188: The effect of orthostatic stress on brain sparing phenomena in asymmetrical and symmetrical...
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186 Is an isolated ventricular septal defect at a genetic sonogram associated with fetal aneuploidy? Gene Lee 1 , Susie Fong 1 , Carl Weiner 1 1 KUMC, OBGYN, Kansas City, KS OBJECTIVE: It has been suggested that an isolated ventricular septal defect (i-VSD) increases the risk of fetal aneuploidy. However, most of the reports and the data they were based upon used equipment from a prior generation and often did not include color Doppler ultrasound. We have had the impression that our rate of aneuploidy associated with an i-VSD has been extremely low. If true, the genetic counseling provided should be revised. Our objective was to deter- mine the current prevalence rate of aneuploidy with pregnancies whose only sonographic abnormality was an isolated VSD. STUDY DESIGN: This is a retrospective cohort investigation. All detailed anatomy ultrasounds from 8/23/2006 to 6/7/2012 per- formed at KUMC were included. A complete evaluation of the fetal heart was accomplished using gray scale and spectral /color Doppler examinations. RESULTS: There were 9048 detailed sonograms performed on 7177 singleton pregnancies < 24 wks. 5047 pregnancies were free of abnormal ultrasound findings; 111 had only an i-VSD (111/7177, 1.5%). Among these pregnancies, the mean gestational age SD was 20.8 1.5 weeks. The mean maternal age was 28.2 5.7 years. There were 2 instances of i-VSD associated with aneuploidy (2/111, 1.8%, each T21). Each case occurred early in our experience. One woman (age 21_y) had an increased T21 risk based on second trimester serum screening, and a subsequent amniocentesis showed Trisomy 21. The other woman (age 27_y) declined second trimester serum screening. There were 9 patients who had abnormal serum screening, and the risk of aneuploidy was increased in this group (1/9, 11%). CONCLUSION: The presence of i-VSD does not dramatically increase the risk of fetal aneuploidy in appropriately screened pregnancies. Larger cohorts are needed to determine whether the i-VSD should have a separate risk estimate for aneuploidy compared to other congenital heart malformations. 187 Prediction of significant birth weight discordance in twin pregnancies with second and third trimester ultrasound Aoife Murray 1 , Fionnuala Breathnach 1 , Fionnuala McAuliffe 2 , Michael Geary 3 , Sean Daly 4 , John Higgins 5 , Alyson Hunter 6 , John Morrison 7 , Gerard Burke 8 , Shane Higgins 9 , Rhona Mahony 2 , Patrick Dicker 10 , Elizabeth Tully 1 , Fergal Malone 1 1 Royal College of Surgeons in Ireland, Obstetrics and Gynaecology, Dublin, Ireland, 2 UCD School of Medicine and Medical Science, National Maternity Hospital, Obstetrics and Gynaecology, Dublin, Ireland, 3 Rotunda Hospital, Obstetrics and Gynaecology, Dublin, Ireland, 4 Coombe Women and Infant’ s University Hospital, Obstetrics and Gynaecology, Dublin, Ireland, 5 College of Medicine and Health, University College Cork & Cork University Maternity Hospital, Obstetrics and Gynaecology, Cork, Ireland, 6 Royal Jubilee Maternity Hospital, Obstetrics and Gynaecology, Belfast, Ireland, 7 National University of Ireland, Obstetrics and Gynaecology, Galway, Ireland, 8 Graduate Entry Medical School, University of Limerick, Obstetrics and Gynaecolgy, Limerick, Ireland, 9 Our Lady of Lourde’ s Hospital, Obstetrics and Gynaecology, Drogheda, Ireland, 10 Royal College of Surgeons in Ireland, Epidemiology and Public Health, Dublin, Ireland OBJECTIVE: To establish 2nd and 3rd trimester ultrasound predictors of clinically significant intertwin birthweight (BW) discordance (18% as prospectively determined by this group). STUDY DESIGN: This prospective cohort study of 1,028 unselected twin pairs recruited over a two year period at 8 academic centers for the Evaluation of Sonographic Predictors of Restricted Growth in Twins (ESPRIT). Participants underwent 2- weekly ultrasonographic surveillance from 24 weeks gestation with surveillance of mono- chorionic (MC) twins 2-weekly from 16 weeks. Complete biometry was available for 960 twin pairs without TTTS. Biometric data from 20 to 40 weeks were evaluated as predictors of a BW discordance level > 18%. Outcomes were adjusted for chorionicity and gesta- tional age using stepwise logistic regression (significance level < 0.05) RESULTS: Between 20 and 24 weeks, a BW discordance level > 18% is predicted most accurately by an intertwin discrepancy in biparietal diameter (BPD) > 5%. At 28-32 weeks an intertwin femur length (FL) discordance of 5% or greater is most useful in predicting 18% BW discordance. Late in the third trimester (32-36 weeks) abdom- inal circumference (AC) of 10% correlates most closely with BW