- Email: [email protected]
The natural history of cervical funneling in high-risk women
Relationship Between FirstTrimester Nuchal Translucency and Second-Trimester Nuchal Skin Fold Sriram C. Perni, MD Weill Medical College of Cornell University, New York, NY
Stephen T. Chasen, MD, Robin B. Kalish, MD, and Frank A. Chervenak, MD OBJECTIVE: To determine the relationship between first-trimester measurement of nuchal translucency and the secondtrimester measurement of nuchal skin fold thickness in singleton, euploid pregnancies. STUDY DESIGN: A retrospective review of our nuchal translucency (NT) database and nuchal skin fold measurements was performed between September 2001 and January 2002. Patients were randomly selected from the database, and nuchal skin fold (NF) thickness was retrieved from the hard copy ultrasound pictures. NT was measured from 11 to 14 weeks (crown-rump length 45– 82 mm) in accordance with the Fetal Medicine Foundation standard. NF was measured from 18 to 21 weeks as a transverse section of the fetal head, including the occipital bone and cerebellum, from the outside of the occipital bone to outside the skin edge. Aneuploid fetuses were excluded. Linear regression was used to compare NT and NF values. NT and NF measurements were also categorized into quartiles based on gestational age, and a statistical analysis was used for comparison. RESULTS: A total of 159 NT/NF pairs were analyzed. The mean NT measurement was 1.57 ⫾ 0.50 mm (SD) (median 1.50), and the mean NF measurement was 3.84 ⫾ 0.85 mm (SD) (median 3.80). Linear regression suggested a trend toward correlation between NT and NF (R ⫽ 0.13, P ⫽ .08). statistics were consistent with a weak correlation ( ⫽ 0.08, P ⫽ .07) as well. CONCLUSIONS: Our data suggest a possible association between first-trimester NT and second-trimester NF. Risk calculations for aneuploidy, based on these measurements, may not be independent.
The Relationship Between Nuchal Translucency and Fetal Gender Sriram C. Perni, MD Weill Medical College of Cornell University, New York, NY
Stephen T. Chasen, MD, Robin B. Kalish, MD, and Frank A. Chervenak, MD OBJECTIVE: Differences have previously been described in various fetal biometric parameters and birth weight based on
120S
WEDNESDAY POSTERS
gender. Our objective was to examine whether first-trimester nuchal translucency measurements differ between genders. STUDY DESIGN: A retrospective review of our nuchal translucency (NT) database was performed from September 2001 to January 2002. Patients were randomly selected from the database, and gender was retrieved from the delivery record. NT was measured from singleton pregnancies from 11 to 14 weeks (crown-rump length [CRL] 45– 82 mm) in accordance with the Fetal Medicine Foundation standard. NT was measured as the width of the lucency alone, with careful visualization of the fetal skin from the amnion. Exclusion criteria included aneuploid fetuses. The Student t test was used to compare CRL and NT between genders. RESULTS: There were 108 male fetuses and 104 female fetuses. CRL measurements were similar in the two groups (mean 62.8 ⫾ 9.1 [SD] mm versus 61.8 ⫾ 9.4 [SD] mm, P ⫽ .42). NTs were similar in male and female fetuses (mean 1.6 ⫾ 0.5 [SD] mm versus 1.5 ⫾ 0.5 [SD] mm, P ⫽ .24). CONCLUSIONS: NT measurements do not differ between genders. Performance of NT in aneuploidy screening is unlikely to vary between genders.
