Color Doppler in the assessment of cervical cancer

Posters

P O S T E R S E S S I O N 1 : O B S T E T R I C S – F I R S T T R I M E S T E R , G Y N E C O L O G Y

P01Early diagnosis in ovarian cancer: role of transvaginalultrasound

M. A. Pascual, F. Tresserra, P. J. Grases & S. Dexeus

Purpose: To evaluate the efficiency of transvaginal ultrasound in theearly diagnosis of ovarian cancer.Methods: Screening transvaginal ultrasound has been annually per-formed during the last 2 years in asymptomatic women without famil-ial history of ovarian cancer. When abnormalities were detected, theprocedure was repeated after 4–6 weeks. If the findings disappeared,the study was repeated after 1 year. If the abnormality persisted, studywas complemented with tumor markers, computed tomography andlaparoscopic surgery. The findings were compared with a controlgroup of women in whom ovarian transvaginal ultrasonography wasformally indicated.Results: A total of 26007 transvaginal ultrasound were performed:8813 (33.8%) belonged to the screening group and 17194 (66.2%)to the control group. In 14 patients of the screening group, a malignanttumor was diagnosed and histologically confirmed. The mean age ofthese patients was 45 years old (SD 12). Eleven of these tumors werestage I (seven Ia, and four Ic), two stage IIIc and one was a metastaticmelanoma in both ovaries. Six lesions were borderline tumors (five ser-ous and one mucinous). In the control group, 27 ovarian cancers werediagnosed in patients with a mean age of 48 years (SD 17). In thisgroup, 11 tumors were in stage I, and six were borderline.Conclusions: Although consensus about the benefits of using transva-ginal ultrasound as a screening procedure is not conclusive, our datareveals that tumors detected in patients screened with transvaginalultrasound are in earlier stages when compared with those diagnosedin the control group. No differences were found in age and number ofborderline tumors between both groups. Additional studies are neededto support this preliminary findings.

P02Endometrial sampling during sonohysterography(SHGes)

E. Ferrazzi, C. Lanzani, N. Ciminera & V. Conserva

Purpose: To assess the diagnostic accuracy of sonohysterography(SHG) and endometrial sampling during SHG (SHGes) compared totraditional hysteroscopy and biopsy.Methods: Seventy-two consecutive patients with irregular bleedingand/or intracavitary abnormalities underwent transvaginal sonogra-phy (TVS) and SHG. SHG was performed with a 4.7-mm intrauterinecatheter. In all patients, an endometrial biopsy was performed by a syr-inge vacuum aspiration at the end of SHG. Procedure-related pain wasassessed. Sonographic findings at SHG were defined as normal, focallesions or diffuse endometrial abnormality. In patients with diffuseendometrial abnormality, hysteroscopy and hysteroscopic guidedbiopsy were performed. In patients with focal lesions, an operativehysteroscopy was performed. Pathologic report was the gold standard.Results: Mean age was 48 years (interquartile range 38–54). At SHG,no pain, mild, and severe discomfort was reported by 75, 18 and 7% ofpatients, respectively. Fifty patients underwent hysteroscopic guidedbiopsy, 22 operative hysteroscopy. Hysteroscopic findings were com-pared to SHG–SHGes finding. (A) Benign lesions: in 56 cases SHGand SHG sampling was concordant with pathologic report, in fivecases SHG and SHG sampling over diagnosed the endometrial lesion.In five cases, simple hyperplasia was missed by SHG endoemetrial sam-pling. (B) (pre)Malignant lesions (six cases): in five cases SHG–SHGeswas correct. One case of adenocarcinoma was intepreted as atypicalhyperplasia at SHG–SHGes. Sensitivity, specificity, positive and

negative values of SHG and SHGes for intracavitary abnormalitieswere 100, 64, 94 and 100%, respectively.Conclusions: SHG and SHGes should be considered a reliable officetriage in the management of patients with intracavitary uterineabnormalities, as adequate as hysteroscopic endometrial biopsies.

P03Factors associated with endometrial thickness and uterinesize in a random sample of postmenopausal women

B. E. Gull, B. Karlsson, I. Milsom & S. Granberg

Objective: To investigate factors possibly associated with endometrialthickness and uterine size in a random sample of postmenopausalwomen.Study design: A random sample (n ¼ 1000) of the total population ofwomen aged 45–80 years resident in the city of Goteborg was invitedto attend for a transvaginal sonography examination. Eight hundredand twenty-seven women accepted the invitation and underwent agynecological and a transvaginal sonographic examination with mea-surement of endometrial thickness and uterine size. The women’sheight and weight were measured and a blood sample for analysis ofserum estradiol and follicle stimulating hormone was taken. Thewomen also provided information regarding previous medical andgynecological history, possible medication and smoking habits.Results: Five-hundred and fifty-nine women were postmenopausaland 183 of them were taking some form of hormonal substitution(33%). Factors associated with endometrial thickness and uterine sizewere analyzed using univariate and stepwise multiple regression anal-yses. The current use of hormone replacement treatment was the mostimportant factor associated with both endometrial thickness and allthe uterine size parameters studied. The presence of fibroids was alsoassociated with endometrial thickness. Other factors shown to be asso-ciated with uterine size were age, parity, smoking, hypertension anddiabetes mellitus.Conclusions: Several of the known risk factors for endometrial cancerwere shown to be associated with endometrial thickness and uterinesize parameters.

P04Morphological and color Doppler velocimetry ultrasoundevaluation of breast solid lumps – a malignancy S-scoreproposition

E. F. Marussi, J. G. Cecatti, M. Alvarenga, M. R. M. Machado,C. M. M. O. Franzin & E. C. Martinez

The purpose was to evaluate the sensitivity, specificity and predictivesvalues for each morphological or CDV ultrasound criteria, alone orassociated, for the prediction of breast’s solid lumps malignancy andto create a malignancy’s score. We studied 430 women with 502 breastlumps (359 benign and 143 malignant). They were cared at CAISM-UNICAMP from May 1998 to November 1999 when a US examina-tion of the breast were performed and the results compared with thepathological diagnosis, the gold standard. They had been evaluatedthrough US morphological criteria such as borders, posterior wall, eco-texture, ecogenic halo, Cooper ligaments, diameters, volume, skin,compressibility, ratio between width and depth and CDV criteria suchvenous flow, color index, maximum systolic velocity, resistance index,pulsatility index and A/B ratio intra- and peritumoral. For data anal-ysis, the groups of benign and malignant tumors were compared regard-ing control variables adjusted by age via logistic regression. The bestindividual performance among the morphologic criteria, were borders,ecogenic halo, Cooper ligaments, ecotexture, width/depth ratio andbiggest diameter and among the CDV criteria, they were the color

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index, maximum systolic velocity, pulsatility and resistance indexinside tumor. In the logistic regression analysis, the criteria identifiedas statistically associated to the malignancy were the borders, ecogenichalo, the largest diameter and the woman’s age. They compoundthe equation of the malignancy’s score, whose performance was of95.2%. No one CDV criteria improved the global performance ofthe score. Excluding subjective criteria, the logistic regression analysisselected, for compound another equation of malignancy’s score, thewoman’s age, the lump’s largest diameter, the measure of the Cooperligament and the VSmx inside the lump. This second score had aslightly lower performance than the first one (92% against 95.2%).

P05Three-dimensional ultrasound and treatment of choice incervical cancer

A. Babinszki, A. Artner, J. Szalay, L. Palfalvi & L. Ungar

Purpose: Tumor volume, parametrial involvement, lymph nodal sta-tus, urinary bladder and rectum involvement are essential parametersin the treatment planning of early stage cervical cancer. Fertility spar-ing trachelectomy criteria has become a new diagnostic challengewithin the last years. We assumed that three-dimensional (3D) ultra-sound may add useful information for the oncologists in planningthe treatment of cervical cancer patients.Methods: Three-dimentional transvaginal sonography was performedin all cases to assess tumor volume, parametrial involvement, local anddistant spread of the tumor. Tumor vascularization was also examinedby 3D power Doppler.Results: In the last 5 months, 15 patients with early stage cervical can-cer, considered for primary surgical treatment, have been examinedwith 3D sonography prior to surgery. Two out of 15 patients haveundergone abdominal radical trachelectomy, 13 were surgicallyexplored with the intention of Wertheim hysterectomy. In one patient,paraaortal tumor spread was suspected on our 3D examination, sur-gical finding at exploration has proven lymphatic spread extendingabove the renal blood vessels, that has made the surgeon to abandonfirst line surgery as a curative intent treatment.Conclusions: Tumor volume was difficult to measure since most of theearly stage patients underwent cone biopsy prior to referral for radicalsurgery. Macroscopic pelvic lymph node involvement was assessedaccurately in all of our patients. Our impression was, that parametriuminvolvement, especially the caudal third of the parametrium, and theurinary bladder wall could be visualized and assessed more accuratelythan it was possible with 2D method. Involvement of the upper part ofthe cervical canal could be examined accurately in candidates for radi-cal trachelectomy. Early experience suggest, that 3D examination ofthe macroscopic lymph node involvement, parametrial, urinary blad-der and rectal wall tumor spread can be helpful for treatment planningof early stage cervical cancer patients.

P06Transit-time study of an ultrasound contrast agent in benignand malignant adnexal tumors

M.-R. Orden, J. S. Jurvelin & P. P. Kirkinen

Purpose: To evaluate objectively the effects of a microbubble contrastagent on the power Doppler ultrasonographic examination of adnexaltumors specially focusing in timing of the transit of the microbubblebolus.Methods: Seventy patients with suspected ovarian tumors were exam-ined pre-operatively using contrast-enhanced ultrasonography. A5 min examination was stored digitally and the behavior of the con-trast agent was evaluated objectively by measuring the time-dependentimage intensity at the region of interest with a computer program. Atime–intensity curve of each case was derived and analyzed.Results: Both the baseline and maximum power Doppler intensities aswell as the absolute and relative (%) rise in intensity were significantlyhigher (P < 0.001) in malignant as compared to benign tumors. Thearrival time was shorter (17.5 s vs. 22.5 s; P ¼ 0.005) and the wash-out time longer (219 s vs. 128 s; P ¼ 0.000) in malignant than in

benign tumors. A wash-out time >170 s showed a 91% sensitivityand 75% specificity for the diagnosis of ovarian malignancy, and theaccuracy was 78%.Conclusions: After microbubble contrast agent injection, malignantand benign adnexal lesions behave differently in degree, onset, andduration of Doppler ultrasound enhancement.

P07Value of texture analysis in ultrasonographic examinationof exised specimens of breast masses

W. Bader, G. Westhof, J. Hackmann, S. Dieterle, W. Hatzmann& S. Boehmer

Purpose: Specimen sonography is necessary for successful surgicalexcision of non-palpable breast masses, discovered only in breast ultra-sound. But is there any difference in echogenicity and echostructurebetween native and in vitro sonography?Methods: The ultrasound images from 46 benign and malignantbreast tumors were documented under standardized conditions pre-and postoperative, using a linear array machine (Shimadzu, US deviceSDU-490) and 7.5 MHz transducer with a water path interposedbetween the transducer and skin or the plastic bag, containing the freshspecimens after surgical excision. Two images of each tumor weredocumented on a 3/4 in. Sony high-band video device (U-matic BVU-800-P), and the recordings were digitized with an 8-bit resolution in384 � 288 pixels (frame grabber band, Ing. Buro Fa. Fricke, Berlin).In each sonographic image, the maximum area of the region of interestof the tumor was marked and then subjected to consecutive textureanalysis and correlation to the histological findings. For evaluationof tumor status eight parameters of first and second order texture sta-tistics (grey level histogram, Fourier analysis, co-occurrence matrix)were applied.Results: In all cases, the mass was clearly identified on sonogramsobtained in the operating room. Fibroadenomas (n ¼ 11), fibrocysticdiseases (n ¼ 5) and ductal carcinomas (n ¼ 26) showed comparableresults in texture analysis. On the other hand, lobular carcinomas(n ¼ 4) were clearly different in all parameters, in especially meanof grey level, homogeneity and contrast (P < 0.001 on the basis ofWilcoxon and Student’s t-test).Conclusions: In vitro examination is a rapid and efficient methodof localizing impalpable breast masses in excised specimens, butdifferences in echostructure and echogenicity are possible.

P08Which is the role of color Doppler sonography in thediagnoses of malignancy in postmenopause ovariescarcinomas?

S. Speca, V. Summaria, A. M. Costantini & P. Marano

Aim: To assess the reliability of B-mode sonography signs in associa-tion with color Doppler (CDS) flow analysis in diagnosing the ovariescancer in postmenopause women.Material and methods: We studied by sovrapubic and transvaginalsonography 400 consecutive female patients (age 48–64) from January1996 to September 2000. All the patients were asymptomatic andunder estro-progestinic therapy (postmenopause). We evaluated themorphological, volumetric and sonography changes of the ovaries, inassociation with the angioarchitecture (absence or presence of a neo-vascularization; low impedence arterial flow with PI < 0.8 andRI < 0.4).Results: In the 710 ovaries studied, we diagnosed 37 benign lesions(25 cystis, eight cystic teratomas, and 14 unilateral hydrosalpinxes),all with no flow signal at CDS and four carcinomas (one bilateralovaries adenocarcinoma, one endometrial adenocarcinomas, onehidrosalpinx with Walthard’s nidus); all these last lesions showed aneovascularization with a RI < 0.4 and a PI < 0.8.Conclusion: Our study confirmed the validity of the CDS in the diag-noses of ovaries malignant lesions, above all if associated to high flowspeed and low impedence flow rate.

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P09Abnormal ductus venosus blood flow in fetuses with normalnuchal translucency (NT)

A. A. Yamasaki & D. Pares

Objective: To assess the incidence of reverse flow during atrial con-traction at ductus venosus in fetuses with normal nuchal translucencyand correlation with cardiac abnormalities.Methods: Ductus venosus Doppler ultrasound blood flow velocitywaveform were obtained in 932 fetuses with 11–14 weeks’ gestationduring measurement of nuchal translucency.Results: Among 932 fetuses, NT was increased in 43 (4.6%). The inci-dence of reverse flow was observed in 5.4% of fetuses with normal NT(2.5 mm) and 13.9% of fetuses with increased NT (>2.5 mm). Amongfetuses with normal NT, there was no cardiac abnormalities observed.Conclusion: Reversed flow in fetuses with normal NT is not associatedwith cardiac abnormalities.

P10Color Doppler in the assessment of cervical cancer

M. Ciampelli, C. Mastromarino, R. Lopez, D. Basso, M. Distefano,A. Poerio & G. Scambia

The treatment and prognosis of cervical cancer depends on the clinicalstage based on the FIGO classification and the presence of lymph nodemetastases. Clinical staging of cervical cancer does not attain a gooddiagnostic performance, since it is incorrect in approximately one-thirdof patients who undergo surgical staging. Magnetic resonance (MR)imaging resulted to be superior to clinical evaluation and computedtomography (CT) in parametrial evaluation and in the staging of uter-ine cervical carcinoma. Endoluminal ultrasound was introduced toanalyse the cervix but no improvement in the diagnostic accuracy withrespect to clinical staging was obtained. Color Doppler velocimetrywas proposed as a non-invasive tool in the examination of cervical can-cer. Cervical cancers with detectable intratumoral blood flow wereassociated with larger size, invasion of parametrium, pelvic lymphnode metastases and greater microvessel density. A ‘vascularity index’resulted to be correlated with staging and lymph node metastases. Theaims of our study were to assess color Doppler characteristics of 48 cer-vical cancers at different stages and to analyse the correlation betweenDoppler parameters and clinical–pathological features of the tumors.Three-dimensional color power Doppler technique was used toinvestigate the vascular architecture of the neoplastic tissue. Three-dimensional vascular images were compared to magnetic resonanceresults. The actual clinical application of the three-dimensional vascu-lar analysis in the evaluation of cervical cancers remains still to bedefined.

P11Doppler evaluation in gynecological tumor recurrences

M. Ciampelli, C. Mastromarino, R. Lopez, D. Lorusso,C. F. Filidi & G. Scambia

Diagnosis of recurrent malignant disease in the abdomen and in thepelvis is a challenging problem. Because the survival of patients withdisease recurrence is improved only in patients with small recurrentlesions, the detection of recurrences at a very early stage is of greatimportance. Clinical examination and tumor markers are used forthe follow up of oncological patients; however, their diagnostic valueis not very reliable. Computed tomography (CT) and magnetic reso-nance (MR) have been studied extensively and their diagnostic accu-racy varies from 50 to 84%. Transrectal ultrasound has been used inmonitoring recurrent female cancer with a diagnostic accuracy of90.5% for pelvic lesions. However the ultrasound approach cannotbe used to differentiate between radiation fibrosis and recurrent malig-nancy on the basis of tissue appearance. Color Doppler examinationwas proposed in the management of patients treated for rectal tumor.The aim of our study was to evaluate the ultrasound diagnostic accu-racy in the detection of recurrent gynecological disease in a group of350 patients, followed up every 3–6 months at our Departmentafter surgical treatment of a pelvic gynecological malignancy. The

ultrasound data have been compared to clinical examination, tumormarkers and instrumental tools such as CT and MR. The usefulnessof color Doppler velocimetry in the examination of recurrent malig-nant lesions has been analyzed. In a selected group of patients withsmall-sized pelvic masses located in the central region of the pelvis,color Doppler analysis was able to differentiate recurrent vs. benignlesions.

P12Ductus venosus blood flow assessment at 10–16 weeks’gestation and chromosomal abnormalities

E. Antolın, C. Comas, M. Echevarrıa, M. Torrents, A. Munoz,F. Figueras, M. Cararach & J. M. Carrera

Background: Enlarged fetal nuchal translucency (NT) is a well estab-lished ultrasonographic marker for aneuploidy screening, especiallyduring the first trimester of gestation. Nuchal translucency screeningcombined with maternal age at early mid-trimester can identify about75–80% of chromosomal abnormalities with a false–positive rate of5%. Recently, Doppler parameters have been included in fetal aneu-ploidy screening, in order to improve the test performance. Changesin the ductus venosus (DV) blood flow velocity waveforms have beenreported in a significant proportion of chromosomally abnormalfetuses at first and early mid-trimester of pregnancy.Objective: The aim of our study was to evaluate the role of the DVblood flow assessment at 10–16 weeks’ gestation in the screening forchromosomal abnormalities.Methods: From December 1998 to June 2001, DV blood flow wasprospectively evaluated in 5067 consecutive pregnancies between 10and 16 weeks of gestation. Pulsatility index for the DV (DVPI) was cal-culated. All cases were screened for chromosomal defects combiningmaternal age and fetal NT thickness.Results: The average maternal age was 32 years (range 22–47).Seventy-four percent of the women were younger than 35. The inci-dence of chromosomal abnormalities was 1.06% (n ¼ 54), includingtrisomy 21 (n ¼ 25), trisomy 18 (n ¼ 6), trisomy 13 (n ¼ 2) and others(n ¼ 21). The incidence of chromosomal abnormalities was 13.8% inthose cases where DVPI was greater than the 95th centile, comparedwith an incidence of 0.3% in the remaining cases with a DVPI belowthis cut-off. This fact gives and odds ratio (OR) of 48 (95% IC: 26–87).The overall detection rate (DR), specificity (S), positive predictivevalue (PPV) and negative predictive value (NPV) for chromosomalabnormalities were 70.4, 95.3, 13.8, and 99.7%, respectively, whenusing the 95th centile DVPI as a cut-off. According to gestationalage, all the statistical parameters were increased in early gestationalage (10–13 weeks) when comparing with late gestational age (14–16 weeks), the corresponding DR and OR being 76.3% and 64(95% CI: 30–138) compared with 56.3% and 26 (95% CI: 9–72),respectively. Moreover, when only autosomal trisomies were consid-ered, a DR of 87.9% was reached with an S, PPV, NPV and OR of95.3, 10.9, and 99.9% and 146 (95% CI: 51–418).Conclusions: Our results suggest that the evaluation of DVPI at10–16 weeks’ gestation is a useful tool in the screening for chromo-somal defects, especially in detecting autosomal trisomies and whenit is assessed in early gestational age.

P13Abnormal umbilical vein blood flow in trisomy 9 fetusduring early pregnancy

C. C. V. Murta, A. F. Moron, M. A. P. Avila & F. A. P. Vasques

We describe a case of reversed flow in the umbilical vein and in the duc-tus venosus during atrial contraction of one fetus at 12 weeks’ gesta-tion with increased nuchal translucency (9.1 mm). In addition,Doppler velocimetry detected high retrograde flow in the inferior venacava. Cytogenetic analysis of chorionic villi revealed trisomy 9. Wesuggest that these findings can be an early sign of chromosomalabnormalities and cardiac defects in the first trimester. To the best ofour knowledge, this is the second report of reverse umbilical venousblood flow described in the literature and the earliest case reportedin pregnancy.

11th World Congress on Ultrasound in Obstetrics and Gynecology Poster Session 1: Obstetrics – First Trimester, Gynecology

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P14Correlation between ductus venosus, gestational ageand nuchal translucency at 11–14 weeks scan:preliminary study

H. Munoz, M. Parra, D. Pedraza, P. Jimenez, S. Villa& M. Puga

Background/objective: Fetal ductus venosus assessment at 11–14 weeks’ gestation is one of the best tests to identify fetuses with car-diac malformation. Negative blood flow during atrial contraction hasbeen used as qualitative sign in this cases. The aim of this study is todescribe normal ranges for Doppler velocimetry of ductus venosusat 11–14 weeks’ gestation and correlate it with nuchal translucencythickness.Material and methods: We performed a prospective study, 88patients were examined at 11–14 weeks of pregnancy. Crown rumplength, nuchal translucency, fetal anatomy and uterine artery Dopplervelocimetry were evaluated transabdominally. Ductus venosus wasidentified using longitudinal plane and Doppler velocimetry indexwas measured using Doppler duplex ultrasound. An average ofthree waveforms were analyzed and pulsatility index venousus wasmeasured. For statistical analysis mean values and 95% CI for pulsa-tility index of ductus venosus was established for each crownrump length, Spearman regression and normal centile distributionwas performed.Results: The 77 out of 88 patients with nuchal translucencybelow 95th centile were used for calculating normal ranges foreach gestational age. Mean maternal age was 29 � 6.5 years old(range ¼ 15–42), and 20% was over 35 years old. Mean pulsatilityindex was 1.02, 0.99, 0.95 and 0.92 at 11, 12, 13 and 14 weeks,respectively. Although ductus venosus pulsatility index was not mod-ified according to gestational age, there was a significant positivecorrelation with nuchal translucency thickness (r ¼ 0.59, P � 0.001).Conclusion: Ductus venousus pulsatility index is correlated positivelywith nuchal translucency at 11–14 weeks’ gestation.

P15Abstract withdrawn

P16Diagnosis and management of low segment Cesareansection scar pregnancies

B. Woelfer, R. Salim, J. Elson, A. C. Lawrence & D. Jurkovic

Background: Rising Cesarean section rates have led to an increasingnumber of pregnancies implanted into postoperative uterine scars.We report a large series of Cesarean scar pregnancies treated in a singletertiary referral center.Methods: The diagnosis of Cesarean scar pregnancy was made onultrasound scan when trophoblast was seen covering the lower seg-ment uterine scar. Pregnancies <14 weeks size were treated eithermedically (local injection of methotrexate � KCl) or with conservativesurgery (dilatation and curettage � insertion of Foley catheter). Surgi-cal treatment was used for smaller, non-viable pregnancies and in casescomplicated by heavy bleeding or infection. Clinically stable patientswith larger, viable pregnancies were treated medically. A single viablepregnancy >14 weeks required total abdominal hysterectomy.Results: In a 4-year period, 14 Cesarean section scar pregnancies werediagnosed. Out of 13 women who were <14 weeks pregnant, sevenwere treated surgically (54%), five medically (38%) and one expec-tantly (8%). Surgery was successful in all cases. Three women (43%)required insertion of Foley catheter into the cervix to arrest the bleed-ing and one (14%) required blood transfusion. Three out of five (60%)women who received medical treatment were cured. Two womenrequired surgery because of prolonged and heavy bleeding, one of themwas transfused (20%). A case managed expectantly resolved sponta-neously without any intervention. Five women tried to conceive againafter treatment. All three women who succeeded (60%) had normalsingleton intrauterine pregnancies.Conclusion: Early Cesarean scar pregnancies can be safely treat-ed both medically and by conservative surgery. Although surgicaltreatment was more effective, this may be due to the selectioncriteria, which favored use of surgery in cases of smaller, non-viablepregnancies.

P17Experience with fetal nuchal translucency in a privateclinic in Sao Paulo

S. C. Cha, P. A. Chinen & D. Pares

The fetal nuchal translucency (NT) has been used since 1995 as screen-ing exam for abnormal karyo-type and structural malformations. Fetalnuchal translucency measurements were performed in 1877 pregnan-cies, during the period from 1995 to 2000, between 11 weeks to13 weeks and 6 days. From the 1877 exams, we obtained 29 (1.4%)with abnormal NT and these data are the object of our study. Nineteenpregnancies (65.5%) had no structural malformation and/or karyo-type abnormalities. We had one (3.4%) case of congenital heart diseasewith hypoplasia of left ventricle (death in the third day of life), one(3.4%) case of fetal dead for true knots of the cord, without other mor-phological disturb. Others three (10.3%) cases had spontaneous abor-tion (one case of 46 XX; one case of 69 XXY and the other case doesnot have karyo-type). In two (6.9%) cases induced abortion happened,without karyo-type study.