discordance. The greatest sensitivity and specificity of any single predictor is an estimated fetal weight (EFW) discordance > 10% at 32 to 36 weeks. Cumulative analysis of all above sonographic pre- dictors offers the most accurate means of predicting significant BW discordance way (sensitivity 67%, specificity 87%). CONCLUSION: Sonographic biometry in the 2nd and 3rd trimester can successfully identify twin pregnancies at risk for significant BW discordance. Although these individual parameters are helpful in predicting BW discordance, it is a sequential and cumulative pattern observed on serial evaluation that is most sensitive and specific. Importantly, for all individual biometric measurements and for composite biometry, ultrasound underestimates intertwin size discordance Second and third trimester predictors of significant birthweight discordance of > 18% 188 The effect of orthostatic stress on brain sparing phenomena in asymmetrical and symmetrical fetal growth restriction Israel Thaler 1 , Nizar Khatib 1 , Yuval Ginsberg 1 , Zeev Weiner 1 , Shoshana Haberman 2 1 Rambam Medical Center, Obstetrics & Gynecology, Haifa, Israel, 2 Maimonides Medical Center, Obstetrics & Gynecolgy, New York, NY OBJECTIVE: We have recently shown that maternal supine re- cumbency in normal pregnancy leads to vascular autoregulation that activates the brain sparing effect in the fetus. In this research we studied the effect of orthostatic stress on fetal blood flow patterns in the middle cerebral artery, in pregnancies complicated by asym- metrical and symmtrical fetal growth restriction (FGR) and compared the results with low risk pregnancies. STUDY DESIGN: Nineteen pregnant women with asymmetrical growth-restricted fetuses were compared with 9 women with sym- metrical FGR and with 23 low-risk pregnant women. Doppler flow velocity waveforms were obtained from the fetal middle cerebral artery (MCA) and the pulstaility index (PI) calculated in the left lateral recumbency and the supine positions. RESULTS: The baseline MCA PI in left lateral position in the asym- metrical FGR group was significantly lower compared with the symmetrical FGR and with the low-risk groups (median values 1.37 vs.1.72 and 1.82, p<0.001, respectively).During orthostatic stress the pulsatility index (PI) in the MCA significantly decreased in the symmetrical FGR and the low-risk groups from 1.770.44 and Poster Session I Ultrasound, Fetus, Genetics www.AJOG.org S104 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
Transcript of 188: The effect of orthostatic stress on brain sparing phenomena in asymmetrical and symmetrical...
Poster Session I Ultrasound, Fetus, Genetics www.AJOG.org
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Is an isolated ventricular septal defect at a geneticsonogram associated with fetal aneuploidy?Gene Lee1, Susie Fong1, Carl Weiner11KUMC, OBGYN, Kansas City, KSOBJECTIVE: It has been suggested that an isolated ventricular septaldefect (i-VSD) increases the risk of fetal aneuploidy. However, mostof the reports and the data they were based upon used equipmentfrom a prior generation and often did not include color Dopplerultrasound. We have had the impression that our rate of aneuploidyassociated with an i-VSD has been extremely low. If true, the geneticcounseling provided should be revised. Our objective was to deter-mine the current prevalence rate of aneuploidy with pregnancieswhose only sonographic abnormality was an isolated VSD.STUDY DESIGN: This is a retrospective cohort investigation. Alldetailed anatomy ultrasounds from 8/23/2006 to 6/7/2012 per-formed at KUMC were included. A complete evaluation of the fetalheart was accomplished using gray scale and spectral /color Dopplerexaminations.RESULTS: There were 9048 detailed sonograms performed on 7177singleton pregnancies < 24 wks. 5047 pregnancies were free ofabnormal ultrasound findings; 111 had only an i-VSD (111/7177,1.5%). Among these pregnancies, the mean gestational age � SDwas 20.8 � 1.5 weeks. The mean maternal age was 28.2 � 5.7 years.There were 2 instances of i-VSD associated with aneuploidy (2/111,1.8%, each T21). Each case occurred early in our experience. Onewoman (age 21_y) had an increased T21 risk based on secondtrimester serum screening, and a subsequent amniocentesis showedTrisomy 21. The other woman (age 27_y) declined second trimesterserum screening. There were 9 patients who had abnormal serumscreening, and the risk of aneuploidy was increased in this group(1/9, 11%).CONCLUSION: The presence of i-VSD does not dramatically increasethe risk of fetal aneuploidy in appropriately screened pregnancies.Larger cohorts are needed to determine whether the i-VSD shouldhave a separate risk estimate for aneuploidy compared to othercongenital heart malformations.
