First trimester screening (FTS) in the detection of down syndrome
1
626 LUNG-TO-HEAD RATIO AND LIVER POSITION TO PREDICT OUTCOME IN EARLY DIAGNOSED ISOLATED LEFT SIDED DIAPHRAGMATIC HERNIA FETUSES: A MULTICENTER STUDY JACQUES JANI 1 , ALEXANDRA BENACHI 2 , RENE ´ FAVRE 3 , ROBERTA KELLER 4 , HILDE VANDECRUYS 5 , JULIAN DELGADO 6 , MICHAEL HARRISON 7 , JACQUELINE MATIS 8 , EDUARD GRATACOS 6 , KYPROS NICOLAIDES 5 , JAN DEPREST 1 , 1 University Hospital Gasthuisberg, Obstetrics and Gynecology, Leuven, Belgium, 2 Hoˆpital Necker-Enfants Malades, Obstetrics and Gynaecology, Paris, France, 3 CHRU Strasbourg, Obstetrics and Gynecology, Schiltigheim, France, 4 University of California, San Francisco, Neonatology/Pediatrics, San Francisco, California, 5 King’s College London, Harris Birthright Research Centre, London, United Kingdom, 6 Hospital Universitari Vall Hebron, Obstetrics and Gynecology, Barcelona, Spain, 7 University of California, San Francisco, Surgery & Pediatrics, San Francisco, California, 8 CHRU Strasbourg, Neonatology, Schiltigheim, France OBJECTIVE: Congenital diaphragmatic hernia (CDH) is associated to high neonatal mortality. Accurate prediction of outcome is crucial in counselling parents about management options. We evaluated Lung-to-Head Ratio (LHR) and liver position in prediction of outcome of isolated Left CDH. STUDY DESIGN: Retrospective review of consecutive patients diagnosed with isolated LCDH %28 weeks, evaluated at 6 tertiairy units from 1995 onwards. Only patients with LHR measurements by experienced sonographers and with known liver position by ultrasound or MRI, both %28 wks, were included. Outcome measure was survival at discharge from NICU. RESULTS: 134 cases had an LHR obtained at 24.4 G 2.8 wks. 11 patients (8%) opted for termination after evaluation, all with LHR !1.4. There were no postnatal diagnoses of chromosomal anomalies. Overall survival was 43% (58/ 134), after substraction of antenatal losses 47% (58/123). In case of liver herniation survival was 35 %. LHR correlated to survival irrespective of liver position but combination of both variables predicted neonatal outcome better: liver up & LHR !1 predicted a survival of 9%. When LHR !0.8 and liver up, there were no survivors, but with liver down (37% of cases) survival was 40%. When LHR !0.6 there were no survivors irrespective of liver position. CONCLUSION: Combination of liver up& LHR !1 at %28 wks predicts a !10 % chance of survival, dropping to 0% if LHR !0.8. 8% of patients opted for termination after second opinion, all with LHR !1.4, but only in half this coincided with the above poor prognostic indicators. Liver Up Up Up Down Down Down n LHR n Survival, n (%) TOP (n) n Survival, n (%) TOP (n) 4 !0.6 3 0/3 (0%) 0 1 0/1 (0%) 0 27 0.6-0.8 18 0/14 (0%) 4 9 4/9 (44%) 0 23 0.8-1.0 16 3/15 (20%) 1 7 3/6 (50%) 1 46 1.0-1.4 29 14/28 (50%) 1 17 9/13 (69%) 4 34 R1.4 9 7/9 (78%) 0 25 18/25 (72%) 0 134 Total 75 24/69 (35%) 6 59 34/54 (63%) 5 627 CLINICAL IMPLICATIONS OF PRENATALLY DIAGNOSED MARGINAL PLACENTAL CORD INSERTION DEBORAH FELDMAN 1 , KATJE KONING 1 , RENEE BOBROWSKI 1 , ADAM BORGIDA 1 , CHARLES INGARDIA 1 , 1 Hartford Hospital, Obstetrics and Gynecology, Hartford, Connecticut OBJECTIVE: To compare pregnancy and neonatal outcomes in marginal placental cord insertion (MPCI) diagnosed by ultrasound to a group of matched controls with a central placental cord insertion (CPCI). STUDY DESIGN: We reviewed our ultrasound database and identified patients with a singleton pregnancy from 1/2002-12/2003 with MPCI, defined as placental cord insertion !2 cm from the placental edge. For each case, two controls with CPCI were matched for maternal age and