: Electronic Poster Abstracts

Objectives: The aim of this study is to compare the value of IR and IP in the two different sites (fetal and placental site) and between the two arteries at each end, in eutrophic and growth-restricted fetuses. Methods: We included singleton pregnancies. Cases with congenital malformations of single umbilical arteries were excluded. RI, IP and systole/diastole ratio were calculated in both arteries at the two ends. Comparison was performed using the student’s t-test. Growth restriction was defined as an estimated fetal weight under the 10th percentile. Results: We included 77 measurements in eutrophic fetuses and 16 in growth restricted fetuses, between 18 and 40 WG. The mean RI was significantly different ( (A’-A) =0.0741 (IC95[0.057; 0.091]; (B’-B) = 0.08 (IC95[0.61; 0.10] ; (A’B) = 0. 079 (IC95[0.62; 0.66]; (B’-A) = 0. 075 (IC95[0.058; 0.092] in the two arteries located at the abdominal site compared to the placental insertion, with a higher resistance at the abdominal site. Nonetheless, no statistical difference was demonstrated between the two arteries at each insertion. The same results are found in the group of the growth restricted fetuses. Conclusions: As we have demonstrated a significant difference between the two ends of the umbilical cord, we can conclude that the interpretation of the cerebroplacental ratio would be dependent of the site of measure of the umbilical RI and the PI. Thus, by indicating which umbilical insertion is measured, we can reflect the pathophysiology of fetoplacental circulatory disease in the most precise way, and diminish inter-observer variability. We can recommend that further studies on this subject should specify which end of the umbilical cord is examined.

Decision outcomes in women offered noninvasive prenatal test (NIPT) for positive Down screening results

Abstract In this first Asian study, the decision outcomes (decision conflict, decision regret, and anxiety) of 262 pregnant women offered noninvasive prenatal test (NIPT) for high-risk Down screening results were assessed. Decision conflict was experienced by 3.5% and level of decisional regret low (mean score 15.7, 95%CI 13.2–18.3). All 13 cases of decisional regret were NIPT acceptors. Elevated anxiety was experienced by 55.9% at the time of decision making about NIPT and persistent in 30.3%. Insufficient knowledge about NIPT was associated with elevated anxiety at decision making (p = .011) and with decisional regret (p = .016). Decisional regret was associated with prolonged anxiety (p = .010).

Study of the extent of information desired by women undergoing non‐invasive prenatal testing following positive prenatal Down‐syndrome screening test results

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/ijgo.12146 This article is protected by copyright. All rights reserved. Received Date: 20-Oct-2016 Revised Date: 01-Dec-2017 Accepted Date: 08-Mar-2017 Article Type: Brief Communication

Comparison of selective and non-selective internal iliac artery embolization for abnormal placentation with major postpartum hemorrhage.

Internal iliac artery (IIA) occlusion is a recognized treatment option for an adherent placenta and postpartum hemorrhage.1 However, the ideal selectivity of the occlusion has long been debated. The present study presents details of a clinical case illustrating this longtime controversy. A 36yearold woman with a history of lowersegment cesarean delivery for major placenta previa underwent a classical cesarean delivery at 35 weeks of pregnancy for recurrent major placenta previa and suspected accreta. The patient gave informed consent for the publication of the present study. Adherent placenta separation failed and, consequently, conservative management was used. The anterior division of the left IIA was embolized using gelfoam while the right IIA was not visualized by angiogram. After 11 hours, massive postpartum hemorrhage necessitated relaparotomy. The placenta was found separated and was removed. Examination by angiogram demonstrated an engorged right uterine artery and persistent left uterine arterial flow. The right IIA and the anterior division of the left IIA were embolized with gelfoam. Postoperatively, the patients developed right lowerlimb claudication and a 4cm×6cm ischemic ulcer developed over the right buttock (Fig. 1). Claudication subsided and the ulcer healed after 6 weeks of conservative management. Ischemic skin necrosis is an exceedingly rare adverse event of obstetric interventional radiology that is probably due to increased vascularity. The only other patient who experienced ischemic skin necrosis resulting from obstetric interventional radiology identified in the literature had the main trunks of the IIAs embolized bilaterally and had the ulcer treated surgically.2 In the present study, the buttock ulcer was conservatively treated. To the best of our knowledge, the present study included the first lowresource settings, with resultant improvement in obstetric ultrasonography skills. Consequently, emulating this model in similar settings is recommended.

