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617 Natural history of prenatally diagnosed choroid plexus cysts
$248 SMFM Abstracts 617
December 2001 Am J Obstet Gynecol
NATURAL HISTORY OF PRENATALLY DIAGNOSED CHOROID PLEXUS CYSTS MICHAEL BARSOOM 1, ADAM BORGIDAt, JAMES EGAN2; iUniversity of Connecticut, Obstetrics and Gynecology, Farmington, CT; 2St Francis Hospital and Medical Center, Obstetrics and Gynecology, Hartford, CT OBJECTIVE: Choroid plexus cysts (CPC) are seen in 2-3% ofsonograms at 16-20 weeks gestation. When seen without other anomalies they are presumed to be asyn~ptomatic and transient. Howevel, due to their location in the fetal brain they may cause parental anxiety. We have routinely followed CPC with an ultrasound 4-6 weeks later for resolution. Our objective was to determine the natural history of CPC. STUDY DESIGN: We conducted a retrospective review of our ultrasound database from Jan 1995 to May 2001. We studied all patients with a CPC identified by ultrasound. Subsequent ultrasounds for these patients were reviewed. We determined 1) the frequency of CPC in our population, 2) the percentage of CPC which resolve, and 3) the timing of resolution. Descriptive statistics were used as appropriate. RESULTS: We performed 44,395 ultrasound exams on 20,198 fetuses. CPC were seen in 336 (1.7%) fetuses at a mean (+SD) gestational age of 18.4 (+1.9) weeks. Of these, 306 had fofiow-up ultrasounds. Resolution of CPC occurred in 290 (95%) fetuses, while 16 (5%) did not resolve. The final ultrasound on the 16 without CPC resolution was perfolaned at a mean (+range) gestation age of 23.3 weeks (16.6-27.9). The mean (_+SD) gestation age of CPC resolution was 23.3 (-+2.9) weeks. As seen in the survival curve with resolution of 50%, 75%, and 90% of CPC occurred at 23.0, 24.4, and 29.0 weeks gestation respectively. The latest a CPC was seen was at 37.6 weeks. CONCLUSION: We documented resolution of 95% of prenatally identifed CPC prior to birth. Over 90% resolved by 29 weeks gestation. Figure Survival curve for resolution of CPC
619
DOWN SYNDROME RISK R E D U C T I O N AFTER NORMAL GENETIC SONOGRAPHY ANTHONYVINTZILEOS1, EDWIN GUZMAN1,JOHN SMULIAN1, LAMI YEO 1, WILLIAM SCORZA l, ROBERT KNUPPEL 1, 1UMDNJRobert Wood Johnson Medical School/Saint Peter's University Hospital, Obstetrics, Gynecology and Reproductive Sciences, New Brunswick, NJ OBJECTIVE: To determine if there are any indication-specific variations in risk reduction for fetal Down syndrome (DS) after a n o r m a l genetic sonogram. STUDY DESIGN: Since November 1, 1992, a second trinaester genetic sonogram has been offered to all pregnant women who are at increased risk for fetal DS (> 1:274) because of either advanced maternal age (AMA, _>35 years), abnormal serum biochemistry or both. Outcome information included the results of genetic amniocentesis, if performed, and the results of pediatric assessment and follow up afterbirth. Normal genetic sonogram was defined as the absence of all ultrasound aneuploidy markers (structural anomaly, nuchal fold _>6ram, short femur, short humerus, echogenic intracardiac focus, echogenic bowel, pyelectasis, choroid plexus cysts, clinodactyly, sandal gap and two-vessel cord). RESULTS: The overall sensitivity of genetic sonography in detecting DS was 86% (44/51). The results according to the indication for testing are shown in the Table. CONCLUSION: There were no clinically significant variations in the risk reduction for DS after normal genetic sonography; regardless of the indication for testing the likelihood for fetal DS was reduced by 81-88% by normal genetic sonography.
Table DS risk reduction table RISK REDUCTION
L0
P-DS
0.9-
0.8 ~0.7
~
0.6
AMA (n = 2677) 0.9% ABN TS (n = 1073) 2.5% ABN TS in _<35yo (n = 679) 3% ABN TS & AMA (n = 394) 1.5%
-
~0,4
-
~0.3
-
0.2-
P-DSNGS
OR (CI)
NEGATIVE PERCENT LR (CI) (%)
0.17% (4/2393) 5.36 (1.86, 15.48)
0.19 (0.06, 0.54)
81
0.33% (3/898)
7.53 (2.28, 24,91)
0.13 (0.04,0.44)
87
0.36% (2/555)
8.58 (2.00, 36,76)
0.12 (0.03, 0.50)
88
0.29% (1/343)
5.22 (0.63, 43.60)
0.19 (0.02, 1.60)
81
P-DS, Prevalence of DS; PDS-NGS, prevalence of DS alter nolxnal genetic sonograrn; OR, odds ratio; LR, likelihood ratio; C/, 95% confidence interval; ABN,abnormal; TS, triple screen.