P18Fetus with osteogenesis imperfecta presenting as increasednuchal translucency thickness in the first trimester:a case report

T.-C. Hsieh & G.-P. Yeh

Background: Nuchal translucency (NT) has been used successfullyin screening for chromosomal abnormalities at 11–14 weeks of gesta-tion. Increased NT thickness is also associated with lots of fetal anoma-lies in chromosomally normal fetuses. We report a case of osteogenesisimperfecta (OI), type II, presenting with increased NT thickness. A 26-year-old Taiwanese woman, gravida 2, para 1, without medical orfamily history was scanned for confirmation of menstrual gestational


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age at 13 weeks of gestation. Crown-rump length was compatiblewith menstrual age. Increased NT thickness was noted (3.6 mm).Follow up scan 2 weeks later revealed hypomineralization of skull,multiple fractures of long bones and ribs and severe micromelia. Apresumptive diagnosis of OI type II was made based on sonographicfindings. After counseling, the parents decided to terminate the preg-nancy. A stillborn weighing 70 g was delivered after intravaginalmisoprostol application. Postmortem radiograph and autopsyconfirmed the diagnosis of OI.Discussion: NT screening for chromosomal and structural abnormal-ities at 11–14 weeks of gestation was proposed by Nicolaides in the1990s. It has gained worldwide popularity due to early screening andhigh detection rate. Distorted and narrow thoracic cage due to rib frac-tures or altered composition of the extracelluar matrix has beenthought to be the possible mechanisms of increased NT thickness infetuses with OI. In our opinion, the characteristic of hypomineraliza-tion in OI enables clear visualization of intracranial structures whichmay resemble the sonographic features of increased NT thickness insome cases. This finding should prompt the sonographer to measureNT thickness and scan for possible anomalies.

P19First trimester Down syndrome screening by nuchaltranslucency in Thai population

S. Ajjimakorn, P. Tungkajiwangoon & A. Jaowisidha

Purpose: To examine the significance of the fetal nuchal translucency(NT) at 10–13 þ 6 weeks’ gestation in the prediction of DS in a Thaipopulation.Methods: Total 2353 pregnant women were recruited from January1996 to June 1999. Almost all women underwent transabdominalscanning (TAS) (Toshiba 140, TAS probe 5.0 MHz Toshiba PVF-5.00 MT). When the result showed an increased risk for DS(>2.5 mm NT), the pregnant woman was counseled and the invasivetest was optional. All the newborns were physically examined thor-oughly by pediatricians to detect the markers for major chromosomalanomalies such as DS, trisomy 18 and 13. For the suspected DS orother chromosomal abnormalities, the newborn’s blood was sent forthe chromosome study.Results: The mean maternal age was 28.71 þ 0.13 years and 2037pregnant women (86.57%) were <35 years old. The mean gestationalage was 11.94 þ 1.07 weeks. Sixty-five pregnant women who hadNT > 2.5 mm decided to have the invasive tests. Sixty had normalkaryo-types while five had abnormal chromosome abnormalities (onetrisomy 13, two trisomy 18 and two trisomy 21). All of them were>35 years old. Sixty pregnant women with normal chromosomefetuses had detailed ultrasound scanning at 18–20 weeks’ gestationand screening for maternal toxoplasmosis, cytomegalovirus, rubellavirus, and herpes virus. The infection screen was negative in all cases.There were 20 congenital heart diseases, four fetal deaths in utero at28–30 weeks, one Bart’s hydrops fetalis and 10 abortion. The resthad normal pregnancy outcomes and NT resolved by 20 weeks. Therewere 316 (13.43%) cases with maternal age >35 years. Twenty-threehad >2.5 mm. NT and all of them had the invasive tests which revealedfive abnormal chromosomes (as mentioned above). However, no DSfetuses were detected in <35 years pregnant women. Two hundredpregnant women with normal NT decided to have the invasive testsdue to advanced maternal age and all of them had normal karyo-types.The sensitivity, specificity, positive predictive values and negative pre-dictive values for trisomy 21, 18 or 13 with different cut-off values forfetal NT were studied. This is the first report of the first trimester NTscreening for DS in Thai people. The cut-off of >2.5 mm NT was usedto increase sensitivity. We can detect all the cases of DS with this cut-off value but one case of DS will be missed if we use the cut-off of>3.0 mm.Conclusions: This study revealed the feasibility in NT measurementfor DS screening in the first trimester of pregnancy in Thai population.This test can increase detection rate of DS in the high-risk pregnantwomen, who did not accept the invasive prenatal diagnosis procedures,as well as in the low risk pregnancy.

P20First trimester determination of fetal gender byultrasound

M. Podobnik & M. Podgajski

Objective: To determine the feasibility of correctly identifying fetalgender from 11 to 13 weeks of gestation.Methods: Fetal gender assessment by ultrasound was prospectivelycarried out in 425 singleton pregnancies at 11–13 weeks of gestation(confirmed by crown-rump length or biparietal diameter) immediatelybefore chorionic villus sampling for karyo-typing. A total of 425women underwent a detailed assessment of fetal anatomy at 11–13 weeks of gestation by means of transabdominal and transvaginalsonography. Fetal gender was identified in transverse and sagitalplanes, and was confirmed by chorionic villus sampling.Results: The accuracy of sex determination increased with gestationfrom 91.7% at 11 weeks, to 97.2% at 12 weeks and 100% at13 weeks. Male fetus were wrongly assigned as female in 5.5% of casesin 11 weeks, 2.4% at 12 weeks and 0% at 13 weeks. The accuracy ofcorrectly identifying fetal gender increased with gestational age.Conclusion: Whilst the accuracy of sonographic determination offetal gender at 11–13 weeks is good, our decision on invasive testingfor sex-linked conditions should be undertaken only after 12 weeksof gestation.

P21Heart activity visualization in embryos with crown-rumplength shorter than 5 mm

A. A. Yamasaki & D. Pares

Introduction: In the past, heart activity was only visualized by ultra-sound in embryos with a crown-rump length (CRL) of 5 mm or more.When CRL was shorter than 5 mm, non-visualization of heart activitywas considered normal. However, improvement in ultrasound equip-ment resolution has made it possible to diagnose viability in embryoswith CRL as small as 2 mm.Objective: The aims of this study were to determine: (a) how oftenheart activity is visualized in embryos with CRL between 2 and5 mm; (b) outcome when CRL is shorter than 5 mm and heart activityis not visualized.Methods: Presence or absence of heart activity was examined inembryos with CRL between 2 and 5 mm by vaginal ultrasound (Med-ison Model Voluson 530 and Aloka Model 1700), 4–7 MHz; B- andM-mode). Follow up scans were carried out one-week later when theinitial scan did not demonstrate heart activity.Results: Two hundred and forty-four embryos were examined andheart activity was demonstrated in 210 (86%) cases. Follow up scansdemonstrated heart activity in six (17.5%) of the 34 embryos in whichheart activity was not initially visualized.Conclusion: This study has demonstrated that visualization of heartactivity is possible in most embryos with CRL between 2 and 5 mmnowadays. Non-visualization at this stage is associated with embryonicdemise in about 80% of cases.

P22How to discriminate between normal and abnormalearly pregnancy

S. A. Jun & M. O. Ahn

Early fetal growth delay and early oligohydramnios have been sus-pected as signs of embryonal jeopardy. Sonographic examinations of100 early pregnancies between the sixth and ninth gestational weekwere performed to investigate predictable sonographic findings of earlyabortion. Sonographic measurements of the gestational sac (G-SAC),Crown-rump length (CRL) and fetal heart rate (FHR) were performedusing a transvaginal transducer with Doppler. All measurement of 11early abortions were compared to those of 89 normal pregnancies toinvestigate the objective rules for the screening of early abortion.Most of the early aborted pregnancies were classified correctly bydiscriminant analysis with G-SAC and CRL (G-SAC ¼ 0.5222 �CRL þ 14.6673 ¼ 0.5 � CRL þ 15). In conclusion, early fetal growth


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retardation and oligohydramnios could discriminate the poor prog-nosis of early pregnancies.

P23Nuchal translucency screening and antenatal maternalserum screening for Down syndrome: resultsof a project

C. E. Benavides, C. C. Garcia, N. C. Lagos, X. C. Melgarejo& M. I. C. Ferres

Objectives: To asses the implementation of antenatal screening forDown syndrome using individual risk estimates based on maternalage, nuchal translucency and three serum markers; alpha fetoprotein,unconjugated estriol and human chorionic gonadotrophin (hCG) inmaternal blood. Women with an estimated risk of 1 in 250 or greaterwere classified as screen positive and offered diagnostic amniocentesis.Subjects: A total of 1956 women of all ages with singleton pregnanciesseen between June 1999 and March 2001.Results: The screening result of combination of first trimester ultra-sonographic and serum screening was 85% Down syndrome detectionand the false positive rate was 3%. The median gestational age ofnuchal translucency was 11 weeks and the time of serum screeningwas 16 weeks.Conclusion: The combination of nuchal translucency and serumscreening increases the Down syndrome detection and decreases thefalse positive rate. Is very important because the amniocentesis is asso-ciated with a risk of pregnancy loss from 0.5 to 1%. Besides, it is cost-effective and performs better than the selection for amniocentesis onthe basis of maternal age only, nuchal translucency only or serumscreening.

P24Reduction of complications during first trimester abortionwith the use of sonography

A. Malvasi, A. Losito, D. Baldini, A. Mudoni & V. Traina

Background: In our reproductive medicine service, more than 3000abortions have been practised every year, since 1978. The standardoperation for legal abortion is executed, according to law 194/78within 90 days. The technique in voluntary or spontaneous abortionprovides D&C as well as hysterosuction with the patients in generalanesthesia. In order to reduce the possible complications for this opera-tion and the increasing legal cases, routine perioperative sonographyhas been used to evaluate sudden abortion complications.Methods: Besides ordinary preoperative sonography assessing gesta-tional age, evolution of pregnancy, pelvic disease, etc. the use of intra-operative sonography has been shown to be necessary. A permanentteam of four operators performs the operation under sonographicguide by using an R–T 36600 General Electric apparatus owned byour medicine service. In a lapse of time of five years, 16804 abortionsunder sonographic guide were practised and in a retrospective waythere was a statistically significant reduction of complications accord-ing to literature. The 16118 cases in the previous 5 years and within thetwo homogeneous groups.Results: We registered 11 complete and 13 incomplete uterine perfora-tions vs. 4 and 7 (P < 0.01), 18 cases of retention of ovule remaindersvs. 6 (P < 0.05), which required hospital readmission for a furtherexamination of uterine cavity. In addition, the group under sono-graphic guide has shown a lower rate of failures in operations, anti-biotics administrations (P < 0.001), endovaginal prostaglandin use(P < 0.005), anesthetics use (P < 0.05) and hospital stay (P < 0.01).If for the 24 previous uterine perforations in 19 cases the operationwas delayed (11 � days later) 13, when intraoperative sonographywas used, it occurred only in three cases, for the other patients undersonographic guide, the uterine cavity was completely cleared with nocomplications at all (P < 0.001).Conclusions: In our service, as well as according to literature, intra-operative sonography during abortions, led to a great reduction ofcomplications with a better compliance for the patient and a significantreduction of costs. In particular, thanks to the use of sonography,complete and incomplete uterine perforations descreased, in 91% cases

under sonographic guide the uterine cavity was emptied with nocomplications for the patients. Because of the favorable relationshipbetween costs and benefits, the intervention can be performed undersonographic guide.

P25The combination of uterine artery Doppler and placentalvolume measurement in the first trimester for the predictionof high risk pregnancies

K. Schuchter, M. Metzenbauer, E. Hafner & K. Philipp

Purpose: To evaluate the combination of placental volume measure-ment and uterine artery Doppler in the first trimester for the predictionof pregnancies complicated by preeclampsia, pregnancy inducedhypertension, preterm placental abruption or fetal growth retardation.Methods: At the booking scan in the first trimester one single operatorwas performing Doppler examinations of both uterine arteries on 380women with singleton pregnancies. Both the pulsatility index (PI) andthe criteria of notching or not notching were recorded. Another opera-tor was recording and afterwards calculating the placental volume atthe same visit. In order to correct the placental volume measurementfor the gestational age a placenta quotient was calculated (placentalvolume/crown-rump length).Results: Uterine artery PI above the 90th centile could be recorded in38 pregnant women. Three of these pregnancies were complicated withplacental abruption, two of these were preterm placental abruptionswith additional PIH. Six of the 38 pregnancies ended with SGA babies.On 39 women, the calculated placental quotient was below the 10thcentile. Two of these women developed PIH in addition to the occur-ance of placental abruption. Six babies had a birth weight below the10th centile and one of these had PIH. Only eight pregnancies metthe criteria of uterine artery PI above the 90th centile and placenta quo-tient below the 10th centile. Two of these ended with placental abrup-tion and PIH before 37 weeks of gestation, four of these babies had abirth weight below the 10th centile and none of these had a birthweight above the 50th centile.Conclusion: Regarding our results we think that the combination ofplacental volume measurement and uterine artery Doppler might bea possible way for the evaluation of high risk pregnancies.

P26Transvaginal ultrasound and induced abortion

A. N. Balic, D. B. Balic, B. Balic & I. Zukic

Background: The aim of this study was to audit prospectively thevalue of preabortion ultrasonography.Methods: All women who came to our center because of doubtunplanned pregnancy in first trimester from March 1994 to July2001 underwent an exam by vaginal ultrasound before abortion. Weanalyzed these data and compared them with complications after legalinduced abortion.Results: During 2 years a total of 334 women were surveyed. Fifty-three women (8.04%) were not pregnant. In 65 cases (9.86%), thepregnancy was greater by 2 weeks than we expected on the basis oflast menstrual period. Also we found: 41 (6.22%) myoma uteri, 10(1.51%) ovarian cysts, 15 (2.27%) multiple pregnancy, 8 (1.21%)anomaly of the uterus, 4 (0.61%) missed abortions and 5 (0.76%)embrionic abnormality (anencephalus, abdominal cyst, nuchaltranslucency).Conclusion: Preabortion ultrasonography increases security of thisintervention by eliminating some problems linked induced abortion.Since the examination is simple, fast and cheap, we recommendedit for routine use. We hope that it is one way for decreasing latecomplications after abortion, like infertility.

P27Twin cervical ectopic pregnancy

M. P. Bethune & A. Sampson

A 40-year-old woman presented for IVF treatment due to 8 yearsof secondary infertility. Two embryos were transferred without


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ultrasound guidance. The patient presented at 6.5 weeks gestation withheavy vaginal bleeding. A transvaginal ultrasound revealed twin cer-vical ectopic pregnancies, lying side by side in the cervical canal andwithin 6 mm of the external os. One contained a 9-mm embryo witha normal fetal heart rate. The other sac was anembryonic. The bHCGlevel was 129 000 IU/L. The patient was treated with the same regimenof methotrexate as used for persistent trophoblast disease: second dailymethotrexate with folinic acid rescue after each dose. Completeresolution of the twin pregnancy occurred, bleeding was however,recurrently heavy over the next 6 weeks.Discussion: Cervical ectopic pregnancy is a rare event, accounting forless than 1% of ectopic pregnancies. The incidence is increasing due tothe increased use of in vitro fertilization. Prior to the advent of conser-vative treatments most patients required hysterectomy due to severe,uncontrollable bleeding. Conservative measures include dilatationand curettage (usually combined with uterine artery embolization, liga-tion or cervical balloon tamponade); local injection of methotrexate orpotassium chloride (ultrasound guided); or systemic methotrexate.Twin cervical pregnancy is an extremely rare event with only two pre-vious case reports in the literature [1]. Due to the large size of this twinpregnancy mass, the high bHCG level and the large volume of vasculartrophoblast; we decided to treat this patient in a similar manner to apatient with gestational trophoblast disease. This mode of treatmentshould be considered with cervical ectopic pregnancies where thebHCG level is abnormally elevated.Reference

1 Pascual MA, Ruiz J, Tresserra F, Sanuy C, Grases PJ, Tur R, BarriPN. Cervical ectopic twin pregnancy diagnosis and conservativetreatment. Human Reproduction 2001; 16, 584–6

P28Ultrasonographically measured umbilical cord cross-sectionalarea – reproducibility of the method

F. A. P. Vasques, A. F. Moron, C. G. V. Murta, F. H. C. Carvalho,H. Cattini, T. R. Goncalves, M. M. Barbosa & W. J. Hishaba

A prospective cross-sectional study was developed in order to deter-mine the reproducibility of the measurement of the umbilical cordcross-sectional area (UCCSA) during normal pregnancies (patientswith known dates of LMP and an ultrasound examination before the20th week, without any pathologic condition), measured by differentand trained examiners. The measurements of the umbilical cordcross-sectional area were obtained in a plane adjacent to the insertionof the cord abdomen, as proposed by Raio et al. 1999, after the differ-ent examiners were trained by the author. The inclusion criteria were:(1) singleton pregnancy; (2) gestation age >20 weeks; (3) intact mem-branes (4) normal umbilical Doppler flow velocimetry. The exclusioncriteria, in the presence of any of those were: (1) congenital and/orchromosomal abnormalities; (2) pregnancy complications (any type);(3) inadequate size for gestational age with when the examinationwas performed, i.e. the weight below the 10th percentile or abovethe 90th; (4) abnormal AFI for the gestational age. The patients wereexamined and included only once. During the period of the study(February 2000–May 2001), 545 patients were examined, after meet-ing the inclusion criteria determined for the present study. The age ofthe patients ranged from 15 to 42 years (mean ¼ 26.7 � 4.8), 242patients (44.4%) had two gestations, 135 patients (28.1%) were attheir first gestation, 129 patients (23.7%) were at their third gestationand 39 patients had four or more gestations (3.8%). The ultrasoundmachine used was the Synergy Multi Sync M 500. The statistical pro-gram used was the statistical package for social sciences (SPSS). Thefirst examiner collected 22% of the data, the second examiner collected45% of the data, the third examiner collected 24% of the data andthe fourth one collected 9% of the data. According to the analysis ofvariance (ANOVA), we performed, comparing the data obtained by thedifferent examiners, no significance was found and this fact wasalso showed by the comparison of the data among them and verifyingthat the data had a dispersion inside tolerable limits. The ANOVA

showed the following data (example for 3 weeks): At 25 weeks, theF-test showed a value of 0.930 and a P-value of 0.454; at 32 weeks

the values were 0.106 for the F-test and 0.956 for the P-value andfor week 38 the values were 0.102 (F-test) and 0.904 (P-value). Weconclude that the measurement of the UCCSA as proposed byRaio et al. 1999 is reproductible and can be adopted as a new obstetricultrasound parameter.

P29A comparison of the uterine and intraovarian arterialflows in women having a history of recurrentspontaneous miscarriage associated withantiphospholipid syndrome

J. Jirous, M. E. Diejomaoh, F. Al-Abdulhadi & M. H. Boland

Purpose: To study the relationship between values of Doppler indicescharacterizing the uterine and intraovarian arterial flows in the pre-sence of antiphospholipid syndrome in women with history of recur-rent spontaneous miscarriage (RSM). We are not aware of anyprevious study undertaken on this specific topic.Methods: Sixty-two women attending our recurrent spontaneous mis-carriage clinic were recruited for this prospective study and subse-quently divided to group A (n ¼ 35) involving RSM women withnormal anticardiolipin antibodies values (ACL IgM, ACL IgG) andgroup B (n ¼ 27) for those with antiphospholipid syndrome (abnormalACL IgM, ACL IgG values). ACL IgM and ACL IgG antibodieswere measured in the blood using the standardized enzyme linkedimmunosorbent assay (ELISA). Color and power Doppler transvaginalultrasonography was used to estimate the uterine artery pulsatilityindex (UTAPI), spiral artery resistance index (SARI) and intraovarianresistance index (IOARI) in the 21st day of a regular 28-day unstimu-lated menstrual cycle. The data were analyzed using the statisticalsoftware SPSS 9.0 Windows. Statistical significance was defined asP < 0.05.Results: There was no statistically significant difference in the meanage in group A (33.67 � 5.52 years) and group B (32.70 � 5.85 years),the mean UTAPI values (3.14 � 1.16 for group A and 3.44 � 0.88 forgroup B), the mean SARI values (0.73 � 0.13 for group A and0.73 � 0.07 for group B). The incidence of the first trimester miscar-riages in women over 30 years was significantly higher in group B com-pared with group A (P < 0.01).Conclusions: Our preliminary study has revealed that there was nosignificant difference in UTAPI, SARI and IOARI values of RSMwomen with normal and abnormal ACL IgM and ACL IgG values.This fact could be explained by the predominantly mild form of anti-phospholipid syndrome in Kuwait confirmed in our previous studies.We could hypothesise that such mild disease will have minimal/mildvascular effects in the non-pregnant uterus and subsequently in the pla-cental bed.

P30Vascularity index of the testis: a guiding technique fortesticular sperm extraction (TESE)

J. Har-Toov, O. Eitan, R. Hauser, A. Butchan, I. Gull, I. Wolman,H. Yavez & A. J. Jaffa

Aim: To develop a non-invasive computerized technique that predictsthe presence of spermatogenic sites within the testes of non-obstructiveazoospermic (NOA) patients.Material and methods: Power Doppler ultrasound images of thetestes of seven NOA patients and six fertile men were acquired. Threesagittal, three transverse and one coronal cross-sections of the testiswere scanned by a linear 7.5 MHz transducer. Three-dimensional(3D) matrix of 32 elements was generated from all images of each tes-tis. Each element carried information (a vascularity index, VI) aboutthe blood vessels that crossed its volume. The matrix (4 � 4 � 2) wasdivided into regions of 16 elements which were classified as ‘positive’,‘negative’ and ‘undetermined’ according to the VI values in the anteriorand posterior layers of a region. The NOA patients underwent testicu-lar biopsies at three locations along the midline of the testis. The resultsof the biopsies were correlated to the appropriate regions in the 3Dmatrix.


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Results: Of the seven NOA patients, 12 testes were scanned, however,only 27 biopsies were performed. Accordingly, only 27 regions wereconsidered. Thirteen regions were ‘positive’, 12 regions were ‘nega-tive’, and two were ‘undetermined’. Motile spermatozoa were foundin nine out of 12 ‘positive’ regions (69.2%). No sperm was found in10 of the 12 ‘negative’ region (83.3%). In the control group of sixpatients, there were 12 testes, which divided into 36 regions.Twenty-four regions were ‘negative’ (66.7%), one was ‘positive’(2.7%) and 11 were ‘undetermined’ (30.6%).Conclusion: The results yielded that positive/negative region predictthe presence or absence of spermatozoa, and thus, this method appearsto be a promising non-invasive guiding tool for TESE in NOA patients.TESE will be more effective, less biopsies will be needed, and testiculardamage will significantly be lowered. However, this method is not sui-table to identify spermatozoa in fertile men.

P31Lower abdomen cystic masses diagnosed in femaleinfants in fetoneonatal period: diagnosis andmanagement

M. Hrehorcak, D. Smetanova, K. Pycha, A. Zuntova,J. Horejsi & M. Holemarova

Cystic masses in female fetuses and neonates are in waste majority ofcases identified in screening ultrasound during pregnancy. Often theyare detected as early as in second trimester screening sonography (18–22 weeks). When they are identified, problems with differential diag-nosis and management modalities arise. In majority of cases, the cysticformation is simple ovarian cyst. It might be misinterpreted with otherconditions such as: hydronephrosis, bowel obstruction, mesenterialcysts, etc. We attempt to identify US criteria for reliable prenatal diag-nosis of simple not complicated ovarian cysts. Define treatment possi-bilities and recommendations. Forty-three cases of such formation inlower abdomen were reported in our hospital either in pediatric gyne-cology or pediatric surgery departments. Thirty-three were diagnosedprenataly, nine diagnosed postnataly. Cysts were unilateral in all cases.Twenty-two cases were treated surgically by ovarectomy. Nine of thetreated cases were cysts larger than 60 mm, in four cases the diameterwas less than 40 mm, Nine cases were cyst between 40 and 60 mm.Histological examination proved 18 cases with hemorrhagic necrosisof the ovarian cyst, four cases were diagnosed as follicular cysts andone case of malignant retroperitoneal sarcoma. Twenty cases of cysticformation were observed and expectation management was applied.All of them were smaller than 40 mm in largest diameter and theyresolved spontaneously within 1 year of age. We conclude that basiccriteria for accurate diagnosis include mandatory visualization of thekidneys and stomach in the time of diagnosis. Simple ovarian cysthas following features on ultrasound: one chamber cystic formationin lower abdomen, smooth walls, anechogenic. Expectation manage-ment with serial follow up is recommended for cysts smaller than40 mm in diameter, Surgical treatment should be instituted only in caseof ovarian torsion (cyst diameter seems to be of good predictive value)or rupture with bleeding. Simple cysts with diameter larger than40 mm remains controversial. Should we treat them to prevent torsion?We conclude that conservative approach is adequate in certain cases,when risk of acute abdomen is low and spontaneous disappearance ispresumable in respect to preservation of future reproductive functionof female infant.

