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609 Increased incidence of stillbirth in fetuses with gastroschisis
$246 SMFM Abstracts 609
INCREASED INCIDENCE OF STILLBIRTH IN FETUSES W I T H GASTROSCHISIS RICHARD BROTH 1, PHILIP SHLOSSMAN2, MARION KAUFMANN 1, VINCENZO BERGHELLA3; 1Thomas Jefferson University, Maternal Fetal Medicine, Philadelphia, PA, 2Christian Hospital, Maternal-Fetal Medicine, Newark, DE; 3Thomas Jefferson University, Obstetrics and Gynecology, Philadelphia, PA OBJECTIVE: To determine the incidence of stillbirth and neonatal death in one of the largest cohort of pregnancies complicated by gastroschisis. STUDY DESIGN: All cases of antenatally diagnosed gastroschisis from Thomas Jefferson University Hospital and Christiana Hospital between January 1991 and August 2001 were reviewed for incidence of stillbirth and neonatal death. RESULTS: 78 fetuses with gastroschisis were identified. Six were excluded for potentially lethal congenital ma/forn~ation (n = 1 ), pregnancy terntination (n - 1), and undelivered (n = 4). The stillbirth rate (>28 weeks) was 85/1000 births, as compared to 5.4/1000 births in the State of New Jersey 1991-1998 (lAMA; 6/2001). All of these stillbirths occurred between 33 and 40 weeks gestation. The neonatal death rate (within 28 days of birth) was 17.5/1000 births, as compared to the national rate of 4.7/1000 births (CDC, 1999). CONCLUSION: In one of the largest series of isolated gastroschisis, the incidence of stillbirth was 14 times greater than cross-sectional controls. Neonatal mortality was increased fore-fold. This data suggests the need for close fetal monitoring in the third trimester in these fetuses and possible early intervention. Further research with an even bigger population of gastroschisis fetuses may suggest the ideal time of delivery to best prevent stillbirths.
December 2001 A m J Obstet Gynecol 611
FEASIBILITY OF MAGNETIC RESONANCE L U N G VOLUMES IN FETUSES AT RISK FOR PULMONARY HYPOPLASIA DM TWICKLER~, J CAIRE 1, DD MCINTIRE2, KP MAGEE~, RM RAMUS2: ]University of Texas Southwestern, Radiology, Dallas, TX; '-'University of Texas Southwestern, Obstetrics and Gynecology; 3Perinatal Associates of Texas, Dallas, TX OBJECTIVE: To compare magnetic resonance (MR) lung volume calculations in fetuses with suspected renal or chest abnormalities for trends in prediction of puhnonary hypoplasia. STUDY DESIGN: Fetuses with suspected renal or chest abnormalities underwent blinded retrospective calculation of total lung volume (TLV) by outlining regions of interest on consecutive 7mm MR slices obtained in 90 seconds with superfast technique. Groups were assigned based on neonatal outcome or autopsy of lethal anomaly, non-lethal anomaly or diaphragmatic hernia. Analysis of covariauce was performed. The TLV/Gestational age (GA) of each group was compared. RESULTS: Of 24 MR studies presently perfbrmed, there were 9 live born fetuses, 11 lethal outcomes, and 4 diaphragmatic hernias, 3 of whom survived. The TLV/GA significantly differerent in between lethal and non-lethal groups (P< .05). CONCLUSION: 1. A significant difference is seen between lethal and nonlethal fetuses in MR assessment of puhnonary volume, especially at later gestations. 2. The diaphragmatic hernia curve has the smallest slope in spite of three of four neonates surviving. 3. MR lung volume measurement is feasible and may be performed in cases where assessment by ultrasound is problematic, such as during the third trimester or in the setting of oligohydramnios. Figure 120 100
g
80
=s
60
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40
==
P-values for differen0es in slopes Lethal vs. Nofl-leth~: 0.004 Lethal v~. Oiaph. Hernia: 0.148 Non-lethal v~. Diaph, Hernia: 0.002
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610