The Natural History of Cervical Funneling in High-Risk Women Vincenzo Berghella, MD NICHD MFMU Network, Bethesda, MD
OBJECTIVE: To determine the natural history of funneling (FUN), and whether FUN is associated with spontaneous preterm birth less than 35 weeks (SPTB35). METHOD: Blinded multicenter observational study of 183 high-risk (at least one prior SPTB less than 32 weeks) singleton gestations. Cervical length (CL), FUN (membrane prolapse through the internal os of at least 5 mm), and fundal pressureinduced or spontaneous dynamic changes were recorded initially at 16 –18 weeks, and then every 2 weeks until 23 6/7 weeks. A total of 590 scans were performed, and the incidence SPTB35 was 26%. RESULTS: FUN was observed initially in 16 (9%) women, and after controlling for CL, FUN was not a significant independent predictor of SPTB35 in either contingency table or logistic regression analyses. With serial evaluations, and including all observed dynamic changes, 60 (33%) women had FUN on at least one evaluation. In 50 women, FUN was present on their final scan, whereas in ten (5%) cases previously identified FUN resolved. Women with FUN were significantly more likely to have SPTB35 (48% versus 15%, P ⬍ .001); however, if FUN resolved, SPTB35 was significantly reduced to 10% versus 56% if FUN persisted and 15% if FUN was never observed (P ⬍ .0001). After controlling for the shortest observed CL, which was highly associated with SPTB35 in a logistic regression model (P ⬍ .001), FUN observed at any time was not a significant independent risk factor (P ⫽ .85). Moreover, FUN did not appreciably affect SPTB35 in women with
OBSTETRICS & GYNECOLOGY
either shortest observed CL of at least 25 mm (RR 1.9; 0.6, 6.1) or CL of less than 25 mm (RR 1.1; 0.6, 2.0). CONCLUSIONS: Although the natural history of second-trimester funneling in high-risk women suggests that it has a significant association with SPTB, as an independent finding it does not add appreciably to the risk of SPTB associated with the finding of a shortened second-trimester CL.
The Economic Efficacy of Sonohysterography in the Triage of Abnormal Uterine Bleeding Ted R. Cox, MD, RDMS Brookwood Medical Center, Birmingham, AL
OBJECTIVE: To show the cost and time savings using sonohysterography in the triage of abnormal uterine bleeding. METHODS: Data were collected from area hospitals and gynecologist offices related to charges for operative procedures, anesthesia, clinic visits, pelvic ultrasounds, endometrial biopsies, blood work, pathology, and sonohysterography (SHG) used in the evaluation of abnormal uterine bleeding (AUB). The total cost of the standard workup was compared with the total cost of the workup using SHG to triage AUB. RESULTS: Using SHG in evaluation of AUB when vaginal ultrasound revealed an endometrial thickness greater than 5 mm or the endometrial stripe was indistinct and could not be measured accurately in many cases allowed the avoidance of endometrial biopsies, D&C hysterography, and general anesthesia. The data reveal time saved, increased reimbursement for doctor, and decreased overall medical cost.
patients’ perceptions with male and female operators and 2) to correlate the estimation of cervical length (CL) by TVUs and DEs. METHODS: We performed TVUs and DEs at greater than 37 weeks’ gestation in singleton pregnancies. Women were surveyed before and after the procedures. RESULTS: From May 1, 2001 to January 31, 2002, 155 pregnant women underwent both TVUs and DEs on the same day. Male sonographers performed 54% of the TVUs. There was a significant association between embarrassment and sonographer male gender (P ⫽ .009). Participants who had prior TVUs were less anxious (14% versus 54%, P ⬍ .001). CL by TVU was significantly associated (P ⬍ .001) with DE assessments of effacement; consistency; and cervical dilatation. When the cervix was closed, there was no correlation between CL by TVU and effacement by DE (P ⫽ .055), whereas there was a significant correlation when the cervix was dilated (P ⫽ .02). CONCLUSIONS: Pregnant women are more comfortable with TVU when done by a female. Other factors that may affect women’s perception have to be evaluated further. Cervical dilatation allows the examiner to make an accurate estimation of cervical length by DE, but high technology (ie, TVU) may be necessary when the cervix is closed.
Ultrasound of the Cervix for the Prediction of Preterm Birth in Patients With Two or More Abortions
CONCLUSIONS: SHG, when used appropriately, can offer a dramatic reduction in medical costs and time for the patient and physician.
