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Abnormal first-trimester fetal heart rate and pregnancy outcome: a population-based screening study (The faster trial)
S238 SMFM Abstracts
December 2003 Am J Obstet Gynecol
659
INFLUENCE OF FETAL HEART ORIENTATION ON THE IDENTIFICATION OF AN ECHOGENIC CARDIAC FOCUS IN THE LEFT VENTRICLE RICHARD FISCHER1, GRACE SVEINBJORNSSON1, 1Cooper Hospital, Obstetrics and Gynecology, Camden, NJ OBJECTIVE: To determine the influence of fetal heart orientation on the visualization of an echogenic cardiac focus (ECF) in the left ventricle. STUDY DESIGN: Over a 2-year period, 117 fetuses between 15 and 24 weeks’ gestation who were identified to have an ECF were viewed from at least two different angles by a single examiner (RLF). Orientations attempted included apical, left lateral, right lateral, and basilar views. An ECF was recorded as present if an intensely bright focus was visualized within the left ventricle. RESULTS: Mean maternal age was 28.7 ± 6.8 years, with a mean BMI of 26.5 ± 6.2 kg/m2. Forty-two percent were Caucasian, 36% African American, 13% Hispanic, 8% Asian. Mean gestational age at time of ultrasound was 19.6 ± 1.9 weeks. 10.3% had another significant ultrasound finding (choroid plexus cysts, 2-vessel cord, axillary cystic hygroma, intraabdominal cyst, severe growth restriction, pyelectasis, bilateral cleft lip, Dandy-Walker complex). One infant (with Dandy-Walker complex) was discovered at birth to have Down syndrome. ECF was seen in 100% (111/111) of apical views, 49.2% (29/59) of left lateral views, 46.0% (29/63) of right lateral views, and 100% (12/12) of basilar views. Combining longitudinal (apical or basilar) and lateral (right or left) views, ECF was seen in 100% of longitudinal views and 48.7% of lateral views (P < .001 by McNemar test). CONCLUSION: ECF is more consistently seen from the apical and basilar views than from the right or left lateral views of the fetal heart. Therefore, to truly rule out an ECF, an apical or basilar view of the fetal heart should be visualized.
661
THE GENETIC SONOGRAM: HOW DOES FETAL ANATOMIC VISUALIZATION DEPEND UPON DURATION OF THE SCAN? VAL CATANZARITE1, KIM DELANEY1, SUSAN WOLFE1, DAVID DOWLING1, SEAN DANESHMAND1, DEBRA POELTER2, LARRY COUSINS1, 1San Diego Perinatal Center, San Diego, CA 2Sharp Mary Birch Hospital for Women, Biostatistics, San Diego, CA OBJECTIVE: To determine the relationship between visualization of key fetal anatomic structures during genetic sonography with increasing gestational age and increasing duration of examination. STUDY DESIGN: One hundred genetic sonograms performed at 16-22 weeks’ gestation were reviewed to determine the times at which key fetal anatomic features were seen. Scans were terminated at 30 minutes or when a comprehensive fetal anatomic survey was complete. Exclusion criteria included maternal weight >170 pounds, abdominal wall scarring, and suspected fetal anomalies. RESULTS: Visualization of cranial anatomy including lips, face, midline, ventricles, choroid, and cerebellum was obtained in 98 patients by 30 minutes. Corresponding figures for spine, cardiac screening (4-chamber, aortic, and pulmonic outflow views) and for abdominal anatomy (stomach, kidneys, bladder, ventral wall, and 3-vessel cord) were 91, 91, and 99 cases, respectively. A completed anatomic survey, including each of the above elements, was obtained by 10, 15, 20, 25, and 30 minutes in 8, 31, 53, 72, and 81 cases, respectively. Rates of competed anatomic surveys within 30 minutes improved by gestational age interval, from 20/30 (67%) at 16-18 weeks, to 36/44 (82%) at 1820 weeks, and 25/26 (96%) at 20-22 weeks; this rise was primarily due to improvements in visualization of the spine and heart. CONCLUSION: A comprehensive genetic sonogram including a comprehensive anatomic survey can be completed in 10 minutes or less in a minority of patients, but for each 5-minute time increment up to 30 minutes, the rate of complete surveys improves.