Women’s stated test preference on questionnaire versus their actual choice in real clinical setting regarding non-invasive prenatal test

Patient V., 30 years, was admitted for acute pancreatitis, focal fatty pancreatic necrosis, parapancreatic infiltration, acute parapancreatic liquid accumulation, diffuse enzymatic ascites and peritonitis, and systemic inflammatory response syndrome. The patient was 17 weeks pregnant. On March 25th, 2016 the patient underwent laparoscopic surgery, and abdominal and omental drainage. Her laboratory results were: blood alpha-amylase – 491 IU/l; urinary alpha-amylase – 3780 IU/l. The patient’s condition was deteriorating due to the development of pancreatic head abscess, which prompted the second surgery on March 31st, 2016: drainage of the pancreatic head abscess, sequestrectomy, and abdominal and omental drainage. The postoperative period was complicated by arrosive hemorrhage from the omental bursa, leading to moderate anemia of mixed etiology (post-hemorrhage and intoxication) and missed miscarriage at 18 weeks of gestation. The patient underwent the third surgery on June 14th, 2016, during which surgical hemostasis via vessel suturing was performed, and pancreatic abscesses in the head and the tail regions were redrained. After the end of the surgery, it was decided to perform the removal of the unviable embryonic sac from the uterine cavity. Dilapan-S size 3 was placed intracervically for the preparation of the cervix for 12h. After the removal of Dilapan-S, an induced miscarriage took place without any additional therapy. The miscarriagewas complicated by hematometra, prompting vacuum aspiration of the uterine contents. In parallel, the patient developed an additional postoperative complication, a pancreatic tail abscess and diffuse serous peritonitis. On June 16th, 2016 she underwent ultrasound-guided aspiration of the pancreatic tail abscess. After this surgery the patients condition gradually improved, and she was discharged 3 weeks later in a satisfactory condition. Patient V., 30 years, was admitted at 10 weeks of pregnancy with swelling and pain in the left leg, and mild breathing difficulties, associated with varicose veins. She did not have a history of chronic venous insufficiency. A multi-spiral CT scan of the chest with intravenous contrast showed the signs of embolism in the right lower lobe artery and ischemic pneumonia in S8-9. Treatment with low molecular weight heparins was initiated. Pregnancy ultrasound identified a missed miscarriage at 10 weeks of gestation. The following hereditary thrombophilia panel results were obtained: MTHFR: 677-C/T, MTRR: 66A/G, ITGB3: 1565 T/C, PAI-1: 4G/4G. Dilapan-S size 3 was placed intracervically for cervical preparation for 12h. The patient miscarried three hours after the removal of Dilapan-S. No intrauterine pathology was observed at the follow-up ultrasound scan. The patient received uterotonic and antibacterial therapy, along with enoxaparin sodium followed by warfarin. Thus, Dilapan-S not only causes the dilation of the cervical canal, but in some cases independently facilitates induced abortion. Dilapan-S simultaneously impacts the cervical tissue and results in cervical dilation via the promotion of endogenous prostaglandin release as the result of collagen degradation. This leads to cervical softening and ripening and, in some cases, induced miscarriage, including in women with embryonic/fetal death.

Scalloping of placenta–myometrium interface on ultrasound in case with myomectomy scar

A 41-year-old primigravid woman presented at 16 weeks’ gestation for antenatal care. Two years previously, she had undergone laparoscopic enucleation of 12 myomas during which the uterine cavity was not entered. Ultrasound examination at 20 weeks showed an anterior placenta that was not low-lying, and an irregular placenta–myometrium interface with focal myometrial thinning, suspicious of placenta accreta (Figure 1a and b). She failed to attend follow-up examinations until 36 weeks, when ultrasound showed scalloping of the placenta and persistence of focal myometrial thinning, again suggesting placenta accreta (Figure 1c–e). Typical sonographic features of myometrial invasion described in cases with Cesarean scar and placenta previa, such as placental lacunae or subplacental hypervascularity, were absent. A plan for Cesarean delivery and uterine conservation should accreta be encountered intraoperatively was made at the patient’s request. Elective lower-segment Cesarean section was performed at 38 weeks, and the neonate was delivered in good condition. Despite monitoring for 3 h, less than 10 g of placenta separated from the uterine wall spontaneously. Bilateral uterine artery embolization was performed. Total blood loss was 1.2 L. On ultrasound examination, the retained placenta measured 13 × 12 × 8 cm (Figure 2a and b). Postoperative recovery