Jacquelyn J. Pelham, MD
Transvaginal Ultrasound and Digital Examination at Term: Does the Operator’s Gender Matter?
OBJECTIVE: To determine the predictive value (PV) for preterm birth (PTB) of transvaginal ultrasound(TVU) cervical length (CL) in patients with two or more induced abortions.
Lama L. Tolaymat, MD, MPH University Of Miami, Miami, FL
Victor Hugo Gonzalez-Quintero, MD, MPH, Orlando Gomez-Marin, MSC, PhD, Dibe Martin, MD, and Mary J. O’Sullivan, MD OBJECTIVE: Transvaginal ultrasounds (TVUs) and digital examinations (DEs) are commonly performed during pregnancy. Operators of either gender perform these examinations. Funded by ACOG District IV, TVUs and DEs were performed to assess the cervix. Our objectives were 1) to compare
VOL. 101, NO. 4 (SUPPLEMENT), APRIL 2003
Thomas Jefferson University, Philadelphia, PA
Jason Baxter, MD, and Vincenzo Berghella, MD
STUDY DESIGN: Pregnant patients with a history of induced abortion by D&C less than 12 weeks (IA) were retrospectively identified between 1995 and 2002. Exclusion criteria were less than two IAs, prior term pregnancy after IA, multiple gestations, prophylactic cerclage (PC), no TVU data, drug abuse, loss to follow-up, induced PTB, and fetal demise. Patients were prospectively observed with TVU CL between 14 and 24 weeks. The PV of TVU was evaluated using less than 25 mm CL as criteria for the diagnosis of a short cervix. The primary outcome was PTB less than 35 weeks. RESULTS: 190 patients with prior IAs were identified; 147 were excluded, leaving 43 patients for analysis. 22 of 43 (51%) had a short cervix. Of these, eight (36%) had PTB less than 35 weeks. Of the 21 patients without a short cervix, only two (10%) had PTB less than 35 weeks. The sensitivity, specificity, positive PV, and negative PV of TVU CL for PTB less than 35
WEDNESDAY POSTERS
121S
Stephen T. Chasen, MD, Robin B. Kalish, MD, and Frank A. Chervenak, MD OBJECTIVE: To determine the relationship between first-trimester measurement of nuchal translucency and the secondtrimester measurement of nuchal skin fold thickness in singleton, euploid pregnancies. STUDY DESIGN: A retrospective review of our nuchal translucency (NT) database and nuchal skin fold measurements was performed between September 2001 and January 2002. Patients were randomly selected from the database, and nuchal skin fold (NF) thickness was retrieved from the hard copy ultrasound pictures. NT was measured from 11 to 14 weeks (crown-rump length 45– 82 mm) in accordance with the Fetal Medicine Foundation standard. NF was measured from 18 to 21 weeks as a transverse section of the fetal head, including the occipital bone and cerebellum, from the outside of the occipital bone to outside the skin edge. Aneuploid fetuses were excluded. Linear regression was used to compare NT and NF values. NT and NF measurements were also categorized into quartiles based on gestational age, and a statistical analysis was used for comparison. RESULTS: A total of 159 NT/NF pairs were analyzed. The mean NT measurement was 1.57 ⫾ 0.50 mm (SD) (median 1.50), and the mean NF measurement was 3.84 ⫾ 0.85 mm (SD) (median 3.80). Linear regression suggested a trend toward correlation between NT and NF (R ⫽ 0.13, P ⫽ .08). statistics were consistent with a weak correlation ( ⫽ 0.08, P ⫽ .07) as well. CONCLUSIONS: Our data suggest a possible association between first-trimester NT and second-trimester NF. Risk calculations for aneuploidy, based on these measurements, may not be independent.