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Prediction of significant birth weight discordance intwin pregnancies with second and third trimester ultrasoundAoife Murray1, Fionnuala Breathnach1, Fionnuala McAuliffe2,Michael Geary3, Sean Daly4, John Higgins5, Alyson Hunter6,John Morrison7, Gerard Burke8, Shane Higgins9, Rhona Mahony2,Patrick Dicker10, Elizabeth Tully1, Fergal Malone11Royal College of Surgeons in Ireland, Obstetrics and Gynaecology, Dublin,Ireland, 2UCD School of Medicine and Medical Science, National MaternityHospital, Obstetrics and Gynaecology, Dublin, Ireland, 3Rotunda Hospital,Obstetrics and Gynaecology, Dublin, Ireland, 4Coombe Women and Infant’sUniversity Hospital, Obstetrics and Gynaecology, Dublin, Ireland, 5College ofMedicine and Health, University College Cork & Cork University MaternityHospital, Obstetrics and Gynaecology, Cork, Ireland, 6Royal Jubilee MaternityHospital, Obstetrics and Gynaecology, Belfast, Ireland, 7National Universityof Ireland, Obstetrics and Gynaecology, Galway, Ireland, 8Graduate EntryMedical School, University of Limerick, Obstetrics and Gynaecolgy, Limerick,Ireland, 9Our Lady of Lourde’s Hospital, Obstetrics and Gynaecology,Drogheda, Ireland, 10Royal College of Surgeons in Ireland, Epidemiology andPublic Health, Dublin, IrelandOBJECTIVE: To establish 2nd and 3rd trimester ultrasound predictorsof clinically significant intertwin birthweight (BW) discordance(18% as prospectively determined by this group).STUDY DESIGN: This prospective cohort study of 1,028 unselectedtwin pairs recruited over a two year period at 8 academic centers forthe Evaluation of Sonographic Predictors of Restricted Growth in
S104 American Journal of Obstetrics & Gynecology Supplement to JANUARY
Twins (ESPRIT). Participants underwent 2- weekly ultrasonographicsurveillance from 24 weeks gestation with surveillance of mono-chorionic (MC) twins 2-weekly from 16 weeks. Complete biometrywas available for 960 twin pairs without TTTS. Biometric data from20 to 40 weeks were evaluated as predictors of a BW discordancelevel >18%. Outcomes were adjusted for chorionicity and gesta-tional age using stepwise logistic regression (significance level <0.05)RESULTS: Between 20 and 24 weeks, a BWdiscordance level > 18% ispredicted most accurately by an intertwin discrepancy in biparietaldiameter (BPD) > 5%. At 28-32 weeks an intertwin femur length(FL) discordance of 5% or greater is most useful in predicting 18%BW discordance. Late in the third trimester (32-36 weeks) abdom-inal circumference (AC) of 10% correlates most closely with BWdiscordance. The greatest sensitivity and specificity of any singlepredictor is an estimated fetal weight (EFW) discordance > 10% at32 to 36 weeks. Cumulative analysis of all above sonographic pre-dictors offers the most accurate means of predicting significant BWdiscordance way (sensitivity 67%, specificity 87%).CONCLUSION: Sonographic biometry in the 2nd and 3rd trimester cansuccessfully identify twin pregnancies at risk for significant BWdiscordance. Although these individual parameters are helpful inpredicting BW discordance, it is a sequential and cumulative patternobserved on serial evaluation that is most sensitive and specific.Importantly, for all individual biometric measurements and forcomposite biometry, ultrasound underestimates intertwin sizediscordance
Second and third trimester predictors of significantbirthweight discordance of > 18%
188 The effect of orthostatic stress on brain sparing
phenomena in asymmetrical and symmetrical fetal growthrestrictionIsrael Thaler1, Nizar Khatib1, Yuval Ginsberg1, Zeev Weiner1,Shoshana Haberman21Rambam Medical Center, Obstetrics & Gynecology, Haifa, Israel,2Maimonides Medical Center, Obstetrics & Gynecolgy, New York, NYOBJECTIVE: We have recently shown that maternal supine re-cumbency in normal pregnancy leads to vascular autoregulation thatactivates the brain sparing effect in the fetus. In this research westudied the effect of orthostatic stress on fetal blood flow patterns inthe middle cerebral artery, in pregnancies complicated by asym-metrical and symmtrical fetal growth restriction (FGR) andcompared the results