- Email: [email protected]
2095290 Sonography Interval and Diagnosis of Twin-Twin Transfusion Syndrome
S40
Ultrasound in Medicine and Biology
Objectives: This study aimed to validate the feasibility and accuracy of a new 6-step basic approach for obstetric ultrasound examination intended for the low-resource setting. Methods: Standardized stepwise approach was performed prospectively on 100 pregnant women between 18+0 and 27+6 weeks of gestation; and another 100 pregnant women between 28+0 and 36+6 weeks of gestation. Findings on the basic standardized approach were compared to the conventional ultrasound examination in the second and third trimester. Six steps focused on different aspects, step 1: fetal presentation; step 2: cardiac activity; step 3: number of fetus(es); step 4: position of placenta; step 5: amniotic fluid; step 6: fetal biometry. Results: The stepwise approach was successfully performed on all 200 pregnant women. In cases between 18+0 and 27+6 weeks of gestation, percentage of matched pairs between basic stepwise approach and conventional approach from steps 1 to 5 were 96%, 99%, 100%, 95% and 98%, respectively. Kappa value also showed good consistency. The coefficient of variation for biparietal diameter (BpD), head circumference (HC), abdominal circumference (AC) and femur length (FL) were 1.8%, 1.9%, 3.5% and 2.5%, respectively. In cases between 28+0 and 36+6 weeks of gestation, percentage of matched pairs between basic stepwise approach and regular approach from step 1 to 5 were 99%, 99%, 100%, 99% and 94%, respectively. Kappa value also showed a good consistency. Conclusions: The new basic stepwise approach can be performed successfully and accurately between 18+0 and 36+6 weeks of gestation. 2076943 The Role of Ultrasound in the Lebanese Outreach Setting Reem Abu-Rustum,1,2 M. Fouad Ziade,3 Sameer Abu-Rustum,4 Hadi Danawi5 1Center For Advanced Fetal Care, Tripoli, Lebanon; 2SANA Medical NGO, Tripoli, Lebanon; 3Faculty of Public Health, Lebanese University, Tripoli, Lebanon; 4 Dept. of Ob/Gyn, Nini Hospital, Tripoli, Lebanon; 5 College of Health Sciences School of Public Health, Walden University, Baltimore, MD, United States Objectives: To assess the role of introducing ultrasound into the obstetrical outreach setting in Lebanon among a mixed population of mothers of underserved Lebanese and Syrian refugees. Methods: This was a cross sectional study carried out over a three years period during the medical outreach missions of SANA Medical NGO in North Lebanon. Data were collected by a single obstetrician who obtained full medical and obstetrical histories. The obstetrician examined all patients and performed obstetrical sonography. The sonographic goals were to: 1- ascertain pregnancy dating 2- evaluate fetal well being and screen for congenital malformations 3- measure the amniotic fluid and 4-
Volume 41, Number 4S, 2015
determine placental location. Descriptive statistics were performed and sonographic findings were compared between the Lebanese and the Syrian refugees mothers. Outcome delivery data were not available. Data were analyzed using SPSS Version 19. Chi-square test was utilized to compare any differences between mothers of the underserved Lebanese and the Syrian refugees. P , 0.05 was considered statistically significant. Results: There were a total of 669 patients included in the analysis of whom 467 (69.8%) were Lebanese and 202 (30.2%) were Syrian refugees. SANA redated the pregnancies of 124/669 (18.5%). There were 7/669 (1%) fetuses with anomalies and 11/669 (2.6%) pregnancies with amniotic fluid abnormalities. In addition, there were 2/669 (0.3%) pregnancies with a placenta previa and another 2/669 (0.3%) with an in utero fetal demise. There was a statistically significant difference between the Lebanese and Syrian patients in terms of wrong dates (P ,0.0001) and the presence of fetal anomalies (P 0.017). Conclusions: The introduction of ultrasound into the Lebanese outreach settings plays a significant role in properly dating the pregnancies in addition to identifying at risk fetuses and detecting placental abnormalities. In the Lebanese setting, this impact is greater amongst the Syrian refugees. As such, sonographic evaluation in the Lebanese outreach obstetrical setting needs to be more available and more systematic in order to secure a safe outcome for mothers and their offspring. 