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Diagnosis of polydactyly during routine anatomy ultrasound examinations
V o l u m e 176, N m n b e r 1, Part 2 A m J O b s t e t Gynecol
SPO Abstracts
$67
201
A 7-POINT ULTRASOUND "FETAL PHYSICAL EXAM" T O IDENTIFY PATHOLOGICAL POLYHYDRAMNIOS. DE Carlson, LD Platt. Dept O b / Gyn Cedars-Sinai Medical Center. Los Angeles CA OBJECTIVE: The task of correctly identifying the abnormal fetus in the face of polyhydramnios is exhausting and confusing for the novice ultrasound practitioner. We propose a rapid but accurate "tetal physical exam" that will focus the examiner to the areas of concern. STUDY DESIGN: We prospectively examined 66 singleton fetuses with polyhydramnios (AFI > - 2 4 cm) from 26 weeks to term utilizing a 7-point checklist of body parts and an inquiry: 1) Head/Brain maltormation? 2) Neck & mouth/Obstruction? 3) Heart/Failure? 4) Chest/Compression? 5) Esophagus/Stomach bubble? 6) Upper GI/Obstruction? 7) Neuro / P o o r tone? This included cardiac four chamber, long and short axis views and observation of hand opening and closing. Outcomes were confirnmd by newborn physical exam and chart review. RESULTS: The ultrasound examination took an average of 17 minutes. (Range: 11-23). 43 had a negative prenatal exam and a normal newborn exam. O f these, 20 were large for gestational age at birth. 23 fetuses were abnormal. 14 had an isolated anomaly, one of them had aneuploidy. 6 had more than one area that was abnormal and 2 of them had aneuploidy. 3 fetuses had poor tone only and none had aneuploidy, but all had movement disorders. CONCLUSIONS: A directed but simple step-wise head-to-toe physical exam can be accomplished rapidly by ultrasound to identify the physically a n d / o r karyotypically abnormal fetus with polyhydramnios. In this study a fetus with a normal "fetal physical exam" had a normal kmTotype.
203
DIAGNOSIS OF POLYDACTYLY DURING ROUTINE ANATOMY ULTRASOUND EXAMINATIONS. KS StewarP, MC Treadwell, Dept. OB/GYN, Wayne State University, Hutzel Hospital, Detroit, Michigan. OBJECTIVE: To determine the accuracy of transabdomial ultrasound in making the diagnosis of polydactyly of the hand. STUDY DESIGN: BetweenJmruary 1, 1994 and May 31, 1996, 153 infants with polydactyly diagnosed on newborn exam were delivered at our tertimT care institution. O f the 132 charts available for analysis, 130 infants were found to have polydactyly of the upper extremity. Seventy-five of the 130 patients had prenatal uhrasonnd at our institution at greater than or equal to I6 weeks gestation. These uhrasounds included survey of hand anatomy which was coded as normal, abnormal or subopthnally viewed. RESULTS: The diagnosis of polydactyly was made prenatally by transabdominal ultrasound in 12% (9/75) cases and the diagnosis not made in 63% (47/75). Suboptimal views were obtained in 25% (19/75) and with complete visualization of the hands recorded in the remaining 56. O f these 56 ultrasounds 9, or 16%, were diagnostic for polydactyly and 47, or 84%, were thought to be consistent with normal anatomy. Five of the infants required surgical follow-up after discharge fi-om the hospital. Four of these infants had isolated polydactyly which required more than suture ligation, and one infant with associated anomalies recognized on prenatal ultrasound was diagnosed with Jeune Syndrome. O f the 5 clinically significant cases, only the infant with associated anomalies was diagnosed prenatally. CONCLUSIONS: Only one out of the five clinically significant cases of polydactyly was diagnosed prenatally. Transabdominal ultrasound examination of the hands was relatively insensitive in making the diagnosis of isolated polydactyly. The prenatal diagnosis of isolated polydactyly has limited clinical significance and may, therefore, warrant minimal time expenditure in attempting diagnosis. Late first trimester or early second trimester transvaginaI ultrasounds in patients with clinical indications, however, may improve the accuracy of diagnosis.