with low risk pregnancies.STUDY DESIGN: Nineteen pregnant women with asymmetricalgrowth-restricted fetuses were compared with 9 women with sym-metrical FGR and with 23 low-risk pregnant women. Doppler flowvelocity waveforms were obtained from the fetal middle cerebralartery (MCA) and the pulstaility index (PI) calculated in the leftlateral recumbency and the supine positions.RESULTS: The baseline MCA PI in left lateral position in the asym-metrical FGR group was significantly lower compared with thesymmetrical FGR and with the low-risk groups (median values 1.37vs.1.72 and 1.82, p<0.001, respectively).During orthostatic stress thepulsatility index (PI) in the MCA significantly decreased in thesymmetrical FGR and the low-risk groups from 1.77�0.44 and
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www.AJOG.org Ultrasound, Fetus, Genetics Poster Session I
1.79�0.27 in the left lateral decubitus position to 1.43�0.24 and1.3�0.16 in the supine position, respectively (p<0.0001 andp<0.03). In contrast, the MCA PI significantly increased in theasymmetric FGR group (1.47�0.31 and 1.69�0.39 respectively,p<0.01).CONCLUSION: In asymmetric growth-restricted fetuses with evidentbrain-sparing phenomena, additional impairment in placentalperfusion elicited by postural stress, significantly abolishes thisprotective mechanism. In contrast, in normal pregnancies and inpregnancies with symmetrical FGR, postural stress activates thebrain sparing phenomena. By measuring MCA PI in different pos-tures one can discriminate between the two types of fetal growthrestriction, and also between true placental insufficiency andother pregnancy complications not related to decreased placentalperfusion.
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Perinatal survival in cases of twin-twin transfusionsyndrome complicated by selective intrauterine growthrestrictionKristi Van Winden1, Ruben Quintero2, Eftichia Kontopoulos2,Lisa Korst1, Arlyn Llanes1, Ramen Chmait11Keck School of Medicine, University of Southern California, Department ofObstetrics and Gynecology, Division of Maternal-Fetal Medicine, LosAngeles, CA, 2Jackson Memorial Hospital, Jackson Fetal Therapy Institute,Miami, FLOBJECTIVE: To evaluate the impact of co-existing selective intra-uterine growth restriction (SIUGR) on outcomes of monochorionicmultiple gestations undergoing laser surgery for twin-twin trans-fusion syndrome (TTTS).STUDY DESIGN: This was a retrospective study of fetal and perinatalsurvival among patients undergoing laser surgery for TTTS from2006-2012. All patients met classic criteria for TTTS. TheTTTS+SIUGR group included patients with a donor twin weight< 10th centile for gestational age (GA), and the TTTS_ONLY groupincluded those with a donor twin weight > 10th centile. Multivar-iable logistic regression analyses were conducted to identify riskfactors for 30-day survival of the donor twin for both the entirestudy population and for the TTTS+SIUGR group.RESULTS: Of 369 total patients, 65% (N¼241) were in theTTTS+SIUGR group. Patients in this group were more likely to havea higher TTTS stage at presentation (Quintero Stage III/IV: 71% vs.54%, p¼0.0011) and an increased rate of fetal demise of the donortwin compared to the TTTS_ONLY group (20.3% vs. 10.2%,p¼0.013). The 30-day survival rate for the donor twin withTTTS+SIUGR after laser was 75% vs. 84% for the TTTS_ONLYgroup (p¼0.035). In the subgroup of Stage III Donor TTTS+SIUGRpatients (N¼112), 30-day survival for the donor twin was 65%.Multivariable logistic regression showed that patients in theTTTS_ONLY group were twice as likely to achieve 30-day donorsurvival compared to those in the TTTS+SIUGR group (OR ¼ 2.01,95%CI 1.11-3.66, p ¼ 0.021). Among patients in the TTTS+SIUGRgroup only, factors associated with increased 30-day donor survivalwere: Stage I or II (OR 2.32, 95%CI 1.09-4.94, p ¼ 0.0287) andgestational age at surgery (OR ¼ 1.19, 95%CI 1.04-1.37, P ¼0.0139).CONCLUSION: SIUGR of the donor fetus was present in two-thirds ofTTTS patients that underwent laser surgery at our institution. Donortwin SIUGR is a pre-operative risk factor for decreased fetal andneonatal survival of the donor twin.
