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651 Use of telemedicine in fetal echocardiography — A preliminary study
$256 SMFM Abstracts 649
December 2001 A m J Obstet Gynecol
CAN FETAL G R O W T H IN DIABETIC PREGNANCY BE PREDICTED? ANDRZEJ LYSIKIEWICZ 1, BARAK M. ROSENN ] , ODED IANGER2; tSt Luke's Roosevelt Hospital Center, Obstetrics a n d Gynecology, New York, NY; 2Columbia University, Obstetrics & Gynecology, New York, NY OBJECTIVE: To determine if fetal biometry in mid pregnancy can predict fetal size at term in gestational diabetes (GDM). STUDY DESIGN: 30 patients that were referred to our Perinatal Center with a diagnosis of GDM were followed with serial sonographic biometry from m i d p r e g n a n c y (26-30 wks) to t e r m (38-40 wks). Fetal m e a s u r e m e n t s of abdominal circumference (AC), f e m u r length (FL) a n d h e a d circumference (HC) c o n f o r m e d to AIUM standards a n d were expressed in percentiles for gestationaL age. The control g r o u p included 120 nondiabefic patients with fetal biometry p e r f o r m e d at the same intervals. RESULTS: Fetal AC, FL a n d H C were above 50th percentile in GDM patientS during mid pregnancy. This trend was reversed at term when fetal AC, FL, a n d H C were below 50th percentile a n d n o different from the NON GDM group. C O N C L U S I O N : Accelerated fetal growth in GDM patientS observed in mid pregnancy did n o t predict fetal size at term. This effect may be the result of glucose control in GDM patients. Figure Fetal percentile
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TARGETED U L T R A S O U N D AS A SCREEN F O R D O W N SYNDROME IN H I G H RISK WOMEN: H O W MANY MISSED DIAGNOSES? AARON
CAUGHEY1, DEIRDRE LYELL2, A. EUGENE WASHINGTON s, ROY FILLY4, MARY NORTON3; ~University of California, San Francisco, Obstetrics & Gynecology, Daly City, CA; 2Stanford University, Maternal-Fetal Medicine, Stanford, CA; 3University of California, San Francisco, Obstetrics & Gynecology, San Francisco, CA; 4University of California, San Francisco, Unknown, San Francisco, NY OBJECTIVE: To d e t e r m i n e the effectiveness of targeted u l t r a s o u n d markers to screen for Down syndrome (DS) in a high-risk population in terms of numbers of DS fetuses identified, procedure related losses a n d the ratio between these two. STUDY DESIGN: A decision analytic model was designed to compare 1) the c u r r e n t s t a n d a r d of universal amniocentesis in all w o m e n of either advanced maternal age (AMA) or with a serum screen positive (SSP) to 2) a policy of evaluating these same patients with a targeted u l t r a s o u n d a n d p e r f o r m i n g amniocentesis only in those with ultrasound findings. Baseline assumptions included 4,000,000 pregnancies, 87% to women < 35, with risks of DS of 1:165 in women > 35 a n d 1:60 for w o m e n SSP < 35. A sensitivity for targeted ultrasound of 60.6% with a screen positive rate of 15.6% were used. The sensitivities a n d screen positive rates of targeted ultrasound for DS were varied in the sensitivity analysis. RESULTS: When targeted ultrasound is used to screen already identified at-risk patients, 39% (n = 2002) of the DS fetuses identified by the initial screen are missed. The biggest difference is seen a m o n g those patients who are both AMA a n d SSP, in this subgroup of patients, 1106 DS fetuses will be missed. The procedure related losses (PRLs) mad amnios per each DS fetus that would be diagnosed if the ultrasound screen was not used are shown in the Table below. CONCLUSION: Substantially fewer DS fetuses will be identified with the use of targeted u l t r a s o u n d as a screen a m o n g already identified high risk patients. Table Targeted ultrasound vs. current screen
DS missed by US PRL per DS Dx Amnios per DS Dx
ALL SSP AND/OR AMA
SSP
AMA
ONLY
ONLY
AMA W/SSP
2002 1.31 261
759 0.58 116
1243 1.75 351
1106 0.39 79
USE O F TF,I.EMEDICINE IN FETAL E C H O C A R D I O G R A P H Y - - A PRELIM-