P32A large pedunculated leiomyoma with unusualfeatures – a case report

S.-L. Lee & S.-K. Tay

Introduction: Leiomyoma, a benign tumour arising from smooth mus-cle, is a common finding on gynecological ultrasound examination. Itusually presents as a heterogeneous, hypoechoic mass with ill-definedborders. According to its location, it may be described as submucous,subserosal, and intraligamentous. With the new generation ultrasoundunits, its perfusion may be mapped with accuracy.

Case report: The patient is a 39-year-old lady who was first seen in ourdepartment in October 1998. She just had a delivery by cesarean sec-tion in August 1998. Her pregnancy was looked after by a differenthospital, where she was told to have a fibroid. No follow up wasarranged for her after her delivery. When she came to our department,she was complaining of occasional lower abdominal pain. An ultra-sound scan that was performed revealed some small intramural andsubserous leiomyomata of 1–2.6 cm. A predominantly cystic, loculatedmass with an irregular contour was seen in the POD. It had some echo-genic components and its measurements were 10.7 cm � 7.5 cm �11 cm. Power Doppler detected some intratumoral venous flow.Impression was that it was not of ovarian origin. The patient wasscheduled for a myomectomy/frozen section for fibroid on 9 November1998.Histopathology report: Leiomyomas with edema, hyalinization andinfarction.Discussion: The ultrasonic features in this case are not typical of a leio-myoma. Although cystic degeneration are sometimes seen in myomata,it is usually not so predominant. Although the state-of-the-art ultra-sound units, with color and power Doppler facilities, are supposed tobe capable of producing very accurate assessment of pelvic masses, itwas found to be inadequate in this instance. Firstly, the classificationaccording to its location was not possible as the stalk was not seen,probably as a result of tumor size. Secondly, the blood flow resultswere not helpful as this is a predominantly cystic mass. Hence,not much useful information could be derived for the planning of thesurgery.

P33Asymptomatic endometrial polyps in postmenopausalwomen: are they an indication for surgicalremoval?

E. Ferrazzi, C. Lanzani, V. Conserva & A. Padoan

Purpose: To compare demographic, sonographic, and outcome dataof postmenopausal patients with asymptomatic endometrial polyp,surgically treated or not treated.Methods: Ninety postmenopausal women with sonographic/sonohys-terographic diagnosis of asymptomatic endometrial polyp were pro-spectively enrolled in this study. All patients underwent transvaginalsonography with color Doppler evaluation (Voluson 5300, KRETZ),and sonohysterography in selected cases. Patients were counseled onthe risk of malignancy (estimated risk < 1/200). Sonographic followup at 3, 6 and 12 months was proposed as an option to standard hys-teroscopic polipectomy. Surgery was considered in case of bleeding,polyp enlargement, or Doppler PI < 0.6. Demographic and sono-graphic data of both groups were recorded. Surgical complications ingroup B patients were considered as abnormal outcome.Results: Sonographic follow up was chosen by 42 women (group A)and surgical removal by 47 patients (group B). Forty-three patientsunderwent operative hysteroscopy, and four patients hysterectomy(group B). One major (uterine perforation not requiring surgery)and three minor complications (two cervical lacerations requiringhemostatic suturing, one false entry) (9%). Demographic (age, yearsof menopause, blood hypertension/diabetes, BMI, nulligravidity, hor-monal replacement therapy assumption, tamoxifen assumption) andsonographic data) Endometrial thickness mean (interquartile range) ¼8 (5–10) vs. 11 mm (7–13); volume (cc): 3 (1–4) vs. 4 (1–5); PI: 0.48(0.44–0.51) vs. 0.49 (0.45–0.53) were not significantly differentbetween group A and B. Pathologic findings were glandulocystic andhyperplastic polyp in 45 and in two patients, respectively. All groupA patients remained asymptomatic in the follow up period (mean10 months, interquartile range 5–16).Conclusions: Demographic and sonographic data were not signifi-cantly different in the two groups. No untreated patient became symp-tomatic during follow up period. Benign lesions only were found intreated patients, at the cost of one uterine perforation. A large multi-centre study is needed to understand the exact prevalence of endome-trial cancer in asymptomatic endometrial polyp, and verify the safetyof conservative management.


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P34Sonographic based triage – transvaginal sonography (TVS)and sonohysterography (SHG) – for benign uterinelesions and surgical management

F. P. G. Leone, A. Tonta, C. Lanzani, M. Di Grandi& C. Mastromatteo

Purpose: To assess the reduction of clinical indications to hysterect-omy as a consequence of sonographic based triage – transvaginalsonography (TVS) and sonohysterography (SHG) – in the surgicalmanagement of benign uterine lesions.Methods: All women undergoing surgery for symptomatic (methror-ragia) benign uterine lesions were included. Women with prolapse, cer-vical lesions and malignant lesions were excluded. Data from 180 and154 patients treated during 1998–99 (group A) and the year 2000(group B), respectively, were analyzed.Diagnostic triage: All patients had complete history collected and pel-vic examination performed. Group A. Patients were evaluated by TVS– not mandatory – VABRA curettage and/or D&C and/or diagnostichisteroscopy with biopsy. Group B. All patients were evaluated byTVS and in case of endometrial thickness >4 mm, a SHG was per-formed to distinguish focal lesions (polyps, myomas, focal hyperplasia)and diffuse lesions (hyperplasia). Theraputic protocol (in group A) wasdecided in each single case by the medical-equipe; in group B: patientswith focal endocavitary lesions underwent operative hysteroscopy.Patients with diffuse lesions underwent hysteroscopy and endometrialguided biopsy. Indications to abdominal miomectomy were: submu-cous myomas (G0–G1) > 5 cm, G2 or subserous myomas in womenasking to preserve the uterus. Indications to hysterectomy (vaginal/abdominal) were large miometrial lesions non-responding to medicaltherapy.Results: Median age of group A and B patients was not significantlydifferent (46 years, interquartile range 40–56). The frequency ofabdominal/vaginal hysterectomy was significantly lower in group B(28%) than in group A (54%) (P < 0.01). Laparotomic myomectomywere not significantly different in the two series (24% vs. 22%). Thefrequency of operative hysteroscopy was significantly higher group B63%) than in group A (9%) (P < 0.01).Conclusions: The introduction of sonographic based triage and thera-peutic protocols for benign uterine lesions determined a dramaticreduction of demolitive uterine surgery, even in the same medicalequipe. This involves a significant reduction of economic cost and animprovement in health care for the same abnormal conditions.

P35Sonohysterographic staging of submucousmyomas

E. Ferrazzi, C. Lanzani, M. Digrandi, A. Padoan& C. Mastromatteo

Purpose: To assess the diagnostic accuracy of sonohysterography inpreoperative assessment of submucous myomas.Methods: Twenty premenopausal patients with submucous myomasand irregular uterine bleeding and/or infertility were consecutively col-lected in 12 months. Before surgery, all patients underwent transvagi-nal sonography (TVS) (Voluson, KRETZ, 5300), with color Dopplerevaluation, and sonohysterography (SHG). Number and site of myo-mas and the myoma–perimetrium distance were considered at TVS.SHG was performed with a 4.7-mm (14F) intrauterine catheter. Patientcompliance to SHG was evaluated by a subjective pain scale. Durationfrom TVS to completion of the procedure, and volume of saline solu-tion instilled for SHG, were evaluated. Sonographic findings at TVSand SHG were classified as submucous myoma G0, G1 and G2 andcompared to hysteroscopic finding. Depending on myoma gradingand volume, selected patients underwent preoperative medical treat-ment with triptorelin (decapeptyl-ipsen). Hysteroscopic myomectomywas the standard surgical approach. Diagnostic accuracy of TVS andSHG was evaluated.Results: Mean age was 41 years (interquartile range 34–47). MeanBMI was 24 kg/m2 (interquartile range 21–28). Twelve patientsreported irregular bleeding, eight infertility. Eleven patients had addi-tional intramural and or subserous myomas. Mean duration time ofSHG was 12 min (interquartile range 9–16). Mean volume of sterilesolution instilled for SHG was 16 mL (interquartile range 8–24). Inall cases, a successful SHG was performed, with no and mild discom-fort in 16 (80%) and 3 (11%) patients, respectively. Hysteroscopicfindings were compared to TVS and SHG considering the submucousmyoma grading. SHG correctly classified all miomas (five cases ofG0, 11 cases of G1, five cases of G2). TVS correctly classified all G0cases, over classified two G1 cases as G2, correctly classified five casesof G2.Conclusions: Sonohysterography was a simple and well tolerated ima-ging technique, with a diagnostic accuracy comparable to hystero-scopy. We speculate that endometrial sampling performed duringSHG could help to exclude coexisting endometrial abnormalitieswhich are likely to occur in larger series.

P O S T E R S E S S I O N 2 : O B S T E T R I C S – D O P P L E R A N D M I S C E L L A N E O U S

P36Weekly and 2-week Doppler investigations to avoidmisunderstanding compromised fetal conditions?SGA fetuses management in our experience

L. Solerte, A. Ragusa & S. Garsia

Fetal surveillance in adequate for gestational age (AGA) and small forgestational age (SGA) allows to predict distress conditions and improveneonatal outcome. Doppler velocimetry (DV), fetal heart rate monitor-ing (CTG), biophysical profile with amniotic fluid index, are the com-mon tools used to have fetal direct–indirect signs of well-being. Severalclinical studies stressed DV and CTG-like reliable evidences of fetalconditions, despite their known limitations, connected with gestationalage and compensatory mechanisms. In order to establish the best fol-low up time for fetal health, we analyzed two different groups of 20non-selected pregnant women with SGA 10–30 percentile. Intrauterinegrowth retardation were excluded for different role of DV in predictionand screening in placental disorders. From January to July 2001 weobserved our two groups divided by maternal history; women werehomogeneous for age and weight, with SGA.Diagnosis: Made at 20–24 weeks scan, according to most commonused biometry diagrams. DV was performed on the main arterial

districts by pulsatility index, in umbilical and middle cerebral artery,and peak velocity in intracardiac aorta, to estimate changes in bloodflow velocity and cardiac out-put, to compare with Apgar index in neo-natal outcome, including cesarean section rate. We closed our assess-ment with a precise definition of utility and applicability of weekly and2-week follow up, in order to improve fetal conditions at delivery time,avoid misunderstanding fetal distress organize better work-time.

P37Cardiac function in fetuses of poorly controlledpregestational (pre-existing) diabetic pregnancies

S.-F. Wong, F.-Y. Chan, R. Cincotta & C. Ward

Background: Cardiac impairment is frequently found in fetuses of dia-betic mothers. Poor diabetic control has been implicated as one of thecause for cardiac dysfunction, but it is still controversial.Aim: To assess the cardiac function in fetuses of well-controlled andpoorly controlled pregestational (pre-existing) diabetic pregnancy inthe third trimester.Methods: Women with pregestational diabetes (Type 1 and 2)were enrolled at 30–36 weeks. Right-, left-ventricular septal wall andinterventricular septal wall thickness were measured by M-mode at


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end-diastolic phase. At the mitral and tricuspid valves inflow, theratio between early ventricular filling and active atrial filling (E/A) atboth atrioventricular valves were measured by Doppler echocardiogra-phy. Peak velocities of ascending aorta and pulmonary artery wereassessed. Angle of isolation was kept at less than 208. Results fromwomen with poorly controlled diabetes (HbA1c > 6.5%) were com-pared with those whose diabetes were satisfactorily controlled(HbA1c � 6.5%).Results: A total of 15 women were included in this study. Six had well-controlled diabetes and the other seven had poorly controlled diabetes.HbA1c in the poorly controlled group was 7.3% and in the well-con-trolled group was 5.4% (P < 0.001). There was no difference betweenthe groups in cardiac size, interventricular septal wall thickness, ejec-tion fraction, aorta and pulmonary artery peak flow velocities. Theright atrioventricular E/A ratio was significantly lower among thepoorly controlled DM pregnancies (0.71 vs. 0.54; P < 0.05). Thisreflected an impaired right ventricular compliance in fetuses of poorlycontrolled diabetic mothers.Conclusion: Fetuses of poorly controlled diabetic mothers hadlower atrioventricular E/A ratio. This may be due to impaired rightventricular compliance.

P38Changes in fetal blood flow in hypoxemia during labor

M. Ropacka, M. Dubiel, K. Marsal, S. Gudmundsson& G. H. Breborowicz

Objective: The aim of this study was evaluation of intrapartumDoppler velocimetry changes in fetuses with signs of fetal hypoxemiain fetal pulse oximetry (arterial hemoglobin saturation <30%).Study design: Examinations were performed on 44 women in laborwith singleton pregnancies. The subject of analysis was Doppler bloodflow velocimetry in umbilical cord, fetal brain and lung. In all cases thefollowing examinations were performed: blood flow velocimetry inmiddle cerebral artery (MCA), umbilical artery (UA), and pulmonaryvein (PV). Among fetuses with normal Doppler velocimetry at the timeof admission, we selected those with cephalic presentation and non-reassuring fetal heart rate pattern during labor. The fetuses wereincluded to the group of fetal pulse oximetry monitoring. All cases withsigns of fetal distress in ctg and intrapartum fetal arterial oxygensaturation <30% for at least 5 min were included to the study group.Fetuses with abnormal ctg and fetal oxygen saturation >30% consti-tuted the control group.Results: Doppler indices (PI, RI) in MCA were significantly lower inthe presence of reduced oxygen saturation. Pulsatility and resistanceindex in UA in the study group were higher, comparing to the controlgroup. But, there was no statistically significant difference betweenboth groups in analyzing parameters. There were no statistically signif-icant changes in parameters describing blood flow in pulmonary veinsin both studied groups.Comments: The combined intrapartum fetal monitoring, includingpulse oximetry and Doppler blood flow velocimetry, proved that thereduction of fetal arterial oxygen saturation (<30%) is associated withchanges in hemodynamics of fetal cerebral circulation. It has been notobserved any changes in blood flow in umbilical artery and pulmonaryvein in the presence of decreased fetal saturation.

P39Comparison of power Doppler and velocimetry inpredicting outcome of high-risk pregnancy

M. A. Dubiel, G. H. Breborowicz, K. Marsal & S. Gudmundsson

Purpose: To prospectively evaluate semiquantitative computer anal-ysis of power Doppler (PD) signals in the placenta, fetal brain, lung,liver, kidney and spleen in high-risk pregnancies in relationship to peri-natal outcome and also to compare tissue blood flow in the fetal brainand placenta with Doppler velocimetry.Methods: PD signals were recorded in 180 high-risk pregnanciesbetween 27 and 41 weeks of gestation. Images from PD scans angio-graphics were transmitted for computer analysis of pixel intensity.Mean flow signal intensity was recorded for each organ. The PD

brain/lung ratio was calculated. The PD results were plotted onreference values and related to perinatal outcome. Middle cerebral(MCA), umbilical (UA) and uterine artery (Ut. A) velocimetry was alsoperformed.Results: High-risk pregnancies displayed lower PD signal intensityfrom the placenta, fetal lung, liver and kidney as compared to normal.However, the brain and spleen signals showed higher intensities sug-gesting increased tissue perfusion. PD signals from the fetal brain, lung,placenta and PD brain/lung ratio were correlated with perinatal out-come. The PD signal intensity from the fetal liver, kidney and spleenshowed poor correlation with perinatal outcome. Fetal brain tissueblood flow showed better correlation with the outcome than MCAvelocimetry. Placental tissue blood flow results were similar in predict-ing outcome to those obtained by means of UA and Ut. A velocimetry.Conclusions: In comparison with conventional Doppler velocimetry,computer analysis of PD signals, give similar results in the predictionof adverse perinatal outcome.

P40Diagnosis and prognostic value Doppler flow velocitywaveform in high risk pregnancies

M. R. Ghoneim, H. Megahed, M. Habba, M. M. El-Biely& G. L. Lotfy

Objective: To determine whether Doppler umbilical artery flow velo-city waveforms (FVW) would improve the clinical management andreduce the prenatal morbidity or not, in cases of high risk pregnancies.Methods: A total of 160 pregnant women of 28 weeks or more gesta-tional age were included in this study. The age of the cases were from20- to 30-year-old and their gravidity ranged from gravida 1 to 5. Thecases were classified into two groups. Low risk group, not associatedwith medical or obstetric complications and includes 70 cases. Highrisk groups include, the other 90 cases, such as the following: mildpre-eclampsia (20), severe pre-eclampsia (15), diabetes mellitus (10),postdated pregnancy (15), previous one or more cesarean section(15), rheumatic heart (4), decreased perception of fetal movement(3), bronchial asthma (2), Rh incompatibility (2) and previous IUFD.All of them were subjected to thorough general and obstetric examina-tion, investigations, ultrasonic examination, biophysical profile scoringand Doppler umbilical artery FVW study. The cases of low risk groupwere examined every 2 weeks, while high risk ones, were examinedevery week or twice weekly according to the results of the previousexamination.Results: There is a highly significant difference between values ofumbilical artery FVW indices in low and high risk group. Dopplerhas specificity 92.8% in cases of low risk group while has sensitivity52.8% and specificity 55.6% in cases of high risk group and it is moresensitive than biophysical profile. Doppler of umbilical artery is verybeneficial in cases of pre-eclampsia, where its sensitivity 78.5% andits specificity 52%.Conclusion: There is a strong association between abnormal FVW andadverse fetal outcome. The Doppler will identify a group of fetusestruly at risk, where intensive fetal monitoring or delivery will berequired.

P41Differentiated evaluation of blood flow middle cerebralartery in relation to the fetal well-being

P. Rozpravka & A. Ostro

Objective: To state clinical signification of differentiated evaluationDoppler velocimetry middle cerebral artery (MCA) of ultrasonogra-phically detected intrauterine growth retarded (IUGR) fetuses, duringpregnancies complicated hypertension (PIH) and pre-eclampsia.Methods: In prospective, comparative clinical studies evaluated Dop-pler velocimetric curve MCA separately in proximal (basal) segment(PS) and distal (cortical) anatomical segment (DS). Values of pulsatilityindex (PI) were compared in proximal and distal segment MCA. Cor-ticocerebral index (CCI) was stated as ratio PIPS/PIDS. Results werecompared in the group-A with IUGR detected and in control group-B with normal growth of the fetuses. Period of measurements complex

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biometry was l week, fetal flowmetry minimally 24 h, maximallyl week.Results: Values of PI in PS and DS MCA were significantly different.Resistance of MCA in cortical direction decrease. Values of PIPS werehigher comparing PIDS. We found statistically significant correlationCCI and >1 and chronical fetal hypoxy resulted in IUGR. Differen-tiated flow analysis of MCA did not show statistically significant differ-ences of PIPS and PIDS. Calculated CCI ¼ 1. MCA resistance does notshow changes in cortical direction. We found significantly higher sta-tistical occurrence of perinatal complications of the fetuses, electivecesarean sections for fetal intrauterine hypoxy, when values of CCIand >1. This is the fact concluded worse prognosis of the fetuseswith cortical sparing effect in utero, but also worse postnatal adapta-tion. Main outcome – corticocerebral index is simple parameterfor detection of different saturation of the brain of the fetus underhypoxemia. Fetal prosperity in utero has coming worse during corticalpreservation. There is significantly higher occurrence of perinatalcomplications.

P42Does cigarette smoking causes periodic decreases in bloodflow to the fetus of mothers with hypertensive disordersand/or impaired fetal growth?

T. A. Lawrie, F. Rosier-van Dunne, K. Norman & H. J. Odendaal

Aim: To evaluate the acute effect of maternal cigarette smoking onumbilical and middle cerebral artery blood flow in the fetus of womenwith and without pre-eclampsia and/or intrauterine growth restriction.Methods: Pregnant women and �24 weeks gestation were recruitedfrom the antenatal ward at Tygerberg Hospital, South Africa. Dopplerstudies of the umbilical and middle cerebral arteries were performedbefore and at 10, 20 and 30 min after the mother had smoked a cigarette.The same studies were performed in the non-smoking controls.Results: There were 13 smoking mothers with hypertension and/or afetus with growth restriction (group A), 15 non-smoking mothers withhypertension and/or a growth restricted fetus (group C) and 24 normo-tensive smoking mothers and an appropriately grown fetus (group B).There was a significant difference in the mean umbilical artery RI andPI values in group A vs. group C (P ¼ 0.03 and 0.004, respectively).There was a significant difference in the mean middle cerebral arteryPI between group B and group C (P ¼ 0.004).Conclusions: Smoking significantly reduces the feto-placental perfu-sion in pregnancies compromised by hypertension and/or intrauterinegrowth restriction and should be actively discouraged in these patients.

P43Doppler assessment of the uterine circulation in the secondtrimester in twin pregnancies: prediction of hypertensivedisorders, small-for-gestational age and weight discordance

A. Geipel, C. Berg, U. Germer, S. Groger, M. Krapp, A. Katalinic& U. Gembruch

Objective: To compare singleton nomograms of the uterine circulationwith previously established twin nomograms in the prediction ofhypertensive disorders, small-for-gestational age (SGA) and birthweight discordance >20%.Methods: This was an analysis of maternal and perinatal dataobtained from 256 diamniotic–dichorionic twin pregnancies. The uter-ine artery resistance and pulsatility index were calculated as a meanfrom both sides and the presence and absence of notching wasrecorded. Cut-off levels for abnormal flow parameters were the 95thcentile of reference ranges using singleton and twin nomograms.Results: As mean uterine artery indices are lower in twin gestation, ahigher number of patients (n ¼ 73; 28.5%) was screen positive accord-ing to twin reference values when compared to those of singletons(n ¼ 51; 19.9%). However, singleton reference ranges or recordingof notches only proved to be more efficient than twin reference rangesto correctly predict SGA (17.6, 19, 13.7%), birth weight discordance>20% (30.6, 37.5, 23.9%), and hypertensive disorders (23.5, 21.4,16.4%), respectively. Compared to singleton nomograms of uterineartery Doppler, twin nomograms had higher sensitivities, lower

specific and positive predictive values, but equal negative predictivevalue to comprise adverse pregnancy outcomes.Conclusion: For routine clinical practice, it seems justified to usesingleton nomograms to assess uterine circulation in twin gestation.However, as the negative predictive value of uterine Doppler studiesis slightly lower when compared to singletons, maternal and fetalcomplications might occur despite normal uterine waveforms.

P44Doppler velocimetry of uterine arteries between 12 and 16weeks of gestation

A. A. Yamasaki, G. Braia & O. Toma

Introduction: The aim of prenatal care is to identify high risk preg-nant in order to adopt preventive and/or therapeutic treatments. Thepresence of an end diastolic ‘notch’ at uterine Doppler velocimetryhas been considered a predictor to pre-eclampsia and intrauterinereduced growth. It reflects an answer expressed by a wave ofhigh amplitude representing vascular bed with high resistance (utero-placental circulation).Objective: To identify high risk patients by analysis of uterine Dopplervelocimetry between 12 and 16 weeks of gestation when occurs thesecond wave of trophoblastic invasion.Patients and methods: Between June 1999 and June 2001, we did alongitudinal study with 127 pregnant from 12 to 16 weeks. This studyanalyzed uterine Doppler velocimetry using two types of equipment:Aloka Model 1700 and Medison Model Voluson 530. We determinedthe incidence of end diastolic ‘notch’ between 12 and 16 weeks and itsevaluation during pregnancy.Results: The incidence of end diastolic ‘notch’ was 26% (33 patients).Among these patients only nine (7%) still had notch at 16–24 weeks.Among patients with normal uterine Doppler velocimetry at 12–16 weeks, none developed pre-eclampsia or intrauterine reducedgrowth.Conclusion: It is possible to identify low risk patients (74%) to pre-eclampsia and intrauterine reduced growth at the end of first trimesterof pregnancy by uterine Doppler velocimetry. At the end of first trime-ster, 26% of patients can be identified as high risk for pre-eclampsia orintrauterine reduced growth. The advantage of this early screeningmethod is the possibility to give aspirin (100 mg/day) at time of secondwave of trophoblastic invasion as prophylactic treatment.

P45Evaluation of placental Doppler velocimetry in pregnanciescomplicated with oligohydramnios

K. Blaszczyk, A. Lukasik, K. Swadzba, M. Stokowacka & R. Poreba

Objective: The objective of the study was to evaluate intraplacentalDoppler indices in pregnancies complicated with oligohydramnios.Methods: Thirty-six singleton pregnancies between 32 and 39 weekscomplicated with oligohydramnios (cases of premature rupture ofthe membranes and fetal malformations were excluded from the study)and 40 normal pregnancies were examined by real time ultrasonogra-phy, color and pulse Doppler. Placental Doppler velocity waveformswere estimated in the placental cord insertion (umbilical artery veloci-metry) and in three different pulsatile intraplacental vessels (the meanvalue). Placental Doppler velocity waveforms analysis was performedon the base of Haberman and Friedman method. The ratios betweenintraplacental and umbilical artery pulsatility index values werecalculated. Fetal well-being was evaluated by means of non-stress testanalyzed according to Fischer method.Results: In normal pregnancies group all Doppler velocity waveformsvalues were between 10 and 90th percentile of the normal for gesta-tional age values based on Doppler indices nomograms, as well as allpatients had the normal (<1) intraplacental to umbilical artery pulsa-tility index ratio. In the group complicated with oligohydramnios in 15patients abnormal (>1) intraplacental to umbilical pulsatility indexratio were observed (P < 0.05, sensitivity 42%, specificity 100%, posi-tive predictive value 100%, negative predictive value 65%). In thatgroup the results of non-stress test analysis according to Fisher methodwere pathological (Fisher <5) significantly more often (P < 0.05).