660
ABNORMAL FIRST-TRIMESTER FETAL HEART RATE AND PREGNANCY OUTCOME: A POPULATION-BASED SCREENING STUDY (THE FASTER TRIAL) TRACY SHEVELL1, FERGAL D. MALONE1, JOHN VIDAVER2, T. FLINT PORTER3, DAVID A. LUTHY4, CHRISTINE H. COMSTOCK5, RADEK BUKOWSKI6, KEITH EDDLEMAN7, SUSAN J. GROSS8, LORRAINE DUGOFF9, SABRINA D. CRAIGO10, ILAN E. TIMOR11, STEPHEN R. CARR12, HONOR M. WOLFE13, MARY E. D’ALTON1, 1Columbia University, New York, NY 2DM-STAT, Boston, MA 3University of Utah, Salt Lake City, UT 4 Swedish Medical Center, Seattle, WA 5William Beaumont Medical Center, Royal Oak, MI 6University of Texas Medical Branch, Galveston, TX 7Mount Sinai Medical Center, New York, NY 8Albert Einstein College of Medicine, New York, NY 9University of Colorado, Denver, CO 10Tufts University, Boston, MA 11NYU Medical Center, New York, NY 12Women and Infants Hospital, Providence, RI 13University of North Carolina, Chapel Hill, NC OBJECTIVE: To determine if an abnormally slow or an abnormally fast firsttrimester fetal heart rate is associated with poor pregnancy outcome. STUDY DESIGN: A prospective database from a large multicenter investigation of singleton pregnancies, the FASTER Trial, was examined. This database contains detailed antenatal, birth, and pediatric outcomes on a large unselected obstetric population. All included patients had a nuchal translucency ultrasound examination performed at 10-14 weeks’ gestation, at which time the fetal heart rate was documented. Subjects were divided into three groups: slow fetal heart rate (less than/equal to 125 bpm), normal fetal heart rate (125-175 bpm), and fast fetal heart rate (greater than/equal to 175 bpm). Univariate and multivariate logistic regression analyses were used (significance: P < 0.05). RESULTS: Complete data were available for 28,531 pregnancies for this analysis. Of these, 27,454 (96.2%) had a normal, 126 (0.4%) had a slow, and 951 (3.3%) had a fast fetal heart rate. Confounding variables controlled for included maternal age, race, gender, use of assisted reproductive technology, and prior aneuploid pregnancies. An abnormally slow heart rate was significantly associated with fetal loss or neonatal death (Adjusted OR: 3.2, 95% CI: 1.0, 10.2, P < 0.05). An abnormally fast heart rate was associated with the adverse outcomes shown in the Table. There was no association between abnormal fetal heart rate and aneuploidy. CONCLUSION: Patients with either an abnormally slow or fast firsttrimester fetal heart rate are at increased risk for fetal loss and neonatal death. Fast fetal heart rate is also an independent risk factor associated with increased risk of pregnancy complications and adverse pregnancy outcomes.
