Wojciech Cnota

Doppler study of the embryonic heart in normal pregnant women

Objective. To describe normal fetal cardiac and hemodynamic development in normal early first trimester pregnancies. Materials and methods. Eighty-eight women with singleton, uncomplicated pregnancies were prospectively studied with transvaginal ultrasound, pulsed and color Doppler. Heart diameter, heart rate, and inflow and outflow waveforms with valve signals were documented. The proportion of the cardiac cycle of isovolumetric relaxation time (IRT%) and isovolumetric contraction time (ICT%) as well as Tei index were calculated. Results. Ninety-one percent of studies were successful. Heart diameter and the fetal heart rate showed a positive correlation with increasing gestational age: R = 0.80 (p < 0.000001), R = 0.76 (p < 0.000001), respectively. Mean heart diameter at 6 weeks was 1.28 ± 0.26 mm and mean fetal heart rate was 117 ± 6 bpm compared to 3.88 ± 0.54 mm and 171 ± 6 bpm at 10 weeks. The inflow waveform was monophasic (atrial contraction) in all cases from 6 to 9 weeks. Eight pregnancies (9%) miscarried between 6 and 12 weeks of gestation and the heart exams were characterized by increased IRT% compared with the survivors. In survivors, IRT% decreased between 7 and 8 weeks, from 32.9 ± 10.7% to 20.8 ± 5.7% (p < 0.0001). ICT% decreased from 18.6 ± 4.4% of the cardiac cycle at 8 weeks to 12.6 ± 4.4% at 9 weeks (p < 0.0008) (after heart development period). Conclusions. Doppler examination of the fetal cardiac function is possible after 5 weeks of gestation. After 8 weeks of gestation, the fetal heart is morphologically mature but has not yet achieved effective myocardial compliance. The embryonic human heart is dependent on the atrial contraction for ventricular filling throughout the period of cardiac development. Non-survivors manifest myocardial dysfunction.

The evolution of fetal presentation during pregnancy: a retrospective, descriptive cross-sectional study

We investigated changes in the frequencies of four primary types of singleton fetal lie/presentation for each gestational week from 18 to 39 weeks in a retrospective, cross‐sectional study which analyzed ultrasound examination records of fetal positions, in the outpatient prenatal diagnosis clinics in two cities in Poland. We calculated the prevalence and 95% confidence intervals for each type of lie/presentation. We then identified the gestational age after which no statistically significant changes in terms of prevalence were observed, by comparing the results at each week with the prevalence of cephalic presentation at 39+0 weeks, used as reference. A total of 18 019 ultrasound examinations were used. From 22 to 36 weeks of gestation, the prevalence of cephalic presentation increased from 47% (45–50%) to 94% (91–96%), before and after which times plateaus were noted. Spontaneous change from breech to cephalic is unlikely to occur after 36 weeks of gestation.

Evaluation of selected ultrasonography parameters in the second stage of labor in prediction mode of delivery.

OBJECTIVES The aim of the study is to determine the usefulness of ultrasound parameters in the second stage of labor in prediction of the method of delivery and to evaluate the benefits to be derived from this study. MATERIAL AND METHODS Ultrasound scan was performed with Convex transabdominal probe on 68 pregnant women in labor at term with fetuses in cephalic presentation at the beginning of the second stage of labor and parameters such as angle of progression, head progression distance, head-symphysis distance and head-perineum distance were measured. The parameters were observed in two scans: a midline scan visualizing the pubic symphysis with the head of the fetus and a transverse scan approximately 1-2 cm below the pubic symphysis visualizing the head of the fetus. RESULTS The ultrasound parameters measured at the beginning of the second stage of labor, differed in the group in which women have delivered vaginally and in the group, in which caesarean section was performed: angle of progression and head progression distance were greater in group of women who delivered naturally and head-perineum distance and head-symphysis distance were smaller in this group. Some relations between each measured parameter and time left to delivery were observed as well as strong relations among parameters were also observed. CONCLUSIONS Intrapartum sonography is a useful and objective tool to assess the progress of labor. Transperineal ultra-sound scans performed in the second stage of labor may play a role in making the decision about the mode of delivery.