NARY STUDY CATHERINE OCAMPO t , BOBBI KORANDA2, LETITIA CURRAN 3, BRIAN M C C U L L O C H 4, EMMANUEL Q ] O M O ~, THOMAS IANNUCCI 4, BETTINA CUNEO1; lThe Heart Institute for Children, Pediatrics, O a k Lawn, IL; 2St Margaret Mercy Fiealthcare System, Echocardiography, H a m m o n d , IN; SCentral DuPage Hospital, Obstetrics, WinfieLd, IL; 4Central DuPage Hospital, Obstetrics, Winfield, IL; 5St Margaret Mercy Healthcare System, Obstetrics, H a m m o n d , IN OBJECTIVE: We investigated the usefulness of real-time telemedicine transmissions for fetal echocardiography in a high-risk population. STUDY DESIGN: Fetal e c h o c a r d i o g r a m s were p e r f o r m e d by 1 of 3 techniques. Real-time fetal cardiac images, via a polycom system with a network speed of 512 kbps at 30 frames per second, were transmitted via 3 or 4 1SDN data lines from two satellite centers to a perinataL cardiologist for immediate results (real-time transmissions, RTT) (Group 1). AlternativeLy, the echo is videotaped by a technician, a n d interpreted 24-48 hours later (tape a n d store, T&S) (Group 2). The cardiologist perfornas the echo at the tertiary center (onsite studies, OSS) (Group 3). Reasons for referral, gestational age, length of encounter, quality of study a n d outcome were c o m p a r e d between 62 RTT, 121 T&S, a n d 92 OSS studies p e r f o r m e d between January-August 2001. Patient satisfaction was ewduated by a questionnaire a n d results c o m p a r e d by ANOVA. RESULTS: Reasons for referral were similar; gestational ages were not different (24 -'_ 5, 25 -+ 5, a n d 25 _+ 5 weeks). T h e time of e n c o u n t e r was significantly shorter for OSS, 15 • 9 minutes (P< .05) as c o m p a r e d to the T&S taped a n d RTT studies, which were similar (23 ± 10 a n d 26 _+14 minutes). 3% of T&S studies were non
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ACCURACY OF PRENATAL ULTRASONOGRAPHY IN THE DIAGNOSIS
O F PLACENTA ACCRETA, INCRETA O R PERCRETA CECILIA AVIIA t , PATR1CIA DEVINE 2, CHERI LOWRE ], J O S H U A WEISS3, ANNETTE PEREZDELBOY 4, FERGAL MALONEt; 1Columbia University, Obstetrics a n d Gynecology, New York, NY; ~New York Presbyterian Hospital, New York, NY; 3Columbia University, Maternal Fetal Medicine, New York, NY; 4Columbia University, Obstetrics or Gynecology, New York, NY OBJECTIVE: Placenta accreta, increta or percreta are important causes of p e r i p a r t u m hysterectomy, a n d are associated with increased morbidity a n d mortality. Fiowevel, n o t all s u c h cases are detected by p r e n a t a l ultrasonography. We studied the accuracy of u l t r a s o n o g r a p h i c p r e d i c t i o n in p e r i p a r t m n hysterectomy with a b n o r m a l placental invasion observed intraoperatively. STUDY DESIGN: Cases of peripartmn hysterectomy for excessive hemorrbage p e r f o r m e d between 1989 a n d 2001 were identified by a departmental database. Medical records were reviewed with respect to a n t e p a r t u m ultrasonographic findings, intraoperative findings, a n d pathological mralysis. RESULTS: Eighteen cases of peripartum hsyterectomy with intraoperative observations of abnornaal placental invasion were t o u n d in which u h r a s o n o g r a p b i c a n d pathological data were available. In these 18 cases, a finding of placenta accreta, increta or p e r c r e t a (with or without placenta previa) was m a d e in a n t e p a r t u m ultrasonography in 9 (50%) cases only, a finding of placenta previa alone was made in an additional 5 (26%) cases (in 4 of these 5 operative observations confirmed the presence of previa in addition to abnormal invasion). The presence of placenta accreta, increta or percreta was f o u n d in pathological analysis in 14 (78%) of the 18 cases. In these 14 cases, ultrasonographic findings of abnormal invasion were m a d e in 6 (43%), a n d of placenta previa alone in 4 (29%). All but 4 of the 18 c~ses h a d at least one previous cesarean section. CONCLUSION: Ufirasonography has a limited sensitivity for the diagnosis of a b n o r m a l placental invasiou as subsequently d i a g n o s e d by operative observations or pathological analysis. Additional diagnostic methods, such as magnetic resonance imaging, are necessary for successful prediction of such abnormalities.