11th World Congress on Ultrasound in Obstetrics and Gynecology Poster Session 2: Obstetrics – Doppler and Miscellaneous

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Conclusion: The results of the study demonstrate, that in pregnanciescomplicated with oligohydramnios the evaluation of intraplacental toumbilical pulsatility index ratio is a valuable method for estimationthe fetoplacental circulation and is an important complement of fetalwell-being assessment.

P46Influence of maternal cigarette smoking on maternalweight gain, uterine and umbilical flow velocitiesand fetal growth

C. A. Albuquerque, K. Smith, C. Johnson & R. Harding

Objective: To investigate the effects of cigarette smoking during preg-nancy on maternal body mass index, maternal weight gain, uterine andumbilical artery flow velocities and fetal growth.Methods: We studied 37 pregnant women (17 cigarette smokers[>10/day] and 20 non-smokers) using an ATL HDI 5000 scannerfor fetal anatomic survey and measurement of uterine and umbilicalartery flow velocities. Maternal BMI change and weight gain duringpregnancy, uterine and umbilical cord flow velocities, and fetal weightat delivery were measured in all patients.Results: There were no differences between the smoking and non-smoking groups in gestational age at scanning (23.7 � 1.5 vs.26.5 � 1.3 week), gravid (2.3 � 0.3 vs. 2.1 � 0.3) and parity (0.9 �0.2 vs. 0.6 � 0.2). The median maternal BMI was less in smokersthan non-smokers both pre-pregnancy (19 vs. 24) and at delivery(27.5 � 1.3 vs. 32.3 � 1.3). Maternal weight gain was less in smokersthan non-smokers (10.2 � 1.6 vs. 14.7 � 1.5 kg, P < 0.05). In the uter-ine artery, there was no significant difference in the systolic/diastolicratio between smokers and non-smokers (1.9 � 0.1 vs. 1.8 � 0.1).The umbilical artery systolic/diastolic ratio was greater in smokersthan non-smokers (3.25 � 0.2 vs. 2.31 � 0.07, P < 0.05) and fetalweight at delivery was lower in smokers (2.7 � 0.2 vs. 3.3 � 0.2 kg,P < 0.05).Conclusions: Decreased BMI and lower weight gain of women whosmoke suggest that their nutritional intake may be lower than innon-smokers. Decreased maternal weight gain in smokers andincreased umbilico–placental resistance may both contribute to fetalgrowth restriction. Smoking appears not to affect utero-placentalresistance.

P47Intrapartum umbilical artery, fetal aorta and middlecerebral artery Doppler velocimetry as a predictorof poor perinatal outcome in growth retardedfetuses

N. Klep, H. Concin & A. Kurjak

Background: The aim of the study was to evaluate the diagnostic pre-diction of the Doppler waveform analysis during active labor foradverse perinatal outcome in a group at significant risk of intrapartumhypoxia.Materials and methods: The study population consisted of 33 preg-nant women at high-risk and ultrasonographic diagnosis of IUGRbetween 28 and 35 weeks of gestation. On the basis of the flow velocitychanges in the fetal vessels during pregnancy, patients were dividedinto two study groups A, with physiological Doppler waveforms (12women) and B, with pathological Doppler waveforms (21 women).The percentage of the changes of the index values during active laborwere correlated with pH values of the blood from the umbilical artery.Results: In group A, no statistically significant correlation was found.In group B, following was established: high negative correlationbetween the changes of the index values and pH values of the bloodfrom the umbilical artery: dPAU 24%, r ¼ � 0.531, t ¼ 2.179,P < 0.05. dPIAFD 26%, r ¼ � 0.655, t ¼ 3.0, P < 0.05; dPIACM10%, r ¼ � 0. 699, t ¼ 3.1, P < 0.01.Conclusions: The study revealed a significant correlation between thechanges of index values of the Doppler waveform analysis duringactive labor and pH values of the blood from the umbilical artery inthe process of intrapartum aggravation of already antepartum fromchronic hypoxemia suffering fetuses.

P48The association between the Doppler hypoxia indexand arterial umbilical cord pH in multiple gestationpregnancies complicated by intrauterine growthrestriction

U. Musser, E. P. Gaziano & P. H. Arbeille

Purpose: To study the relationship between the Doppler hypoxiaindex and umbilical cord pH in multiple gestation pregnancies compli-cated by fetal growth restriction.Methods: Seventeen fetuses were studied from 12 multiple gestationpregnancies (11 twins and 1 triplet). Each pregnancy had at least onegrowth-restricted fetus from which middle cerebral artery and umbili-cal artery Doppler values were collected, the last value of which waswithin 3 weeks of delivery. For each fetus, we calculated the cerebralumbilical ratio and the hypoxia index, which reflects the durationand degree of Doppler determined fetal blood flow redistribution.Umbilical arterial cord blood was obtained for blood gas analysisimmediately after the births. Excluded were fetuses with majorcongenital anomalies and those with reverse end diastolic flow in theumbilical artery.Results: There is a significant correlation at the 0.05 level, one-tailed,between the hypoxia index and arterial umbilical cord pH. A linearregression model suggests that gestational age and birth weights arenot cofounders in the relationship between the hypoxia index andarterial pH. While the hypoxia index has the same sensitivity (75%)as the cerebral umbilical ratio for identifying fetuses who will havean arterial cord pH of less than 7.20, the hypoxia index has a betterspecificity (85 vs. 69%), positive predictive value (50 vs. 38%) andnegative predictive value (92 vs. 90%).Conclusions: There is a significant correlation between the non-inva-sive hypoxia index and arterial umbilical cord pH in the growth-restricted fetus from multiple gestation pregnancies.

P49The evaluation of Doppler indices in renal vessels innormal fetuses and in fetuses with obstructiveuropathy

D. Wyrwas, K. Szaflik, D. Borowski & M. Kozarzewski

Purpose: The aim of the study was an evaluation of Doppler indices inrenal vessels in normal fetuses and in fetuses with diagnosed obstruc-tive uropathy.Methods: In the study, there were included 106 normal fetuses and 21fetuses with signs of the obstructive uropathy. In pregnancies compli-cated by the uropathy, the measurements of Doppler flow in renalarteries were performed twice: in the ahydramnion settings and afterthe diagnostic amnioinfusion. The analyzed indices included the pulsa-tility index and the resistance index.Results: The diagnosis of uropathy was set-up at the mean gestationalage of 20.3 � 2.0 weeks. The control group consisted of 106 healthyfetuses from normal pregnancies at the mean gestational age(28 weeks). The physiological absence of an end-diastolic flow in renalarteries was found in normal pregnancies and that parameter wasexcluded from further analysis. The PI values in normal pregnanciesdecreased with the gestational age from the mean value of 3.16 at15 weeks to 2.19 at 40 weeks of gestation. In pregnancies at gesta-tional age below 26 weeks complicated by the uropathy, the PI was sig-nificantly lower with the mean value of 1.57. However, there were nostatistical difference in PI values for pregnancies above 30 weeks ofgestation, the mean values of PI were 2.39 and 2.33 for normal andpathological pregnancies, respectively. There were also no differencesfor PI values among pregnancies with the uropathy before and afteramnioinfusion.Conclusions: There is a physiological linear decrease in the PI values infetal renal arteries with the gestational age. The RI cannot be used forthe evaluation of renal function due to the physiological absence of anend-diastolic flow in renal arteries. The PI was significantly lower inpregnancies complicated by obstructive uropathy at the gestationalage below 26 weeks.


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P50The role of thromboelastography in conjunction withsecond trimester uterine artery Doppler velocimetry inthe prediction of adverse pregnancy outcome

C. Karidas, P. Anastassopoulos, D. Perry & D. L. Economides

Purpose: A pilot, prospective study to evaluate the use of thromboelas-tography in conjunction with uterine artery Doppler in the secondtrimester as predictors of pre-eclampsia and IUGR (intrauterinegrowth restriction defined as birth weight below the 5th centile forgestational age).Methods: Two-hundred and forty-nine (249) unselected pregnantwomen were recruited at their booking appointment in the Royal FreeHospital. They underwent thromboelastography assessment and colorflow/pulsed Doppler imaging of both uterine arteries at 20–24 weeksgestation. Standard parameters were measured from each thrombo-elastography tracing (R, reaction time; K, clot formation time; A, angle;MA, maximum amplitude). The presence or absence of notches in theflow velocity waveform was noted and the resistance index measured.The main outcome measures were pre-eclampsia and IUGR.Results: Twenty-three pregnancies (9.2%) were complicated by IUGRand 10 (4%) by pre-eclampsia. Assessment using abnormal Dopplervelocimetry, defined as bilateral notches/mean RI � 0.55 (27 cases)or unilateral notch/mean RI � 0.65 (5 cases), demonstrated 52%(95% CI 33–71%) sensitivity for IUGR and 40% (CI 17–69%) forpre-eclampsia with positive predictive values 37.5% (23–55%) and12.5% (5–28%), respectively. Furthermore, in the pregnancies compli-cated by an adverse outcome, the groups with normal (14 cases) andabnormal (15 cases) Doppler velocimetry did not differ significantlyin any of the thromboelastography parameters (Mann–Whitney testfor comparisons).Conclusion: Pulsed Doppler velocimetry of the uterine arteries inthe second trimester is an established predictor of adverse pregnancyoutcome. The additional use of thromboelastography assessmentdoes not appear to contribute significantly in providing further infor-mation. As this is a pilot study, larger trials are required to delineateits role.

P51The sensitivity of Doppler studies vs. biochemical indicesin predicting fetal outcome in cases of pregnancyinduced hypertension

M. R. Ghoneim, K. Nicolaides, M. A. Abd-El Moneim,H. E. Megahid & M. S. Hafez

Location: The Outpatient Clinic of Obstetrics and Gynecology,Faculty of Medicine, Suez Canal University, Ismailia, Egypt and theHigh Risk Pregnancy Unit of King’s College University Hospital,London, UK.Aim of the work: To compare the sensitivity and specificity of theDoppler studies vs. the biochemical indices in predicting fetal outcomein cases of pregnancy induced hypertension.Material and methods: A total of 252 cases were the subject of thisstudy 192 cases from King’s College Hospital and 60 from Suez CanalUniversity Hospital. All cases were selected as having pregnancy-induced hypertension, 226 cases with proteinuric hypertension and26 cases with non-proteinuric pregnancy induced hypertension. Allcases were monitored weekly from 28th gestational week till deliverywhereby all Doppler studies were carried out on a free loop of umbili-cal artery. Serum uric acid, liver enzyme aspartate-aminotransferase,and platelet count were estimated weekly.Results: Out of 252 patients with PIH, 136 patients (54%) had abnor-mal Doppler flow velocimetry associated with abnormal higher meanAST proteinuria, serum urate >350 mm/L, lower platelet count andhigher perinatal mortality. The sensitivity and specificity of abnormalDoppler velocimetry in the prediction of intrauterine growth retarda-tion (IUGR) were 80 and 52.6%. These were raised to 94 and 88%,respectively, with higher mean serum urate and lower platelet counts.However, the specificity of the abnormal Doppler with abnormal allbiochemical indices for the prediction of adverse neonatal outcomeand IUGR was 100%, but this was a late event in cases of PIH as

the sensitivity dropped down. It is not advisable to wait for both tohappen before taking a decision for induction of labor.


P53The use of umbilical artery Doppler velocimetry in themonitoring of pregestational diabetic pregnancy

S.-F. Wong, F.-Y. Chan, R. Cincotta, J. Oats & D. McIntyre

Purpose: To assess whether umbilical artery Doppler velocity wave-form analysis can predict adverse perinatal outcomes for pregnanciescomplicated with pre-existing diabetes mellitus (types 1 and 2 diabetesmellitus).Methods: All diabetic pregnancies (types 1 and 2) delivered at MaterMothers’ Hospital, Australia, between 1st January 1995 and 31stDecember 1999, were included. All pregnant diabetic women weremonitored with umbilical artery Doppler velocimetry at 28, 32, 36,and 38 weeks gestation. Umbilical artery Doppler study was repeatedon weekly basis for pregnancies complicated by macrosomia, polyhy-dramnios, or fetal growth restriction. Adverse perinatal outcome wasdefined as pregnancies with one or more of the following: small-for-gestational age (birth weight <10th centile), cesarean section fornon-reassuring cardiotocography, fetal acidemia at delivery (cordblood arterial pH < 7.2), 1-min Apgar of �3, 5-min Apgar of <7,hypoxic ischaemic encephalopathy, stillbirth and perinatal deaths.Abnormal umbilical artery Doppler index was defined as systolic/dia-stolic ratio of 95th centile or higher for gestation (including absentor reversed end-diastolic flow). The incidence of adverse perinataloutcomes was compared between those with normal umbilical arteryDoppler and those with elevated systolic/diastolic (S/D) ratio.Results: One hundred and four pregnancies had umbilical arterialDoppler studies performed during the study period. Twenty-threepregnancies (22.1%) had elevated S/D ratio of the umbilical arteryDoppler velocimetry. If the scans were performed within 2 weeks ofdelivery, 71% of pregnancy with abnormal umbilical Doppler studyhave adverse outcome. For umbilical artery Doppler studies performed


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within 1 week of delivery, the sensitivity was 35%; specificity was94%; positive predictive value was 80%; and negative predictivevalue was 68%. However, only 30% of women with adverse perinataloutcomes had abnormal umbilical Doppler flow.Conclusion: Elevated umbilical arterial Doppler S/D ratio is associatedwith adverse perinatal outcomes. However, the majority of diabeticpregnancies with adverse perinatal outcomes have normal umbilicalartery Doppler velocimetry. Thus, this could be a useful test formonitoring, but is not a good predictor of adverse perinatal outcomes.

P54Ultrasonic fetal and placental tissue characterizationand the role of Doppler ultrasound in lung maturity

M. Podobnik, M. Podgajski, B. Gebauer & B. Breyer

Background: The aim of this study is to confirm the relationshipbetween the gestational age and quantitative assessment of ultrasonicsigns of placental tissue, fetal lungs and liver tissue and to correlateDoppler parameters from main stems of the pulmonary arteries fordetermining fetal lung maturity in normal pregnancy and pregnancywith pre-eclampsia and diabetes.Methods: The placenta, fetal lungs and fetal liver in 300 normal preg-nancies, 100 pre-eclamptic pregnancies and 100 diabetic pregnancywere examined by ultrasound at 30–41 weeks of gestation. The coeffi-cients of variation (the standard deviation divided by the meanvalue) were used to characterize the tissue in different groups duringpregnancy. Doppler velocimetry was performed in the main stems ofpulmonary arteries in normal pregnancies and pregnancies withpre-eclampsia and diabetes.Results: The coefficients of variation in mature fetuses were greaterthan 29% for placentas in vivo, greater than 34% for placentasin vitro, greater than 28% for liver tissue and greater than 30% forlung tissue. Placental, lung and liver tissue of diabetic pregnancy tendedto have lower coefficients of variation throughout their pregnancies.We found in mature fetuses mean peak systolic velocity higher than40 cm/s and PI lower than 3.00. In mature fetuses with pre-eclampsia,we found higher mean peak systolic velocity in compared withnormotensive patients.Conclusions: The coefficient of variation values for placentas in vivoand in vitro, and fetal lungs and liver increase during pregnancy in nor-mal and pre-eclamptic patients with increasing gestational age anddecrease in diabetic patients.

P55Uterine artery Doppler blood flow resistance indicesin the second half of pregnancy: measures of centraltendency, distribution, inter-ratio dependency,and explanation of variation

M. O. Thompson, K. S. Vines, J. Aqualina & K. F. Harrington

Study objectives: To evaluate the three commonly used indices ofDoppler blood flow resistance in clinical practice for the uterineartery. By assessing the measures of central tendency, dispersion, andvariation, to determine the most appropriate index for clinical usetransabdominally in the second half of pregnancy.Methods: A prospective study of uterine artery Doppler measurementin singleton pregnancies between 18 and 32 weeks gestation. Usingpreviously described methods, two independent measurementswere obtained transabdominally from each side in all subjects. Thesystolic/diastolic ratio (SD ratio), pulsatility index (PI), and resistanceindex (RI) were recorded from both the right and left uterine artery inturn. All measurements were obtained by a single operator (MOT)using the same machine (Philips SD 800). The results were analyzedstatistically for the measures of dispersion, distribution, and thevariation explained.Results: There were 1796 observations from 449 subjects in total,with the SD ratio showing the widest dispersion. The PI measurementswere intermediate with respect to both, while the RI showed the leastdispersion. The RI distribution was the closest to a naturally distribu-ted (Gaussian) pattern, followed by the PI. The SD ratio did not appearto conform to a normal distribution. The interquartile ranges (IRQ) for

the SD ratio were 0.71, 0.73 (left- and right-uterine artery, respec-tively); PI: 0.42, 0.41; and RI: 0.15, 0.17. The mean of three derivedmeasurements of the RI was sufficient to account for over 99% ofthe observed variation.Conclusions: Differences reported between the different resistance andpulsatility Doppler indices could be due to either random or systematicerror, or a combination of both. The observations from this studysuggest that when the RI is used, these are kept to a minimum. Thesefindings may be helpful in selecting the appropriate index for uterineartery Doppler screening and clinical applications in the second halfof pregnancy.

P56Uterine artery Doppler ultrasonography and pregnancyoutcome in women with a history of early onsetpre-eclampsia and thrombophilia

J. van Eyck, B. Arabin & B. Wibbens

Purpose: To assess the relationship between persistence after22 weeks’ gestation of the notch in the uterine artery and pregnancyoutcome in pregnant women with a history of early onset (<32 weeks)pre-eclampsia, were tested for thrombophilia and subsequentlyreceived medication according to the disorder.Methods: Between 1995 and 2000, Doppler ultrasonography of bothuterine arteries was performed between 18 and 24 weeks, in 80 preg-nant women with a history of early onset pre-eclampsia, were tested forthrombophilia. A total of 34 women had no thrombophilia and hadreceived only low-dose aspirin as from 12 weeks’ gestation. Forty-sixwomen had thrombophilic disorders like: protein S deficiency (N ¼10), APC-resistance (N ¼ 11), anticardiolipin antibodies (N ¼ 15)and had received low-dose aspirin as from 12 weeks gestation in com-bination with low-molecular heparin as from 7 weeks’ gestation.Seventeen women from this group of 46 women also suffered fromhyperhomocysteinemia. Next to their treatment with folic acid andpyridoxin, they had received low-dose aspirin as from 12 week gesta-tion. Five women had a combination of two disorders and one womanhad three disorders.Results: In 29 women with single hit thrombophilia (protein S defi-ciency, APC-resistance or anticardiolipin antibodies), notches persistedin only one woman, who subsequently developed pre-eclampsia (PE) at31 weeks. Of the remaining 28 women, four developed PE at 31, 31, 35and 39 weeks despite disappearance of notches. In 12 women with sin-gle hit hyperhomocysteinemia, notches persisted in three women, oneof them developing PE at 33 weeks. From the remaining nine women,two developed PE at 31 and 35 weeks. In 34 women without thrombo-philia, notches persisted in four, one of them developing PE at36 weeks. From the remaining 30 women, 3 developed PE at 29, 29and 38 weeks.Conclusions: The percentage of persistence of uterine notch in womenwith ‘treated’ thrombophilia is comparable to women without throm-bophilia (11 vs. 12%), whereas recurrence rate of PE is, respectively,19 and 12%. In both groups averaged gestational age at which PEdeveloped was 3 weeks later than in the index pregnancy. Whetherthese observations can be contributed to the described medication iscurrently evaluated in a large prospective, randomized, multicenterstudy in The Netherlands (FRUIT study).

P57Uterine Doppler evaluation in 12 women withpregnancy-induced hypertension: correlation withfetal Doppler study and perinatal outcome

O. Gomez, M. Del Rıo, J. M. Martınez, M. Palacio,B. Puerto & V. Cararach

Introduction: Classification of hypertensive disorders of pregnancy isproblematic due to variable clinical presentation and confusing termi-nology. Management is based on severity of clinical and laboratorycriteria, which, unfortunately, do not select pregnancies that will bedelivered because of maternal or fetal indication.Objective: To evaluate whether maternal uterine Doppler evaluationcorrelates with fetal Doppler study and maternal and perinatal results.


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Design: Twelve women with pregnancy-induced hypertension (ISSHPcriteria) between 26 and 38 weeks of gestation were divided intotwo groups based on uterine Doppler examination (presence – groupA, or absence – group B, of a bilateral protodiastolic uterine notch)at diagnosis.Results: There were seven patients in group A (four severe and threemild pre-eclampsia) and five patients in group B (one severe and onemild pre-eclampsia, two severe gestational hypertension, one Hellpsyndrome). The mean gestational age at delivery (weeks gestation),the mean birth weight (grams) and the mean umbilical artery pH ingroups A and B were, respectively, 31.1 vs. 36.1, 1256 vs. 2428, and7.20 vs. 7.25. Doppler evaluation showed statistically significanthigher pulsatility index of the right and left uterine artery, as well asin the umbilical artery, in group A vs. group B. Fetal vascular redistri-bution or a ductus venosus PI >1 were detected only in group A (5/7and 3/7, respectively), whereas in none of the group B. Indication fordelivery was always for fetal risk (four cases) or maternal risk (threecases) among group A, whereas for maternal indication was only inone case of the group B.Comments: We suggest that uterine Doppler examination at the timeof diagnosis in patients with hypertensive disorders of pregnancy mayhelp to identify pregnancies at serious maternal and fetal risks betterthan classical clinical and laboratory criteria.


P59Accuracy of ultrasonographic determination of fetalweight at term among Filipinos

M. R. S. Vitug, R. P. Rivera & L. R. Clemente

Background: The birth weight of an infant is one of the most impor-tant factors affecting its survival. Four computer-generated formulas,

Hadlock, Merz, Osaka and Shepard for weight estimation are in com-mon use in our institution, but none of them has been devised specifi-cally for Filipinos. It is the objective of the study to determine whichamong these formulas is accurate in diagnosing the fetus weighing4000 g or more among Filipinos.Methods: The accuracy of in utero fetal weight estimations were eval-uated prospectively in 74 Filipino patients during the study period.Sonographic estimate was performed by a single sonologist within24–48 h of delivery. Estimates of fetal weight were calculated usingthe Hadlock, Merz, Osaka and Shepard. The newborn birth weightwere measured within 30 min of delivery. The results were thencompared with the actual birth weight.Results: Of the 74 patients seen, 62 patients were included. Eighteen(29%) had a birth weight less than 3000 g, 40 (65%) weighed between3000 and 3999 g and six (10%) had a birth weight of 4000 g or more.When birth weight is less than 3000 g, Osaka and Merz conferred thesame diagnostic accuracy but the former had a significantly highernegative predictive (88%). For birth weight ranging from 3000 to3999 g, Hadlock had the highest diagnostic accuracy (100%). Thisreport confirms that the best in utero weight estimations among fetusesweighing 4000 g or more result from the use of Shepard formula whichhas sensitivity, specificity, positive and negative predictive values anddiagnostic accuracy of 100%.Conclusion: Since the accuracy of Shepard formula in estimatingfetal weight 4000 g or more is significantly better than those basedon Hadlock, Merz and Osaka, we recommend the use of such formulain intrapartum fetal weight estimations among Filipinos. This esti-mated weights can offer guidance in predicting fetal macrosomia,and therefore, aid in obstetric management.

P60A nomogram for the umbilical cord cross-sectional areain normal pregnancies

F. A. P. Vasques, A. F. Moron, C. G. V. Murta,F. H. C. Carvalho, T. R. Goncalves, H. Cattini,W. J. Hisaba & M. M. Barbosa

A prospective cross-sectional study was developed in order to deter-mine reference ranges for the umbilical cord cross-sectional area(UCCSA) during normal pregnancies (patients with known dates ofLMP and an ultrasound examination before the 20th week, withoutany pathologic condition). The measurements of the UCCSA wereobtained in a plane adjacent to the insertion of the cord abdomen, asproposed by Raio et al, 1999. The inclusion criteria were: (1) singletonpregnancy, (2) gestation age >20 weeks, (3) intact membranes, (4) nor-mal umbilical Doppler flow velocimetry. The exclusion criteria, in thepresence of any of those, were: (1) congenital and/or chromosomalabnormalities; (2) pregnancy complications (any type); (3) inadequatesize for gestational age when the examination was performed, i.e. theweight below the 10th percentile or above the 90th; (4) abnormal AFIfor the gestational age. The patients were examined and included onlyonce. During the period of the study (February 2000–May 2001), 545patients were examined, after meeting the inclusion criteria determinedfor the present study. The age of the patients ranged from 15 to42 years (mean ¼ 26.7 � 4.8), 242 patients (44.4%) had two gesta-tions, 135 patients (28.1%) were at their first gestation, 129 patients(23.7%) were at their third gestation and 39 patients had four or moregestations (3.8%). The ultrasound machine used was the SynergyMulti Sync M 500 and the statistical analysis was performed by theprogram called Statistical Package for Social Sciences (SPSS). Our datawere considered normally by the Kolmogorov–Smirnov test and thenwe figured the nomogram by linear regression analysis. The analysisof variance obtained through the F-test (value ¼ 356.27) showed thatour regression model was significant at the level of P < 0.001, showingthat the curve represented well the studied population and that theconfidence interval (95%) contained the real value of the UCCSA. Theregression equation was: y ¼ � 532.27 þ 44.358x � 0.6555x2. Weconclude that, there is a progressive increase in the UCCSA up to the32nd week of gestation, followed by a stabilization until the 34th weekand a fall of the values from the 35th week of gestation.