Human embryonic cardiovascular function

This review presents an overview of descriptive knowledge on human embryonic cardiovascular physiology mostly based on noninvasive assessment by Doppler ultrasonography. Our objective was to identify and analyze published studies on embryonic cardiovascular function, and summarize available knowledge in this field.

Atrial dominance in the human embryonic heart: a study of cardiac function at 6-10 weeks of gestation.

To investigate the difference in forces developed by atrial and ventricular myocardium during contraction in human embryos using a novel method.

Screening for trisomy 21 based on maternal age, nuchal translucency measurement, first trimester biochemistry and quantitative and qualitative assessment of the flow in the DV — the assessment of efficacy

OBJECTIVES The aim of the study was to compare effects of addition of two methods of ductus venosus (DV) flow assessment: qualitative - the assessment of shape of the A-wave (positive or negative), and quantitative - based on the pulsatility index for veins (DVPI) to the basic screening for trisomy 21 at 11 to 13 + 6 weeks of pregnancy. MATERIAL AND METHODS The ultrasound examination was performed in 8230 fetuses in singleton pregnancies at 11- -13 + 6 wks, as a part of a routine screening for chromosomal defects. In DV A-wave was assessed and DVPI was calculated. After the scan blood sample was taken for first trimester biochemistry (BC). Risk for chromosomal defects was calculated and high-risk patients were offered an invasive test for karyotyping. RESULTS Basic screening with following combination of markers: MA, NT and BC provided lowest detection rate (DR) 87.50% for FPR = 6.94%. After adding qualitative DV A-wave assessment DR increased to 88.75% for FPR = 5.65%. The best DR = 93.75% for FPR = 5.55% was achieved when quantitative DVPI was added. The application of the Receiver Operating Curves curve confirmed validity of the addition of DV flow assessment to the screening model. The highest diagnostic power of the test was achieved when DVPI was added, with the ROC AUC of 0.974. CONCLUSIONS The assessment of DV flow performed at 11-13 + 6 weeks increases DR for trisomy 21 and reduces FPR. The screening model based on the quantitative DV flow analysis (DVPI) gives better results compared to the qualitative flow assessment.

Frontomaxillary facial angle measurement in screening for trisomy 18 at 11 + 0 to 13 + 6 weeks of pregnancy: a double-centre study.

Objective. The aim of this study was to evaluate the effectiveness of prenatal screening for trisomy 18 with the use of the frontomaxillary facial angle (FMF angle) measurement. Material and Methods. The study involved 1751 singleton pregnancies at 11–13 + 6 weeks, examined between 2007 and 2011. Serum PAPP-A and free beta-hCG levels were assessed, and crown-rump length, nuchal translucency, and FMF angle were measured in all patients. 1350 fetuses with known follow-up were included in the final analysis. Results. Highly significant (P < 0.01) negative correlation between the CRL and the FMF angle was found. There were 30 fetuses with trisomy 18. FMF angle was highly significantly larger (P < 0.0001) in fetuses with trisomy 18 as compared to chromosomally normal fetuses. Two models of first trimester screening were compared: Model 1 based on maternal age, NT, and first trimester biochemistry test (DR 80–85% and FPR 0.3–0.6%), and Model 2 = Model 1 + FMF angle measurement (DR 87.3–93.3% and FPR 0.8–1.3%). Conclusions. The use of FMF angle measurement increases the effectiveness of the screening for trisomy 18. Introduction of the FMF angle as an independent marker for fetal trisomy 18 risk requires further prospective research in large populations.

A Retrospective Study on the Risk of Respiratory Distress Syndrome in Singleton Pregnancies with Preterm Premature Rupture of Membranes between 24