The Relationship Between Nuchal Translucency and Fetal Gender Sriram C. Perni, MD Weill Medical College of Cornell University, New York, NY
Stephen T. Chasen, MD, Robin B. Kalish, MD, and Frank A. Chervenak, MD OBJECTIVE: Differences have previously been described in various fetal biometric parameters and birth weight based on
120S
WEDNESDAY POSTERS
gender. Our objective was to examine whether first-trimester nuchal translucency measurements differ between genders. STUDY DESIGN: A retrospective review of our nuchal translucency (NT) database was performed from September 2001 to January 2002. Patients were randomly selected from the database, and gender was retrieved from the delivery record. NT was measured from singleton pregnancies from 11 to 14 weeks (crown-rump length [CRL] 45– 82 mm) in accordance with the Fetal Medicine Foundation standard. NT was measured as the width of the lucency alone, with careful visualization of the fetal skin from the amnion. Exclusion criteria included aneuploid fetuses. The Student t test was used to compare CRL and NT between genders. RESULTS: There were 108 male fetuses and 104 female fetuses. CRL measurements were similar in the two groups (mean 62.8 ⫾ 9.1 [SD] mm versus 61.8 ⫾ 9.4 [SD] mm, P ⫽ .42). NTs were similar in male and female fetuses (mean 1.6 ⫾ 0.5 [SD] mm versus 1.5 ⫾ 0.5 [SD] mm, P ⫽ .24). CONCLUSIONS: NT measurements do not differ between genders. Performance of NT in aneuploidy screening is unlikely to vary between genders.
The Natural History of Cervical Funneling in High-Risk Women Vincenzo Berghella, MD NICHD MFMU Network, Bethesda, MD
OBJECTIVE: To determine the natural history of funneling (FUN), and whether FUN is associated with spontaneous preterm birth less than 35 weeks (SPTB35). METHOD: Blinded multicenter observational study of 183 high-risk (at least one prior SPTB less than 32 weeks) singleton gestations. Cervical length (CL), FUN (membrane prolapse through the internal os of at least 5 mm), and fundal pressureinduced or spontaneous dynamic changes were recorded initially at 16 –18 weeks, and then every 2 weeks until 23 6/7 weeks. A total of 590 scans were performed, and the incidence SPTB35 was 26%. RESULTS: FUN was observed initially in 16 (9%) women, and after controlling for CL, FUN was not a significant independent predictor of SPTB35 in either contingency table or logistic regression analyses. With serial evaluations, and including all observed dynamic changes, 60 (33%) women had FUN on at least one evaluation. In 50 women, FUN was present on their final scan, whereas in ten (5%) cases previously identified FUN resolved. Women with FUN were significantly more likely to have SPTB35 (48% versus 15%, P ⬍ .001); however, if FUN resolved, SPTB35 was significantly reduced to 10% versus 56% if FUN persisted and 15% if FUN was never observed (P ⬍ .0001). After controlling for the shortest observed CL, which was highly associated with SPTB35 in a logistic regression model (P ⬍ .001), FUN observed at any time was not a significant independent risk factor (P ⫽ .85). Moreover, FUN did not appreciably affect SPTB35 in women with
OBSTETRICS & GYNECOLOGY
either shortest observed CL of at least 25 mm (RR 1.9; 0.6, 6.1) or CL of less than 25 mm (RR 1.1; 0.6, 2.0). CONCLUSIONS: Although the natural history of second-trimester funneling in high-risk women suggests that it has a significant association with SPTB, as an independent finding it does not add appreciably to the risk of SPTB associated with the finding of a shortened second-trimester CL.