December 2001 A m J Obstet Gynecol
CAN FETAL G R O W T H IN DIABETIC PREGNANCY BE PREDICTED? ANDRZEJ LYSIKIEWICZ 1, BARAK M. ROSENN ] , ODED IANGER2; tSt Luke's Roosevelt Hospital Center, Obstetrics a n d Gynecology, New York, NY; 2Columbia University, Obstetrics & Gynecology, New York, NY OBJECTIVE: To determine if fetal biometry in mid pregnancy can predict fetal size at term in gestational diabetes (GDM). STUDY DESIGN: 30 patients that were referred to our Perinatal Center with a diagnosis of GDM were followed with serial sonographic biometry from m i d p r e g n a n c y (26-30 wks) to t e r m (38-40 wks). Fetal m e a s u r e m e n t s of abdominal circumference (AC), f e m u r length (FL) a n d h e a d circumference (HC) c o n f o r m e d to AIUM standards a n d were expressed in percentiles for gestationaL age. The control g r o u p included 120 nondiabefic patients with fetal biometry p e r f o r m e d at the same intervals. RESULTS: Fetal AC, FL a n d H C were above 50th percentile in GDM patientS during mid pregnancy. This trend was reversed at term when fetal AC, FL, a n d H C were below 50th percentile a n d n o different from the NON GDM group. C O N C L U S I O N : Accelerated fetal growth in GDM patientS observed in mid pregnancy did n o t predict fetal size at term. This effect may be the result of glucose control in GDM patients. Figure Fetal percentile
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TARGETED U L T R A S O U N D AS A SCREEN F O R D O W N SYNDROME IN H I G H RISK WOMEN: H O W MANY MISSED DIAGNOSES? AARON
CAUGHEY1, DEIRDRE LYELL2, A. EUGENE WASHINGTON s, ROY FILLY4, MARY NORTON3; ~University of California, San Francisco, Obstetrics & Gynecology, Daly City, CA; 2Stanford University, Maternal-Fetal Medicine, Stanford, CA; 3University of California, San Francisco, Obstetrics & Gynecology, San Francisco, CA; 4University of California, San Francisco, Unknown, San Francisco, NY OBJECTIVE: To d e t e r m i n e the effectiveness of targeted u l t r a s o u n d markers to screen for Down syndrome (DS) in a high-risk population in terms of numbers of DS fetuses identified, procedure related losses a n d the ratio between these two. STUDY DESIGN: A decision analytic model was designed to compare 1) the c u r r e n t s t a n d a r d of universal amniocentesis in all w o m e n of either advanced maternal age (AMA) or with a serum screen positive (SSP) to 2) a policy of evaluating these same patients with a targeted u l t r a s o u n d a n d p e r f o r m i n g amniocentesis only in those with ultrasound findings. Baseline assumptions included 4,000,000 pregnancies, 87% to women < 35, with risks of DS of 1:165 in women > 35 a n d 1:60 for w o m e n SSP < 35. A sensitivity for targeted ultrasound of 60.6% with a screen positive rate of 15.6% were used. The sensitivities a n d screen positive rates of targeted ultrasound for DS were varied in the sensitivity analysis. RESULTS: When targeted ultrasound is used to screen already identified at-risk patients, 39% (n = 2002) of the DS fetuses identified by the initial screen are missed. The biggest difference is seen a m o n g those patients who are both AMA a n d SSP, in this subgroup of patients, 1106 DS fetuses will be missed. The procedure related losses (PRLs) mad amnios per each DS fetus that would be diagnosed if the ultrasound screen was not used are shown in the Table below. CONCLUSION: Substantially fewer DS fetuses will be identified with the use of targeted u l t r a s o u n d as a screen a m o n g already identified high risk patients. Table Targeted ultrasound vs. current screen
DS missed by US PRL per DS Dx Amnios per DS Dx
ALL SSP AND/OR AMA
SSP
AMA
ONLY
ONLY
AMA W/SSP
2002 1.31 261
759 0.58 116
1243 1.75 351
1106 0.39 79
USE O F TF,I.EMEDICINE IN FETAL E C H O C A R D I O G R A P H Y - - A PRELIM-