gestational age (GA) at initial ultrasound. Maternal demographics and pregnancy and neonatal out- comes were compared using Student’s t test, ANOVA, and c 2 with Fisher exact test where appropriate. RESULTS: During the study period, 38/3722 patients(1.0%) with a singleton pregnancy had a MPCI documented by ultrasound; 25 had complete data. There was no difference in maternal demographics between the two groups. The incidence of preterm delivery was higher (20% vs 5.4%, P = .042)) in the MPCI group. Although the mean birth weight (BW) was lower in the MPCI group, there was no difference in the rate of BW !2500 g (LBW). There were no differences in the rates of preeclampsia, oligohydramnios, fetal growth re- striction, fetal distress, or primary cesarean delivery between the groups. Neonatal outcomes showed similar rates of meconium, nuchal cord, small-for- gestational age (SGA), and NICU admission between the groups. Composite maternal and fetal morbidity were also similar for both groups. CONCLUSION: MPCI was associated with earlier delivery and lower birth weight when compared to fetuses with CPCI. While no significant differences were noted with regard to maternal or neonatal morbidity, larger studies are required to elucidate the need for closer surveillance in these pregnancies. Pregnancy outcomes of MPCI versus CPCI Outcome MPCI (n = 25) CPCI (n = 50) P value PTD (%) 20 5.4 .04 BW (g) 3168 699 3486 510 .016 LBW (%) 8.0 4.0 .427 NICU (%) 4.0 0.0 .250 628 FIRST TRIMESTER SCREENING (FTS) IN THE DETECTION OF DOWN SYNDROME JO- ANN JOHNSON 1 , BARRY HOFFMAN 2 , DAVID CHITAYAT 3 , ELIZABETH WINSOR 2 , KENNETH PRITZKER 4 , 1 University of Calgary, Obstetrics and Gynecology, Calgary, Alberta, Canada, 2 University of Toronto, Pathology and Laboratory Medicine, Toronto, Ontario, Canada, 3 University of Toronto, Paediatrics, Toronto, Ontario, Canada, 4 University of Toronto, Laboratory Medicine & Pathobiology, Toronto, Ontario, Canada OBJECTIVE: The aim of this study was to evaluate the performance of first trimester screening (FTS) in the detection of fetal Down syndrome (DS). STUDY DESIGN: The study population consisted of unselected patients (single site) between 11-13.6 weeks gestation who consented to FTS (maternal age, nuchal translucency (NT) and biochemical markers (free b-human chorionic gonadotropin [hCG], pregnancy-associate plasma protein-A [PAPP-A]) and follow-up of pregnancy outcome. All NT measurements were performed by sonographers trained according to the standards set by the Fetal Medicine Foundation, UK. A screening result was considered positive for Down syndrome if the calculated risk was greater than or equal to 1:350 (term risk). RESULTS: Between January 2002 and Jan 2004, 8805 women underwent FTS. The detection rate for DS was 87.8% (27/31) and false positive rate (FPR) 4.7%. During the same time period, the amniocentesis rate decreased by 22%. CONCLUSION: FTS is associated with a higher DR and lower FPR compared with second trimester maternal serum screening. A decrease in the number of invasive tests (mainly amniocentesis) has also been observed since the in- troduction of the program. 