662
SONOGRAPHIC ESTIMATES OF FETAL WEIGHT BEYOND 38 WEEKS’ GESTATION: ACCURACY AT THE EXTREMES OF BIRTHWEIGHT MICHAEL DIVON1, VICTORIA MINIOR2, MARIUS KUBLICKAS3, MAGNUS WESTGREN3, 1Lenox Hill Hospital, Dept. OB/GYN, New York, NY 2 New York University Medical Center, Dept. OB/GYN, New York, NY 3 Huddinge Hospital, Dept. OB/GYN, Stockholm, Sweden OBJECTIVE: To determine the accuracy of sonographic estimates of fetal weight (sEFW) for infants with birthweights (BW) that are greater than 2 standard deviations (SD) above or below the population mean. STUDY DESIGN: Viable, singleton, term ($38-42 6/7 weeks) gestations delivered at Huddinge University Hospital in Stockholm, Sweden between 1996 and 2003 that underwent sEFW within one week of delivery were included in the study. Population means and SD for each gestational age (GA) week were derived. Infants with BW < 2 SD below the mean were considered small (SGA) and those with BW >2 SD above the mean were considered large (LGA). sEFW were compared to actual BW. 232 tables were derived, and descriptive statistics, calculated for each GA week. RESULTS: There were 17,320 deliveries during the study period. sEFW and BW were available for 2425 (14%) patients. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the sEFW in the prediction of BW are depicted below (denoted as SGA/LGA in the Table). In the SGA fetus, the sensitivity of the sEFW decreased with advancing GA. The PPV of the sEFW decreased over gestation as more SGA sEFWs were false-positive tests. However, the ability of the sEFW to exclude the SGA infant remained high and stable across GA. In the LGA fetus, the sEFW accurately excluded this condition across GA. However, sensitivity and PPV were low across GA. CONCLUSION: The utility of sEFW at extremes of birthweight at term is questionable at best. However, the sEFW accurately excludes these conditions (i.e., is associated with a high NPV).
Outcome—Fast Fetal Heart Rate Fetal loss/NND IUGR Preeclampsia Neonatal readmission
Adjusted OR 2.1 1.8 1.8 1.6
95% CI
P value
1.2, 1.1, 1.3, 1.1,
0.01 0.02 0.0002 0.01
3.6 2.8 2.5 2.1
Sensitiv. Specific. PPV NPV
Week 38
Week 39
Week 40
Week 41
Week 42
0.80/0.70 0.96/0.95 0.80/0.70 0.96/0.95
0.63/0.63 0.95/0.96 0.63/0.54 0.95/0.97
0.69/0.78 0.91/0.97 0.51/0.74 0.96/0.98
0.54/0.40 0.97/0.98 0.38/0.39 0.99/0.98
0.33/0.61 0.98/0.98 0.36/0.52 0.97/0.98
December 2003 Am J Obstet Gynecol
659
INFLUENCE OF FETAL HEART ORIENTATION ON THE IDENTIFICATION OF AN ECHOGENIC CARDIAC FOCUS IN THE LEFT VENTRICLE RICHARD FISCHER1, GRACE SVEINBJORNSSON1, 1Cooper Hospital, Obstetrics and Gynecology, Camden, NJ OBJECTIVE: To determine the influence of fetal heart orientation on the visualization of an echogenic cardiac focus (ECF) in the left ventricle. STUDY DESIGN: Over a 2-year period, 117 fetuses between 15 and 24 weeks’ gestation who were identified to have an ECF were viewed from at least two different angles by a single examiner (RLF). Orientations attempted included apical, left lateral, right lateral, and basilar views. An ECF was recorded as present if an intensely bright focus was visualized within the left ventricle. RESULTS: Mean maternal age was 28.7 ± 6.8 years, with a mean BMI of 26.5 ± 6.2 kg/m2. Forty-two percent were Caucasian, 36% African American, 13% Hispanic, 8% Asian. Mean gestational age at time of ultrasound was 19.6 ± 1.9 weeks. 10.3% had another significant ultrasound finding (choroid plexus cysts, 2-vessel cord, axillary cystic hygroma, intraabdominal cyst, severe growth restriction, pyelectasis, bilateral cleft lip, Dandy-Walker complex). One infant (with Dandy-Walker complex) was discovered at birth to have Down syndrome. ECF was seen in 100% (111/111) of apical views, 49.2% (29/59) of left lateral views, 46.0% (29/63) of right lateral views, and 100% (12/12) of basilar views. Combining longitudinal (apical or basilar) and lateral (right or left) views, ECF was seen in 100% of longitudinal views and 48.7% of lateral views (P < .001 by McNemar test). CONCLUSION: ECF is more consistently seen from the apical and basilar views than from the right or left lateral views of the fetal heart. Therefore, to truly rule out an ECF, an apical or basilar view of the fetal heart should be visualized.