NARY STUDY CATHERINE OCAMPO t , BOBBI KORANDA2, LETITIA CURRAN 3, BRIAN M C C U L L O C H 4, EMMANUEL Q ] O M O ~, THOMAS IANNUCCI 4, BETTINA CUNEO1; lThe Heart Institute for Children, Pediatrics, O a k Lawn, IL; 2St Margaret Mercy Fiealthcare System, Echocardiography, H a m m o n d , IN; SCentral DuPage Hospital, Obstetrics, WinfieLd, IL; 4Central DuPage Hospital, Obstetrics, Winfield, IL; 5St Margaret Mercy Healthcare System, Obstetrics, H a m m o n d , IN OBJECTIVE: We investigated the usefulness of real-time telemedicine transmissions for fetal echocardiography in a high-risk population. STUDY DESIGN: Fetal e c h o c a r d i o g r a m s were p e r f o r m e d by 1 of 3 techniques. Real-time fetal cardiac images, via a polycom system with a network speed of 512 kbps at 30 frames per second, were transmitted via 3 or 4 1SDN data lines from two satellite centers to a perinataL cardiologist for immediate results (real-time transmissions, RTT) (Group 1). AlternativeLy, the echo is videotaped by a technician, a n d interpreted 24-48 hours later (tape a n d store, T&S) (Group 2). The cardiologist perfornas the echo at the tertiary center (onsite studies, OSS) (Group 3). Reasons for referral, gestational age, length of encounter, quality of study a n d outcome were c o m p a r e d between 62 RTT, 121 T&S, a n d 92 OSS studies p e r f o r m e d between January-August 2001. Patient satisfaction was ewduated by a questionnaire a n d results c o m p a r e d by ANOVA. RESULTS: Reasons for referral were similar; gestational ages were not different (24 -'_ 5, 25 -+ 5, a n d 25 _+ 5 weeks). T h e time of e n c o u n t e r was significantly shorter for OSS, 15 • 9 minutes (P< .05) as c o m p a r e d to the T&S taped a n d RTT studies, which were similar (23 ± 10 a n d 26 _+14 minutes). 3% of T&S studies were non
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ACCURACY OF PRENATAL ULTRASONOGRAPHY IN THE DIAGNOSIS
O F PLACENTA ACCRETA, INCRETA O R PERCRETA CECILIA AVIIA t , PATR1CIA DEVINE 2, CHERI LOWRE ], J O S H U A WEISS3, ANNETTE PEREZDELBOY 4, FERGAL MALONEt; 1Columbia University, Obstetrics a n d Gynecology, New York, NY; ~New York Presbyterian Hospital, New York, NY; 3Columbia University, Maternal Fetal Medicine, New York, NY; 4Columbia University, Obstetrics or Gynecology, New York, NY OBJECTIVE: Placenta accreta, increta or percreta are important causes of p e r i p a r t u m hysterectomy, a n d are associated with increased morbidity a n d mortality. Fiowevel, n o t all s u c h cases are detected by p r e n a t a l ultrasonography. We studied the accuracy of u l t r a s o n o g r a p h i c p r e d i c t i o n in p e r i p a r t m n hysterectomy with a b n o r m a l placental invasion observed intraoperatively. STUDY DESIGN: Cases of peripartmn hysterectomy for excessive hemorrbage p e r f o r m e d between 1989 a n d 2001 were identified by a departmental database. Medical records were reviewed with respect to a n t e p a r t u m ultrasonographic findings, intraoperative findings, a n d pathological mralysis. RESULTS: Eighteen cases of peripartum hsyterectomy with intraoperative observations of abnornaal placental invasion were t o u n d in which u h r a s o n o g r a p b i c a n d pathological data were available. In these 18 cases, a finding of placenta accreta, increta or p e r c r e t a (with or without placenta previa) was m a d e in a n t e p a r t u m ultrasonography in 9 (50%) cases only, a finding of placenta previa alone was made in an additional 5 (26%) cases (in 4 of these 5 operative observations confirmed the presence of previa in addition to abnormal invasion). The presence of placenta accreta, increta or percreta was f o u n d in pathological analysis in 14 (78%) of the 18 cases. In these 14 cases, ultrasonographic findings of abnormal invasion were m a d e in 6 (43%), a n d of placenta previa alone in 4 (29%). All but 4 of the 18 c~ses h a d at least one previous cesarean section. CONCLUSION: Ufirasonography has a limited sensitivity for the diagnosis of a b n o r m a l placental invasiou as subsequently d i a g n o s e d by operative observations or pathological analysis. Additional diagnostic methods, such as magnetic resonance imaging, are necessary for successful prediction of such abnormalities.