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Fetal alert network∗: A need for a population based antenatal network
SMFM Abstracts S219 733 FETAL DESCENDING AORTA DETAILED VELOCITY PROFILES IN REAL-TIME USING A NOVEL GLOBAL ACQUISITION & SIGNAL PROCESSING (G.A.S.P.) SOFTWARE FOR THE MULTIGATE SPECTRAL DOPPLER ANALYSIS GABRIELE URBAN1, PASQUALE PATRIZIO1, PIERO TORTOLI2, STEFANO RICCI2, FABIO SANGUINETI1, PATRIZIA VERGANI3, MICHAEL PAIDAS1, 1Yale University, Obstetrics & Gynecology, New Haven, Connecticut, 2University of Florence, Electronic Engineering, Florence, Italy, 3University of Milano-Bicocca, Monza, Milano, Italy OBJECTIVE: To study velocity profiles, relative wall distension rate (rWDR) of fetal descending aorta (FDA) and shear rate (WSR) in uncomplicated singleton pregnancy. STUDY DESIGN: Eighty Two uncomplicated singleton fetuses were studied at different gestational ages using Multigate Spectral Doppler Analysis (MSDA) working with GASP software. This consists of a PC add-on board including a single high-speed digital signal processor. The analysis of echosignals backscattered from 256 range cells located along the axis of the interrogating ultrasound (US) beam. Post-processing were done using GASP software. Statistical analysis consisted of Spearman correlation and chi-square test. RESULTS: Velocity profiles, wall distension, wall shear rate were obtained from fetal descending aorta at different gestational age. Comparables results from conventional Doppler masks different velocity profiles, turbulent flow (4 cases), downstream (5 cases), partial reverse in diastole (3 cases). WDR[%] is highly correlated with gestational age and fetal growth (2.7G1.8 , rs=0.471 p!0.01) with linear regression with standardized coefficient of 0.4 (p!0.01). Otherwise WSR (432G191) is not significantly variable (P=0.7) from first , second and third trimester. CONCLUSION: This novel technology is more sensitive than conventional Doppler in detecting patterns other than pseudo-laminar flow. The progressive linear increase of wall distansibility detected could be explained by the accumulation of elastin that contributes most to developmental change. The mean WSR for the study group was independent and constant throughout the gestation. This suggest that unless the increase of aortal size adapts to the flow demands and maintain constant the hemodynamic characteristics. The relative WDR changes during gestation, in normal growth, may be secondary to adaptive vascular and autonomic responses and the evolving composition of the vessel wall, particularly with respect to elastin.
735 FETAL ALERT NETWORK*: A NEED FOR A POPULATION BASED ANTENATAL NETWORK FETAL ALERT NETWORK TORONTO1, RORY WINDRIM2, 1Hospital for SickKids, Provincial Project, Toronto, Ontario, Canada, 2Mount Sinai Hospital, Maternal Fetal Medicine, Toronto, Ontario, Canada OBJECTIVE: Fetal diagnosis and intervention are changing the nature and natural history of congenital anomalies seen today. Given the small cohort numbers and complexity of anomalies, a population-based integrated network of accurate and timely information sharing is essential for evidence-based best clinical practice and outcomes. STUDY DESIGN: A population-based real-time provincial database has been established. The cohort is under a single payer-based health care system for 12 million inhabitants in a defined area. A prospective collection of antenatal care and systems utilization information started on April 2, 2005. Comparisons were made to a provincial perinatal database which includes all birth cohorts in the region. RESULTS: Analysis was based on closed records of 720 cohorts registered between 2/4/05 and 31/3/06. Maternal characteristics including mean age, parity and age range were not significantly different from the general population. Most women spontaneously conceived (O 90%) and had no predisposing genetic history(O90%). Of concern was the delay in timely access suggested by the mean time of initial diagnosis at 21 wks GA while the mean time of referral was 24.6 wk GA. Surprisingly, 47% of