0A0.0-
3o
3s
,0
EOA
618
T H E VALUE OF REPEATING A FULL ANATOMIC SURVEY AT SUBSEQ U E N T OBSTETRICAL ULTRASOUND EXAMINATIONS IN WOMEN WITH A NORMAL SCAN AT 18-20 WEEKS NATHAN WAGSTAFFt, EMMANUEL BUJOLD 1, MARK REDMAN1, SEAN M. BLACKWELL1, SONIA S. HASSAN 1, STANLEY M. BERRYJ, 1Wayne State University, Obstetrics & Gynecology, Detroit, MI OBJECTIVE: Many ultrasound units, including ours, repeat a full anatomic sm-vey each time a patient returns for follow-up exam. We sought to assess how often anomalies were diagnosed by repeating the full survey when the ultrasound at 18-20 weeks was nornlal. STUDY DESIGN: Review of a computerized ultrasound database identified all patients who had undergone a screening obstetrical ultrasound examination between 18-20 weeks Irom August 1, 1999 through June 30, 2001. Records with abnormal anatomic findings were excluded. Patients who underwent subsequent ultrasounds during the same pregnancy comprised the study population. The records of subsequent ultrasounds in which an anomaly was reported were reviewed. RESULTS: Of the 18,666 uhrasounds performed during the study period, 1,651 were initial exams at 18-20 weeks' and 83 (5%) had anomalies. Of 1,568 w o m e n who had a normal ultrasound, 328 (20.9%) underwent 457 repeat anatomic surveys. Seven anomalies were identified: 5 cases of renal pelvis dilatation (RPD), 1 bronchial cyst (BC), and 1 enlarged cisterna m a g n a (ECM). None of the renal anomalies were present at postnatal ultrasound. At birth the BC was found to be a thymal cyst of no consequence. Postnatal ultrasound showed the ECM to be a "normal variant." Thus, 229 full anatomic smweys were repeated for each anomaly confirmed at birth. The total cost of repeat ultrasounds was $125,675. The added cost of the fun anatomic survey was $3,428 per anomaly confirmed at birth. The two infants bad a completely normal postnatal course. CONCLUSION: Over 20% of patients with a normal ultrasound between 18-20 weeks had a full anatomic survey repeated, but only 0.4% of the repeat scans revealed an anomaly that was confirmed at birth. Our data call into question the practice of routinely repeating a full anatomic survey subsequent to a normal ultrasound performed between 18-20 weeks.
620
DO SECOND TRIMESTER ULTRASOUND MARKERS CORRELATE WITH SERUM SCREEN ANALYTES? L1LLIAN KAMINSKY1,JAMES E G A N 1, GARRY TURNER1, CHARLES INGARDIA2, PETER BENNa; i University of Connecticut, Obstetrics/Gynecology, Farmingtun, CT; 2Hartford Hospital, Hartford, CT; 3University of Connecticut, Pediatrics, Farmingtun, CT OBJECTIVE: Down syndrome (DS) risks have been modified by serum screening and ultrasound, which are assumed to be independent. O u r objective was to determine the correlation between individual maternal serum screen analytes and ultlasound markers. STUDY DESIGN: The study group consisted of women with DS fetuses who had both serum screen and ultrasound performed and a control group of normal fetuses. In both groups, maternal serum alpha-fetoprotein (MSAFP), hCG, unconjugated estriol (E3), inhibin-A (INH-A), nuchal fold thickness, and biparietal diameter to f e m u r and humerus length ratios (BPD/FL and BPD/HL) were tested by Pearson correlation coefficient. We used the nonparametric Wilcoxon two group test to analyze echogenic bowel, ventriculomegaly, pyelectasis, clinodactyly, echogenic intracardiac focus and serum screen analytes in DS fetuses only. RESULTS: T h e r e were 67 DS cases (31 with quad screens and 36 with triple screens) and 169 controls (81 with quad screens and 88 with triple screens). Increased nuchal fold thickness (n = 41) correlated with higher hCG levels (R = 0.41, P = .003) in DS fetuses, but not in the controls. Increased BPD/FL and B P D / H L ratios correlated with lower E3 levels (R = 0.32 and 0.36, P = .006 and .002) in DS fetuses, but not in the controls. No other associations were identified between ultrasound markers and serum screen analytes. CONCLUSION: Common pathophysiology of nuchal fold thickening and hCG elevation may exist. In addition, lower E3 concentrations appear to be related to short femur or humerus in DS pregnancies. Observed correlations n e e d to be considered when a d j u s t i n g 2rid trimester DS risks following maternal serum and ultrasound screens.