629 THE HAZARDS OF OBSTETRICS AND GYNECOLOGICAL ULTRASOUND TO PRACTITIONERS RINAT HACKMON 1 , EYAL SHEINER 2 , RUTH BEER-WEISEL 3 , ISRAEL MEIZNER 4 , 1 Tel Aviv University, Ob/Gyn, NYC, New York, 2 Soroka University Medical Center, Ob/Gyn, Beer-Sheva, Israel, 3 Soroka University Medical Center, Ob/Gyn, Beer- Sheva, Israel, 4 Beilinson University Medical Center, OB/GYN, Petach Tiqwa, Israel OBJECTIVE: In the practice of Obstetrics and Gynecology (Ob/Gyn), the ultrasound examination has become so common that it is considered as an integral part of the physical examination.New unexpected symptoms such as myalgia and arthralgia among sonographers have arisen. The aim of this study is to investigate the complains of physicians and technicians performing Ob/Gyn ultrasound examinations. STUDY DESIGN: A cross sectional retrospective survey was performed between 2002 and 2003. Questionnaires were distributed to members of the Society of Gynecological Ultrasound. Statistical analysis included c 2 , Fisher’s exact, or Student’s t test, Pearson’s correlation coefficient and Multivariable analysis. P ! .05 was considered significant. RESULTS: One hundred thirty three (66.5%) of 200 surveys distributed, were filled out. Sixty nine were female 64 were male. The vast majority of technicians were female 97.3%, while 89.6% of physicians were males. The average number of examination per day for technicians was 29 as compared to 20 for physicians. Joint pain (JP) was reported by 51.7% technicians compared to 25.3% of the physicians (OR = 3.16; 95% CI 1.4-7.0; P = .002). JP complains were more common in females as compared to males (44.9% vs 28.1%, P = .04) and among those who performed abdominal ultrasound more frequently than the transvaginal procedure (mean 21 vs 19, P = .004). A significant association was found between the performance of abdominal ultrasound and back pain (BP), using the Pearson’s correlation coefficient (P = .05). Visual deterioration was the most common complain (3.8%) answered to the open question of symptoms. Surgical procedures were performed more often among male as compared to female technicians (12.5% vs 2.9%, P = .05). CONCLUSION: There is a direct correlation between the number of abdominal ultrasound examinations and JP or BP. In addition, gender differences in pain perception and therapy exist. Attention should be focused on the mobility, angulation, shape and weight of the various equipment in order to prevent physiological damage to the performers. S176 SMFM Abstracts
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Transcript of First trimester screening (FTS) in the detection of down syndrome
626 LUNG-TO-HEAD RATIO AND LIVER POSITION TO PREDICT OUTCOME IN EARLYDIAGNOSED ISOLATED LEFT SIDED DIAPHRAGMATIC HERNIA FETUSES: AMULTICENTER STUDY JACQUES JANI1, ALEXANDRA BENACHI2, RENE FAVRE3,ROBERTA KELLER4, HILDE VANDECRUYS5, JULIAN DELGADO6, MICHAEL HARRISON7,JACQUELINE MATIS8, EDUARD GRATACOS6, KYPROS NICOLAIDES5, JAN DEPREST1,1University Hospital Gasthuisberg, Obstetrics and Gynecology, Leuven,Belgium, 2Hopital Necker-Enfants Malades, Obstetrics and Gynaecology,Paris, France, 3CHRU Strasbourg, Obstetrics and Gynecology, Schiltigheim,France, 4University of California, San Francisco, Neonatology/Pediatrics, SanFrancisco, California, 5King’s College London, Harris Birthright ResearchCentre, London, United Kingdom, 6Hospital Universitari Vall Hebron,Obstetrics and Gynecology, Barcelona, Spain, 7University of California, SanFrancisco, Surgery & Pediatrics, San Francisco, California, 8CHRU Strasbourg,Neonatology, Schiltigheim, France
OBJECTIVE: Congenital diaphragmatic hernia (CDH) is associated to highneonatal mortality. Accurate prediction of outcome is crucial in counsellingparents about management options. We evaluated Lung-to-Head Ratio (LHR)and liver position in prediction of outcome of isolated Left CDH.
STUDY DESIGN: Retrospective review of consecutive patients diagnosed withisolated LCDH %28 weeks, evaluated at 6 tertiairy units from 1995 onwards.Only patients with LHR measurements by experienced sonographers and withknown liver position by ultrasound or MRI, both %28 wks, were included.Outcome measure was survival at discharge from NICU.