patients had no antenatal screening. The utilization of antenatal diagnostic procedures including amnio, CVS, fetal Echo and MRI varied from 3.8 to 42% reflecting regionalization of care and different practice patterns. The outcomes including live birth, stillbirth, terminations, neonatal death !28 days and geographical mapping demonstrate significant regional differences in fetal anomalies prevalence, practice differences and clinical outcomes. CONCLUSION: The preliminary data from this antenatal database reveals critical challenges in health care and systems utilization. Accurate, precise, and real-time collection of fetal care and health systems utilization information establishes a new benchmark, and will become an essential and critical tool for establishing new standards, clinical guidelines, health policy and resource allocation. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2006.10.797
0002-9378/$ - see front matter doi:10.1016/j.ajog.2006.10.795
734 SIMULTANEOUS UMBILICAL ARTERIES AND VEIN VELOCITY PROFILES USING A NOVEL GLOBAL ACQUISITION & SIGNAL PROCESSING (G.A.S.P.) SOFTWARE FOR THE MULTIGATE SPECTRAL DOPPLER ANALYSIS: A LONGITUDINAL STUDY GABRIELE URBAN1, PASQUALE PATRIZIO1, STEFANO RICCI2, PIERO TORTOLI2, FABIO SANGUINETI1, PATRIZIA VERGANI3, MICHAEL PAIDAS1, 1Yale University, Obstetrics & Gynecology, New Haven, Connecticut, 2University of Florence, Electronic Engineering, Florence, Italy, 3University of Milano-Bicocca, Monza, Italy OBJECTIVE: To characterize the velocity profiles (VP), relative wall distension rate (WDR) and wall shear rate (WSR) of the FUA and FUV in the 1st, 2nd and 3rd trimesters of normal pregnancies. STUDY DESIGN: The MSDA system consisted of commercial ultrasound machine (Aloka SSD1400), a personal computer and a proprietary electronic board working with GASP software. Interrogated vessels consisted of the FUA and FUV in a total of 57 singleton uncomplicated fetuses. Velocity profiles, relative wall distension rate [WDR(%)] and shear rate [WSR(1/s)] were calculated over multiple consecutives cardiac cycles in real-time. The designation of arterial pseudo-laminar flow was applied if one peak occurred in systole, while if O1 peak in systole was classified as turbulent. Statistical analysis consisted of Spearman correlation and. RESULTS: FUA displayed a laminar flow pattern throughout gestation in all 57 cases bilaterally. Mean WDR[%] was not correlated with gestational age and fetal growth. Mean WSR (484G117) remained constant throughout gestation, beginning at 7 wks. FUV WSR decrease during gestation (r=0.56, p=0.02), WDR is also constant during gestation. CONCLUSION: Real-time velocity profile analysis of the FUA and FUV is now possible using MSDA and GASP software. In normal pregnancies, velocity characteristics are remarkably stable throughout gestation. This study suggest that umbilical arteries wall distension adapts to flow demands and mantains constant mean wall shear rate. Increase in shear rate in unbilical vein seams remark the decrease in maternal viscosity flow. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2006.10.796
736 A LONGITUDINAL STUDY OF THE MIDDLE CEREBRAL ARTERY PULSATILITY INDEX AND PEAK SYSTOLIC VELOCITY – IS THERE A CORRELATION BETWEEN THEIR TRENDS AND FETAL DEMISE? FARHAN HANIF1, ERICH COSMI2, GIANCARLO MARI3, 1 Wayne State University, Obstetrics/Gynecology, Detroit, Michigan, 2 University of Padua, Padua, Italy, 3Wayne State University, Obstetrics & Gynecology, Maternal-Fetal Medicine Section, Detroit, Michigan OBJECTIVE: The longitudinal changes that occur in the middle cerebral artery (MCA) pulsatility index (PI) in severe IUGR fetuses remain unclear. Animal studies have shown that blood velocity is a better indicator of blood flow than angle independent indexes. The aims of this study were to determine 1) the longitudinal changes that occur in the MCA-PI and MCA-PSV in severe IUGR fetuses; and 2) the correlation between these two parameters and fetal demise. STUDY DESIGN: This study included 13 IUGR fetuses (EFW ! 