The Economic Efficacy of Sonohysterography in the Triage of Abnormal Uterine Bleeding Ted R. Cox, MD, RDMS Brookwood Medical Center, Birmingham, AL
OBJECTIVE: To show the cost and time savings using sonohysterography in the triage of abnormal uterine bleeding. METHODS: Data were collected from area hospitals and gynecologist offices related to charges for operative procedures, anesthesia, clinic visits, pelvic ultrasounds, endometrial biopsies, blood work, pathology, and sonohysterography (SHG) used in the evaluation of abnormal uterine bleeding (AUB). The total cost of the standard workup was compared with the total cost of the workup using SHG to triage AUB. RESULTS: Using SHG in evaluation of AUB when vaginal ultrasound revealed an endometrial thickness greater than 5 mm or the endometrial stripe was indistinct and could not be measured accurately in many cases allowed the avoidance of endometrial biopsies, D&C hysterography, and general anesthesia. The data reveal time saved, increased reimbursement for doctor, and decreased overall medical cost.
patients’ perceptions with male and female operators and 2) to correlate the estimation of cervical length (CL) by TVUs and DEs. METHODS: We performed TVUs and DEs at greater than 37 weeks’ gestation in singleton pregnancies. Women were surveyed before and after the procedures. RESULTS: From May 1, 2001 to January 31, 2002, 155 pregnant women underwent both TVUs and DEs on the same day. Male sonographers performed 54% of the TVUs. There was a significant association between embarrassment and sonographer male gender (P ⫽ .009). Participants who had prior TVUs were less anxious (14% versus 54%, P ⬍ .001). CL by TVU was significantly associated (P ⬍ .001) with DE assessments of effacement; consistency; and cervical dilatation. When the cervix was closed, there was no correlation between CL by TVU and effacement by DE (P ⫽ .055), whereas there was a significant correlation when the cervix was dilated (P ⫽ .02). CONCLUSIONS: Pregnant women are more comfortable with TVU when done by a female. Other factors that may affect women’s perception have to be evaluated further. Cervical dilatation allows the examiner to make an accurate estimation of cervical length by DE, but high technology (ie, TVU) may be necessary when the cervix is closed.
Ultrasound of the Cervix for the Prediction of Preterm Birth in Patients With Two or More Abortions
CONCLUSIONS: SHG, when used appropriately, can offer a dramatic reduction in medical costs and time for the patient and physician.
Jacquelyn J. Pelham, MD
Transvaginal Ultrasound and Digital Examination at Term: Does the Operator’s Gender Matter?
OBJECTIVE: To determine the predictive value (PV) for preterm birth (PTB) of transvaginal ultrasound(TVU) cervical length (CL) in patients with two or more induced abortions.
Lama L. Tolaymat, MD, MPH University Of Miami, Miami, FL
Victor Hugo Gonzalez-Quintero, MD, MPH, Orlando Gomez-Marin, MSC, PhD, Dibe Martin, MD, and Mary J. O’Sullivan, MD OBJECTIVE: Transvaginal ultrasounds (TVUs) and digital examinations (DEs) are commonly performed during pregnancy. Operators of either gender perform these examinations. Funded by ACOG District IV, TVUs and DEs were performed to assess the cervix. Our objectives were 1) to compare
VOL. 101, NO. 4 (SUPPLEMENT), APRIL 2003
Thomas Jefferson University, Philadelphia, PA
Jason Baxter, MD, and Vincenzo Berghella, MD
STUDY DESIGN: Pregnant patients with a history of induced abortion by D&C less than 12 weeks (IA) were retrospectively identified between 1995 and 2002. Exclusion criteria were less than two IAs, prior term pregnancy after IA, multiple gestations, prophylactic cerclage (PC), no TVU data, drug abuse, loss to follow-up, induced PTB, and fetal demise. Patients were prospectively observed with TVU CL between 14 and 24 weeks. The PV of TVU was evaluated using less than 25 mm CL as criteria for the diagnosis of a short cervix. The primary outcome was PTB less than 35 weeks. RESULTS: 190 patients with prior IAs were identified; 147 were excluded, leaving 43 patients for analysis. 22 of 43 (51%) had a short cervix. Of these, eight (36%) had PTB less than 35 weeks. Of the 21 patients without a short cervix, only two (10%) had PTB less than 35 weeks. The sensitivity, specificity, positive PV, and negative PV of TVU CL for PTB less than 35
WEDNESDAY POSTERS
121S