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Fetal Face in the First Trimester
S134
Ultrasound in Medicine and Biology
T11-16-IN11 First Trimester Prediction of Preeclampsia by Ultrasound Chiu Yee Poon Liona Clinical Associate Professor, Obstetrics and Gynaecology, the Chinese University of Hong Kong Preeclampsia is an important cause of death and disability for the mother and baby. The risk for such complications is considerably higher when the disease is severe and of early onset, leading to preterm birth at less than 37 weeks of gestation rather than term preeclampsia. A major challenge in modern obstetrics is early identification of pregnancies at high-risk of preterm preeclampsia and undertaking the necessary measures to reduce the prevalence of the disease. Professional bodies now recommend the prophylactic use of lowdose aspirin (60-80 mg per day) in women considered to be at highrisk of preeclampsia. In the UK, the National Institute for Health and Clinical Excellence (NICE) recommends selection of the high-risk group on the basis of 10 factors from maternal characteristics, medical history and obstetric history; however, the performance of such screening is poor with detection of about 40% of preterm preeclampsia and 33% of term preeclampsia at screen positive rate of 11%. In the USA, the American College of Obstetricians and Gynecologists (ACOG) recommends use of aspirin for women with a history of preeclampsia in more than one pregnancy or history of preeclampsia requiring delivery before 34 weeks of gestation; however, this subgroup constitutes about 0.3% of all pregnancies, contains only 5% of those that would develop preterm preeclampsia and 2% of term preeclampsia. In normal pregnancy the spiral arteries in the placental bed are invaded by trophoblast, which becomes incorporated into the vessel wall and replaces the endothelium, muscular layer and neural tissue. These physiological changes convert the spiral arteries from narrow muscular vessels to wide non-muscular channels independent of maternal vasomotor control. In preeclampsia there is impaired trophoblastic invasion of spiral arteries and this impairment is most marked in early preeclampsia. Indirect evidence for impaired placental perfusion in pregnancies destined to develop preeclampsia has been provided by ultrasound Doppler studies of the uterine arteries which showed increased pulsatility index (PI) in the firsttrimester of pregnancy. Uterine artery PI has been proven to be one of the most predictive parameters for the development of early onset preeclampsia. Our proposed method of screening is one that utilises Bayes theorem to combine the a priori risk from maternal factors, with uterine artery PI, mean arterial pressure and placental growth factor at 11-13 weeks of gestation; a study involving about 60,000 singleton pregnancies has reported that such screening is superior to the methods proposed by NICE and ACOG and can detect 90%, 75% and 40% of cases of early preeclampsia (,34 weeks), preterm preeclampsia (,37 weeks) and term preeclampsia ($37 weeks), respectively, at screen positive rate of 10%. T11-16-IN12 Fetal Face in the First Trimester Ritsuko K. Pooh, MD, PhD, LL.B CRIFM Clinical Research Institute of Fetal Medicine Pooh Maternity Clinic, Osaka, Japan Fetal face examination is important because the facial appearance is strongly related with genetic condition, brain disorder and developmental delay. In the first trimester, fetal face structure is almost created. The points of facial structure which can be assessed are profile, nasal bone, nasal appearance, mandible, maxilla, chin by sagittal view, eyeballs, lips and alveolar by coronal-axial view, and ear position and chin development by three-dimensional ultrasound. The eyeballs are bilaterally created in early embryological stage. The eyeball is visualized by silhouette ultrasound. At the beginning of 12
Volume 43, Number S1, 2017 weeks, a small cystic part appears and at the middle of 12 weeks, the eyeball is depicted much larger and at 13 weeks, The lens and vitreous body in the eyeball can be identified and thereafter the lens and vitreous body are continuously demonstrated by silhouette ultrasound. This new technology has a great potential to open a new field of ‘fetal 3D sonoophthalmology’, which has been never invented by conventional ultrasound technology. Thus, three-dimensional HDlive ultrasound further ‘‘humanizes’’ the fetus,and enables detailed observation of detailed facial appearance even in the first trimester. A small fetus is not a fetus but a ‘‘person’’ with its personality from the first trimester. T11-16-IN13 NIPT and First Trimester Ultrasound Qingqing Wu The Ultrasound Depart, Beijing Ob&Gyn. Hospital, Capital Medical University, Beijing, China Non-invasive prenatal testing (NIPT) is rapidly being incorporated into prenatal care with highly efficient. It has changed the traditional methods of prenatal screening and diagnosis. How to reassess the role of prenatal ultrasound? ISUOG has compiled Consensus Statement: ‘‘All women should first be offered a first-trimester ultrasound scan according to ISUOG guidelines, regardless of their intention to undergo NIPT’’. NIPT is not a diagnostic test and need to be confirmed by invasive testing for the presence of any abnormal results (1). Our research results show that after invasive testing, a chromosomal abnormality was detected in 164/1247 (13.2 %) fetuses. 