AN UPDATE ON NUCLEATED RED BLOOD CELLS AS AN INDICATOR OF FETAL ASPHYXIA ROBERT BONEBRAKE l, AMY KELLY1, ALFRED FLEMING~; ICreighton University, Obstetrics and Gynecology, Omaha, NE; 2Creighton University, Department of Obstetrics and Gynecolog), Omaha, NE OBJECTIVE: To determine if nucleated red blood cells (NRBCs) can objectively be used to confirm the presence of fetal asphyxia and deterutine a risk for perinatal neurologic sequelae. STUDY DESIGN: In this study, asphyxia is defined by institutional neonatal intensive care unit discharge diagnosis guidelines as a pH of less than or equal to 7.15, a 5-ntinute APGAR score of <7, and immediate neurologic impairment. Singleton live-born infhnts at 37+ weeks' estimated gestational age (EGA) delivered either vaginally or by cesarean section with the diagnosis of asphyxia were included. Intants with the same criteria, except for asphyxia, were used as a control. The discharge diagnoses tot 9088 neonates over a 9year span fi-om a tertiary care referral hospital were reviewed. 17 neonatal charts met all of the inclusion criteria, and these were reviewed and analyzed. A matched control group consisting of 40 neonates discharged during the same time period were reviewed and analyzed. EGA, APGAR scores, cord pH, and the n m n b e r of NRBCs were analyzed. The Mann Whitney Rank Stun test was used tor analysis between the study and control groups and to analyze the outcome of the study group. The Wilcoxon's nonparametric test was then used to analyze the outcome within the study group. RESULTS: There was no statistically significant difference in EGA. NRBCs were found to be significantly different to P< .001, with a sensitivity of 94% and a specificity of 60%. The cord pH and 1- and 5-ufinute APGARs were all found to be significant. Within the study group, analysis of perinatal outcome and n u m b e r of NRBCs was found to be statistically significant to P < .04. CONCLUSION: NRBCs appear to be an objective, independent variable of fetal asphyxia. Furthermore, there appears to be an association between perinatal outcome and the level of NRBCs.
612
FETAL CENTRAL NERVOUS SYSTEM VENTRICLE AND CISTERNA M A G N A MEASUREMENTS BY MAGNETIC RESONANCE IMAGING DM TWICKLER1, T REICHEL ~, DD MCINTIRE 2, KP MAGEE3, RM RAMUS2; ]University of Texas Southwestern Medical Center, Radiology, Dallas, TX; 2University of Texas Southwestern Medical Center, Obstetrics and Gynecology, Dallas, TX; 3Perinatal Associates of Texas, Dallas, TX OBJECTIVE: To evaluate the ventricular atria and cisterna m a g n a in tetuses with and without suspected central nmwous system (CNS) anomalies by magnetic resonance (MR). STUDY DESIGN: Measurements of the right and lett veturicular atria (RVA, LVA) and cisterna manna (CM) were obtained hy MR in two groups: those with (abn) and without (norm) CNS anomalies. Published mean ultrasound (US) measurements of tile fhr field atrimn were compared to MR. Linear regression, analysis of covariance, and tests fbr nornaality were performed. RESULTS: MR measurements were obtained in 23 fetuses without and 37 fetuses with CNS anomalies. Atrial umasurements were i n d e p e d e n t of gestational age in normals. MR atrial widths were larger in abnormals compared to normals and the mean atrial MR width in normals is less than expected compared to the US width (Table). The atrial cut-off derived by 2SD above the n, ean with MR is 10ram. Asymmetry of ventricular width (>4ram) was seen in 7/35 (20%) abnormal fetuses and none of the normal fetuses. MR CM measurements increased with gestational age (P = .005). CONCLUSION: 1. While mean ventricular widths on MR and US differ slightl), >10mm should be the cut-off for ventriculomegaly on MR. 2. MR umasurements of the cisterna m a g n a are d e p e n d e n t on gestational age, contrary to US findings. 3. Both ventricles are readily measured with MR and asymmetry is seen in 20% of fetuses with CNS abnormalities. Table MR and US ventricular atria width [nnn(SD)]