202
POLYHYDRAIVINIOS IN TERM GESTATION: AN INDEPENDENT RISK FACTOR FOR PERINATAL DEATH. M. ]igazor, F. Ghezzi~, E. Maymon x, L
204
DIFFERENCES IN MEASUREMENTS OF THE ATRIA OF THE LATERAL VENTRICLE: DOES GENDER MATTER? Kramer RI;~, Yaron Y*, Wolfe HM, Treadwell MC Department of Obstetrics and Gynecology, Hutzel Hospital/ Wayne State University, Detroit, MI OBJECTIVE: Previous work has suggested a gender difference in the prevalence and outcome of fetuses with mild ventriculomegaly. Current nomograms for fetal atrial lneasurements are not gender specific nor are different values used for counseling patients regarding prognosis. O u r objective was to determine i f a gender difference exists in the measurements of the normal atria of the lateral ventricle. METHODS: A prospectively entered ultrasound database was reviewed to identi~, 8516 patients undergoing a complete ultrasound exam (>13 weeks gestation) between July 1994 and June 1996. Only patients with idenbfication of fetal gender and no anomalies diagnosed on uhrasound were included in the analysis. The last ultrasound exam performed on each patient was analyzed in cases where multiple studies had been performed. Continuous variables were compared with the Student t-test. Regression analysis was used to identify factors contributing to the variance in atrial measurements. RESULTS: The mean gestational age (GA) at the time of scan was 26.7 weeks with a mean atrial nleasurement of 7 ram. The mean gestational age of fetuses identified as female (42%) was 27.3 weeks vs 26.1 weeks tot males. The mean atrial measurement for males was 7.1 m m vs 6.9 m m for females (p < 0.001). An increase in atrial measurements was noted with advancing GA. GA explained 3.5% of the variance with gender adding an additional 0.7%. CONCLUSIONS: Although there is a statistically significant difference across gestational age and between genders in the atrial measurement of the ti=tus, this difference is not clinically significant. The use of a single nmnogram to counsel patients, regardless of fetal gender, is appropriate.
Shoham-Vardff, R. Gomez~, R. Chen', D. Balestreri, M. Katz, .~R. Leiberman, R. Romero. Dept O b / G y n and Epidentiology, Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel. OBJECTIVE: The excessive perinatal morbidity and mortality obsmwed in patients with polyhydramnios has been attributed to its association with congenital anomalies and preterm birth. The purpose of this study was to determine if polyhydramnios is an independent risk factor for poor pregnancy outcome after adjusting for the effect of congenital anomalies in term gestation. STUDY DESIGN: The study population consisted of 60,702 patients with singleton gestation who delivered at term (>37 weeks). Patients were classified into two groups according to the presence (n - 1,211) or absence of polyhydranmios (n - 59,491). Polyhydramnios was diagnosed by using any of the following criteria: an amniotic fluid index >25 cm, a m a x i m m n vertical pocket > 8 cm or by subjective assessment. Statistical analysis was conducted with univm-iate techniques and multiple logistic regression to adjust for confounding variables. RESULTS: The prevalence of polyhydramnios was 2%. Patients with polybydramnios had a higher incidence of complications than patients with normal anmiotic fluid: cesarean section (11.9% vs 8.4%; p < 0.01), anteparmm death (0.6% vs. 0.2%, p < 0.05), postpartum death (2.8% vs. 0.4%, p < 0.01), abruption (0.9% vs. 0.3%, p < 0.01), fetal distress (6.1% vs. 3.6%, p < 0.01), meconium-stained mrmiotic fluid (17.8% vs. 15%, p < 0.01), low apgar score at 5 minutes (2.9% vs. 1%, p < 0.01), malpresentadon (6.8 vs. 2.9%, p < 0.01), chorioamnionitis (0.3% vs. 0.1, p < 0.05), prolapse of cord (2.2% vs. 0.3%, p < 0.01), LGA (23.8% vs. 8.1%, p < 0.01). When adjusted for risk factors for perinatal mortality and intrapartum morbidity (i.e., congenital anomalies, previous perinatal death, LBW, PIH, diabetes, malpresentation), the presence of polyhydranmios remained strongly associated with perinatal mortality. CONCLUSION: 1) Polyfiydramnios at term is an independent risk tactor for perinatal death; 2) fetal surveillance is warranted in patients with polyhydrmnnios even in the absence of other known risk thctors for adverse pregnancy outcome.