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P61Can sonography represent a marker of dystocia in epiduralanalgesia? A prospective randomized study

A. Malvasi, A. Brizzi, A. Cecinati, L. Liaci, P. Totaro & V. Traina

Purpose: An association between epidural analgesia and dystocia inthe second stage of labor remains controversial. To compare severelabor pain and dystocia at the time of epidural placement for predictingcesarean section (c.s.) risk. We hypothesized, the dystocia causes severelabor pain, such that more epidural medication is required to maintaincomfort.Methods: We examined the relationship between labor outcome andsevere labor pain defined by the number of supplemental anestheticboluses, by cervical dilatation, clinical evaluation of pelvic dimension,sonographic fetal weight and ultrasonographic examination of fetalaxis in cephalic presenting deliveries. This prospective study included375 women in labor with have singleton fetuses at term in vertex pre-sentations. We excluded women with pre-eclampsia, placenta previa,repeat c.s.Results: Seventy-nine of the 375 patients receiving early epiduralanalgesia were delivered by c.s. (68 due to dystocia, 11 due to fetaldistress). A multiple logistic regression model evaluated demographicand labor-related variables associations with cesarean risk. By usingmultivariate analysis, the odds ratio of c.s. among patients whorequired at least three boluses was 2.4 compared with those whorequired two boluses or less (P < 0.001). Variables that proved to bestatistically significant in increasing the likelihood of c.s. were stationat time epidural placement (P < 0.01) and severe labor pain associatedwith dystocia (P < 0.01). The relationship between severe labor pain-dystocia and labor arrest (persistent occipito-posterior or occipito-transverse position in labor progress) we confirmed with sonographyexamination during the first and second stage of labor (82% of cases)(P < 0.01).Conclusions: This is a prospective study demonstrating an associationbetween severe labor pain and c.s. The abnormality of fetal axis existsand it can affect the progress of epidural analgesia labors. The sono-graphic examination in labor reducing the time of labor failure, thepossibility of fetal and maternal complications. Furthermore it reducesforensis implications because of the possibility to give evidence of theintrapartum head fetal axis.

P62Computerized cardiotocography: predictive value ofinstant variability

A. A. Yamasaki & O. T. Toma

Introduction: Computerized cardiotocography differs from classicmethod in measurement of instant variability, also named short-termvariation (STV) which is an important parameter of evaluation of fetalcondition. While classic cardiotocography considers an active fetuswhen in the presence of two transitory accelerations (TA), in compu-terized method, value of STV is the most important parameter and itmust be higher than 4 ms.Objective: Correlation between STV and TA.Methods: Two hundred and forty traces of computerized cardiotoco-graphy were analyzed (SYS 8002), in normal pregnant, between 30 and36 weeks of gestation. They were divided into two groups: group I(n ¼ 200) represented by pregnant whose exam did not show any TAbut STV > 4 ms after 10 min; group II (n ¼ 40) represented by preg-nant with no TA and STV < 4 ms after 10 min. In all cases traces werecontinued until presence of TA, and the longest trace was 60 min ofduration.Results: In group I, all cases showed TA while in group II in 60% casesinitial STV < 4 ms have become more than 4 ms and with presence ofTA, showing fetal in good conditions. In the other hand, in 40% caseseven after keeping trace until complete 60 min there were not changesin STV or presence of TA.Conclusion: Fetuses with STV > 4 ms are related to active fetuses(presence of TA) and the ones with STV < 4 ms does ever not meanaltered result as when prolonging trace until 60 min, 60% of thesefetuses become active.

P63Computerized cardiotocography: correlation betweenSTV > 4 ms and response of fetal cardiac frequency tovibroacoustic stimulation test

A. A. Yamasaki, G. Braia & O. Toma

Introduction: In classic cardiotocography, a fetus is considered activewhen there are two transitory accelerations (TA) or elevation of20 bpm in cardiac frequency after vibroacoustic stimulation test. Incomputerized cardiotocography there must an instant variability, alsonamed short-term variation (STV), higher than 4 ms.Objective: Comparison between STV > 4 ms and fetal response toacoustic stimulus.Patients and methods: Twenty-four normal pregnant were analyzedbetween 30 and 36 weeks by computerized cardiotocography (SYS8002). If STV > 4 ms, but TA is absent after 10 min, a vibroacousticstimulation test was done for 3 s. The fetus was considered reactivewhen heart rate increased by 20 bpm for 3 min. The fetus was consid-ered hyper-reactive when heart rate increased less than 20 bpm orduration of response less than 3 min.Results: Among 24 fetuses, 20 (87%) were considered reactive aftervibroacoustic stimulation test (elevation of 20 bpm for 3 min or more).Only four fetuses (13%) were hyperactive.Conclusion: When STV > 4 ms fetuses are reactive in 87% cases andhyperactive in 13%. The STV can be used as isolated parameter forassessment of fetal well-being.

P64Correlation between the umbilical cord cross-sectionalarea and fetal anthropometric parameters

F. A. P. Vasques, A. F. Moron, C. G. V. Murta, H. Cattini,M. M. Barbosa, T. R. Goncalves, W. J. Hisaba & F. H. C. Carvalho

A prospective cross-sectional study was developed to determine thecorrelation between the umbilical cord cross-sectional (UCCSA) andfetal anthropometric parameters during normal pregnancies (patientswith known dates of LMP and an ultrasound examination before the20th week, without any pathologic condition). The measurements ofthe umbilical cord cross-sectional area were obtained in a plane adja-cent to the insertion of the cord in the abdomen, as proposed by Raioet al., 1999, and compared to the biparietal diameter (BPD), headcircumference (HC), abdominal circumference (AC) and femur length(FL) by the non-parametric correlation of Spearman. The inclusioncriteria were: (1) singleton pregnancy; (2) gestational week >20 weeks;(3) intact membranes; (4) normal umbilical Doppler flow velocimetry.The exclusion criteria, in the presence of any of those were: (1) conge-nital and/or chromosomal abnormalities; (2) pregnancy complications(any type); (3) inadequate size for gestational agent the time the ultra-sound examination was performed, i.e. the weight below the 10th orabove the 90th percentile; (4) abnormal AFI. The patients were exam-ined and included only once. The statistical analysis was performed bythe program called Statistical Package for Social Sciences (SPSS) and weused a Toshiba 140 with a transabdominal transducer of 3.5 MHz.Our results showed a strong correlation (Spearman rank ¼ 0.610, sig-nificant at the level of P < 0.01) between the UCCSA and the estimatedfetal weight by ultrasound examination and also with the fetal an-thropometric parameters (UCCSA � BPD ¼ 0.622; UCCSA � HC ¼0.617; UCCSA � AC ¼ 0.625; UCCSA � FL ¼ 0.604, all of themsignificant at the level of P < 0.01). We concluded that the UCCSAis a parameter that can be included at the routine of obstetricalultrasound examinations.

P65Does amniocentesis (AC) influence fetal growth?

T. huu Nguyen & T. Larsen

Purpose: To examine the relationship between AC and birth weight.Methods: A cohort of singleton pregnancies with AC carried out inDenmark (n ¼ 96893) was compared to the total population of single-ton pregnancies without AC or CVS (chorionic villus sampling)(n ¼ 873254) for infants born in years between 1980 and 1996.


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Exclusion criteria were multiple pregnancies, infants with malforma-tions, chromosomal abnormalities, stillbirths, and death within thefirst living year. The pregnancies with AC were grouped according togestational age (14–19th week of gestation) at the time of AC, andmean birth weight was calculated for each group. Maternal age, parityand previous abortions were taken into account when comparing meanbirth weights. To exclude social status as a confounder, the overallmean birth weight (pregnancies without CVS or AC) was also com-pared to the mean birth weight of a subgroup of infants (also withoutCVS or AC) born to women who undergo AC in some other pregnancy.Results: The mean birth weight of the AC cohort was found to be sig-nificantly higher than that of the total population and inversely relatedto the gestational age at AC.Conclusion: The invasive procedure seems to stimulate growth. Noknown potential cofounders can explain the higher birth weight afterpregnancies with AC.

P66Effect of income on fetal biometry by ultrasound

M. A. Taher

Objective: To compare gestational age corrected fetal biometry amongrich and poor women.Methods: An ultrasound database from August 2000 to January 2001was used for the purpose of this study. One hundred and seventy-fivepatients with certain menstrual history were included. Patient’s incomewas assigned based on their report during the initial evaluation. Therewere 137 rich and 38 poor women. All data were enter into Statistix7.0 statistical package, and analyzed using appropriate statistical tests.Probability values less than 5% were considered significant.Results: Multiple regression analysis using a second-order model forgestational age a S function of fetal biometry, income, and fetal biome-try–income interaction did not show income to alter the relationshipbetween gestational age and fetal biometry except for femur lengths.Ninety-five percent prediction intervals for gestational age did notshow clinically significant difference between rich and poor.Conclusion: There does not appear to be a significant difference inultrasound measured fetal biometry among different income groups.

P67Fetal breathing: a clinically useful paradox

P. G. Hepper, A. Shannon & J. C. Dornan

Purpose: To examine fetal breathing movements in fetuses with con-genital diaphragmatic hernia and compare this to unaffected fetusesand with their outcome after birth.Methods: Twenty women with normal singleton pregnancies and fourcases of congenital diaphragmatic hernia were studied. All fetuses wereobserved for 60 min at 36 weeks of gestation. Fetal breathing move-ments were observed by scan taking a cross-sectional view across theabdomen. The scan was recorded and breathing movements analyzedoff-line. All sessions occurred at the same time of the day and twohours after a light meal. No patients were cigarette smokers. Boutsof fetal breathing activity were defined as the length in seconds of eachseries of successive individual breathing movements bracketed by per-iods of apnea. The absence of fetal breathing movements for more than3 s was called the apnea period. Total duration of breathing was thesum of all bouts.Results: The normal fetuses exhibited a breath to breath interval of1.3 s and displayed breathing movements for around 30–35% of theobservation period. Of the four fetuses with congenital diaphragmatichernia, three died during the neonatal period due to lung hypoplasia,one survived following surgical repair. All four fetuses exhibited a simi-lar breath to breath interval as unaffected fetuses but the three fetuseswho died spent 80% (range 70–90%) of the time breathing whereasthe fetus that survived spent 32% of its time breathing. Increasedyawning was also observed in the fetuses who died.Conclusions: It has been speculated that the inhibition of fetal breath-ing movements may result in pulmonary hypoplasia, yet fetuses withlung hypoplasia spend more time breathing than those without lunghypoplasia. The relationship between breathing movements and lung

development requires further study. Breathing movements mayprovide important information on fetal health and outcome.

P68Fetal responses to invasive procedures

B. M. Petrikovsky, E. Schneider & N. Holsten

Objective: To study fetal responses to invasive procedures.Study design: Seven fetuses underwent invasive procedures between23 and 38 weeks of pregnancy for accepted clinical indications. Twoultrasound machines were used simultaneously; one to provideguidance, and one to register FHR and respiratory rate (RR). A paired-test was used for statistical analysis.Results: Three patients had bladder centesis, two placements of thebladder shunts and two placements of pleuro-amniotic shunts. FHRchanged from 128 � 6 bpm prior to the procedure to 168 � 8 after it(P < 0.05). RR also increased from 26 � 12 to 32 � 8 (P < 0.1).Conclusion: Invasive fetal procedures are accompanied by anincreased FHR and RR which are likely to represent pain response.

P69Predicting neonatal outcome after prolonged pretermmembrane rupture by ultrasound measurement offetal lung length

P. R. Stone, L. Sadler, M. Battin, S. Grant, J. Mitchell & A. Roberts

Purpose of study: To assess the ability of ultrasound measurementsof fetal lung length to predict neonatal respiratory outcome afterprolonged membrane rupture and oligohydramnios.Methods: From the database of all cases of spontaneous membranerupture <28 weeks gestation, normal singleton pregnancies with mem-brane rupture for at least 7 days and delivery after 24 weeks gestation,where lung length measurements were available, were studied. At leastone lung length measurement 7 days after membrane rupture needed tobe available. The last lung length prior to delivery was used to predictthe likelihood of pulmonary hypoplasia. Complete neonatal follow upwas available on all babies. Neonatal outcome measures included, sur-vival, bronchopulmonary dysplasia defined as an oxygen requirementat 36 weeks gestation and in non-survivors a neonatal respiratorydeath. Two groups, good and poor outcomes were defined. A compar-ison between the last lung length before delivery corrected for gestationbetween the good and poor outcome groups was made to determinewhether lung length could predict neonatal outcome. The trends inserial measures of lung length were also examined and compared withneonatal respiratory outcomes.Results: There were 43 live births eligible for study from the databaseof 57 babies. All had received antenatal corticosteroids as part of themanagement of prematurity. There were no differences in maternalage, ethnicity, parity and the incidence of antepartum hemorrhagebetween the good and poor outcome groups. Parameters significantlyassociated with a good outcome included gestation at membrane rup-ture, largest pool of amniotic fluid and gestation at delivery. The lastfetal lung length did not predict adverse neonatal respiratory outcomein the 28 babies, in which membrane rupture was >21 days the find-ings were the same. Serial lung growth data also did not predict out-comes (figures are presented to illustrate the results).Conclusions: Fetal lung length determined by antenatal ultrasounddoes not predict adverse neonatal respiratory outcome and the predic-tion of pulmonary hypoplasia remains an elusive goal.

P70Pregnancy in women with Marfan syndrome

C. G. Garcıa, N. P. Lagos, C. E. Benavides, I. F. Hoffmann,G. A. Castillo, M. A. Astorga, X. Melgarejo & I. Ferres

Background: The Marfan syndrome is inherited as an autosomaldominant trait, and the fetus has a 50% risk of inheriting the mutantgene. It is caused by an abnormal fibrin gene located on chromosome15q. The prevalence of the syndrome is 7�17/100 000. The symp-toms and complications usually affect ocular, skeletal and cardiovascu-lar systems. Pregnancy in the Marfan syndrome is associated with


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major problems: the first are maternal catastrophic cardiovascularcomplications which include aortic dissection, aortic rupture, orcardiac failure, due to mitral and aortic valve regurgitation. Theseconditions are responsible for 90% of the maternal deaths. Thesecond problem is the risk of having a child with the syndrome(50%).Case report: An 18-year-old patient with a Marfan syndrome andwith mental retardation. She had long limbs, slenderness of handsand feet, marked hyperextensible joints, kyphoscoliosis, narrow chestwith pectum excavatum, an high arched palate with malocclusion. Onfirst evaluation by US, she was 18 weeks pregnant. A maternal echocar-diography was done, showing that all four chambers, and the valvularstructures were normal, and the aortic root measured 26 mm, whichwas normal. The echocardiography was repeated at weeks 29 and36, and showed no change in the aortic root or in the rest of the para-meters. Study of the fetus showed normal anatomy, without morpho-type of Marfan in utero. Fetal echocardiography was normal. Therewas moderate IUGR. At 39th week, there was a vaginal delivery, with-out complications, of a male newborn, 2910 g, 49 cm, Apgar 9–9, on anormal physical examination.Conclusions: Maternal and fetal outcomes were monitored with sys-tematic echocardiography, which is the best and safest method avail-able for the follow up of the severe cardiovascular complications.Patients with Marfan syndrome with aortic root of <40 mm, usuallytolerate pregnancy well and can undergo vaginal delivery with epiduralanesthesia, with favorable maternal and fetal outcomes.

P71Sonographic examination of puerperal uterus after repeatcesarean section with traditional and Misgav Ladachmethods

A. Malvasi, P. Totaro, L. Liaci, M. D’Ambrosio & V. Traina

Purpose: In our Department of Obstetrics, where 1600 deliveries arecarried out on average every year, cesarean section (c.s.) with MisgavLadach methods has been practiced since November 1995, for 2078cases in all. In our study, we have examined sonographically 309 repeatc.s. with Misgav Ladach methods compared to 318 traditional repeatc.s. The aim of our investigation is the sonographic examination ofpatients with open peritoneum and those with closed peritoneum todiscriminate the frequency of bladder flap hematomas and other com-plications in the two techniques.Methods: The patients were examined by transvaginal and trans-abdominal sonography, on the third and 10th postoperative day, todemonstrate the presence of a fluid or mixed mass on the lower-uterine-segment (LUS) of 3 cm or more, clean wall, with reinforcementof distal echoes.Results: It has been observed that, in the group open peritoneum c.s.,there were masses of mixed echostructure referring to hematomas onthe 12th day in nine cases, while in the group closed visceral perito-neum in 51 cases (P < 0.05). In 39 cases, they were collection on theLUS from 3 to 4.2 cm in six from 4.2 to 5 cm and only in one case itwas a lateral collection of 6 cm which did not require surgical treat-ment anyway. Besides in 22 patients, the bladder-flap hematoma wasassociated with puerperal fever (values >38.5 8C). In Misgav Ladachmethod, only seven women had adhesion of light-medium importanceso that uterine exteriorization was not necessary, and not significant(NS) in comparison with the reference of nine women.Conclusion: Peritoneum closure in repeat c.s. lengthens operative timeand in some cases favors bladder-flap hematomas which increase post-operative morbidity (P < 0.05), antibiotics use 2.6 and 4.8%(P < 0.01), length of hospital 3 � 1 vs. 7 � 2 days staying (P < 0.01)and costs (P < 0.05). In conclusion, follow up has shown no intra-peritoneal compare to repeat c.s. with closed and open peritoneum.

P72Third trimester abdominal pregnancy

A. Salim, P. Handaya, G. H. Wiknjosastro & B. Karsono

Introduction: Surviving of the fetus of the third trimester abdominalpregnancy is possible although very rare. The high fetal and maternal

mortality rates is associated with it. We report four cases whichsucceed in having two living healthy babies. The subsequent problemis about the placenta which is left in the abdomen.Methods: Four women suspected of late abdominal pregnancy werereferred to our center for further management. All of them underwentabdominal ultrasound and vaginal if necessary. Blood flow of theumbilical artery also studied. They were treated until the fetus is viableaccording to our pediatrician prior to be delivered abdominally.Results: From April 1994 until October 2000, we have four cases ofthird trimester abdominal pregnancy. Two cases of 30 and 32 weeksgestational age with fetal death intra-abdominally. Another two casesof 33 and 31 weeks with living fetus intra-abdominally and placentaimplanted at the superior and posterior side of the uterus. Umbilicalartery RIs were 0.67 and 0.71. The interval between time of admissiontill the delivery were 19 and 33 days. Female babies 2400 g Apgar score9/10 and 1680 g Apgar score 6/8 for 1 and 5 min. They are growingand developing well except the first one has a slight club-feet.Conclusion: We report four cases of third trimester abdominalpregnancies, two of which succeed in delivering healthy babies.

P73Thromboelastography in the second trimester of pregnancyin the prediction of adverse pregnancy outcome

C. Karidas, P. Anastassopoulos, D. Perry & D. L. Economides

Thromboelastography (TEG) is a method of monitoring global homeo-static function as a dynamic process, involving the interaction betweenthe protein coagulation cascade and platelets, as opposed to the iso-lated end points measured by conventional coagulation screens. Thepurpose of this study is to determine whether TEG variables can beused in the second trimester to predict the development of adversepregnancy outcomes such as pre-eclampsia and intrauterine growthrestriction (IUGR defined as birth weight below the 5th centile forgestational age).Methods: A prospective study of a cohort of 273 pregnant womenwho underwent TEG assessment at 18–24 weeks gestation. Standardparameters were measured from each TEG tracing (R is the reactiontime, K the clot formation time, A the angle, and MA the maximumamplitude). Pregnancy outcomes were obtained from the casenotes of 251 participants. Twenty-two patients were lost at followup. The Mann–Whitney test was employed for analysis, as the aboveparameters did not follow normal distribution.Results: Twenty-three pregnancies (9.2%) were complicated by IUGRand 10 (4%) by pre-eclampsia. In the IUGR group, no significant dif-ference was observed in any of the TEG parameters in comparison tothe normal pregnancies (for R time: Mann–Whitney U ¼ 2296, for Ktime: U ¼ 2556, for MA: U ¼ 2514.5, for A-angle: U ¼ 2433, 95% CI(1972, 3273)). Similarly, TEG parameters did not differ significantly inthe pregnancies complicated by pre-eclampsia (for R time: Mann–Whitney U ¼ 971.5, for K time: U ¼ 1063.5, for MA: U ¼ 1199.5and for A-angle: U ¼ 1183, 95% CI (765, 1646)). Comparisons afterlogarithmic transformation, did not reveal any significant differencesbetween the two groups.Conclusion: Thromboelastography parameters in the second trimesterof pregnancy did not differ in normally developed and complicatedpregnancies. Therefore, they cannot be used as a single predictor ofadverse pregnancy outcome. This is a pilot study, therefore, further stu-dies are required to evaluate their use in conjunction with establishedpredictive tests.

P74Ultrasound during breast-feeding in normal term infants

L. A. Jacobs

The primary objective of this pilot study of infant feeding mechanismson ultrasound was to develop local ultrasound techniques to assess theinfant oral cavity during breast-feeding.Study methods: A convenience sample of 32 volunteers with termbabies were invited for ultrasound during a breast-feed in week 1


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and 4 of life. Useable data was obtained in 22 participants but not allattended for both scans yielding 36/44. The whole breast-feedingscan was videotaped for analysis later. Conventionally, acceptedpositioning and attachment criteria were used. The infant was weighedbefore and after feeding to satisfaction from one breast. A submentalapproach was used to obtain a median sagittal view of the nippleposition, hard and soft palate, tongue movements and therelationship between these intraoral structures. Various designs andfrequency of transducers were tested. The optimal transducer is anEC-7 endocavity transducer with a 1358 end-firing 7 MHz small radiuscurved array on a long, thin handle that does not interfere with feedingpositioning.

Conclusions: The relationship of nipple to hard palate/soft palatejunction is shown to be variable with distances from 3 to 11 mm.The participants had previous and present history of breast-feedingsuccess. They were not specifically directed to attach in a particularway since their current infants were recruited as thriving, contentedexamples of the appearances of ‘normal breast-feeding’. It is unknown,whether the participants in the landmark study by Woolridge et al.(1986), were instructed in feeding attachment prior to ultrasoundimaging thus influencing the nipple position. Further data analysis willdetect any infant maturation or learning differences between weeks 1and 4. This simple ultrasound technique can be applied to the assess-ment of infant feeding problems and preterm infant feeding behavior.

P O S T E R S E S S I O N 3 : O B S T E T R I C S – 3 D , F E T A L A N O M A L I E S , F E T A L T H E R A P YA N D C E R V I X

P75Fetal magnetic resonance imaging

S. J. Sinnott, D. Traves, T. Ryan, K. Frawley, T. Wood& R. B. Cincotta

Fetal magnetic resonance imaging (MRI) is rapidly establishing a keyrole in the diagnostic evaluation of fetal central nervous system (CNS)anomalies. We present, a pictorial essay of the effectiveness of fetalMRI in the assessment of cerebral anomalies and ventriculomegaly.High resolution neurosonography remains the cornerstone in antenatalCNS screening. When cerebral anomalies are diagnosed or suspectedby ultrasound examination, MRI clearly has a role and often adds use-ful information or can increase the level of diagnostic confidence andmay alter patient counseling and management. MRI examinations alsocan be used to obtain further opinions from different subspecialists,such as neuroradiologists, neurosurgeons, neurologists and interven-tion radiologists. Subtleties that may not be distinguishable on ultra-sound can be seen on MRI. The MRI should not be seen as acompetitor to ultrasound, rather a complementary study from whichthe imaging specialists can improve their working knowledge in CNSanatomy and pathology.

P76Prenatal diagnosis of congenital cardiac tumors:two cases reports

G. Rodrigues & E. Castela

Introduction: Congenital cardiac tumors are rare. Among the pedia-tric population, more than 90% of cardiac neoplasms are histologicallybenign. However, they have the potential for serious consequences, ifnot detected in a timely manner, usually because of their conspicuouslocation. Rhabdomyomas are the most common tumors of bothinfancy and childhood, occurring in 62% of cases.Case report: Cardiac rhabdomyomas were diagnosed in two patientsat 33 and 34 weeks with support of pediatric cardiology through tele-medicine. The first patient had multiple tumors, in right atrium, atrialseptum, ventricular septum and mitral valve, with variable size andwithout cardiac arrythmia or stigmata of the tuberous sclerosis. Thispatient had unilateral ventriculomegaly due to cerebral ischemy prob-ably linked to tumor embolization. The second patient had a singletumor, localized in ventricular septum without other ultrasounds find-ings. The two patients had not obstructed valvular inflow or outflow.Conclusion: Prenatal diagnosis of congenital cardiac tumors is possi-ble in the hands of an expert, although it is impossible to make ahistological diagnosis in utero, several ultrasonographic criteria,including tumor number, size, location and echogenicity, may help nar-row the differential diagnosis. Thrombosis of cerebral venous circula-tion can occur antenatally. Accurate diagnosis can be made using fetalreal time and color Doppler ultrasound. At the date of preparation ofthis abstract, the pregnancies are in course and delivery is expected inshort-term in a center of pediatric cardiology.