2095290 Sonography Interval and Diagnosis of Twin-Twin Transfusion Syndrome Elaine Duryea,1 Sarah Happe,1 Donald McIntire,1 Jodi Dashe1 1Obstetrics, UT Southwestern, Dallas, TX, United States Objectives: To evaluate the relationship between sonographic surveillance for twin-twin transfusion syndrome (TTTS) and gestational age and stage at diagnosis. Methods: We reviewed monochorionic diamniotic pregnancies with TTTS followed with serial sonography at a single institution from 1997 to 2013. All sonogram images were reviewed by an investigator to confirm Quintero stage. Gestational age and stage were compared in those diagnosed at initial sonogram or at a subsequent sonogram either within or .14 days from a prior exam. Results: TTTS was diagnosed in 48 pregnancies, 50% at the 1st, 19% at the 2nd, and 31% at or after the 3rd sonogram. Overall, 50% were stage I, 10% stage II, 29% stage III, and 10% stages IVor V at diagnosis. Those diagnosed at initial sonogram developed disease earlier than those diagnosed during a subsequent exam, 21.463.6 weeks vs 25.164.3 weeks, P50.001, but there was no difference in TTTS stage at diagnosis, P50.2. Among those diagnosed during a follow-up sonogram, 29% had isolated oligohydramnios and 17% isolated hydramnios at the sonogram preceding diagnosis. Isolated fluid abnormalities were more common if the prior exam was within 14 days than if .14 days, 70% vs. 21%, P50.01. Stage III was more likely to be
Sonography Interval and Diagnosis of TTTS Diagnosed at Initial Sonogram Stage I II III IV V
Sonogram Interval # 14 days
n (%)
Gestational Age, weeks
n (%)
11 (46) 4 (17) 6 (25) 1 (4) 2 (8)
21.2 21.1 20.5 25.5 23.2
3 (30) 1 (10) 6 (60) 0 0
Gestational Age, weeks 24.8 26.1 22.3 -
Sonogram Interval . 14 days Gestational Age, weeks
n (%) 10 (71) 0 2 (14) 2 (14) 0
27.3 23.0 24.7 -
Abstracts
diagnosed #14 days from a prior sonogram than with longer scanning interval, P50.04 (Table), otherwise there was no difference in TTTS stage at diagnosis in relation to sonogram interval. Conclusions: TTTS stage did not differ whether the diagnosis was made at an initial or subsequent sonogram. Sonography interval .14 days was not associated with more advanced stage at diagnosis. Isolated oligohydramnios or hydramnios on prior ultrasound was associated with shorter interval to diagnosis, reflecting increased surveillance for fluid abnormalities. 2070168 The Relationship Between Intertwin Membrane Separation and Pregnancy Outcomes Carolina Bibbo,1 Mark Clapp,1 Daniela Carusi,1 Carol Benson,2 Julian Robinson1 1Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Brigham and Women’s Hospital, Boston, MA, United States; 2Radiology, Brigham and Women’s Hospital, Boston, MA, United States Objectives: The diagnosis of intertwin membrane separation is rare, and there are little data published on its clinical significance. The goal of this study was to assess the relationship between intertwin membrane separation by fluid and pregnancy outcomes. Methods: This study is a case series of women who were diagnosed with intertwin membrane separation by fluid from January 2004 to October 2013 at Brigham and Women’s Hospital. A cohort of 2,026 twin deliveries from 2005- 2011 at the same institution was used as a reference population. Results: The ultrasound database search yielded 53 cases in which the term ‘‘intertwin membrane’’ was used. Twenty-one cases were excluded: 19 because there was no intertwin membrane separation on review of the images, one because the patient delivered at an outside hospital and one because the patient underwent a fetal reduction in the second trimester. Of the 32 twin pregnancies, 31 were dichorionic diamniotic and one was monochorionic diamniotic. Among these 32 cases, 19 (59%) resulted from assisted reproductive techniques. The median gestational age at diagnosis of intertwin membrane separation was 28.1 weeks (range 18-33 weeks). The median gestational age at delivery was 36.8 weeks (reference cohort: 36.1 wks). There were nine cases (32%) of premature rupture of membranes and 17 cases (53%) of preterm delivery (reference cohort preterm delivery rate: 64%). Nine cases were complicated by intrauterine growth restriction of one or both twins. The median birth weights were 2,445 grams for twin A and 2,355 grams for twin B (reference cohort median weights: A 2,409 g, B 2,324 g). There were no cases of fetal demise or aneuploidy. Conclusions: Our case series demonstrates that the diagnosis of intertwin membrane separation by fluid has an overall good prognosis. It seems reasonable to manage these pregnancies expectantly. 