RVA LVA p-(L vs R)
NORMAL US
NORM MR
7.5 (.6)* 7.5 (.6)*
6.6 (2.1)* 6.1 (1.9)* NS
ABN MR
13.8 (10.0)* 12.6 (7.3)* NS
*P< .05 *P< .05
INCREASED INCIDENCE OF STILLBIRTH IN FETUSES W I T H GASTROSCHISIS RICHARD BROTH 1, PHILIP SHLOSSMAN2, MARION KAUFMANN 1, VINCENZO BERGHELLA3; 1Thomas Jefferson University, Maternal Fetal Medicine, Philadelphia, PA, 2Christian Hospital, Maternal-Fetal Medicine, Newark, DE; 3Thomas Jefferson University, Obstetrics and Gynecology, Philadelphia, PA OBJECTIVE: To determine the incidence of stillbirth and neonatal death in one of the largest cohort of pregnancies complicated by gastroschisis. STUDY DESIGN: All cases of antenatally diagnosed gastroschisis from Thomas Jefferson University Hospital and Christiana Hospital between January 1991 and August 2001 were reviewed for incidence of stillbirth and neonatal death. RESULTS: 78 fetuses with gastroschisis were identified. Six were excluded for potentially lethal congenital ma/forn~ation (n = 1 ), pregnancy terntination (n - 1), and undelivered (n = 4). The stillbirth rate (>28 weeks) was 85/1000 births, as compared to 5.4/1000 births in the State of New Jersey 1991-1998 (lAMA; 6/2001). All of these stillbirths occurred between 33 and 40 weeks gestation. The neonatal death rate (within 28 days of birth) was 17.5/1000 births, as compared to the national rate of 4.7/1000 births (CDC, 1999). CONCLUSION: In one of the largest series of isolated gastroschisis, the incidence of stillbirth was 14 times greater than cross-sectional controls. Neonatal mortality was increased fore-fold. This data suggests the need for close fetal monitoring in the third trimester in these fetuses and possible early intervention. Further research with an even bigger population of gastroschisis fetuses may suggest the ideal time of delivery to best prevent stillbirths.
December 2001 A m J Obstet Gynecol 611
FEASIBILITY OF MAGNETIC RESONANCE L U N G VOLUMES IN FETUSES AT RISK FOR PULMONARY HYPOPLASIA DM TWICKLER~, J CAIRE 1, DD MCINTIRE2, KP MAGEE~, RM RAMUS2: ]University of Texas Southwestern, Radiology, Dallas, TX; '-'University of Texas Southwestern, Obstetrics and Gynecology; 3Perinatal Associates of Texas, Dallas, TX OBJECTIVE: To compare magnetic resonance (MR) lung volume calculations in fetuses with suspected renal or chest abnormalities for trends in prediction of puhnonary hypoplasia. STUDY DESIGN: Fetuses with suspected renal or chest abnormalities underwent blinded retrospective calculation of total lung volume (TLV) by outlining regions of interest on consecutive 7mm MR slices obtained in 90 seconds with superfast technique. Groups were assigned based on neonatal outcome or autopsy of lethal anomaly, non-lethal anomaly or diaphragmatic hernia. Analysis of covariauce was performed. The TLV/Gestational age (GA) of each group was compared. RESULTS: Of 24 MR studies presently perfbrmed, there were 9 live born fetuses, 11 lethal outcomes, and 4 diaphragmatic hernias, 3 of whom survived. The TLV/GA significantly differerent in between lethal and non-lethal groups (P< .05). CONCLUSION: 1. A significant difference is seen between lethal and nonlethal fetuses in MR assessment of puhnonary volume, especially at later gestations. 2. The diaphragmatic hernia curve has the smallest slope in spite of three of four neonates surviving. 3. MR lung volume measurement is feasible and may be performed in cases where assessment by ultrasound is problematic, such as during the third trimester or in the setting of oligohydramnios. Figure 120 100
g
80
=s
60
>
40
==
P-values for differen0es in slopes Lethal vs. Nofl-leth~: 0.004 Lethal v~. Oiaph. Hernia: 0.148 Non-lethal v~. Diaph, Hernia: 0.002
•
"l~on-lethal
~=
•
Analysisof Covariance o
oo
,,,~o
20
=
<>
. ....