P77Prenatal sonographic appearance of Beare–Stevenson cutisgyrata syndrome

C.-C. Tsai, T.-Y. Hsu, S.-Y. Chang, T.-J. Wang, C.-Y. Ou,Z.-H. Chen & P.-U. Hsu

Background: Beare first described a 2-year-old boy who had ab-normal physical feature including hypertelorism, cutis gyratum,acanthosis nigrican, cleft palate, functional pyloric obstruction andabnormal genitalia. Ten cases of Beare–Stevenson cutis gyrata syn-drome have been reported. Here, we present, the first case of antenatalultrasound image of this rare syndrome. A 31-year-old Taiwanese,gravida 2, para 1, was referred for fetal evaluation at 32 weeks gesta-tion because of polyhydramnios and fetal head anomaly. Conventionalsonography revealed a single fetus with amniotic index of 27.3 cm,cover leaf skull, and a skin fold-like umbilical cord. Three-dimensionalsonography of the face of the fetus showed, high wide forehead, ocularproptosis, and depressed nasal bridge. The patient delivered a maleinfant weighing 2980 g at 39 weeks gestation. Physical examinationof the infant showed furrows of corrugated appearance of theskin, craniofacial anomalies, particularly craniosynosis, displacedears, prominent umbilical stump and hypospadia. Computer tomogra-phy and magnetic resonance image were performed and revealedfronto-ethmoid-nasal, cephalocele, pansynostosis and frontal basedefect.Conclusion: A total of 10 cases of Beare–Stevenson cutis gyrata syn-drome have been previously reported. All of the previously reportedcases of the syndrome were diagnosed postnatally. Our patient pre-sented with ocular hypertelorism, low-set and creased ears, ocularproptosis, choanal atresia, cloverleaf skull, craniosynosis, cutis gyrata,acanthosis nirican, prominent umbilical stump and bifida scrotum.Here we present the first case of antenatal ultrasound image of this raresyndrome.

P78The post-exercise cervix

M. Gun & D. Gluis

Measurement of the cervix via transvaginal ultrasound is now recog-nized as reproducible and accurate. The length of the cervix as deter-mined by transvaginal ultrasound has an inverse relationship to the riskof preterm delivery. Studies utilizing transfundal pressure to elicitchanges in the cervix have been reported [1,2]. This poster will illus-trate the use of ‘post-exercise’ transvaginal scanning in an attempt toidentify those patients at risk for preterm delivery both pre- and post-cerclage placement.References

1 Iams JK, Goldenberg RL, Meis PJ, Mercer BM, Moawad A, Da A etal. The length of the cervix and the risk of spontaneous prematuredelivery. N Engl J Med1996; 334: 567–72.


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2 Guzman ER, Vintzileos AM, McLean DA, Martins ME, Genito CW,Hanley ML. The natural history of a positive response to transfundalpressure in women at risk for cervical incompetence. Am J ObstetGynaecol 1997; 176: 634–8.

P79Warfarin embryonopathy

S. J. Sinnott, C. McDonald, D. Traves & G. Pritchard

Warfarin sodium readily crosses the placenta due to its low molecularweight and intrauterine exposure to this oral anticoagulant hasmultiple recognized complications. Complication outcomes seem tobe dependent on the timing of exposure. Exposure during the firsttrimester between the 6 and 12 weeks of gestation is associated withwarfarin embryonopathy: characterized by nasal hypoplasia, stippledepiphyses or vertebrae and digital hypoplasia. Warfarin embryonapa-thy has been identified in up to 25 fetuses with known exposureto warfarin sodium during the first trimester. Exposure during thesecond and third trimesters is thought to lead to a number of centralnervous system abnormalities. The authors report a rare case withimages of the prenatal ultrasound and postnatal X-rays and clinicalphotos. A discussion of the pathogenesis and literature review isincluded.

P802D/3D sonographic imaging of thanatophoric dysplasiatype I at 19 weeks of gestation

R. K. Pooh, S. Nishida & Y. Ohno

Thanatophoric dysplasia is a sporadic, lethal congenital skeletal dys-plasia. There are two major subtypes: (1) a short, curved femur char-acterizes type I; and (2) a straighter femur with cloverleaf skullcharacterizes type II. We, here, present a case of type I disease. A30-year-old pregnant woman was referred to the ultrasound unit due tofetal short extremities at 19 weeks and 4 days of gestation. Ultrasoundrevealed short limbs and a severely small thorax. Every limb bone wasmarkedly short, and the femur, tibia, fibula and humerus were remark-ably curved. 3D ultrasound demonstrated the abnormal appearance ofextremities. Cranial and intracranial structures were normal. Oneweek later, no growth of limb bones was seen. Thanatophoric dyspla-sia type I was strongly suspected and counseling of the couple wasdone. Pregnancy was terminated at 21 weeks of gestation and a femalefetus was aborted. Short and curved limb bones were confirmed bypostnatal X-ray. Genomic DNA obtained by cord blood showed apoint mutation in the fibroblast growth factor receptor 3 (FGFR3)gene; a C to T substitution at position 742 in the FGFR3 gene, resultingin a Arg248Cys substitution, known to be associated with type Idisease. By ultrasound in the second trimester, prenatal diagnosisof skeletal dysplasia can be feasible. However, differentiating thislethal disease from non-lethal skeletal disorders should be doneprudently.

P81A critical evaluation of three-dimensional andtwo-dimensional sonographic studies, and color Dopplerultrasound in detecting nuchal cord in utero

U. Hanaoka, T. Yanagihara, A. Kuno, H. Tanaka& T. Hata

Objective: To evaluate whether three-dimensional sonography is morevalid than two-dimensional sonography, and color Doppler ultrasoundin diagnosing nuchal cord in utero.Methods: Eighty-five singleton pregnancies without nuchal cordand 35 with nuchal cord (30 single nuchal cord, four double nuchalcords, and one triple nuchal cords) were studied within 1 week beforedelivery using a transabdominal three-dimensional sonography.Two-dimensional sonography and color Doppler ultrasound were alsoconducted.Results: Three-dimensional sonography identified in utero 22 (73.3%)single and 3 (60%) multiple nuchal cords found at birth. There were nosignificant differences in overall diagnostic indices of each diagnostic

modality for detecting nuchal cord. However, the ability to viewnuchal cord was better with three-dimensional sonography than withtwo-dimensional sonography or color Doppler ultrasound.Conclusions: Three-dimensional surface imaging does not providemore useful diagnostic information than two-dimensional sonographyand color Doppler ultrasound for detecting nuchal cord in utero.

P82Fetal renal blood flow assessment by three-dimensionalpower Doppler ultrasound: preliminary results of athree-dimensional histogram study

F.-M. Chang, C.-H. Chang, C.-H. Yu, T.-P. Liao& H.-C. J. Ko

Purpose: To assess the fetal renal blood flow in normal gestation usingthree-dimensional (3D) power Doppler ultrasound.Methods: The study was under a prospective, consecutive and cross-sectional design. Normal pregnancies that attended the prenatal clinicwere included. We used a three-dimensional power ultrasound scan-ner, Voluson 530D MT (Kretz, Zipf, Austria) to assess the total bloodflow of fetal kidney. First, we used the 3D transabdominal probe toscan the whole fetal kidney under the 3D power Doppler mode at afixed condition. Second, we used the VOCAL software (Kretz, Zipf,Austria) to calculate the histogram indices of fetal renal blood flowobtained from the 3D power Doppler scanning. The histogram indicesincluded vascularization index (VI), flow index (FI) and vasculariza-tion-flow index (VFI).Results: In total, 81 fetuses ranging from 20 to 39 weeks of gestationwere included for final analysis. Our results showed that VI had a highcorrelation with gestational age (r ¼ 0.90, n ¼ 81, P < 0.001). Inaddition, FI was positively correlated with gestational age (r ¼ 0.35,n ¼ 81, P < 0.05), and VFI also presented a high correlation withgestational age (r ¼ 0.88, n ¼ 81, P < 0.001). Furthermore, the VI,FI, and VFI of fetal kidney in the third trimester were all higher thanthose indices of fetal kidney in the second trimester (all P < 0.01).Conclusion: The 3D power Doppler ultrasound can assess the totalblood flow of fetal kidney, which is superior to the previous methodsof blood flow assessment. Our study indicates that fetal renal flowincreases with the advancement of gestational age, and our data maybe a useful reference for further studies of fetal renal flow in abnormalconditions.

P83Prenatal neuroimaging of progressive ventriculomegalyat 20–21 weeks of gestation – a case report

R. K. Pooh, M. Tanemura, M. Yamasaki & K. Pooh

Intrauterine course of genetic hydrocephalus has not been revealed. Wehad a case with progressive ventriculomegaly between 20 and21 weeks of gestation. A pregnant woman was referred to the ultra-sound unit at 20 weeks of gestation. Her 8-year-old son had congenitalhydrocephalus, gait disturbance, mental retardation and adductedthumbs, but genetic examination was not done. The male fetus hadgrown normally with normal BPD. However, 2D/3D sonographyand fetal magnetic resonance imaging (MRI) demonstrated partialagenesis of the corpus callosum, moderate ventriculomegaly and asmall inter-hemispheric cyst. Ventricular volume by 3D volumetrywas estimated as 4.89 mL, which was more than twice as large asnormal ventricle size. Subarachnoid space appeared normally. At21 weeks of gestation, ventricular volume markedly increased to8.29 mL within 7 days. Furthermore, 2D/3D ultrasound revealed thebilateral adducted thumbs. Genetic hydrocephalus, such as corpus cal-losum agenesis, retardation, adducted thumbs, spastic paraparesis, andhydrocephalus (CRASH) syndrome was strongly suspected from thosesonographic findings. Pregnancy was terminated at the end of 21 weeksof gestation. Genetic examination by direct sequenced PCR resulted ina point mutation at Intron 6 of L1CAM located at Xp28. In our case,prodromic sign of progressive hydrocephalus was suspected by USGand MRI at the middle of gestation. Especially, 3D volumetry was use-ful for the assessment of the objective evaluation of the progressiveventriculomegaly.

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P84The assessment of placental blood flow bythree-dimensional color power Doppler ultrasound:preliminary result of a three-dimensional histogram study

C.-H. Yu, C.-H. Chang, F.-M. Chang, T.-P. Liao & H.-C. Ko

Objective: To assess the placenta blood flow in normal gestation bythree-dimensional color power Doppler ultrasound.Methods: We collected normal pregnant women with gestational agebetween 20 and 40 weeks prospectively, consecutively and cross-sectionally. Three-dimensional ultrasound scanner, Voluson, 530D MT(Kretz, Zipf, Austria) was used to assess the placental blood flow ineach case. First, we used the 3D transabdominal probe to scan the pla-centa under the 3D power Doppler mode at a fixed condition. Second,we used the VOCAL software (Kretz, Zipf, Austria) to calculate thehistogram indices of fetal placental blood flow obtained from the 3Dpower Doppler scanning. The histogram indices included vasculariza-tion index (VI), flow index (FI), and vascularization-flow index (VFI).Results: One-hundred singleton pregnant women were enrolledinto the program. The best-fit equations for VI, FI, and VFI are0.27107 � G � 4.02743, 0.56115 � G þ 34.28945, and 0.15663 �GA � 2.53810, respectively. All the P-values are less than 0.05. Allthe indices were positively correlated with the fetal gestational age.Besides, The VI, FI, VFI of fetal placenta in third trimester were allhigher than those indices of fetal placenta in the second trimester.Conclusion: The fetal placental blood flow increases with the advance-ment of gestational age. Our data may be a useful reference for furtherstudies of fetal placental flow in abnormal gestations.

P85Three-dimensional color power angiography of ananeurysm of the vein of Galen

R. Ximenes, D. S. Ximenes, A. Ximenes, J. Szejnfeld, S. Ajzen,G. D’Hippolitto, S. M. Goldman & R. Sandoval

Description of the case: A 26-year-old, gravida 1, para 0, female.The first scan was at 16 weeks, with normal fetal biometry and devel-opment. At 25 weeks’ gestation, a cystic area at the level of thebiparietal-diameter, measuring 25 mm of diameter, ventricles hasnormal sizes, the cystic area was interrogated with color Dopplerand showed a typical ‘turbulent flow’. The transvaginal probe was per-formed for evaluation of the fetal brain. Color Doppler energy was usedto evaluate the cystic area and their communications – ‘angiography’, fol-lowed by tri-dimensional reconstruction of the brain vessels, especiallythe venous drainage and the arterial communications. This pathologyis referred as a complex arterio-venous malformation (AVM). Antena-tal MRI was performed to evaluate the central nervous system. Theparents were counseled about the prognosis. At 34 weeks’ gestation,the shunts of the arteriovenous malformation were more prominent,ventriculomegaly, tricuspid regurgitation and polyhydramnios.Proof of diagnosis: At 35–36 weeks’ gestation, she delivered a femalebaby, weighing 2900 g, with Apgar score 4 and 8. The baby was trans-ferred for the neonatal intensive care, but after 24 h died because ofrenal failure.Relevance: This report demonstrated that 3D color Doppler energymode is useful in prenatal diagnosis and a more detailed angio-archi-tecture of the aneurysm of the vein of Galen, with a excellent correla-tion with MRI. We hope, in the near future this technique could guidethe identification of the fetus at increased risk for intrauterine andneonatal cardiac failure and therefore poor prognosis.

P86Three-dimensional sonographic evaluation of fetal softtissue deposition

T. Yanagihara, M. Matsumoto, U. Hanaoka, A. Kuno & T. Hata

Objectives: To evaluate fetal nutritional status in utero and to detectintrauterine growth restriction and macrosomia by use of three-dimensional ultrasonography.Methods: Fifty-two fetuses from 28 to 41 weeks gestation werestudied within 1 week before delivery using a transabdominal

three-dimensional transducer. The fetal nutrition score values weredetermined from a qualitative assessment of the amount of subcuta-neous tissue present at three locations (face, ribs, and buttocks) onthe antenatal three-dimensional ultrasonograms. Fetal nutritional sta-tus, using fetal nutrition score, was compared with those by modifiedneonatal nutrition score and ponderal index, respectively.Results: There was a significant linear correlation between fetal nutri-tion score and modified neonatal nutrition score. Fetal or neonatalnutrition score correlated well with birth weight and neonatalcrown-heel length, respectively. However, no significant correlationbetween ponderal index and fetal nutrition score or modified neonatalnutrition score was evident. Ponderal index also did not correlate withbirth weight and neonatal crown-heel length, respectively.Conclusion: We do cast doubt on the usefulness of the ponderal indexfor measurement of neonatal soft tissue and muscle mass. Fetal nutri-tion score using three-dimensional ultrasonography provides a novelmeans of evaluating the nutritional status of the fetus in utero, andshould be useful for predicting the extreme in fetal growth earlier.

P87Three-dimensional volumetry in fetal weight estimation,cerebral ventricle measurements, and cardiac function

S. Yagel

Objectives: To examine the applicability and efficacy of 3-D volume-try in three discrete areas: fetal weight estimation, cerebral ventriclemeasurements, and 3-D echocardiographic studies of fetal cardiacfunction.Materials and methods: Group 1: fetal weight estimation: 250 grav-idae with uncomplicated singleton gestations and first-trimester confir-mation of gestational age were examined up to 48 h before deliveryusing both standard 2-D fetal weight estimation and 3-D volumetry.Group 2: fetal cerebral ventricle measurements: 40 gravidae withfirst-trimester confirmation of dates were examined at 15–25 weeksgestation. Fetal lateral ventricles were measured by 3-D volumetry.Group 3: 3-D echocardiography: 40 gravidae with 1st-trimester confir-mation of dates were examined at 15–25 weeks gestation. End-systolicand -diastolic ventricular volumes were studied to evaluate fetalcardiac function.Results: In these preliminary groups 3-D volumetry for fetal weightestimation was shown to have a considerable advantage over standard2-D methods. Three-dimensional volumetry of the fetal cerebral lateralventricles is a simple method of measuring the fetal brain, and mayprove to be a more intelligent method of evaluating cerebral ventricularvolume. Three-dimensional echocardiographic volumetry of the end-systolic and -diastolic ventricular volumes is a new method for evalu-ating fetal cardiac function, and has considerable potential in heartscanning in cases of suspected fetal heart failure.Conclusions: Three-dimensional ultrasonography shows great poten-tial in the evaluation and volumetric measurement of many fetal organsystems.

P88Cervical cerclage after hysteroscopic metroplasty

G. Ragusa, C. Lanzani, M. Digrandi & E. Ferrazzi

Purpose: The objective of the study is to evaluate the role of cervicalcerclage after hysteroscopic metroplasty.Methods: Forty-six women, previously treated by hysteroscopicmetroplasty for subseptate uteri, were prospectively recruited for thisobservational study. A total of 34 patients conceived 46 pregnancies.Miscarriages, ectopic pregnancies, and live births rate were 34, 7,59%, respectively. Elective or ultrasound indicated cervical cerclagewas proposed to these latter 27 patients. After discussing an informedconsent form patients were asked to choose the elective cerclage or theultrasound indicated cerclage. Cervical length was checked every3 weeks, from 12 weeks of gestation. Indications for cervical cerclagewere: cervical funneling or shortening <25 mm. In symptomaticpatients, or when cerclage was indicated, a cervicovaginal swabwas performed, and, if necessary, antibiotic therapy was started. TheShirodkar technique was adopted for cerclage.

11th World Congress on Ultrasound in Obstetrics and Gynecology Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix

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Results: Eleven of 27 patients underwent cervical cerclage: seven onultrasound indication, four electively. Mean gestational age at the timeof indicated cervical cerclage was 20 � 2 weeks. Three patients, in theUS-indicated group, had a pathologic cervicovaginal swab. All no cer-vical cerclage delivered at term (39 � 2 weeks). Mean gestational ageat delivery in patients who underwent indicated cervical cerclage wassignificantly lower (P < 0.05) than in patients with no sonographicindication (37 � 2 vs. 39 � 1 weeks).Conclusions: Ultrasound cervical assessment is a useful tool to selectpatients for therapeutical cerclage. According to our data cervical cerc-lage should be performed only in cases of cervical changes diagnosedby transvaginal sonography.

P89Comparison of two methods of cervical stress testing

O. Okitsu, H. Niki & T. Mimura

Purpose: Cervical ultrasonography provides useful information onthe prediction of preterm delivery. However, the cervix in naturalstate evaluated by sonography does not always show the predictingsigns of preterm delivery. Some insist on the usefulness of thecervical stress testing like transfundal pressure or Valsalva maneuver,which provoke cervical shortening or funneling by increasing intrauter-ine pressure. Our object was to compare the efficiency of the trans-fundal pressure with that of the Valsalva maneuver as cervical stresstesting.Methods: Normal pregnant women visiting our outpatient depart-ment for routine check up underwent transvaginal ultrasonography.Cervical length was measured and the shape of the internal os wereevaluated. When the shape of internal os was flat or mildly depressed,these women were regarded as candidates for the stress testing. First,Valsalva maneuver, second, transfundal pressure were applied. Cervi-cal shortening ratio was calculated in comparison with the naturalstate, and appearance of funneling was evaluated.Results: Twenty-five examinations were performed on 20 pregnantwomen. The shortening ratio in transfundal pressure was 9.8%, whichwas greater than that in Valsalva maneuver, 6.5%. However, the num-ber in which cervical length became 25 mm or less was same in eachtest. On the other hand, funneling was induced in two cases only bytransfundal pressure.Conclusion: Although transfundal pressure seemed better testing thanValsalva maneuver, further examinations is required to concludewhich test is superior.

P90Enhancing cervical sonography with methyl-cellulose gel

J. M. O’Brien, B. A. Houseman, A. A. Allen & J. R. Barton

Purpose: Our purpose was to evaluate the performance of two differ-ent contrast agents for cervical sonography in obstetrical patients. Inaddition, we sought to evaluate this technique in a setting other thanwith transvaginal sonography, such as utilizing a transperineal ortransabdominal approach.Methods: Women with an indication for cervical sonography withoutpremature rupture of the membranes underwent placement of 10 mLof normal saline or water-soluble methyl-cellulose gel. Assessment ofcervical dimensions and contour was performed via transperinealsonography prior to and after contrast placement. Two authors inde-pendently evaluated, the adequacy of visualization of the cervicalcanal, external os, and vaginal fornices. When an improvement invisualization after contrast placement was noted by both observers,the attribute was counted.Results: Twenty-five patients were enrolled into two groups. Themean gestational age at examination was 26.6 � 6.2 weeks in the sal-ine group, and 27.5 � 5.2 weeks in the methyl-cellulose gel group,P ¼ 0.58. Administration of contrast improved visualization in 18women in the gel group vs. six in the saline group, P ¼ 0.002. Seven-teen patients in the gel group had easier identification of the external osand enhanced visualization of the fornices was noted in 13 patients (12patients had both). The mean cervical length was similar prior to andafter administration of contrast (gel 2.8 � 0.9 vs. 2.9 � 1.0 cm,

P ¼ 0.18, and saline 2.5 � 0.9 vs. 2.6 � 0.6 cm, P ¼ 0.45). Intravagi-nal contrast did not alter the identification of funneling in either group.Conclusion: Intravaginal contrast allows for easier identification ofcervical/vaginal anatomy in some patients undergoing ultrasono-graphic examination by transperineal scanning but did not significantlyalter assessment of cervical length. Intravaginal soluble methyl-cellulose gel is the superior cervical contrast agent to normal saline.This methodology may also be useful in other settings, such as witha transabdominal approach.

P91Evaluation of the effects of cervical properties

K. Kepkep, H. Gurpinar & E. Kar

Introduction: Preterm delivery has been faced in all delivery with a7–11% and it keeps its importance by causing perinatal mortalityand morbidity. Therefore it is important to define preterm delivery riskduring the earlier period of the delivery.Objective: The aim of our work is evaluating the influence of thecervical length and funneling which are measured by transvaginalultrasonography (TVUSG) in the asymptotic singleton pregnantwomen, to predefine preterm delivery.Material and methods: The cervical length at 16th, 20th, 24th, 28th,32nd and 36th week of the pregnancy has been measured by TVUSGwithin a sample of 60 pregnant women who do not have any risk aboutthe preterm delivery or who have already had a preterm delivery or anabortus case before. Also, the funneling has been observed within thesame sample. The relation of a cervical length less than or equal 30 mmand the existence of the funneling with a preterm delivery risk beforethe 37th week of the delivery has been evaluated statistically.Results: We have observed the preterm delivery in the seven of the 60pregnant women which were controlled until the delivery (11.7%). Inthis group, the relation between the preterm delivery and a cervixwhich is less than or equal 30 mm has been found to be statisticallyreasonable with the cervical length value at the 28th and 32nd week(P ¼ 0.0001; P ¼ 0.00001). A cervical funneling has been found inone patient and it has been not defined as meaningful with regard tothe preterm delivery risk (P > 0.05).Conclusions: In order to define the risk of the preterm delivery, it ismore meaningful if the cervical length is less than 30 mm and measuredat the 28th and 32nd week of the delivery. On the other hand, funnel-ing could not been determined during the earlier period of the delivery;therefore it is not used as a criteria to predefine the preterm delivery.

P92Prevention of preterm labor by AIWA’s score

H. Yoshitake, Y. Koyama, J. Fukuda, K. Uehira, S. Amiya& S. Yano

Purpose: To elucidate the availability of ‘AIWA’s scoring’ in preven-tion of preterm labor.Patients: We retrospectively studied the 6434 deliveries after 22 weeksof gestation, managed at AIWA-Maternity Hospital from 1986 to1990, and from 1995 to 2000.� C-stage: deliveries from 1986 to 1990: 1786 (control stage

without AIWA’s scoring);� P-stage: deliveries from 1995 to 1997: 2190 (prototype stage

without AIWA’s scoring);� A-stage: deliveries from 1998 to 2000: 2458 (applied stage with

AIWA’s scoring).Nine twins and seven cases of pregnant mother transportation (MT)

in (C) 1786, 25 twins and 3 MT in (P) 2190, and 17 twins, 2 triplets, 6MT in (A) 2458, were involved, respectively.Methods: The ‘AIWA’s score’ of risk assessment for premature deliv-ery consists of cervical consistency, insertion resistance to external osof uterus by internal examination, and cervical length and funneling ofinternal os of uterus measured by transvaginal ultrasonography. Thefull AIWA’s score is 12 point, which means extremely high risk ofpremature labor. On the other hand, 0 point means no risk of it. Then,P-score (0–3) consists of the history of early delivery, abortion after18 weeks of gestation, present multiplicity and so forth. AIWA’s score


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þ P-score ¼ AP-score. (A) From 1998 to 2000, in case with AP-score>8, before 26 weeks of gestation, patients had cervical cerclage ifthey wanted after severely informed consent. We compared someparameters between C- and A-stage.Results: The rate of premature delivery declined (from 4.5 to 3.2%<37 weeks [P < 0.05]; from 2.5 to 1.3%, <36 weeks [P < 0.01]) inA-stage using the risk assessment system. In all premature deliveries,those before 32 weeks of gestation declined from 15.2 to 2.6%(P < 0.01) in A-stage. The rate of preterm PROM <34 weeks in alldeliveries declined from 0.56 to 0.12% (P < 0.05), while the rate ofpreterm PROM in premature labor decreased from 12.7 to 3.9%,and the rate of emergency cervical cerclage also decreased from 13.5to 1.2% (P < 0.05). In single baby delivery, the rate of cervical cerclageslightly decreased from 1.1 to 0.75% in nulliparous mother, however,it extremely increased from 2.7 to 5.3% in multipara.Conclusions: Prevention of preterm labor by prophylactic cervicalcerclage using ‘AIWA’s score’ would be useful to decrease prematuredeliveries and eventually to relieve the shortage of NICU beds in Japan.Preterm PROM before 34 weeks of gestation has been a problem forlong years in perinatal management. Also, the success rate of emer-gency cervical cerclage has been poor. The rate of those two problemswould declined using AIWA’s scoring system. The rate of cervicalcerclage in multipara was two times higher than that in controlstage. The future issues is making of more appropriate indicationand contraindication of cervical cerclage with special reference topatients QOL.