RESULTS: 134 cases had an LHR obtained at 24.4 G 2.8 wks. 11 patients(8%) opted for termination after evaluation, all with LHR !1.4. There were nopostnatal diagnoses of chromosomal anomalies. Overall survival was 43% (58/134), after substraction of antenatal losses 47% (58/123). In case of liverherniation survival was 35 %. LHR correlated to survival irrespective of liverposition but combination of both variables predicted neonatal outcome better:liver up & LHR !1 predicted a survival of 9%. When LHR !0.8 and liver up,there were no survivors, but with liver down (37% of cases) survival was 40%.When LHR !0.6 there were no survivors irrespective of liver position.
CONCLUSION: Combination of liver up& LHR !1 at %28 wks predictsa !10 % chance of survival, dropping to 0% if LHR !0.8. 8% of patientsopted for termination after second opinion, all with LHR !1.4, but only in halfthis coincided with the above poor prognostic indicators.
Liver Up Up Up Down Down Down
n LHR n Survival, n (%) TOP (n) n Survival, n (%) TOP (n)
4 !0.6 3 0/3 (0%) 0 1 0/1 (0%) 0
27 0.6-0.8 18 0/14 (0%) 4 9 4/9 (44%) 0
23 0.8-1.0 16 3/15 (20%) 1 7 3/6 (50%) 1
46 1.0-1.4 29 14/28 (50%) 1 17 9/13 (69%) 4
34 R1.4 9 7/9 (78%) 0 25 18/25 (72%) 0
134 Total 75 24/69 (35%) 6 59 34/54 (63%) 5
627 CLINICAL IMPLICATIONS OF PRENATALLY DIAGNOSED MARGINAL PLACENTALCORD INSERTION DEBORAH FELDMAN1, KATJE KONING1, RENEE BOBROWSKI1,ADAM BORGIDA1, CHARLES INGARDIA1, 1Hartford Hospital, Obstetrics andGynecology, Hartford, Connecticut
OBJECTIVE: To compare pregnancy and neonatal outcomes in marginalplacental cord insertion (MPCI) diagnosed by ultrasound to a group of matchedcontrols with a central placental cord insertion (CPCI).
STUDY DESIGN: We reviewed our ultrasound database and identified patientswith a singleton pregnancy from 1/2002-12/2003 with MPCI, defined asplacental cord insertion !2 cm from the placental edge. For each case, twocontrols with CPCI were matched for maternal age and gestational age (GA) atinitial ultrasound. Maternal demographics and pregnancy and neonatal out-comes were compared using Student’s t test, ANOVA, and c2 with Fisher exacttest where appropriate.
RESULTS: During the study period, 38/3722 patients(1.0%) with a singletonpregnancy had a MPCI documented by ultrasound; 25 had complete data. Therewas no difference in maternal demographics between the two groups. Theincidence of preterm delivery was higher (20% vs 5.4%, P = .042)) in the MPCIgroup. Although the mean birth weight (BW) was lower in the MPCI group,there was no difference in the rate of BW !2500 g (LBW). There were nodifferences in the rates of preeclampsia, oligohydramnios, fetal growth re-striction, fetal distress, or primary cesarean delivery between the groups.Neonatal outcomes showed similar rates of meconium, nuchal cord, small-for-gestational age (SGA), and NICU admission between the groups. Compositematernal and fetal morbidity were also similar for both groups.
CONCLUSION: MPCI was associated with earlier delivery and lower birthweight when compared to fetuses with CPCI. While no significant differenceswere noted with regard to maternal or neonatal morbidity, larger studies arerequired to elucidate the need for closer surveillance in these pregnancies.