SPO Abstracts
$67
201
A 7-POINT ULTRASOUND "FETAL PHYSICAL EXAM" T O IDENTIFY PATHOLOGICAL POLYHYDRAMNIOS. DE Carlson, LD Platt. Dept O b / Gyn Cedars-Sinai Medical Center. Los Angeles CA OBJECTIVE: The task of correctly identifying the abnormal fetus in the face of polyhydramnios is exhausting and confusing for the novice ultrasound practitioner. We propose a rapid but accurate "tetal physical exam" that will focus the examiner to the areas of concern. STUDY DESIGN: We prospectively examined 66 singleton fetuses with polyhydramnios (AFI > - 2 4 cm) from 26 weeks to term utilizing a 7-point checklist of body parts and an inquiry: 1) Head/Brain maltormation? 2) Neck & mouth/Obstruction? 3) Heart/Failure? 4) Chest/Compression? 5) Esophagus/Stomach bubble? 6) Upper GI/Obstruction? 7) Neuro / P o o r tone? This included cardiac four chamber, long and short axis views and observation of hand opening and closing. Outcomes were confirnmd by newborn physical exam and chart review. RESULTS: The ultrasound examination took an average of 17 minutes. (Range: 11-23). 43 had a negative prenatal exam and a normal newborn exam. O f these, 20 were large for gestational age at birth. 23 fetuses were abnormal. 14 had an isolated anomaly, one of them had aneuploidy. 6 had more than one area that was abnormal and 2 of them had aneuploidy. 3 fetuses had poor tone only and none had aneuploidy, but all had movement disorders. CONCLUSIONS: A directed but simple step-wise head-to-toe physical exam can be accomplished rapidly by ultrasound to identify the physically a n d / o r karyotypically abnormal fetus with polyhydramnios. In this study a fetus with a normal "fetal physical exam" had a normal kmTotype.
203
DIAGNOSIS OF POLYDACTYLY DURING ROUTINE ANATOMY ULTRASOUND EXAMINATIONS. KS StewarP, MC Treadwell, Dept. OB/GYN, Wayne State University, Hutzel Hospital, Detroit, Michigan. OBJECTIVE: To determine the accuracy of transabdomial ultrasound in making the diagnosis of polydactyly of the hand. STUDY DESIGN: BetweenJmruary 1, 1994 and May 31, 1996, 153 infants with polydactyly diagnosed on newborn exam were delivered at our tertimT care institution. O f the 132 charts available for analysis, 130 infants were found to have polydactyly of the upper extremity. Seventy-five of the 130 patients had prenatal uhrasonnd at our institution at greater than or equal to I6 weeks gestation. These uhrasounds included survey of hand anatomy which was coded as normal, abnormal or subopthnally viewed. RESULTS: The diagnosis of polydactyly was made prenatally by transabdominal ultrasound in 12% (9/75) cases and the diagnosis not made in 63% (47/75). Suboptimal views were obtained in 25% (19/75) and with complete visualization of the hands recorded in the remaining 56. O f these 56 ultrasounds 9, or 16%, were diagnostic for polydactyly and 47, or 84%, were thought to be consistent with normal anatomy. Five of the infants required surgical follow-up after discharge fi-om the hospital. Four of these infants had isolated polydactyly which required more than suture ligation, and one infant with associated anomalies recognized on prenatal ultrasound was diagnosed with Jeune Syndrome. O f the 5 clinically significant cases, only the infant with associated anomalies was diagnosed prenatally. CONCLUSIONS: Only one out of the five clinically significant cases of polydactyly was diagnosed prenatally. Transabdominal ultrasound examination of the hands was relatively insensitive in making the diagnosis of isolated polydactyly. The prenatal diagnosis of isolated polydactyly has limited clinical significance and may, therefore, warrant minimal time expenditure in attempting diagnosis. Late first trimester or early second trimester transvaginaI ultrasounds in patients with clinical indications, however, may improve the accuracy of diagnosis.