661
THE GENETIC SONOGRAM: HOW DOES FETAL ANATOMIC VISUALIZATION DEPEND UPON DURATION OF THE SCAN? VAL CATANZARITE1, KIM DELANEY1, SUSAN WOLFE1, DAVID DOWLING1, SEAN DANESHMAND1, DEBRA POELTER2, LARRY COUSINS1, 1San Diego Perinatal Center, San Diego, CA 2Sharp Mary Birch Hospital for Women, Biostatistics, San Diego, CA OBJECTIVE: To determine the relationship between visualization of key fetal anatomic structures during genetic sonography with increasing gestational age and increasing duration of examination. STUDY DESIGN: One hundred genetic sonograms performed at 16-22 weeks’ gestation were reviewed to determine the times at which key fetal anatomic features were seen. Scans were terminated at 30 minutes or when a comprehensive fetal anatomic survey was complete. Exclusion criteria included maternal weight >170 pounds, abdominal wall scarring, and suspected fetal anomalies. RESULTS: Visualization of cranial anatomy including lips, face, midline, ventricles, choroid, and cerebellum was obtained in 98 patients by 30 minutes. Corresponding figures for spine, cardiac screening (4-chamber, aortic, and pulmonic outflow views) and for abdominal anatomy (stomach, kidneys, bladder, ventral wall, and 3-vessel cord) were 91, 91, and 99 cases, respectively. A completed anatomic survey, including each of the above elements, was obtained by 10, 15, 20, 25, and 30 minutes in 8, 31, 53, 72, and 81 cases, respectively. Rates of competed anatomic surveys within 30 minutes improved by gestational age interval, from 20/30 (67%) at 16-18 weeks, to 36/44 (82%) at 1820 weeks, and 25/26 (96%) at 20-22 weeks; this rise was primarily due to improvements in visualization of the spine and heart. CONCLUSION: A comprehensive genetic sonogram including a comprehensive anatomic survey can be completed in 10 minutes or less in a minority of patients, but for each 5-minute time increment up to 30 minutes, the rate of complete surveys improves.
660
ABNORMAL FIRST-TRIMESTER FETAL HEART RATE AND PREGNANCY OUTCOME: A POPULATION-BASED SCREENING STUDY (THE FASTER TRIAL) TRACY SHEVELL1, FERGAL D. MALONE1, JOHN VIDAVER2, T. FLINT PORTER3, DAVID A. LUTHY4, CHRISTINE H. COMSTOCK5, RADEK BUKOWSKI6, KEITH EDDLEMAN7, SUSAN J. GROSS8, LORRAINE DUGOFF9, SABRINA D. CRAIGO10, ILAN E. TIMOR11, STEPHEN R. CARR12, HONOR M. WOLFE13, MARY E. D’ALTON1, 1Columbia University, New York, NY 2DM-STAT, Boston, MA 3University of Utah, Salt Lake City, UT 4 Swedish Medical Center, Seattle, WA 5William Beaumont Medical Center, Royal Oak, MI 6University of Texas Medical Branch, Galveston, TX 7Mount Sinai Medical Center, New York, NY 8Albert Einstein College of Medicine, New York, NY 9University of Colorado, Denver, CO 10Tufts University, Boston, MA 11NYU Medical Center, New York, NY 12Women and Infants Hospital, Providence, RI 13University of North Carolina, Chapel Hill, NC OBJECTIVE: To determine if an abnormally slow or an abnormally fast firsttrimester fetal heart rate is associated with poor pregnancy outcome. STUDY DESIGN: A prospective database from a large multicenter investigation of singleton pregnancies, the FASTER Trial, was examined. This database contains detailed antenatal, birth, and pediatric outcomes on a large unselected obstetric population. All included patients had a nuchal translucency ultrasound examination performed at 10-14 weeks’ gestation, at which time the fetal heart rate was documented. Subjects were divided into three groups: slow fetal heart rate (less than/equal to 125 bpm), normal fetal heart rate (125-175 bpm), and fast fetal heart rate (greater than/equal to 175 bpm). Univariate and multivariate logistic regression analyses were used (significance: P < 0.05). RESULTS: Complete data were available for 28,531 pregnancies for this analysis. Of these, 27,454 (96.2%) had a normal, 126 (0.4%) had a slow, and 951 (3.3%) had a fast fetal heart rate. Confounding variables controlled for included maternal age, race, gender, use of assisted reproductive technology, and prior aneuploid pregnancies. An abnormally slow heart rate was significantly associated with fetal loss or neonatal death (Adjusted OR: 3.2, 95% CI: 1.0, 10.2, P < 0.05). An abnormally fast heart rate was associated with the adverse outcomes shown in the Table. There was no association between abnormal fetal heart rate and aneuploidy. CONCLUSION: Patients with either an abnormally slow or fast firsttrimester fetal heart rate are at increased risk for fetal loss and neonatal death. Fast fetal heart rate is also an independent risk factor associated with increased risk of pregnancy complications and adverse pregnancy outcomes.