P93Quantitative ultrasonic tissue characterization of thecervix – a new predictor for prematurity?

I. Tekesin, M. Meyer-Wittkopf, G. Heller, B. Steinfeldt, F. Sierra& S. Schmidt

Background: Since the incidence of premature delivery has remainedconstant, despite intensive safeguard methods over the last decade,the texture features of the uterine cervix were evaluated using quanti-tative sonographic gray level analysis at different gestational ages(GA).Materials and methods: For this purpose quantitative ultrasonic tis-sue densitometry of the uterine cervix was obtained from 30 asympto-tic female patients (group A, mean: 30.3 GA) and compared withvalues obtained from 16 symptomatic female patients (group B, mean:29.5 GA) with uterine contractions and shortening of the cervix atsimilar gestational ages. Once the two-dimensional transvaginal sono-graphic measurement of cervical length was completed a region ofinterest of constant size was defined in the mid-section of the posteriorwall and the tissue-specific gray scale distribution was determined.Results: Quantitative ultrasonic tissue characterization of uterine cer-vix was feasible in all 46 patients at all gestational ages. In patientswith premature contractions and shortening of cervix, the average grayscale values were found to be statistically reduced in comparison withthose obtained from asymptotic patients. These results showed goodreproducibility and intraobserver variability and were found to beindependent from the measured cervical length.Conclusion: Our results prove that quantitative ultrasonic tissue char-acterization of the uterine cervix might serve as a new parameter forpredicting premature delivery in the future.

P94Transvaginal ultrasonography in detection of cervicalincompetence

M. Podobnik, M. Podgajski, B. Gebauer & S. Ciglar

Background: To examine the relationship between transvaginal ultra-sound cervical changes and pregnancy outcome in women at risk ofcervical incompetence and preterm delivery.Methods: In 100 pregnancies with clinical and ultrasonic signs of cer-vical incompetence, the length of the cervix, the thickness of the ante-rior wall of a lower uterine segment and the width of the endo-cervical

canal have been evaluated ultrasonically. These parameters were fol-lowed longitudinally from the 10 to 36 week gestation in the healthypregnancies and pregnancies at risk for cervical incompetence and pre-term delivery.Results: In patients from 10 to 14 weeks, the cervix is significantlylonger than in the 25–36 week group and the anterior wall of the loweruterine segment in the 10–14 week group is significantly thicker than inthe 20–36 week group. In pregnancies at risk for cervical incompe-tence, cervical lengths and wall thickness, were significantly differentfrom those in comparable controls. Forty-five percent of the patientsin the at-risk group, with cervical cerclage, delivered at 37.5 weeksand 8.5% of pregnancies ended in abortion when the amnioticmembrane herniated into the cervical canal. The frequency of pretermdelivery was 60, 38 and 15% for cervical length of <10, 10–20, and20–30 mm.Conclusions: A shortened cervix with decreased thickness of the ante-rior wall of lower uterine segment and dilated endo-cervical canalshows a strong association with cervical incompetence and pretermbirth.

P95Ultrasound assessment of the cervix in recognizingpreterm delivery

J. Brazert, E. Wender-Ozegowska, A. Persona-Sliwinska& R. Biczysko

Background: Cervix is very important structure that separates thefetus from external environment, which we can visualize very preciselytransvaginal ultrasonography. Sonographic examination allows visua-lization of the internal cervical os and the portion of the cervix that liesabove the vaginal fornices, providing information that is inaccessible todigital examination. Cervical length in the pregnancy is one of the pre-dictors of preterm delivery and diagnosis of cervical incompetence.Materials and methods: We have investigated 57 pregnantwomen: 20 diabetic pregnant women, 8 with hypertension, 14 withcervical incompetence, and 15 in uncomplicated pregnancy. Transva-ginal sonography was used to measure cervical length between 20and 30 weeks gestation. Ultrasound examination was performedusing 2000 with 5.0 MHz transvaginal transducer. Maternal ageranged from 19 to 39 years (mean 27.2 � 8.3). The followingmeasurements were obtained: endo-cervical canal length between theinternal and external os, funneling of the cervix, funnel width, funnellength.Results: The mean endo-cervical length measured in ultrasonographywas 17.3 � 5.2 mm in pregnancies delivered preterm (n ¼ 7) and33.4 � 9.6 mm in pregnancies delivered at term (nP). The 11 pregnantwomen with cervical incompetence were treated with cervical cerclage,eight of them delivered at term and three preterm. The mean endo-cervical length was 10.4 mm � 3.0 and in all cases we observed funnel-ing of the cervix in this group. Endo-cervical length was 25 mm in75% pregnant women, who delivered after 37 weeks of pregnancy.No significant relationships were shown between length of the cervixin pregnancy complicated by diabetes mellitus, hypertension anduncomplicated pregnancy. The mean endocervical length in diabeticpregnancy was 34.7 � 4.7 mm; pregnancy with hypertension 32.9 �5.8 mm and uncomplicated pregnancy 35.6 � 3.8 mm.Conclusion: Cervical length measured by ultrasonography between 20and 30 week of pregnancy is very important predictor of preterm deliv-ery. No significant relationships were shown between the length of thecervix and investigated pregnancy complications.

P96Adenomyomatosis causing an echogenic fetalgallbladder – a new association

M. P. Bethune & M. Pahuja

Case report: A primi gravida presented for a third trimester growthscan due to a history of SLE. Biometry was normal but a linearechogenicity was identified in the region of the fetal gallbladder, the


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gallbladder was not separately identified. The patient delivered anappropriately grown term baby with normal Apgar scores. Postnatalultrasound identified a normal-sized gallbladder with echogenic fociin the wall demonstrating the classical ‘comet tail artifact’ seen withadenomyomatosis.Discussion: The fetal gallbladder can be visualized from late in thefirst trimester. Previous case reports of echogenicities within thefetal gallbladder have found a high rate of resolution by the time ofdelivery [1,2]. The persistent echogenic foci in neonates were shownto be gallstones or sludge in almost all cases. All series failed toshow any neonatal consequences of these findings [1]. Adenomyoma-tosis is a benign condition of the gallbladder where the lining epithe-lium extends as down-growth between the muscle bundles to formgland like structures, known as Rokitansky–Aschoff sinuses. Withinthese foci secondary cholesterol crystal deposition occurs. Sonographi-cally these appear as echogenic foci within the gallbladder wall withthe classic description of ‘comet tail artefact’. A detailed medlinesearch failed to reveal any reported cases of neonatal diagnosis of thiscondition. It has only rarely been reported in children. There havebeen no previous case reports of echogenic fetal gallbladder confirmedas adenomyomatosis in the neonatal period. Adenomyomatosisneeds to be included in differential diagnosis of the antenatal echogenicgallbladder.References1 Kiserud T, Gjelland K, Bogno H, Waardal M, Reigstad H, Rosen-

dahl K. Echogenic material in the fetal gallbladder and fetal disease.Ultrasound Obstet Gynecol 1997; 10: 103–6

2 Brown DL, Teele RL, Doubilet PM, DiSalvo DN, Benson CB, VanAlstyne GA. Echogenic material in the fetal gallbladder: sonographicand clinical observations. Radiology 1992; 182: 73–6

P97Associated anomalies and perinatal outcome in fetuseswith prenatally diagnosed single umbilical artery

M. H. Park, K. Y. Oh & J. S. Park

Objective: To evaluate pattern of associated structural anomalies,abnormal karyotypes and perinatal outcomes of fetuses with prenatallydiagnosed single umbilical artery and to evaluate the relation of absentside of a single umbilical artery in association with anomalies andabnormal karyotypes.Materials and methods: Thirty fetuses with a single umbilicalartery were detected by prenatal ultrasound examination betweenMarch 1998 and June 2001 at Eul-Ji University Hospital. All medicalrecords were reviewed for maternal demographics, associated anoma-lies, karyotypic analysis, pregnancy complications, and neonataloutcome.Results: Of the 30 fetuses, 11 (36.7%) were terminated because ofsevere anomalies and 1 (3.3%) experienced neonatal death. 17 fetuses(56.7%) had an associated structural anomaly. The structural anoma-lies found in association with single umbilical artery were multiple mal-formations (seven cases, 41.2%), cardiovascular anomalies (four cases,23.5%), urinogenital anomalies (four cases, 23.5%), CNS anomalies(one case, 5.9%) and ectopia cordis (one case, 5.9%). Karyotype anal-ysis was available in 25 cases and 5 of these were chromosomallyabnormal. All of the karyotypically abnormal fetuses had a structuraldefect diagnosed on prenatal ultrasound examination in addition to thesingle umbilical artery. Of the 13 fetuses without any associated struc-tural or chromosomal anomalies, 3 (23.1%) demonstrated growthrestriction. Of the 26 cases identified, the absent side of a single umbi-lical artery, the right umbilical artery was absent in 13 (50%) and theleft in 13 (50%) fetuses. The frequency with associated structural andchromosomal anomalies was equal on right (46.2, 15.4%) and left(69.2, 23.1%) sides.Conclusion: When single umbilical artery is detected, a detailed ultra-sonographic examination and fetal karyotyping should be recom-mended for search of associated structural and chromosomalabnormalities. In cases, where single umbilical artery is an isolatedfinding on prenatal ultrasound, careful attention to fetal growth isnecessary.

P98Case report: bradycardia in a fetus withtrisomy 21

S. C. Cha & R. Porto

Introduction: Trisomy 21 is the most common chromosomal abnorm-ality and the risk of delivering a child with this defect increases withmaternal age. Diagnosis can only be done by invasive procedures forfetal karyotyping. For parents who choose to avoid such tests, ultra-sound scans can help identify markers of aneuploidy such as increasednuchal translucency thickness. However, these screening methods can-not identify all abnormal cases.Case report: V.L.F.R., 38 years-old, first pregnancy, had a 1.6-mmnuchal translucency thickness measurement at 11 weeks and normalanomaly scan at 20 � 4 weeks. On the basis of these findings, shedecided to avoid fetal karyotyping. Scan at 28 weeks showed normalfetal biometry apart from short femur. Fetal sinusal bradycardia(heart rate ¼ 116 bpm) was diagnosed at 33 weeks and repeat compu-terized fetal heart monitoring from 34 weeks onwards was alwaysnormal apart from previously noted fetal bradycardia. Estimatedfetal weight was 2.080 g at 35 weeks (below the 10th centile for gesta-tion) but amniotic fluid volume and fetal Doppler studies were normal.Elective cesarean section was carried out at 38 weeks and a malenewborn weighing 2.700 g, Apgar score 7-9-10 was delivered.Down syndrome was clinically suspected and confirmed by cytogeneticanalysis.Discussion: Some studies have demonstrated that a silent pattern dur-ing fetal heart monitoring, with fewer accelerations and more decelera-tions, is more often found in trisomic fetuses than in normal ones. Inthis case report, fetal bradycardia was the only abnormal finding. Itraises the possibility of considering this as a marker for aneuploidywhen fetal biophysical profile and Doppler studies are normal in thethird trimester.

P99Choroid plexus cyst revisited – the KK Hospitalexperience

J. V. K. Tan, B. H. Woo & G. S. H. Yeo

Objective: To study the clinical outcome of cases of choroid plexuscysts (CPC), the prognostic factors that increase the risk of aneuploidyand to formulate a counseling strategy for CPC.Study design: Cases of CPC detected at screening ultrasonography(between 18 and 24 weeks gestation) from 1 October 1996 to 30 Sep-tember 2000 in low risk antenatal patients at KK Women’s & Chil-dren’s Hospital, Singapore, were studied. The risk of aneuploidy andpostnatal cranial ultrasonography of the cases were analyzed. Datawas stratified according to maternal age, size of CPC, unilaterality orbilaterality and presence of concomitant structural abnormalities and/or ultrasound markers (non-isolated).Results: There were 485 cases with CPC among 56 746 patients (inci-dence 0.08%). Overall risk of aneuploidy was 6.2%. There were 30cases of chromosomal abnormalities including 23 cases of trisomy18; five cases of trisomy 21; one case of monosomy X and one caseof Klinefelter syndrome. Cases of non-isolated CPC were at signifi-cantly higher risk for aneuploidy (56.8%) compared to isolated CPC(1.4%), P < 0.001. No significant difference in risk was detectedbetween unilateral and bilateral isolated CPC (P ¼ 0.4), and withincreasing size of isolated CPC. A near significant increase in riskwas found between the under-30 age group (0.37%) and the above-30 age group. (2.3%) (P ¼ 0.07). In non-isolated CPC, the risk ofaneuploidy ranged from 14.3% at age 20–24 and 100% at age 41–45. Likelihood ratio for trisomy 18 was 7.2 for isolated CPC, 1276for non-isolated CPC and 0.54 for absent CPC in the whole scannedpopulation.Conclusion and recommendations: Our results support the need for athorough ultrasound anatomic survey for all cases of diagnosed CPC.Karyotyping should be offered to all cases of non-isolated CPC. In iso-lated CPC, there may be benefit from offering karyotyping whenmaternal age exceeds 30.


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P100Dystrophic calcification within fetal myocardium: a casereport

S. L. Rowlands, A. J. Sampson & S. Kahler

A woman presented at 19 weeks gestation for a second opinion of anechogenic cardiac focus. The pregnancy had been complicated by 2 epi-sodes of first trimester vaginal bleeding. She had no significant personalor family medical history. The ultrasound reported a viable fetus withbiometry equivalent to 19 weeks gestation. Morphological examina-tion revealed an anatomically normal heart, but there were multipleechogenic foci present within the myocardium. These ranged in sizefrom 2 to 6 mm, and were within both ventricular walls and the inter-ventricular septum. There were no abnormalities of cardiac blood flow.The remaining morphology was normal, the amniotic fluid volume wasappropriate and the fetus was active. Rhabdomyomata were thoughtto be the likely diagnosis. Their association with tuberous sclerosiswas discussed and the couple elected to terminate the pregnancy. Post-mortem examination showed these echogenic foci to be multiple areasof dystrophic calcification. These were isolated findings. There were nofeatures of rhabdomyomata. Dystrophic calcification within the fetalmyocardium has rarely been reported at autopsy. It is thought to repre-sent sites of injury to the myocardium. There are few previous reportsof its antenatal detection on ultrasound later confirmed at autopsy and,although reported in fetuses which are stillborn or miscarried, it israrely otherwise seen (Veldtman et al. Heart 1999; 81: 92–93).Although generalized ischemia can lead to myocardial calcification inolder individuals, the present case and those reported by Veldtmanet al. do not show evidence of this. The extent of the myocardial calci-fication suggests that there would have been significant cardiac dys-function if the pregnancy had progressed. However, we are unawareof cases in which the pregnancy has continued. This report will discussthe appearance, etiology and prognosis of dystrophic calcification ofthe fetal myocardium and the importance of differentiating it fromrhabdomyoma on ultrasound.

P101Echocardiography should be also performed duringthe third trimester in fetuses of pregestationaldiabetic mothers

B. Puerto, J. M. Martınez, O. Gomez, D. Moyano, M. Palacio,S. Martınez, A. Borrell & V. Cararach

Objective: To assess the risk and types of congenital heart disease inour population of insulin-dependent pregestational diabetic mothers.Methodology: Over a 3-year period, a transabdominal echocardiogra-phy at 20–22 weeks of gestation and a second one at 32–34 weeks ofgestation was performed in 142 insulin-dependent diabetic pregnan-cies. In the last 30 cases, an early examination combining either thetransvaginal or the transabdominal route at 13–16 weeks was also car-ried out. A complete heart evaluation and measurement of the inter-ventricular septum thickness was performed, with color and pulsedDoppler assessment. An accurate postnatal cardiac examination wasalways performed.Results: Twelve significant cardiac defects (8.45%) were detected, butonly two of them before 22 weeks of gestation (one tetralogy of Fallot,and another one critical aortic stenosis). Both followed early termina-tion of pregnancy, and postmortem evaluation confirmed the diagno-sis. The other 10 cases were diagnosed during the third trimester: twocoarctation of the aorta (one neonatal death because hemodynamicdisturbance), three pulmonic stenosis, five significant hypertrophic car-diomiopathy with subaortic stenosis, and a case of supraventriculartachycardia (>240 bpm needing postnatal cardioversion). All thebabies, but one are alive and well, although most of them have neededcatheterization or pharmacological treatment. One case of a ventricu-lar septal defect (2.5 mm, muscular) was overlooked during gestation,but closed by the sixth month of life.Conclusion: Our results confirm that diabetic women are at increasedrisk of having a child with congenital heart disease, and therefore werecommend conventional fetal echocardiography in all pre-gestationaldiabetic pregnancies at 20–22 weeks of gestation. In view of the

pattern of defects we have found, we strongly suggest that a furtherscan during the late trimester should always be performed.

P102Fetal intracardiac echogenic foci: frequency of detectionwith respect to maternal race and other abnormalities

E. Fitchat

Objective: To determine if there is a racial difference in the frequencyof detecting an echogenic intracardiac focus in fetuses and theincidence of other related abnormalities.Methods: Over a 3-month period (December 2000 to February 2001)all fetuses scanned between 12 and 30 weeks were evaluated for thepresence of intracardiac echogenic foci. The sonographer indicatedthe maternal race (black, colored, white or other), gestational age,maternal age and the presence of other abnormalities. Amniocentesisor cordocentesis was performed when indicated. Follow up on fetusesand neonates were obtained from the patient records. The groups werecompared with respect to maternal race, presence or absence of fociand other associated abnormalities.Results: There were 725 fetuses scanned during this period where thegestation was between 12 and 30 weeks. There were 606, 98, and 21fetuses of colored, black and white mothers, respectively. Intracardiacfoci were present in 33 (5.4%) colored, 8 (8.1%) black and one (4.7%)white mother, respectively. The association with other abnormalitieswas 7/42 (16.6%). This was higher in the colored group 5 (15%) com-pared with the black group 1 (12.5%). There was only one fetus in thewhite group with an intracardiac focus and this was a baby born withcongenital rubella syndrome. There were two (5%) fetuses with chro-mosomal abnormalities. One was a black fetus with trisomy 21 andone colored fetus with trisomy 18. The remaining four fetuses had mar-kers associated with normal karyotype on culture. These were polihy-dramnios, hyperechogenic bowel, pyelectasis, and intrauterine growthrestriction.Conclusions: In this preliminary study the black fetus had a higherincidence of intracardiac echogenic foci. Detection of an intracardiacfocus is associated with a 5% risk of chromosomal abnormalitiesand other associated features should be evaluated.

P103Limb body wall complex – a case series and reviewof the literature

B. Luehr, J. Lipsett & J. Quinlivan

Introduction: Limb body wall complex is defined by the presence ofexencephaly and either facial clefts, thoraco- and or abdominoschisisand limb defect. This condition is rare with an incidence of 0.83/1000 in this case series. The aetiology is unknown but two theories bestsupport the evidence. These are firstly that there is early vascular dis-ruption between the 4 and 6 week of gestational age and secondly thatthere is early amnion rupture sequence in combination with a defectivefolding process in the embryo [1,2]. However a similar abnormalityhas been described in the mouse which is caused by the disorganizationgene and there is suggestions for the existence of a human homologuegene [3,4].Methods: All abortions or births coded as limb body wall defect orfetal exencephaly between January 1996 to January 2001 werereviewed. Those cases that fulfilled the criteria of limb body wallcomplex on postmortem examination were summarized. The criteriawere: exencephaly [1] or encephalocele [2] facial cleft, thoraco-and/or abdominoschisis [3], limb defect.Results: During the 5-year period, there were 13 286 deliveries. Ofthese, 11 cases met the criteria of limb body wall complex giving anincidence of 0.83/1000 deliveries. Mean maternal age was 29 (SD5.9) years, and the mean gravidity and parity were 3 (IQR 2–4.5)and 0 (IQR 0–1.5). In 50% (5/10), 50% (5/10) and 30% (3/10) ofwomen a history of cigarette, alcohol and marijuana use, respectively,was noted. Furthermore, 40% (4/10) of the women had a history of aprevious infant with a congenital anomaly being, respectively, amnio-tic band syndrome, cleft-lip, atrial septal defect and a previous affectedpregnancy with LBWC. In this latter case, two male infants with


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LBWC occurred in one patient, supporting the hypothesis that somecases may be due to an X-linked disorganization gene. Overall, the gen-der of the affected infant was male. All cases were diagnosed with amajor abnormality, usually exencephaly, on ultrasound examinationbetween 15 and 19 weeks gestation. The specific diagnosis of LBWCwas usually not made until postmortem examination (91% of cases).One patient had an ultrasound at 17 weeks gestation that was reportedas normal, only to have exencephaly subsequently diagnosed onultrasound at 19 weeks gestation. Without interruption of pregnancy,one fetus survived for 18 h following delivery for its twin at 35 weeksgestational age.Conclusion: Limb body wall complex is a rare fetal anomaly. Struc-tural components of the syndrome, ususally exencephaly, can be iden-tified on second trimester ultrasound examination; however, thedefinitive diagnosis is usually not made until postmortem examination.Several possible mechanisms for LBWC have been discussed includingearly amnion rupture sequence in combination with a defective foldingprocess, early vascular disruption and genetic factors. The mousemutant disorganization is semi dominant with 72% of heterozygotesmanifesting abnormalities, which include cranioschisis, gastro/thora-coschisis and limb defects. A human homologue for disorganizationmay be the cause for at least some examples of LBWC [3,4]. The pre-dominance of male fetuses suggests that there may be a X-linked inheri-tance. However, environmental teratogens such as nicotine, alcohol orillicit drug abuse may be responsible to manifest the disorder in othercases by impairing the uteroplacental flow during critical periods ofdevelopment as shown in mouse and rat fetuses [5–7].References

1 Russo R, D’Armiento M, Angrisani P, Vecchione R. Limb body wallcomplex: a critical and sonological proposal. Am J Med Genet 1993,November 1; 47 (6): 893–900

2 Deruelle P, Hay R, Chauvet MP, Duroy A, Decoqu J, Puech F.Antenatal diagnosis of limb body wall complex. J. de Ginecologie,Obstetrique et Biologie de la Reproduction 2000, June; 29 (4):385–91

3 Winter RM, Donnai D. A Possible human homologue for the mousemutant disorganization. J. Med Genet 1989, July; 26 (7): 417–20

4 Donnai D, Winter RM. Disorganization: a model for ‘‘early amnionrupture’’? J Med Genet 1989, July; 26 (7): 421–5

5 Viscarello RR, Ferguson DD, Nores J, Hobbins JC. Limb body wallcomplex associated with cocaine abuse. Further evidence ofcocaine’s teratogenicity Obstetr Gynaecol 1992, September; 80(3Pt2): 523–6

6 Padmanabhan R, Muawad WM. Exencephaly and axial dysmor-phogenesis induced by acute doses of ethanol in mouse fetuses. DrugAlcohol Dependence 1985, December; 16 (3): 215–27.

7 Screenathan RN, Padmanbhan R, Singh S. Teratogenic effects ofacetaldehyde in the rat Drug Alcohol Dependence 1982, August; 9

(4): 339–50.

P104Outcome of 25 pregnancies complicated with CCAM

S. P. Higgins & F. NiChuileannain

Congenital cystic adenomatoid malformation (CCAM) is a pulmonarydevelopmental anomaly arising from an overgrowth of the terminalrespiratory bronchioles, while the development of the alveoli is com-pletely suppressed except at the periphery. The condition, in the vastmajority of cases is confined to a single lung (85%) or lobe. Congenitalcystic adenomatoid malformation has been classified into three sub-groups according to the size of the cysts. The inheritance pattern ofthe lesion appears to be sporadic, with no known teratogenic associa-tions. The condition is usually isolated and there is no associationwith chromosomal defects. The ultrasound diagnosis is based on thefinding of a solid or cystic, non-pulsatile intrathoracic tumor. Commonassociated findings are polyhydramnios (65%), which is likely to bedue to decreased fetal swallowing, the consequence of esophagealcompression by the mass or decreased absorption of lung fluid by thehypoplastic, malformed lungs, hydrops (common in microcystic form)and placentomegaly (in cases of hydrops). Unilateral lesions are often

associated with deviation of the mediastinum in the contralateral side.In bilateral disease, the heart may be severely compressed, and this isusually associated with ascites from venocaval obstruction or cardiaccompression. We wish to present the outcome of 25 pregnancies wherea diagnosis of congenital cystic adenomatoid malformation was madeon the basis of ultrasound findings during second and third trimesterscans. The patients were subsequently managed through the FetalManagement Unit at the Royal Women’s Hospital over the 6-yearperiod from 1995 to 2001. We will present data on the progressionof the lesions through pregnancy, pregnancy outcome with short-and long-term follow up data on the babies.