2091256 Fetal Blood Flow Measurement by AngleIndependent 3D Sonography in High-Risk Patients Stephen Pinter,1 Oliver Kripfgans,1 Marjorie Treadwell,2 Anna Kneitel,2 1 1 1 J. Brian Fowlkes, Jonathan Rubin Radiology, University of Michigan, Ann Arbor, MI, United States; 2Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
S41
Objectives: Identify fetal blood volume flow in a high-risk maternal patient population using a 3D sonographic technique that is independent of angle, flow profile, and vessel geometry. Methods: Volume flow measurements were performed using a GE LOGIQ E9 ultrasound system and RAB6-D transducer (2.0-8.0 MHz). The proposed 3D flow measurement technique overcomes limitations of traditional pulsed-wave Doppler methods. Volume flow is computed through a user-specified c-surface (lateral-elevational plane) by integrating Doppler-measured velocity vectors. Partial volume effects are corrected using power Doppler. The study consisted of 16 singleton fetuses (gestation range: 26-37 weeks) of patients admitted to the University of Michigan Medical Center High Risk Obstetrics Clinic. Subjects were being observed for medical conditions such as hypertension, pre-eclampsia, obesity, gestational diabetes, advanced maternal age, and for detected fetal anomalies such as fetal ascites and bronchopulmonary sequestration. For each subject, blood flow was measured at three different locations along the umbilical cord. On average, 28 6 4 (mean 6 SD) volumes were sampled at each location to determine overall flow. The median of the three flow measurements was plotted as a function of gestational age. Linear regression slope and 95% confidence intervals (CI) were compared to normal and compromised populations reported in the literature (Tchirikov et al., Ultrasound Obstet Gynecol, 20:580-5, 2002). Results: Linear regression slope for flow measurements was 5.78 mL/min/week (CI: 1.01-10.6), which was significantly different from the regression slope of a normal population, reported as 17.0 mL/min/week (CI: 15.0-19.0) in the literature. All flow measurements from this study were positioned below the normal population’s regression line. Conclusions: Preliminary results suggest that fetal blood flow is adversely affected by multiple maternal factors. Measured fetal blood flow was significantly lower in this study’s high risk population compared to normal fetuses. Therefore, fetal blood flow measurement, using the proposed 3D sonographic technique, may provide a quantitative and robust parameter to monitor fetal well-being and assess fetal therapies. 2083673 Texture Analysis Using the Tissue Histogram Utility on Fetal Liver and Reference Organs in the Third Trimester James Maher,1,2 Curtis Boyd,1 Wainann Bejil,1 Phillip Watkins,3 Daniel Castracane,1 V. Daniel Castracane1 1OB, TTUHSC, Odessa, TX, United States; 2Maternal Fetal Medicine, Medical Center Hospital, Odessa, TX, United States; 3 TTUHSC Clinical Research Institutte, Lubbock, TX, United States Objectives: Examine texture analysis of ultrasound images in the third trimester fetus using the histogram utility on fetal liver,lung, kidney,adrenal, and spleen. Methods: Non diabetic gravidas with a BMI 19- 25 between 32 and 38 weeks were evaluated. The fetal liver was imaged repetatively in various planes. For each liver image, a reference organ was captured in the same image: Axial liver with spleen or adrenal, sagital liver with kidney, or lung Using an ROI box we attempted to obtain 3 measures of pixel intensity for each organ. Care was taken to avoid acoustic artifact. The median of the pixel intensity measurements for each image was used for analysis. GE voluson 730 RAB 4-8 probe was used on all patients.