662
SONOGRAPHIC ESTIMATES OF FETAL WEIGHT BEYOND 38 WEEKS’ GESTATION: ACCURACY AT THE EXTREMES OF BIRTHWEIGHT MICHAEL DIVON1, VICTORIA MINIOR2, MARIUS KUBLICKAS3, MAGNUS WESTGREN3, 1Lenox Hill Hospital, Dept. OB/GYN, New York, NY 2 New York University Medical Center, Dept. OB/GYN, New York, NY 3 Huddinge Hospital, Dept. OB/GYN, Stockholm, Sweden OBJECTIVE: To determine the accuracy of sonographic estimates of fetal weight (sEFW) for infants with birthweights (BW) that are greater than 2 standard deviations (SD) above or below the population mean. STUDY DESIGN: Viable, singleton, term ($38-42 6/7 weeks) gestations delivered at Huddinge University Hospital in Stockholm, Sweden between 1996 and 2003 that underwent sEFW within one week of delivery were included in the study. Population means and SD for each gestational age (GA) week were derived. Infants with BW < 2 SD below the mean were considered small (SGA) and those with BW >2 SD above the mean were considered large (LGA). sEFW were compared to actual BW. 232 tables were derived, and descriptive statistics, calculated for each GA week. RESULTS: There were 17,320 deliveries during the study period. sEFW and BW were available for 2425 (14%) patients. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the sEFW in the prediction of BW are depicted below (denoted as SGA/LGA in the Table). In the SGA fetus, the sensitivity of the sEFW decreased with advancing GA. The PPV of the sEFW decreased over gestation as more SGA sEFWs were false-positive tests. However, the ability of the sEFW to exclude the SGA infant remained high and stable across GA. In the LGA fetus, the sEFW accurately excluded this condition across GA. However, sensitivity and PPV were low across GA. CONCLUSION: The utility of sEFW at extremes of birthweight at term is questionable at best. However, the sEFW accurately excludes these conditions (i.e., is associated with a high NPV).
Outcome—Fast Fetal Heart Rate Fetal loss/NND IUGR Preeclampsia Neonatal readmission
Adjusted OR 2.1 1.8 1.8 1.6
95% CI
P value
1.2, 1.1, 1.3, 1.1,
0.01 0.02 0.0002 0.01
3.6 2.8 2.5 2.1
Sensitiv. Specific. PPV NPV
Week 38
Week 39
Week 40
Week 41
Week 42
0.80/0.70 0.96/0.95 0.80/0.70 0.96/0.95
0.63/0.63 0.95/0.96 0.63/0.54 0.95/0.97
0.69/0.78 0.91/0.97 0.51/0.74 0.96/0.98
0.54/0.40 0.97/0.98 0.38/0.39 0.99/0.98
0.33/0.61 0.98/0.98 0.36/0.52 0.97/0.98