202
POLYHYDRAIVINIOS IN TERM GESTATION: AN INDEPENDENT RISK FACTOR FOR PERINATAL DEATH. M. ]igazor, F. Ghezzi~, E. Maymon x, L
204
DIFFERENCES IN MEASUREMENTS OF THE ATRIA OF THE LATERAL VENTRICLE: DOES GENDER MATTER? Kramer RI;~, Yaron Y*, Wolfe HM, Treadwell MC Department of Obstetrics and Gynecology, Hutzel Hospital/ Wayne State University, Detroit, MI OBJECTIVE: Previous work has suggested a gender difference in the prevalence and outcome of fetuses with mild ventriculomegaly. Current nomograms for fetal atrial lneasurements are not gender specific nor are different values used for counseling patients regarding prognosis. O u r objective was to determine i f a gender difference exists in the measurements of the normal atria of the lateral ventricle. METHODS: A prospectively entered ultrasound database was reviewed to identi~, 8516 patients undergoing a complete ultrasound exam (>13 weeks gestation) between July 1994 and June 1996. Only patients with idenbfication of fetal gender and no anomalies diagnosed on uhrasound were included in the analysis. The last ultrasound exam performed on each patient was analyzed in cases where multiple studies had been performed. Continuous variables were compared with the Student t-test. Regression analysis was used to identify factors contributing to the variance in atrial measurements. RESULTS: The mean gestational age (GA) at the time of scan was 26.7 weeks with a mean atrial nleasurement of 7 ram. The mean gestational age of fetuses identified as female (42%) was 27.3 weeks vs 26.1 weeks tot males. The mean atrial measurement for males was 7.1 m m vs 6.9 m m for females (p < 0.001). An increase in atrial measurements was noted with advancing GA. GA explained 3.5% of the variance with gender adding an additional 0.7%. CONCLUSIONS: Although there is a statistically significant difference across gestational age and between genders in the atrial measurement of the ti=tus, this difference is not clinically significant. The use of a single nmnogram to counsel patients, regardless of fetal gender, is appropriate.
Shoham-Vardff, R. Gomez~, R. Chen', D. Balestreri, M. Katz, .~R. Leiberman, R. Romero. Dept O b / G y n and Epidentiology, Soroka Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel. OBJECTIVE: The excessive perinatal morbidity and mortality obsmwed in patients with polyhydramnios has been attributed to its association with congenital anomalies and preterm birth. The purpose of this study was to determine if polyhydramnios is an independent risk factor for poor pregnancy outcome after adjusting for the effect of congenital anomalies in term gestation. STUDY DESIGN: The study population consisted of 60,702 patients with singleton gestation who delivered at term (>37 weeks). Patients were classified into two groups according to the presence (n - 1,211) or absence of polyhydranmios (n - 59,491). Polyhydramnios was diagnosed by using any of the following criteria: an amniotic fluid index >25 cm, a m a x i m m n vertical pocket > 8 cm or by subjective assessment. Statistical analysis was conducted with univm-iate techniques and multiple logistic regression to adjust for confounding variables. RESULTS: The prevalence of polyhydramnios was 2%. Patients with polybydramnios had a higher incidence of complications than patients with normal anmiotic fluid: cesarean section (11.9% vs 8.4%; p < 0.01), anteparmm death (0.6% vs. 0.2%, p < 0.05), postpartum death (2.8% vs. 0.4%, p < 0.01), abruption (0.9% vs. 0.3%, p < 0.01), fetal distress (6.1% vs. 3.6%, p < 0.01), meconium-stained mrmiotic fluid (17.8% vs. 15%, p < 0.01), low apgar score at 5 minutes (2.9% vs. 1%, p < 0.01), malpresentadon (6.8 vs. 2.9%, p < 0.01), chorioamnionitis (0.3% vs. 0.1, p < 0.05), prolapse of cord (2.2% vs. 0.3%, p < 0.01), LGA (23.8% vs. 8.1%, p < 0.01). When adjusted for risk factors for perinatal mortality and intrapartum morbidity (i.e., congenital anomalies, previous perinatal death, LBW, PIH, diabetes, malpresentation), the presence of polyhydranmios remained strongly associated with perinatal mortality. CONCLUSION: 1) Polyfiydramnios at term is an independent risk tactor for perinatal death; 2) fetal surveillance is warranted in patients with polyhydrmnnios even in the absence of other known risk thctors for adverse pregnancy outcome.