P105Prenatal detection of cardiac rhabdomyomas andcerebral lesions in a fetus with tuberoussclerosis: a case report

I. Dias, M. J. S. Bernardo, T. T. Kay, S. de Almeida, M. Marques& J. Bugalho

Tuberous sclerosis is characterized by the development of hamarto-matous lesions throughout many tissues, particularly the brain, theskin, the heart and the kidneys. The authors report a case of tuberoussclerosis suspected by prenatal ultrasound detection of cardiac rhabdo-myomas and brain masses. At 20 weeks the ultrasound evaluation didnot reveal any cardiac or brain lesions. Later on, at 33 weeks, multipleechogenic masses in the heart, located in the ventricular walls andinterventricular septum and two small cerebral echogenic masses werediagnosed. No other abnormalities were noted. There is no previousgenetics history in the family. Sequential examination revealed a dis-crete increase in size of the tumors; no hemodynamic or arrhythmicconsequences were detected. A male fetus was delivered at term, withnormal weight and Apgar score. Postnatal magnetic resonance imagingconfirmed the small brain tumors. The baby had some seizures thatwere controlled with anti-epileptic therapy. Cardiac tumors sponta-neously decreased and their regression was confirmed, a few monthslater, by echocardiogram. The skin of the baby showed some de-pigmented spots. No other abnormalities were detected namely inthe kidneys. At 13 months, the child had normal growth and developedappropriately. As in other cases confirmed by literature the findingsof cerebral lesions on fetal ultrasound can help in the prenatal diagno-sis of tuberous sclerosis, but does not necessarily indicate a poorprognosis.

P106Prenatal diagnosis of ovarian cyst

S. C. Cha & D. Pares

Introduction: The prenatal diagnosis of a fetal abdominal cyst raisesthe following possibilities: mesenteric cysts, obstructive uropathy withdilated ureter, intestinal duplication and ovarian cysts when the fetus isfemale. Ovarian cysts have been described in association with diabetesmellitus, alloimmunization and fetal hypothyroidism, but the etiologyis often unknown. In normal pregnancies, the development of ovariancysts has been attributed to hormonal stimuli due to immaturity of theneuro–endocrine axis. A possible mechanism involves gonadotropinelevation that stimulates fetal foliculogenesis and the development ofcysts. Management is usually expectant since most cysts resolve spon-taneously after birth. However, complications such as rupture or tor-sion of the cyst can lead to destruction of this organ. Drainage isindicated when the diameter is greater than 5 cm or there signs sugges-tive of internal hemorrhage, such as internal septa or echogenic debris.N.M.F., a 31-year-old, first pregnancy, had an ultrasound scan at 22-weeks which showed no fetal abnormalities. At 30 weeks, repeat scanshowed an abdominal cyst between the bladder and the right kidneymeasuring 4.3 cm � 4.2 cm � 3.8 cm in a female fetus. Two weekslater, it became larger (6.3 cm � 5.5 cm � 5.4 cm) and drainage wasperformed with aspiration of 50 mL of sero-sanguineous fluid. Proges-terone levels in the aspirated fluid were 17 000 ng/dL and estrogenlevels, 1350 ng/dL; these findings confirmed the hypothesis that itwas an ovarian cyst. This case highlights the need to perform follow


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up scans when a fetal abdominal cyst is diagnosed and the importanceof intrauterine drainage as a diagnostic and therapeutic tool to preserveovarian function.

P107Prognostic factors of non-immune hydrops fetalisin Korean population

J. Y. Lee, S. S. Shim, J. S. Park, J. K. Jun, B. H. Yoon,H. C. Syn & H. P. Lee

Objective: Non-immune hydrops fetalis (NIHF) is rare and carries agrave prognosis. We undertook this study to find out prognostic factorsof NIHF in Korean population.Material and methods: From October 1988 to February 2001, 71pregnancies of NIHF were evaluated with antenatal testes, includingfetal karyotyping, fetal echocardiography, detailed ultrasonography,and infection work-up. In some cases, we performed them afterdelivery and included autopsy results. Twenty cases were sacrificeddue to parents’ decision before viable stage. Four cases were lost infollow up. Sixteen cases of cystic hydroma were excluded becausethey were regarded as a different entity. Thirty-one cases were retro-spectively evaluated to find out prognostic factors in NIHF. We anal-yzed, the presumed prognostic factors, such as gestational age atdetection, gestational age at delivery, birth weight over 90th percentile,the presence of associated conditions, 5 min Apgar score lessthan 4, number of body cavities filled with fluid, and the presence ofpolyhydramnios.Results: Of 31 cases, 21 cases were expired in utero or neonatal period(67%) and 10 cases were survived till at least 28 days after birth. Only5 min Apgar score less than 4 was significantly associated with perina-tal death (Odds ratio 6.000, CI 1.693–21.262). Other factors were notrisk factors of increased perinatal mortality.Conclusion: On the basis of our data, we concluded that 5 min Apgarscore less than 4 was a significant risk factor for predicting increasedperinatal death in NIHF.

P108The accuracy and indications of fetal echocardiography inhigh-risk patients: a 4-year clinical experience in anobstetric unit

J. M. Martınez, O. Gomez, B. Puerto, A. Borrell, M. Palacio& V. Cararach

Objective: To evaluate the accuracy and assess the indications of fetalechocardiography to diagnose structural heart disease in our high-riskpopulation, by an obstetric team.Methodology: Over a 4-year period, a transabdominal echocardiogra-phy was performed in 912 high-risk pregnancies for congenital heartdisease at 18–38 weeks of gestation. In the last 140 cases an earlyexamination combining either the transvaginal or the transabdominalroute at 13–16 weeks was also carried out. Follow up was obtainedfrom neonatal examinations and autopsies. The main indicationsfor referral were: pregestational diabetes mellitus, family risk,increased nuchal translucency, suspected cardiac anomaly at screeningultrasound, women at high risk of chromosomal abnormality reluctantto invasive test, suspected arrhythmia, single umbilical artery, expo-sure to teratogens, and pregnancies affected by a chromosomalabnormality.Results: There were 79 (8.6%) major congenital heart defects, andmost of them were yielded in the group of screening by ultrasound.Seventy of them (88.6%) were diagnosed correctly as abnormal prena-tally. Atrioventricular septal defects (21 cases) and hypoplastic left ven-tricle syndrome (12 cases) were the most prevalent heart anomalies inthe fetus. Isolated septal defects and coarctation of the aorta were themost difficult lesions to detect, being the ones with false positive andnegative diagnosis. Another four cases of insignificant (<3 mm, no sur-gery nor medical treatment required) ventricular septal defects wereoverlooked during gestation, but closed by the sixth month of life.Fifteen apparently normal cases were lost to follow up.Conclusion: Our obstetric team results, in accordance with others pre-viously published, show a good effectiveness to diagnose congenital

heart anomalies. Most major detectable cardiac anomalies occur inthe group without previously known risk.

P109The Significance of non-visualization of the fetalgallbladder in early pregnancy

S. Blazer, E. Z. Zimmer & M. Bronshtein

Purpose: To assess the incidence of a non-visualized gallbladder inearly pregnancy and to determine its prognostic significance.Material and methods: Transvaginal ultrasound examination wasperformed in 29 749 consecutive pregnant women at 14–16 weeksgestation. All women underwent a detailed fetal survey prospectively.The incidence and associated risk in cases of a non-visualized fetalgallbladder was determined.Results: The gallbladder was not visualized in early pregnancy in 34fetuses, giving an incidence of 0.11% (1 in 875 pregnancies). Asso-ciated malformations were detected in 14 fetuses (41%), and in 20fetuses non-visualization of the gallbladder was an isolated finding.All fetuses with an isolated finding had a normal outcome, in 13 fetusesthe gallbladder was detected later on in pregnancy, in five no gallblad-der was found after delivery, and two patients were lost in follow up.Of the 14 fetuses with associated anomalies, five had also an abnormalkaryotype. Termination of pregnancy was performed in nine of thesefetuses. Of the cases which continued pregnancy there was one case ofneonatal death, two cases of developmental delay and only one normalchild.Conclusion: Non-visualization of the fetal gallbladder in the earlypregnancy is uncommon but is associated with a high incidence of asso-ciated anomalies. Fetuses with an isolated finding of a non-visualizedgallbladder have usually a favorable outcome.

P110Ultrasonographic findings of VATER association

M. Tanemura, S. Tsukishiro & K. Suzumori

Purpose: VATER association is a combination of congenital anoma-lies including vertebral defects (V), anal atresia (A), tracheoesophagealfistula (TE), esophageal atresia (E), and radial and renal anomalies (R).This report describes the prenatal progress of four such cases and thefeatures of ultrasonographic findings.Methods: Case (1): the mother was referred at 12 weeks gestationbecause of a fetal abdominal cyst. Bilateral hydronephroses and anexpansive bladder were detected by ultrasonography. At 36 weekspolyhydramnios appeared, and soon she delivered. V, A, TE, E andR were confirmed. Case (2): the mother was referred at 14 weeksbecause of a fetal abdominal cyst and oligohydramnios. Ultrasonogra-phy suggested megalocystis based on urethral atresia. An infant wasdelivered at 27 weeks and died right thereafter. Autopsy confirmedV, A, R, tracheal atresia, genital anomaly and megalocystis. Case (3):the mother was transported at 37 weeks because of fetal distress. Poly-hydamnios had been suspected on a routine office visit. The infant wasdelivered by cesarean section. TE, E and limb defects were detected.Case (4): the mother was referred at 26 weeks because of anhydram-nios and mediastinal shift. Ultrasonography and fetal MRI indicatedrenal agenesis and congenital diaphragmatic hernia. Autopsy on astillborn infant revealed V, A, TE, E, R and diaphragmatic hernia.Results and conclusions: The features of ultrasonographic findings ofVATER association were abnormality of urinary organs and amnioticfluid volume. However, in the cases with esophageal atresia, estimationof renal function was difficult.

P111Ultrasonographic normograms of the fetal chin and filtrumduring pregnancy

A. J. Jaffa, I. Wolman, J. Har-Toov, G. Fait, R. Amster,J. B. Lessing, I. Gull & A. J. Jaffa

Introduction: Abnormal sizes of the chin and of the filtrum or theirproportions are morphological features in certain syndromes. Bothchin and filtrum can be visualized and measured from the early second


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trimester until term. As of today there are no normograms of the chinand of the filtrum during pregnancy, and dysmorphism is evaluatedonly by subjective criteria.Purpose: To establish normograms of the fetal chin and filtrum.Methods: We studied cross-sectioned the size of the chin and length ofthe filtrum in 153 fetuses from the 13th to the 42nd week of gestation.The chin was measured from the lower lip to the skin under the man-dibular edge. The filtrum was measured from the nose to the upper lip.Results: The growth normograms for the chin was best described bythe regression equation: Y ¼ � 9.799 þ 1.312X � 0.013 � 2; R2 ¼0.87 (Y ¼ chin size in mm, X ¼ gestational week). The growth normo-grams for the filtrum was best described by the regression equation:Y ¼ � 2.672 þ 0.477X � 0.005 � 2, R2 ¼ 0.82 (Y ¼ filtrum size inmm, X ¼ gestational week). The ratio chin/filtrum tends to increasefrom 2 at the beginning of the second trimester to 2.8 at term.Conclusions: We present the first normograms of fetal chin and filtrumalong the pregnancy. One of the fetuses was found to have micrognatiaat 32 weeks and both his chin and filtrum were abnormal. We used thenormograms to evaluate another two past cases of face dysmorphism,which were evaluated by subjective criteria and found abnormal chinand filtrum sizes. These normograms can be used in consulting geneticdisorders.

P112Antenatal transabdominal amnio-infusion foroligo-hydramnios due to preterm premature ruptureof membranes

T.-C. Tan & A. Tan

A reduction in the amount of amniotic fluid occurs in 3–5% of all deliv-eries. This could be due to congenital anomalies, IUGR or prematurerupture of membranes. Preterm rupture of membranes places the fetusat risk of cord compression and amnionitis. On the other hand, oligo-hydramnios has been associated with severe pulmonary hypoplasia. In1983, Miyazaki and Nevarez first reported the effectiveness of intrau-terine installation of saline solutions in relieving variable decelerationsduring labor. Since then, amnio-infusion has aroused interest. To ourknowledge, there has been no conclusive study done to evaluate the useof antenatal amnio-infusion for oligo-hydramnios diagnosed antena-tally. We would like to present three case-studies of oligo-hydramniosseen in our department in the period 1997–2001 which we performedantenatal transabdominal amnio-infusion. Warm saline/Hartmannsolution was injected through a 22G spinal needle under ultrasoundguidance. Vaginal delivery occurred in two cases (one term and onepreterm); the third pregnancy is still on-going. There was no meconiumaspiration and no signs of fetal distress. Both cases had good maternaland neonatal outcome except that the preterm baby was treatedwith intravenous ampicillin/gentamicin for pneumonia. There was nocongenital malformation noted.


P114Pregnancy outcome following amnioinfusion inoligohydroamnios

G. J. Kim, S. Y. Kim & M. S. Son

Objective: We sought to evaluate the fetal outcome following antepar-tum transabdominal amnioinfusion in oligohydroamanios exceptmembrane rupture.Materials and methods: Twenty-six transabdomial amnioinfusionwere performed in 17 cases of singleton pregnancy with severe oligo-hydroamnios. We excluded premature membrane rupture cases. Trans-abdominal amnioinfusion was done with warmed lactate Ringersolution.Results: Infusion (mean volume 545 mL) of lactate Ringer’s solutionsignificantly increased the amniotic fluid index from 4 dm to 9.3 cm.Mean infusion time was 56.8 min The gestational weeks were pro-longed significantly from 29.4 to 36.5 weeks. There was one case offetal death. The mean birth weight was 2.6 kg and the mean Apgarscore at 1, 5 min was 7.6 and 8.9. Uterine contractions after infusionwere observed 3 in 21, no needle scratching marks detected at birth.No chorioamnionitis were observed.Conclusions: Our results show that antepartum transabdominalamnioinfusion is a relatively safe procedure, and it can significantlyincrease the amniotic fluid index and prolong the gesational age.

P115Prenatal treatment of severe congenital erythropoeticporphyria (CEP) – a case report

P. Calda, Z. Zizka, M. Dokoupilova, V. Sebron, L. Haakova,V. L. Eretova & R. Plavka

Introduction: Less than 3% of porhpyhia cases affect children andCEP is the most severe.Case report: We report a case of a 21-year-old second digravidawhose first pregnancy terminated with intrauterine death in the27th week of gestation due to hydrops fetalis, cause unknown. Thepathologist found organ infiltration with blastic blood elements. Thepatient was referred to our unit in the 25th week of the second preg-nancy with oligohydramnion, ascites, hepatosplenomegaly, and gener-alized hydrops. The mother was AB Rh-positive, with negative resultsfor irregular antibodies, CMV, toxoplasmosis, and parvovirus B19.The initial cordocentesis showed severe anemia (Hct 7.7, Hgb 27,RBC 0.89, WBC 2.3, Plt 72), fetal karyotype: 46XY. Virologic exam-ination, direct Coombs test, and amniotic fluid culture were negative.We treated the anemia with five intrauterine transfusions of O Rh-negative erythrocyte concentrate. In the 25th week the Hgb was 59,during treatment it reached 91 (week 26), 120 (week 27), 134(week 28), 114 (week 31), and 119 in the 33rd week, respectively. Amale fetus was delivered in the 33rd week, with sanguineous amnioticfluid, birth weight 2370 g, APGAR 6-7-8, and arterial blood pH 7.25.The newborn had hepatosplenomegaly, anemia, and skin suffusions.Mild RDS was stabilized with nCPAP. From the fourth day, therewas macroscopic hematuria. The treatment of renal failure was suc-cessful, the skin changes remained as the dominating sign. Eighteendays postpartum the diagnosis of congenital erythroid porphyria (auto-somal recessive) was established based on the skin excoriation andurine examination for porphyrins.Discussion: This rare case of ascites, anemia and thrombocytopeniawas diagnosed postnatally, but symptomatic treatment enabled thedelivery of a fetus that could be successfully treated postnatally withumbilical blood transfusion.Conclusion: In all cases of unexplained ascites or hydrops the possibil-ity of CEP should be considered.


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P117Radiofrequency ablation of fetal cervical teratoma

F.-Y. Chan, J. Clouston, R. Cincotta & P. Borzi

Background: Highly vascular fetal tumors can lead to death beforeviability as a result of vascular steal syndrome. Open fetal surgery isassociated with significant risks for prematurity and maternal morbid-ity. Various local ablative techniques have been tried to reduce tumorvascularity, with variable success. Radiofrequency ablation has beenperformed for sacrococcygeal teratoma, but cervical teratoma poisefurther significant challenges with its proximity to vital neck structures.Purpose: This is the first report in which percutaneous radiofrequencyablation was used to reduce tumor vascularity in a human fetus with alarge cervical teratoma.Methods: A partly solid, partly cystic neck tumor was first detected ina 19-week fetus. The tumor grew rapidly and caused signs of cardiacdecompensation by 26 weeks. After extensive counseling and ethicsdiscussion, operation was performed at 28 weeks under generalanesthesia. Radiofrequency ablation to the solid component of thetumor was performed with a nine-prong retractable needle electrodewith thermal couples (RITA), deployed to a maximum diameter of5 cm. The operation was uneventful and fetal condition was monitoredthroughout the procedure.Results: Tumor growth was arrested temporarily with improvementof the cardiac status. Re-growth of the tumor was noted after32 weeks, necessitating delivery at 33 weeks. Postnatal investigationshowed extensive tumor infiltration into the neck tissues and probableliver metastases. Biopsy showed immature teratoma, and chemother-apy was considered to be futile. Intensive care was withdrawn andthe baby died 6 days after delivery.Conclusions: Radiofrequency ablation of fetal tumor in utero canreduce blood flow sufficiently to reverse high-output fetal heart failure.Cervical tumors poise extra challenges with its proximity to vital neckstructures. With careful and meticulous placement of the probe, abla-tion can be performed without injury to surrounding tissues. Experi-ence in this area is preliminary and all such experiences should bereported.

P118The effect of intercellular Mg2þ in pre-eclempsia

A. P. Mitrovic & M. Djukic

Approximately 2–10% of pregnancies are complicated by pre-eclampsia. The pathophysiology of pre-eclampsia is general arteriolarconstriction and increased vascular sensitivity to precursor peptidesand amines. The etiology of pre-eclamsia is unknown. We examined

(105 gravids) prospectively, the correlation between intra- and extra-celullar magnesium deficit and uterine artery Doppler in women withpre-eclampsia. We used bilateral early diastolic notch at 24 weeks asthe definition of an abnormal waveform (circulatory parameters: Pi,Ri, of gravids art. uterina were excluded). For evaluation of RBCand plasma magnesium and calcium level we used atomic absorptionspectrophotometry (AAS). According to our results, in majority ofcases, we determined significantly low level of intracellular magnesium0.86 þ 0.22 mmol/L in group with bilateral notch, and positive corre-lation between bilateral notch, intercellular magnesium deficiency,increase level of intracellular calcium (0.69 þ 0.18 mmol/L) and pre-eclampsia. These results support hypothesis that misbalance of intra-cellular electrolytes, especially, intracellular magnesium and calciumare strong determinants of risk of pre-eclampsia because these factscould cause grater excitability of vascular smooth muscle contraction.

P119The importance of fluid analysis in fetal intra-abdominalcyst aspiration

G. Fait, J. Har-Toov, I. Gull, R. Amster, I. Wolman,J. B. Lessing & A. J. Jaffa

The importance of fluid analysis in the evaluation of intraperitonealcysts in female fetuses is demonstrated. Case 1: A 30-year-oldwoman had an unremarkable pregnancy until 29 gestational weeks,when a routine US examination revealed an anechoic cyst of 4.0 cmin diameter located in the lower abdomen of a female fetus. At33 weeks of gestation the cyst enlarged to 6.5 cm. Intrauterine aspira-tion of the cyst was performed. A volume of 75 mL of yellowfluid was obtained and collapse of the cyst was noted. Fluid biochem-istry revealed estradiol >200000 pg/mL, progesterone 1648 ng/mL,creatinine undetectable. A fetal ovarian cyst was diagnosed. At34 weeks of gestation the cyst enlarged again to 6 cm and 78 mL ofyellow fluid was obtained on intrauterine aspiration. Again, collapseof the cyst was noted on US. Repeated scans until birth showed ananechoic cyst of 4.0 cm. Postnatal abdominal US confirmed the diag-nosis and a complete disappearance of the cyst after 2 weeks. Case 2: A28-year-old woman had an unremarkable pregnancy until 34 gestationalweeks, when a routine US examination revealed an anechoic cystof 6.0 cm in diameter located in the lower abdomen of a femalefetus. Intrauterine aspiration of the cyst was performed. A volume of147 mL of yellow fluid were obtained and collapse of the cyst wasnoted. Fluid biochemistry revealed estradiol 781 pg/mL, progesterone37 ng/mL, and creatinine 4 mg/dL. An unusual urinary tract malforma-tion was diagnosed. Repeated scans until birth showed an anechoiccyst of 6 cm. After delivery a fistula between the urinary bladder andthe upper vagina, and an imperforated hymen, were diagnosed. Incases of prenatal needle aspiration, fluid biochemistry may be helpfulto establish the origin of intraperitoneal cysts in the female fetus, espe-cially when recurrence occurs, and prevent unnecessary attempt ofdecompression of intraperitoneal cysts.

P120Three-dimensional magnetic resonance imaging of the fetalbrain in utero

L. Schierlitz, H. Dumanli, A. G. Schreyer, J. N. Robinson,P. E. Burrows, R. Kikinis, F. Jolesz & C. Tempany

Background: Fetal anomalies are presently assessed predominantly bytwo-dimensional imaging techniques. Three-dimensional (3D) recon-struction derived from magnetic resonance imaging (MRI) holds pro-mise to clarify abnormalities identified in utero. We demonstrate theapplication and the possible clinical use of 3D reconstruction derivedfrom MRI of fetal brain in utero.Methods: We studied 10 patients who underwent clinically indicatedMRI with 17 examinations to assess fetal brain anomalies in vivo.After image acquisition and postprocessing of the images, the anatomi-cal anomalies were assessed on a 3D model and compared to thetwo-dimensional imaging findings. Assessment of the volume ofintracranial ventricles and periventricular hemorrhage was performed.Four of the cases have been chosen to demonstrate this technique.


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Results: The technique was successfully applied in six patients and 12examinations. The demonstration of significant additional clinicalinformation in the assessment of anomalous anatomy was shown intwo of the cases. Serial assessment of volumetric measurement was per-formed in the clinical setting of hydrocephalus and periventricularhemorrhage. Reconstruction of the cerebral vascular system with avein of Galen malformation and its feeding and draining vessels at37 weeks gestation allowed the planning of the postnatal managementby the interventional radiologist.Conclusions: 3D fetal reconstruction may be used in surgical simula-tion and treatment planning prior to delivery. This may become evenmore relevant in the planning and performance of fetal surgical andpostpartum intervention for selected life threatening birth defects.Further evaluation of this technique will be needed before the fullextent of its use can be determined.

P121Assessment of normal fetal upper arm volume bythree-dimensional ultrasound

C.-H. Yu, F.-M. Chang & T.-P. Liao

Purpose: Precise assessment of the fetal organ volumes by prenatalultrasound (US) is very important in the evaluation of fetal well-being

and maturation. Limb volume may be a possible predictive factor ofintrauterine growth retardation. However, using two-dimensional(2D) US to accurately estimate the fetal upper arm volume is difficult.With the advent of three-dimensional (3D) US, the obstacle of 2DUScan be overcome. In this study we attempt to construct a normal refer-ence centiles of fetal upper arm volume during gestation for clinicalapplication using 3DUS.Materials and methods: In total, 206 singleton fetuses rangedbetween 20 and 40 weeks of gestation and fit the criteria of normalpregnancies were enrolled in this study. Three-dimensional US wasapplied to measure the fetal upper arm volume. Linear regression,correlation analysis and polynomial regression analysis were used asthe statistical methods. A P-value of less than 0.05 was consideredstatistically significant.Results: Our results showed that fetal upper arm volume is highly cor-related with the fetal gestational age (GA). Using GA as the indepen-dent variable and upper arm volume as the dependent variable, thebest-fit regression equation is upper arm volume (mL) ¼ 43.54579�4.53032 � GA þ 0.13305 � GA2 (r ¼ 0.91257, P < 0.0001). Thenormal growth centiles of upper arm volume is established based onthis equation.Conclusion: In conclusion, we can use the data of fetal upper armvolume assessed by 3DUS as a reference in evaluating fetal growth.


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