December 2001 Am J Obstet Gynecol
NATURAL HISTORY OF PRENATALLY DIAGNOSED CHOROID PLEXUS CYSTS MICHAEL BARSOOM 1, ADAM BORGIDAt, JAMES EGAN2; iUniversity of Connecticut, Obstetrics and Gynecology, Farmington, CT; 2St Francis Hospital and Medical Center, Obstetrics and Gynecology, Hartford, CT OBJECTIVE: Choroid plexus cysts (CPC) are seen in 2-3% ofsonograms at 16-20 weeks gestation. When seen without other anomalies they are presumed to be asyn~ptomatic and transient. Howevel, due to their location in the fetal brain they may cause parental anxiety. We have routinely followed CPC with an ultrasound 4-6 weeks later for resolution. Our objective was to determine the natural history of CPC. STUDY DESIGN: We conducted a retrospective review of our ultrasound database from Jan 1995 to May 2001. We studied all patients with a CPC identified by ultrasound. Subsequent ultrasounds for these patients were reviewed. We determined 1) the frequency of CPC in our population, 2) the percentage of CPC which resolve, and 3) the timing of resolution. Descriptive statistics were used as appropriate. RESULTS: We performed 44,395 ultrasound exams on 20,198 fetuses. CPC were seen in 336 (1.7%) fetuses at a mean (+SD) gestational age of 18.4 (+1.9) weeks. Of these, 306 had fofiow-up ultrasounds. Resolution of CPC occurred in 290 (95%) fetuses, while 16 (5%) did not resolve. The final ultrasound on the 16 without CPC resolution was perfolaned at a mean (+range) gestation age of 23.3 weeks (16.6-27.9). The mean (_+SD) gestation age of CPC resolution was 23.3 (-+2.9) weeks. As seen in the survival curve with resolution of 50%, 75%, and 90% of CPC occurred at 23.0, 24.4, and 29.0 weeks gestation respectively. The latest a CPC was seen was at 37.6 weeks. CONCLUSION: We documented resolution of 95% of prenatally identifed CPC prior to birth. Over 90% resolved by 29 weeks gestation. Figure Survival curve for resolution of CPC
619
DOWN SYNDROME RISK R E D U C T I O N AFTER NORMAL GENETIC SONOGRAPHY ANTHONYVINTZILEOS1, EDWIN GUZMAN1,JOHN SMULIAN1, LAMI YEO 1, WILLIAM SCORZA l, ROBERT KNUPPEL 1, 1UMDNJRobert Wood Johnson Medical School/Saint Peter's University Hospital, Obstetrics, Gynecology and Reproductive Sciences, New Brunswick, NJ OBJECTIVE: To determine if there are any indication-specific variations in risk reduction for fetal Down syndrome (DS) after a n o r m a l genetic sonogram. STUDY DESIGN: Since November 1, 1992, a second trinaester genetic sonogram has been offered to all pregnant women who are at increased risk for fetal DS (> 1:274) because of either advanced maternal age (AMA, _>35 years), abnormal serum biochemistry or both. Outcome information included the results of genetic amniocentesis, if performed, and the results of pediatric assessment and follow up afterbirth. Normal genetic sonogram was defined as the absence of all ultrasound aneuploidy markers (structural anomaly, nuchal fold _>6ram, short femur, short humerus, echogenic intracardiac focus, echogenic bowel, pyelectasis, choroid plexus cysts, clinodactyly, sandal gap and two-vessel cord). RESULTS: The overall sensitivity of genetic sonography in detecting DS was 86% (44/51). The results according to the indication for testing are shown in the Table. CONCLUSION: There were no clinically significant variations in the risk reduction for DS after normal genetic sonography; regardless of the indication for testing the likelihood for fetal DS was reduced by 81-88% by normal genetic sonography.
Table DS risk reduction table RISK REDUCTION
L0
P-DS
0.9-
0.8 ~0.7
~
0.6
AMA (n = 2677) 0.9% ABN TS (n = 1073) 2.5% ABN TS in _<35yo (n = 679) 3% ABN TS & AMA (n = 394) 1.5%
-
~0,4
-
~0.3
-
0.2-
P-DSNGS
OR (CI)
NEGATIVE PERCENT LR (CI) (%)
0.17% (4/2393) 5.36 (1.86, 15.48)
0.19 (0.06, 0.54)
81
0.33% (3/898)
7.53 (2.28, 24,91)
0.13 (0.04,0.44)
87
0.36% (2/555)
8.58 (2.00, 36,76)
0.12 (0.03, 0.50)
88
0.29% (1/343)
5.22 (0.63, 43.60)
0.19 (0.02, 1.60)
81
P-DS, Prevalence of DS; PDS-NGS, prevalence of DS alter nolxnal genetic sonograrn; OR, odds ratio; LR, likelihood ratio; C/, 95% confidence interval; ABN,abnormal; TS, triple screen.