3rd percentile and an umbilical artery PI O 95% confidence interval) in which at least three measurements were performed before delivery (median, 4; range: 3 to 8). The last MCA-PI and MCA-PSV values were obtained at a median interval of 1 day (range: 1 to 3 days) before delivery or before fetal demise. Middle cerebral artery PSV, and MCA-PI values were plotted on the normal reference ranges and their trends were compared to their normal values. A Fisher´ s Exact test was used for statistical analysis. P ! 0.05 was considered statistically significant. RESULTS: Gestational age at delivery ranged between 23.1 weeks and 31.4 weeks´ gestation (median 27.5 weeks). Birth weight ranged from 282 g to 1220 g (median: 471 g). An abnormal MCA-PI preceded the appearance of an abnormal MCA-PSV. In all fetuses, there was consistently an initial increase in MCA-PSV. This increase was followed by a decrease in the PCA-PSV in the 4 fetuses that died in utero (P ! 0.05). This decrease occurred at a median interval of 2 days (median 1 to 3 days) before delivery. CONCLUSION: Our data indicate that (a) the trends of the MCA-PSV and MCA-PI provide more information than one single value, and (b) the MCAPSV might become clinically useful in timing the delivery of the IUGR fetus. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2006.10.798
735 FETAL ALERT NETWORK*: A NEED FOR A POPULATION BASED ANTENATAL NETWORK FETAL ALERT NETWORK TORONTO1, RORY WINDRIM2, 1Hospital for SickKids, Provincial Project, Toronto, Ontario, Canada, 2Mount Sinai Hospital, Maternal Fetal Medicine, Toronto, Ontario, Canada OBJECTIVE: Fetal diagnosis and intervention are changing the nature and natural history of congenital anomalies seen today. Given the small cohort numbers and complexity of anomalies, a population-based integrated network of accurate and timely information sharing is essential for evidence-based best clinical practice and outcomes. STUDY DESIGN: A population-based real-time provincial database has been established. The cohort is under a single payer-based health care system for 12 million inhabitants in a defined area. A prospective collection of antenatal care and systems utilization information started on April 2, 2005. Comparisons were made to a provincial perinatal database which includes all birth cohorts in the region. RESULTS: Analysis was based on closed records of 720 cohorts registered between 2/4/05 and 31/3/06. Maternal characteristics including mean age, parity and age range were not significantly different from the general population. Most women spontaneously conceived (O 90%) and had no predisposing genetic history(O90%). Of concern was the delay in timely access suggested by the mean time of initial diagnosis at 21 wks GA while the mean time of referral was 24.6 wk GA. Surprisingly, 47% of patients had no antenatal screening. The utilization of antenatal diagnostic procedures including amnio, CVS, fetal Echo and MRI varied from 3.8 to 42% reflecting regionalization of care and different practice patterns. The outcomes including live birth, stillbirth, terminations, neonatal death !28 days and geographical mapping demonstrate significant regional differences in fetal anomalies prevalence, practice differences and clinical outcomes. CONCLUSION: The preliminary data from this antenatal database reveals critical challenges in health care and systems utilization. Accurate, precise, and real-time collection of fetal care and health systems utilization information establishes a new benchmark, and will become an essential and critical tool for establishing new standards, clinical guidelines, health policy and resource allocation. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2006.10.797
0002-9378/$ - see front matter doi:10.1016/j.ajog.2006.10.795