Aim This study aimed to investigate the cause of respiratory distress syndrome (RDS) in neonates from singleton pregnancies with preterm premature rupture of membranes (pPROM) between 24+0 and 36+6 weeks by using regression analysis for various factors. Methods In 175 singleton pregnancies with pPROM, 95 cases of RDS (54,29%) were diagnosed. In all cases the following information was collected: latency period of PROM, gestational age at birth, Umbilical Artery Pulsatility Index (UA PI), Middle Cerebral Artery Pulsatility Index (MCA PI), fetal distress, antenatal steroids use, delivery type, pregnancy hypertension disease, gestational glucose intolerance or diabetes, neonatal laboratory parameters, gender, weight, Apgar score, and other neonatal complications. Logistic regression analysis was used to investigate the effect of variables on RDS. Results The results of logistic regression analysis showed that the following variables are closely correlated with RDS: female gender (OR=0.52; 95%CI:0.28-0,97), antenatal steroids use (OR=0,46; 95%CI:0,34-0,64), abnormal UA PI and MCA PI (OR=2.96; 95%CI:1,43-6,12) (OR=2.05; 95%CI:1,07-3,95), fetal distress (OR=2.33; 95%CI:1,16-4,71), maternal HGB (OR=0.69; 95%CI:0,5-0,96), and neonatal RBC, HGB (OR=0.32; 95%CI:0,19-0,55) (OR=0.75; 95%CI:0,65-0,88). Conclusions The main RDS risk factors in premature neonates are gender, abnormal fetoplacental circulation, and fetal distress. The laboratory parameters such as lower RBC and HGB count are observed in infants with RDS.

Influence of first trimester biochemistry methodology on detection rate in screening for trisomy 21

OBJECTIVES The purpose of the study was to compare detection rates (DR) of FMF-certified and non-certified biochemical tests (BC) in trisomy 21 screening at 11-13 + 6 weeks. MATERIAL AND METHODS In 2267 singleton pregnancies FMF-certified doctors measured crown to rump length (CRL) and nuchal translucency (NT). Serum samples were tested for free β-hCG and the PAPP-A using 2 analysers (Delfia - Perkin Elmer and Immulite 2000 - DPC), the results were expressed in MoM values and used for computer calculation of the risk for trisomy 21. The cut-off value for the high trisomy 21 risk was 1:300. RESULTS Comparison of free β-hCG MoMs by DPC and Delfia demonstrated statistically significant differences in normal, and trisomy 21 fetuses respectively. Similarly, statistically significant differences were noted for PAPP-A MoMs. The above differences in MoMs resulted in altered sensitivity in screening for aneuploidy. The application of the FMF-certified method ensures a markedly higher DR = 74%, compared to non-certified tests (64%), both at 5% FPR. The ROC analysis was performed in order to assess the efficacy of both tests. Results of trisomy 21 BC + NT risk scales using the Delfia and DPC methods are highly significant (p < 0.0001), which means that their discrimination ability is > 90%. The difference between results obtained using the Delfia and DPC methods is AUC = 0.0150 and is statistically significant (Z = 2.4728, p = 0.0134). CONCLUSIONS The use of FMF-certified first trimester biochemistry analysers improves DR for trisomy 21. The use of non-certified analysers causes reduction of DR and an increase of invasive procedure rate.

Nasal bone in screening for T21 at 11–13 + 6 weeks of gestation — a multicenter study

OBJECTIVES Trisomy 21 is one of the most common chromosomal defects diagnosed prenatally. Screening for Down syndrome is based on maternal age, measurement of crown-rump length, nuchal translucency and fetal heart rate, together with free β-hCG and PAPP-A at 11 to 13 + 6 weeks. Introduction of additional ultrasound marker of trisomy 21 (evaluation of the nasal bone) may result in increased DR and decreased invasive diagnostic testing rates (FPR). MATERIAL AND METHODS Ultrasound scan with NB evaluation was performed in 5814 fetuses during routine screening for chromosomal defects at 11 to 13 + 6 weeks of gestation. DR and FPR coefficients were calculated for 4 levels of risk as cut-off points for screening model 1, based on MA, NT, and first trimester biochemistry, as well as for screening model 2, based on MA, NT, first trimester biochemistry and NB. RESULTS There were 5708 normal cases, 71 cases of trisomy 21 and 35 cases of other chromosomal defects. NB was absent in 46 (64.8%) cases and present in 25 (35.3%) cases of trisomy 21, comparing to present NB in 5463 (95.7%) and absent in 245 (4.3%) of normal cases. CONCLUSIONS First-semester screening with additional NB assessment significantly increases the detection rate for trisomy 21 and decreases the rate of false-positive results. Adding NB evaluation at the risk level of 1:50 causes only a small increase in detection rate. Invasive procedures should be performed in that group regardless NB assessment.