Ultrasound in Medicine and Biology
Objectives: This study aimed to validate the feasibility and accuracy of a new 6-step basic approach for obstetric ultrasound examination intended for the low-resource setting. Methods: Standardized stepwise approach was performed prospectively on 100 pregnant women between 18+0 and 27+6 weeks of gestation; and another 100 pregnant women between 28+0 and 36+6 weeks of gestation. Findings on the basic standardized approach were compared to the conventional ultrasound examination in the second and third trimester. Six steps focused on different aspects, step 1: fetal presentation; step 2: cardiac activity; step 3: number of fetus(es); step 4: position of placenta; step 5: amniotic fluid; step 6: fetal biometry. Results: The stepwise approach was successfully performed on all 200 pregnant women. In cases between 18+0 and 27+6 weeks of gestation, percentage of matched pairs between basic stepwise approach and conventional approach from steps 1 to 5 were 96%, 99%, 100%, 95% and 98%, respectively. Kappa value also showed good consistency. The coefficient of variation for biparietal diameter (BpD), head circumference (HC), abdominal circumference (AC) and femur length (FL) were 1.8%, 1.9%, 3.5% and 2.5%, respectively. In cases between 28+0 and 36+6 weeks of gestation, percentage of matched pairs between basic stepwise approach and regular approach from step 1 to 5 were 99%, 99%, 100%, 99% and 94%, respectively. Kappa value also showed a good consistency. Conclusions: The new basic stepwise approach can be performed successfully and accurately between 18+0 and 36+6 weeks of gestation. 2076943 The Role of Ultrasound in the Lebanese Outreach Setting Reem Abu-Rustum,1,2 M. Fouad Ziade,3 Sameer Abu-Rustum,4 Hadi Danawi5 1Center For Advanced Fetal Care, Tripoli, Lebanon; 2SANA Medical NGO, Tripoli, Lebanon; 3Faculty of Public Health, Lebanese University, Tripoli, Lebanon; 4 Dept. of Ob/Gyn, Nini Hospital, Tripoli, Lebanon; 5 College of Health Sciences School of Public Health, Walden University, Baltimore, MD, United States Objectives: To assess the role of introducing ultrasound into the obstetrical outreach setting in Lebanon among a mixed population of mothers of underserved Lebanese and Syrian refugees. Methods: This was a cross sectional study carried out over a three years period during the medical outreach missions of SANA Medical NGO in North Lebanon. Data were collected by a single obstetrician who obtained full medical and obstetrical histories. The obstetrician examined all patients and performed obstetrical sonography. The sonographic goals were to: 1- ascertain pregnancy dating 2- evaluate fetal well being and screen for congenital malformations 3- measure the amniotic fluid and 4-
Volume 41, Number 4S, 2015
determine placental location. Descriptive statistics were performed and sonographic findings were compared between the Lebanese and the Syrian refugees mothers. Outcome delivery data were not available. Data were analyzed using SPSS Version 19. Chi-square test was utilized to compare any differences between mothers of the underserved Lebanese and the Syrian refugees. P , 0.05 was considered statistically significant. Results: There were a total of 669 patients included in the analysis of whom 467 (69.8%) were Lebanese and 202 (30.2%) were Syrian refugees. SANA redated the pregnancies of 124/669 (18.5%). There were 7/669 (1%) fetuses with anomalies and 11/669 (2.6%) pregnancies with amniotic fluid abnormalities. In addition, there were 2/669 (0.3%) pregnancies with a placenta previa and another 2/669 (0.3%) with an in utero fetal demise. There was a statistically significant difference between the Lebanese and Syrian patients in terms of wrong dates (P ,0.0001) and the presence of fetal anomalies (P 0.017). Conclusions: The introduction of ultrasound into the Lebanese outreach settings plays a significant role in properly dating the pregnancies in addition to identifying at risk fetuses and detecting placental abnormalities. In the Lebanese setting, this impact is greater amongst the Syrian refugees. As such, sonographic evaluation in the Lebanese outreach obstetrical setting needs to be more available and more systematic in order to secure a safe outcome for mothers and their offspring. 