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Risk factors for anophthalmia/microphthalmiaStephanie Dukhovny1, Carol Louik2, Stephen Kerr2,Martha Werler2, Angela Lin3, Allen Mitchell21Brigham and Women’s Hospital, Obstetrics and Gynecology, Boston, MA,2Boston University, Slone Epidemiology Center, Boston, MA, 3MassachusettsGeneral Hospital, Medical Genetics, Boston, MAOBJECTIVE: Anophthalmia and microphthalmia are rare birth defectsthat cause significant disability, but little is known about possibleenvironmental risk factors. We explored associations betweenmaternal characteristics and exposures during pregnancy andanophthalmia/microphthalmia.STUDY DESIGN: Data were obtained from the National Birth DefectsPrevention Study (NBDPS), an ongoing population-based case-control study of birth defects in the United States. We identified caseinfants (n¼161) with isolated anophthalmia/microphthalmia from1997 to 2007. Control infants (n¼8434) were live births withoutmajor birth defects. We used logistic regression to calculate the crudeodds ratios (cORs) and 95% confidence intervals (CIs) for prenatalexposures; adjusted ORs (aORs) controlled for maternal race.RESULTS: We found that, compared with non-Hispanic whitewomen, Hispanic women were more likely to have infants withanophthalmia/microphthalmia (cOR 1.46; 95% CI 1.02, 2.10), aswere women with fewer than 12 years of maternal education (cOR1.67; 95% CI 1.22, 2.29). Obese women (BMI > 29.0) were alsomore likely to have affected infants (aOR 1.68; 95% CI 1.14, 2.46).Infants with anophthalmia/microphthalmia were more likely to below birthweight and very low birthweight (aOR’s 3.97; 95% CI 2.54,6.21 and 12.5; 95% CI 6.67, 23.3, respectively). We found thatanophthalmia/ microphthalmia was associated with 1st trimesterNSAID use (aOR 1.60; 95% CI 1.13, 2.25) and with 1st trimesternitrofurantoin use (cOR 3.06; 95% CI 1.22, 7.64). No increased riskswere observed for retinoic acid exposure, caffeine, alcohol, cigarettesmoking, or cold/flu during pregnancy.CONCLUSION: Anophthalmia/microphthalmia was more commonamong women of Hispanic origin, women with low education levelsand obese women. NSAID use in the first trimester of pregnancy wasassociated with anophthalmia/ microphthalmia. Confirming previ-ous reports, we found an elevated odds ratio for nitrofurantoin andanophthalmia/microphthalmia.
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Rate of and risk factors for non-visualization of theappendix with magnetic resonance imaging (MRI) in pregnantwomen with suspected appendicitisLauren Theilen1, Vincent Mellnick2, Ryan Longman1,George Macones1, Alison Cahill11Washington University in St. Louis, Obstetrics & Gynecology, St. Louis, MO,2Washington University in St. Louis, Mallinckrodt Institute of Radiology,St. Louis, MOOBJECTIVE: To determine the rate of and risk factors for appendixnon-visualization with MRI for suspected appendicitis in pregnantwomen. Current radiology guidelines recommend initial imagingwith ultrasound in these women, so we secondarily aimed to assessthe ability of ultrasound to identify the appendix.STUDY DESIGN: We performed a retrospective cohort study ofconsecutive pregnant women who underwent standardized non-contrast MRI for suspected appendicitis at a single center from 2007-2012. Data on clinical presentation, imaging, and surgical pathologywere extracted from electronic medical records. Odds ratios esti-mated risk factors for non-diagnosis. Secondary analysis wasperformed among women who underwent initial imaging withultrasound.
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