Pregnancy outcomes of MPCI versus CPCI
Outcome MPCI (n = 25) CPCI (n = 50) P value
PTD (%) 20 5.4 .04
BW (g) 3168 � 699 3486 � 510 .016
LBW (%) 8.0 4.0 .427
NICU (%) 4.0 0.0 .250
S176 SMFM Abstracts
628 FIRST TRIMESTER SCREENING (FTS) IN THE DETECTION OF DOWN SYNDROME JO-ANN JOHNSON1, BARRY HOFFMAN2, DAVID CHITAYAT3, ELIZABETH WINSOR2,KENNETH PRITZKER4, 1University of Calgary, Obstetrics and Gynecology,Calgary, Alberta, Canada, 2University of Toronto, Pathology and LaboratoryMedicine, Toronto, Ontario, Canada, 3University of Toronto, Paediatrics,Toronto, Ontario, Canada, 4University of Toronto, Laboratory Medicine &Pathobiology, Toronto, Ontario, Canada
OBJECTIVE: The aim of this study was to evaluate the performance of firsttrimester screening (FTS) in the detection of fetal Down syndrome (DS).
STUDY DESIGN: The study population consisted of unselected patients (singlesite) between 11-13.6 weeks gestation who consented to FTS (maternal age,nuchal translucency (NT) and biochemical markers (free b-human chorionicgonadotropin [hCG], pregnancy-associate plasma protein-A [PAPP-A]) andfollow-up of pregnancy outcome. All NT measurements were performed bysonographers trained according to the standards set by the Fetal MedicineFoundation, UK. A screening result was considered positive for Downsyndrome if the calculated risk was greater than or equal to 1:350 (term risk).
RESULTS: Between January 2002 and Jan 2004, 8805 women underwent FTS.The detection rate for DS was 87.8% (27/31) and false positive rate (FPR) 4.7%.During the same time period, the amniocentesis rate decreased by 22%.
CONCLUSION: FTS is associated with a higher DR and lower FPR comparedwith second trimester maternal serum screening. A decrease in the number ofinvasive tests (mainly amniocentesis) has also been observed since the in-troduction of the program.
629 THE HAZARDS OF OBSTETRICS AND GYNECOLOGICAL ULTRASOUND TOPRACTITIONERS RINAT HACKMON1, EYAL SHEINER2, RUTH BEER-WEISEL3,ISRAEL MEIZNER4, 1Tel Aviv University, Ob/Gyn, NYC, New York, 2SorokaUniversity Medical Center, Ob/Gyn, Beer-Sheva, Israel, 3Soroka UniversityMedical Center, Ob/Gyn, Beer- Sheva, Israel, 4Beilinson University MedicalCenter, OB/GYN, Petach Tiqwa, Israel
OBJECTIVE: In the practice of Obstetrics and Gynecology (Ob/Gyn), theultrasound examination has become so common that it is considered as anintegral part of the physical examination.New unexpected symptoms such asmyalgia and arthralgia among sonographers have arisen. The aim of this study isto investigate the complains of physicians and technicians performing Ob/Gynultrasound examinations.
STUDY DESIGN: A cross sectional retrospective survey was performedbetween 2002 and 2003. Questionnaires were distributed to members of theSociety of Gynecological Ultrasound. Statistical analysis included c2, Fisher’sexact, or Student’s t test, Pearson’s correlation coefficient and Multivariableanalysis. P ! .05 was considered significant.
RESULTS: One hundred thirty three (66.5%) of 200 surveys distributed, werefilled out. Sixty nine were female 64 were male. The vast majority of technicianswere female 97.3%, while 89.6% of physicians were males. The average numberof examination per day for technicians was 29 as compared to 20 for physicians.Joint pain (JP) was reported by 51.7% technicians compared to 25.3% of thephysicians (OR = 3.16; 95% CI 1.4-7.0; P= .002). JP complains were morecommon in females as compared to males (44.9% vs 28.1%, P = .04) andamong those who performed abdominal ultrasound more frequently than thetransvaginal procedure (mean 21 vs 19, P = .004). A significant association wasfound between the performance of abdominal ultrasound and back pain (BP),using the Pearson’s correlation coefficient (P = .05). Visual deterioration wasthe most common complain (3.8%) answered to the open question of symptoms.Surgical procedures were performed more often among male as compared tofemale technicians (12.5% vs 2.9%, P = .05).
CONCLUSION: There is a direct correlation between the number of abdominalultrasound examinations and JP or BP. In addition, gender differences in painperception and therapy exist. Attention should be focused on the mobility,angulation, shape and weight of the various equipment in order to preventphysiological damage to the performers.