0A0.0-
3o
3s
,0
EOA
618
T H E VALUE OF REPEATING A FULL ANATOMIC SURVEY AT SUBSEQ U E N T OBSTETRICAL ULTRASOUND EXAMINATIONS IN WOMEN WITH A NORMAL SCAN AT 18-20 WEEKS NATHAN WAGSTAFFt, EMMANUEL BUJOLD 1, MARK REDMAN1, SEAN M. BLACKWELL1, SONIA S. HASSAN 1, STANLEY M. BERRYJ, 1Wayne State University, Obstetrics & Gynecology, Detroit, MI OBJECTIVE: Many ultrasound units, including ours, repeat a full anatomic sm-vey each time a patient returns for follow-up exam. We sought to assess how often anomalies were diagnosed by repeating the full survey when the ultrasound at 18-20 weeks was nornlal. STUDY DESIGN: Review of a computerized ultrasound database identified all patients who had undergone a screening obstetrical ultrasound examination between 18-20 weeks Irom August 1, 1999 through June 30, 2001. Records with abnormal anatomic findings were excluded. Patients who underwent subsequent ultrasounds during the same pregnancy comprised the study population. The records of subsequent ultrasounds in which an anomaly was reported were reviewed. RESULTS: Of the 18,666 uhrasounds performed during the study period, 1,651 were initial exams at 18-20 weeks' and 83 (5%) had anomalies. Of 1,568 w o m e n who had a normal ultrasound, 328 (20.9%) underwent 457 repeat anatomic surveys. Seven anomalies were identified: 5 cases of renal pelvis dilatation (RPD), 1 bronchial cyst (BC), and 1 enlarged cisterna m a g n a (ECM). None of the renal anomalies were present at postnatal ultrasound. At birth the BC was found to be a thymal cyst of no consequence. Postnatal ultrasound showed the ECM to be a "normal variant." Thus, 229 full anatomic smweys were repeated for each anomaly confirmed at birth. The total cost of repeat ultrasounds was $125,675. The added cost of the fun anatomic survey was $3,428 per anomaly confirmed at birth. The two infants bad a completely normal postnatal course. CONCLUSION: Over 20% of patients with a normal ultrasound between 18-20 weeks had a full anatomic survey repeated, but only 0.4% of the repeat scans revealed an anomaly that was confirmed at birth. Our data call into question the practice of routinely repeating a full anatomic survey subsequent to a normal ultrasound performed between 18-20 weeks.
620
DO SECOND TRIMESTER ULTRASOUND MARKERS CORRELATE WITH SERUM SCREEN ANALYTES? L1LLIAN KAMINSKY1,JAMES E G A N 1, GARRY TURNER1, CHARLES INGARDIA2, PETER BENNa; i University of Connecticut, Obstetrics/Gynecology, Farmingtun, CT; 2Hartford Hospital, Hartford, CT; 3University of Connecticut, Pediatrics, Farmingtun, CT OBJECTIVE: Down syndrome (DS) risks have been modified by serum screening and ultrasound, which are assumed to be independent. O u r objective was to determine the correlation between individual maternal serum screen analytes and ultlasound markers. STUDY DESIGN: The study group consisted of women with DS fetuses who had both serum screen and ultrasound performed and a control group of normal fetuses. In both groups, maternal serum alpha-fetoprotein (MSAFP), hCG, unconjugated estriol (E3), inhibin-A (INH-A), nuchal fold thickness, and biparietal diameter to f e m u r and humerus length ratios (BPD/FL and BPD/HL) were tested by Pearson correlation coefficient. We used the nonparametric Wilcoxon two group test to analyze echogenic bowel, ventriculomegaly, pyelectasis, clinodactyly, echogenic intracardiac focus and serum screen analytes in DS fetuses only. RESULTS: T h e r e were 67 DS cases (31 with quad screens and 36 with triple screens) and 169 controls (81 with quad screens and 88 with triple screens). Increased nuchal fold thickness (n = 41) correlated with higher hCG levels (R = 0.41, P = .003) in DS fetuses, but not in the controls. Increased BPD/FL and B P D / H L ratios correlated with lower E3 levels (R = 0.32 and 0.36, P = .006 and .002) in DS fetuses, but not in the controls. No other associations were identified between ultrasound markers and serum screen analytes. CONCLUSION: Common pathophysiology of nuchal fold thickening and hCG elevation may exist. In addition, lower E3 concentrations appear to be related to short femur or humerus in DS pregnancies. Observed correlations n e e d to be considered when a d j u s t i n g 2rid trimester DS risks following maternal serum and ultrasound screens.