65/ 1247 (5.2 %) cases concerned trisomy 21, 18 or 13, 12/1247 (0.96 %) an aneuploidy of sex chromosomes and 1/1247 (0.08 %) triploidy. In 71/1247 (5.6 %) a chromosome aberration was seen and in 2/1247 (0.16 %) cases of UPD was found. Fetal structural abnormality was detect in 91/19232 (0.47%), NT$3mm was in 370/19232(1.92%) by ultrasonography. NIPT positive in 17 cases including 8/17 trisomy 21, 4/17 trisomy 18. The false positive in 5 cases including 1/5 trisomy 21, 1/5 trisomy 18, 2/5 trisomy 13, 1/5 Sex chromosome. The false negative in 3 cases. NIPT could not detect all chromosome aberrations in the first trimester. Reference: 1. Ultrasound Obstet Gynecol 2014; 44: 122–123. 2. Srebniak et al. Molecular Cytogenetics (2016) 9:69. T11-16-IN14 Shifting the Fetal Anomaly Scan To the First Trimester Dr. Suresh Seshadri Mediscan Systems Since the last three decades, the diagnostic capability of Obstetric ultrsound has significantly inreased thanks to technological advances and improven in understanding fetal anatomy, physiology and anomalies. The traditional approach for fetal anatomical evalution is to perform a detaild anatomical scan between 18-20 weeks. The quest for early diagnosis was strengthened by research in first trimester diagnosis of aneuploidies. We now realise that fetal anatomical evaluation can be effectively done in the first trimester since embryogenesis is complete by 12 weeks form LMP. Hence major malformations can be seen at this time. A meticulous protocol based ‘‘rule of 2’’ checklist approach will help diagnose about 60% of anomalies in the first trimester. By using this protocol it is possible to classify anomalies as those that can always be detected in the first trimester and those that cannot be detected in this period. Major CNS anomalies, cardiac anomalies, abdominal wall defects and limb defects can be diagnosed during the 11-13 week scan. Considering the possible yield, the first trimester should be considered as the first milestone for screening for structural defects. However this
Ultrasound in Medicine and Biology
T11-16-IN11 First Trimester Prediction of Preeclampsia by Ultrasound Chiu Yee Poon Liona Clinical Associate Professor, Obstetrics and Gynaecology, the Chinese University of Hong Kong Preeclampsia is an important cause of death and disability for the mother and baby. The risk for such complications is considerably higher when the disease is severe and of early onset, leading to preterm birth at less than 37 weeks of gestation rather than term preeclampsia. A major challenge in modern obstetrics is early identification of pregnancies at high-risk of preterm preeclampsia and undertaking the necessary measures to reduce the prevalence of the disease. Professional bodies now recommend the prophylactic use of lowdose aspirin (60-80 mg per day) in women considered to be at highrisk of preeclampsia. In the UK, the National Institute for Health and Clinical Excellence (NICE) recommends selection of the high-risk group on the basis of 10 factors from maternal characteristics, medical history and obstetric history; however, the performance of such screening is poor with detection of about 40% of preterm preeclampsia and 33% of term preeclampsia at screen positive rate of 11%. In the USA, the American College of Obstetricians and Gynecologists (ACOG) recommends use of aspirin for women with a history of preeclampsia in more than one pregnancy or history of preeclampsia requiring delivery before 34 weeks of gestation; however, this subgroup constitutes about 0.3% of all pregnancies, contains only 5% of those that would develop preterm preeclampsia and 2% of term preeclampsia. In normal pregnancy the spiral arteries in the placental bed are invaded by trophoblast, which becomes incorporated into the vessel wall and replaces the endothelium, muscular layer and neural tissue. These physiological changes convert the spiral arteries from narrow muscular vessels to wide non-muscular channels independent of maternal vasomotor control. In preeclampsia there is impaired trophoblastic invasion of spiral arteries and this impairment is most marked in early preeclampsia. Indirect evidence for impaired placental perfusion in pregnancies destined to develop preeclampsia has been provided by ultrasound Doppler studies of the uterine arteries which showed increased pulsatility index (PI) in the firsttrimester of pregnancy. Uterine artery PI has been proven to be one of the most predictive parameters