2095290 Sonography Interval and Diagnosis of Twin-Twin Transfusion Syndrome Elaine Duryea,1 Sarah Happe,1 Donald McIntire,1 Jodi Dashe1 1Obstetrics, UT Southwestern, Dallas, TX, United States Objectives: To evaluate the relationship between sonographic surveillance for twin-twin transfusion syndrome (TTTS) and gestational age and stage at diagnosis. Methods: We reviewed monochorionic diamniotic pregnancies with TTTS followed with serial sonography at a single institution from 1997 to 2013. All sonogram images were reviewed by an investigator to confirm Quintero stage. Gestational age and stage were compared in those diagnosed at initial sonogram or at a subsequent sonogram either within or .14 days from a prior exam. Results: TTTS was diagnosed in 48 pregnancies, 50% at the 1st, 19% at the 2nd, and 31% at or after the 3rd sonogram. Overall, 50% were stage I, 10% stage II, 29% stage III, and 10% stages IVor V at diagnosis. Those diagnosed at initial sonogram developed disease earlier than those diagnosed during a subsequent exam, 21.463.6 weeks vs 25.164.3 weeks, P50.001, but there was no difference in TTTS stage at diagnosis, P50.2. Among those diagnosed during a follow-up sonogram, 29% had isolated oligohydramnios and 17% isolated hydramnios at the sonogram preceding diagnosis. Isolated fluid abnormalities were more common if the prior exam was within 14 days than if .14 days, 70% vs. 21%, P50.01. Stage III was more likely to be
Sonography Interval and Diagnosis of TTTS Diagnosed at Initial Sonogram Stage I II III IV V
Sonogram Interval # 14 days
n (%)
Gestational Age, weeks
n (%)
11 (46) 4 (17) 6 (25) 1 (4) 2 (8)
21.2 21.1 20.5 25.5 23.2
3 (30) 1 (10) 6 (60) 0 0
Gestational Age, weeks 24.8 26.1 22.3 -
Sonogram Interval . 14 days Gestational Age, weeks
n (%) 10 (71) 0 2 (14) 2 (14) 0
27.3 23.0 24.7 -
Abstracts
diagnosed #14 days from a prior sonogram than with longer scanning interval, P50.04 (Table), otherwise there was no difference in TTTS stage at diagnosis in relation to sonogram interval. Conclusions: TTTS stage did not differ whether the diagnosis was made at an initial or subsequent sonogram. Sonography interval .14 days was not associated with more advanced stage at diagnosis. Isolated oligohydramnios or hydramnios on prior ultrasound was associated with shorter interval to diagnosis, reflecting increased surveillance for fluid abnormalities. 2070168 The Relationship Between Intertwin Membrane Separation and Pregnancy Outcomes Carolina Bibbo,1 Mark Clapp,1 Daniela Carusi,1 Carol Benson,2 Julian Robinson1 1Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Brigham and Women’s Hospital, Boston, MA, United States; 2Radiology, Brigham and Women’s Hospital, Boston, MA, United States Objectives: The diagnosis of intertwin membrane separation is rare, and there are little data published on its clinical significance. The goal of this study was to assess the relationship between intertwin membrane separation by fluid and pregnancy outcomes. Methods: This study is a case series of women who were diagnosed with intertwin membrane separation by fluid from January 2004 to October 2013 at Brigham and Women’s Hospital. A cohort of 2,026 twin deliveries from 2005- 2011 at the same institution was used as a reference population. Results: The ultrasound database search yielded 53 cases in which the term ‘‘intertwin membrane’’ was used. Twenty-one cases were excluded: 19 because there was no intertwin membrane separation on review of the images, one because the patient delivered at an outside hospital and one because the patient underwent a fetal reduction in the second trimester. Of the 32 twin pregnancies, 31 were dichorionic diamniotic and one was monochorionic diamniotic. Among these 32 cases, 19 (59%) resulted from assisted reproductive techniques. The median gestational age at diagnosis of intertwin membrane separation was 28.1 weeks (range 18-33 weeks). The median gestational age at delivery was 36.8 weeks (reference cohort: 36.1 wks). There were nine cases (32%) of premature rupture of membranes and 17 cases (53%) of preterm delivery (reference cohort preterm delivery rate: 64%). Nine cases were complicated by intrauterine growth restriction of one or both twins. The median birth weights were 2,445 grams for twin A and 2,355 grams for twin B (reference cohort median weights: A 2,409 g, B 2,324 g). There were no cases of fetal demise or aneuploidy. Conclusions: Our case series demonstrates that the diagnosis of intertwin membrane separation by fluid has an overall good prognosis. It seems reasonable to manage these pregnancies expectantly. 