Lethal
o. - .~iaphragmati¢ Hernia
demise
15
20
25
30
35
40
Gestational a g e
610
AN UPDATE ON NUCLEATED RED BLOOD CELLS AS AN INDICATOR OF FETAL ASPHYXIA ROBERT BONEBRAKE l, AMY KELLY1, ALFRED FLEMING~; ICreighton University, Obstetrics and Gynecology, Omaha, NE; 2Creighton University, Department of Obstetrics and Gynecolog), Omaha, NE OBJECTIVE: To determine if nucleated red blood cells (NRBCs) can objectively be used to confirm the presence of fetal asphyxia and deterutine a risk for perinatal neurologic sequelae. STUDY DESIGN: In this study, asphyxia is defined by institutional neonatal intensive care unit discharge diagnosis guidelines as a pH of less than or equal to 7.15, a 5-ntinute APGAR score of <7, and immediate neurologic impairment. Singleton live-born infhnts at 37+ weeks' estimated gestational age (EGA) delivered either vaginally or by cesarean section with the diagnosis of asphyxia were included. Intants with the same criteria, except for asphyxia, were used as a control. The discharge diagnoses tot 9088 neonates over a 9year span fi-om a tertiary care referral hospital were reviewed. 17 neonatal charts met all of the inclusion criteria, and these were reviewed and analyzed. A matched control group consisting of 40 neonates discharged during the same time period were reviewed and analyzed. EGA, APGAR scores, cord pH, and the n m n b e r of NRBCs were analyzed. The Mann Whitney Rank Stun test was used tor analysis between the study and control groups and to analyze the outcome of the study group. The Wilcoxon's nonparametric test was then used to analyze the outcome within the study group. RESULTS: There was no statistically significant difference in EGA. NRBCs were found to be significantly different to P< .001, with a sensitivity of 94% and a specificity of 60%. The cord pH and 1- and 5-ufinute APGARs were all found to be significant. Within the study group, analysis of perinatal outcome and n u m b e r of NRBCs was found to be statistically significant to P < .04. CONCLUSION: NRBCs appear to be an objective, independent variable of fetal asphyxia. Furthermore, there appears to be an association between perinatal outcome and the level of NRBCs.
612
FETAL CENTRAL NERVOUS SYSTEM VENTRICLE AND CISTERNA M A G N A MEASUREMENTS BY MAGNETIC RESONANCE IMAGING DM TWICKLER1, T REICHEL ~, DD MCINTIRE 2, KP MAGEE3, RM RAMUS2; ]University of Texas Southwestern Medical Center, Radiology, Dallas, TX; 2University of Texas Southwestern Medical Center, Obstetrics and Gynecology, Dallas, TX; 3Perinatal Associates of Texas, Dallas, TX OBJECTIVE: To evaluate the ventricular atria and cisterna m a g n a in tetuses with and without suspected central nmwous system (CNS) anomalies by magnetic resonance (MR). STUDY DESIGN: Measurements of the right and lett veturicular atria (RVA, LVA) and cisterna manna (CM) were obtained hy MR in two groups: those with (abn) and without (norm) CNS anomalies. Published mean ultrasound (US) measurements of tile fhr field atrimn were compared to MR. Linear regression, analysis of covariance, and tests fbr nornaality were performed. RESULTS: MR measurements were obtained in 23 fetuses without and 37 fetuses with CNS anomalies. Atrial umasurements were i n d e p e d e n t of gestational age in normals. MR atrial widths were larger in abnormals compared to normals and the mean atrial MR width in normals is less than expected compared to the US width (Table). The atrial cut-off derived by 2SD above the n, ean with MR is 10ram. Asymmetry of ventricular width (>4ram) was seen in 7/35 (20%) abnormal fetuses and none of the normal fetuses. MR CM measurements increased with gestational age (P = .005). CONCLUSION: 1. While mean ventricular widths on MR and US differ slightl), >10mm should be the cut-off for ventriculomegaly on MR. 2. MR umasurements of the cisterna m a g n a are d e p e n d e n t on gestational age, contrary to US findings. 3. Both ventricles are readily measured with MR and asymmetry is seen in 20% of fetuses with CNS abnormalities. Table MR and US ventricular atria width [nnn(SD)]
RVA LVA p-(L vs R)
NORMAL US
NORM MR
7.5 (.6)* 7.5 (.6)*
6.6 (2.1)* 6.1 (1.9)* NS
ABN MR
13.8 (10.0)* 12.6 (7.3)* NS
*P< .05 *P< .05