734 SIMULTANEOUS UMBILICAL ARTERIES AND VEIN VELOCITY PROFILES USING A NOVEL GLOBAL ACQUISITION & SIGNAL PROCESSING (G.A.S.P.) SOFTWARE FOR THE MULTIGATE SPECTRAL DOPPLER ANALYSIS: A LONGITUDINAL STUDY GABRIELE URBAN1, PASQUALE PATRIZIO1, STEFANO RICCI2, PIERO TORTOLI2, FABIO SANGUINETI1, PATRIZIA VERGANI3, MICHAEL PAIDAS1, 1Yale University, Obstetrics & Gynecology, New Haven, Connecticut, 2University of Florence, Electronic Engineering, Florence, Italy, 3University of Milano-Bicocca, Monza, Italy OBJECTIVE: To characterize the velocity profiles (VP), relative wall distension rate (WDR) and wall shear rate (WSR) of the FUA and FUV in the 1st, 2nd and 3rd trimesters of normal pregnancies. STUDY DESIGN: The MSDA system consisted of commercial ultrasound machine (Aloka SSD1400), a personal computer and a proprietary electronic board working with GASP software. Interrogated vessels consisted of the FUA and FUV in a total of 57 singleton uncomplicated fetuses. Velocity profiles, relative wall distension rate [WDR(%)] and shear rate [WSR(1/s)] were calculated over multiple consecutives cardiac cycles in real-time. The designation of arterial pseudo-laminar flow was applied if one peak occurred in systole, while if O1 peak in systole was classified as turbulent. Statistical analysis consisted of Spearman correlation and. RESULTS: FUA displayed a laminar flow pattern throughout gestation in all 57 cases bilaterally. Mean WDR[%] was not correlated with gestational age and fetal growth. Mean WSR (484G117) remained constant throughout gestation, beginning at 7 wks. FUV WSR decrease during gestation (r=0.56, p=0.02), WDR is also constant during gestation. CONCLUSION: Real-time velocity profile analysis of the FUA and FUV is now possible using MSDA and GASP software. In normal pregnancies, velocity characteristics are remarkably stable throughout gestation. This study suggest that umbilical arteries wall distension adapts to flow demands and mantains constant mean wall shear rate. Increase in shear rate in unbilical vein seams remark the decrease in maternal viscosity flow. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2006.10.796
736 A LONGITUDINAL STUDY OF THE MIDDLE CEREBRAL ARTERY PULSATILITY INDEX AND PEAK SYSTOLIC VELOCITY – IS THERE A CORRELATION BETWEEN THEIR TRENDS AND FETAL DEMISE? FARHAN HANIF1, ERICH COSMI2, GIANCARLO MARI3, 1 Wayne State University, Obstetrics/Gynecology, Detroit, Michigan, 2 University of Padua, Padua, Italy, 3Wayne State University, Obstetrics & Gynecology, Maternal-Fetal Medicine Section, Detroit, Michigan OBJECTIVE: The longitudinal changes that occur in the middle cerebral artery (MCA) pulsatility index (PI) in severe IUGR fetuses remain unclear. Animal studies have shown that blood velocity is a better indicator of blood flow than angle independent indexes. The aims of this study were to determine 1) the longitudinal changes that occur in the MCA-PI and MCA-PSV in severe IUGR fetuses; and 2) the correlation between these two parameters and fetal demise. STUDY DESIGN: This study included 13 IUGR fetuses (EFW ! 3rd percentile and an umbilical artery PI O 95% confidence interval) in which at least three measurements were performed before delivery (median, 4; range: 3 to 8). The last MCA-PI and MCA-PSV values were obtained at a median interval of 1 day (range: 1 to 3 days) before delivery or before fetal demise. Middle cerebral artery PSV, and MCA-PI values were plotted on the normal reference ranges and their trends were compared to their normal values. A Fisher´ s Exact test was used for statistical analysis. P ! 0.05 was considered statistically significant. RESULTS: Gestational age at delivery ranged between 23.1 weeks and 31.4 weeks´ gestation (median 27.5 weeks). Birth weight ranged from 282 g to 1220 g (median: 471 g). An abnormal MCA-PI preceded the appearance of an abnormal MCA-PSV. In all fetuses, there was consistently an initial increase in MCA-PSV. This increase was followed by a decrease in the PCA-PSV in the 4 fetuses that died in utero (P ! 0.05). This decrease occurred at a median interval of 2 days (median 1 to 3 days) before delivery. CONCLUSION: Our data indicate that (a) the trends of the MCA-PSV and MCA-PI provide more information than one single value, and (b) the MCAPSV might become clinically useful in timing the delivery of the IUGR fetus. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2006.10.798