2091256 Fetal Blood Flow Measurement by AngleIndependent 3D Sonography in High-Risk Patients Stephen Pinter,1 Oliver Kripfgans,1 Marjorie Treadwell,2 Anna Kneitel,2 1 1 1 J. Brian Fowlkes, Jonathan Rubin Radiology, University of Michigan, Ann Arbor, MI, United States; 2Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
S41
Objectives: Identify fetal blood volume flow in a high-risk maternal patient population using a 3D sonographic technique that is independent of angle, flow profile, and vessel geometry. Methods: Volume flow measurements were performed using a GE LOGIQ E9 ultrasound system and RAB6-D transducer (2.0-8.0 MHz). The proposed 3D flow measurement technique overcomes limitations of traditional pulsed-wave Doppler methods. Volume flow is computed through a user-specified c-surface (lateral-elevational plane) by integrating Doppler-measured velocity vectors. Partial volume effects are corrected using power Doppler. The study consisted of 16 singleton fetuses (gestation range: 26-37 weeks) of patients admitted to the University of Michigan Medical Center High Risk Obstetrics Clinic. Subjects were being observed for medical conditions such as hypertension, pre-eclampsia, obesity, gestational diabetes, advanced maternal age, and for detected fetal anomalies such as fetal ascites and bronchopulmonary sequestration. For each subject, blood flow was measured at three different locations along the umbilical cord. On average, 28 6 4 (mean 6 SD) volumes were sampled at each location to determine overall flow. The median of the three flow measurements was plotted as a function of gestational age. Linear regression slope and 95% confidence intervals (CI) were compared to normal and compromised populations reported in the literature (Tchirikov et al., Ultrasound Obstet Gynecol, 20:580-5, 2002). Results: Linear regression slope for flow measurements was 5.78 mL/min/week (CI: 1.01-10.6), which was significantly different from the regression slope of a normal population, reported as 17.0 mL/min/week (CI: 15.0-19.0) in the literature. All flow measurements from this study were positioned below the normal population’s regression line. Conclusions: Preliminary results suggest that fetal blood flow is adversely affected by multiple maternal factors. Measured fetal blood flow was significantly lower in this study’s high risk population compared to normal fetuses. Therefore, fetal blood flow measurement, using the proposed 3D sonographic technique, may provide a quantitative and robust parameter to monitor fetal well-being and assess fetal therapies. 2083673 Texture Analysis Using the Tissue Histogram Utility on Fetal Liver and Reference Organs in the Third Trimester James Maher,1,2 Curtis Boyd,1 Wainann Bejil,1 Phillip Watkins,3 Daniel Castracane,1 V. Daniel Castracane1 1OB, TTUHSC, Odessa, TX, United States; 2Maternal Fetal Medicine, Medical Center Hospital, Odessa, TX, United States; 3 TTUHSC Clinical Research Institutte, Lubbock, TX, United States Objectives: Examine texture analysis of ultrasound images in the third trimester fetus using the histogram utility on fetal liver,lung, kidney,adrenal, and spleen. Methods: Non diabetic gravidas with a BMI 19- 25 between 32 and 38 weeks were evaluated. The fetal liver was imaged repetatively in various planes. For each liver image, a reference organ was captured in the same image: Axial liver with spleen or adrenal, sagital liver with kidney, or lung Using an ROI box we attempted to obtain 3 measures of pixel intensity for each organ. Care was taken to avoid acoustic artifact. The median of the pixel intensity measurements for each image was used for analysis. GE voluson 730 RAB 4-8 probe was used on all patients.