for the development of early onset preeclampsia. Our proposed method of screening is one that utilises Bayes theorem to combine the a priori risk from maternal factors, with uterine artery PI, mean arterial pressure and placental growth factor at 11-13 weeks of gestation; a study involving about 60,000 singleton pregnancies has reported that such screening is superior to the methods proposed by NICE and ACOG and can detect 90%, 75% and 40% of cases of early preeclampsia (,34 weeks), preterm preeclampsia (,37 weeks) and term preeclampsia ($37 weeks), respectively, at screen positive rate of 10%. T11-16-IN12 Fetal Face in the First Trimester Ritsuko K. Pooh, MD, PhD, LL.B CRIFM Clinical Research Institute of Fetal Medicine Pooh Maternity Clinic, Osaka, Japan Fetal face examination is important because the facial appearance is strongly related with genetic condition, brain disorder and developmental delay. In the first trimester, fetal face structure is almost created. The points of facial structure which can be assessed are profile, nasal bone, nasal appearance, mandible, maxilla, chin by sagittal view, eyeballs, lips and alveolar by coronal-axial view, and ear position and chin development by three-dimensional ultrasound. The eyeballs are bilaterally created in early embryological stage. The eyeball is visualized by silhouette ultrasound. At the beginning of 12
Volume 43, Number S1, 2017 weeks, a small cystic part appears and at the middle of 12 weeks, the eyeball is depicted much larger and at 13 weeks, The lens and vitreous body in the eyeball can be identified and thereafter the lens and vitreous body are continuously demonstrated by silhouette ultrasound. This new technology has a great potential to open a new field of ‘fetal 3D sonoophthalmology’, which has been never invented by conventional ultrasound technology. Thus, three-dimensional HDlive ultrasound further ‘‘humanizes’’ the fetus,and enables detailed observation of detailed facial appearance even in the first trimester. A small fetus is not a fetus but a ‘‘person’’ with its personality from the first trimester. T11-16-IN13 NIPT and First Trimester Ultrasound Qingqing Wu The Ultrasound Depart, Beijing Ob&Gyn. Hospital, Capital Medical University, Beijing, China Non-invasive prenatal testing (NIPT) is rapidly being incorporated into prenatal care with highly efficient. It has changed the traditional methods of prenatal screening and diagnosis. How to reassess the role of prenatal ultrasound? ISUOG has compiled Consensus Statement: ‘‘All women should first be offered a first-trimester ultrasound scan according to ISUOG guidelines, regardless of their intention to undergo NIPT’’. NIPT is not a diagnostic test and need to be confirmed by invasive testing for the presence of any abnormal results (1). Our research results show that after invasive testing, a chromosomal abnormality was detected in 164/1247 (13.2 %) fetuses. 65/ 1247 (5.2 %) cases concerned trisomy 21, 18 or 13, 12/1247 (0.96 %) an aneuploidy of sex chromosomes and 1/1247 (0.08 %) triploidy. In 71/1247 (5.6 %) a chromosome aberration was seen and in 2/1247 (0.16 %) cases of UPD was found. Fetal structural abnormality was detect in 91/19232 (0.47%), NT$3mm was in 370/19232(1.92%) by ultrasonography. NIPT positive in 17 cases including 8/17 trisomy 21, 4/17 trisomy 18. The false positive in 5 cases including 1/5 trisomy 21, 1/5 trisomy 18, 2/5 trisomy 13, 1/5 Sex chromosome. The false negative in 3 cases. NIPT could not detect all chromosome aberrations in the first trimester. Reference: 1. Ultrasound Obstet Gynecol 2014; 44: 122–123. 2. Srebniak et al. Molecular Cytogenetics (2016) 9:69. T11-16-IN14 Shifting the Fetal Anomaly Scan To the First Trimester Dr. Suresh Seshadri Mediscan Systems Since the last three decades, the diagnostic capability of Obstetric ultrsound has significantly inreased thanks to technological advances and improven in understanding fetal anatomy, physiology and anomalies. The traditional approach for fetal anatomical evalution is to perform a detaild anatomical scan between 18-20 weeks. The quest for early diagnosis was strengthened by research in first trimester diagnosis of aneuploidies. We now realise that fetal anatomical evaluation can be effectively done in the first trimester since embryogenesis is complete by 12 weeks form LMP. Hence major malformations can be seen at this time. A meticulous protocol based ‘‘rule of 2’’ checklist approach will help diagnose about 60% of anomalies in the first trimester. By using this protocol it is possible to classify anomalies as those that can always be detected in the first trimester and those that cannot be detected in this period. Major CNS anomalies, cardiac anomalies, abdominal wall defects and limb defects can be diagnosed during the 11-13 week scan. Considering the possible yield, the first trimester should be considered as the first milestone for screening for structural defects. However this