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Lung-to-Head Ratio and liver position to predict outcome in early diagnosed isolated left sided diaphragmatic hernia fetuses: A multicenter study
S176 SMFM Abstracts 626
627
LUNG-TO-HEAD RATIO AND LIVER POSITION TO PREDICT OUTCOME IN EARLY DIAGNOSED ISOLATED LEFT SIDED DIAPHRAGMATIC HERNIA FETUSES: A MULTICENTER STUDY JACQUES JANI1, ALEXANDRA BENACHI2, RENE´ FAVRE3, ROBERTA KELLER4, HILDE VANDECRUYS5, JULIAN DELGADO6, MICHAEL HARRISON7, JACQUELINE MATIS8, EDUARD GRATACOS6, KYPROS NICOLAIDES5, JAN DEPREST1, 1 University Hospital Gasthuisberg, Obstetrics and Gynecology, Leuven, Belgium, 2Hoˆpital Necker-Enfants Malades, Obstetrics and Gynaecology, Paris, France, 3CHRU Strasbourg, Obstetrics and Gynecology, Schiltigheim, France, 4University of California, San Francisco, Neonatology/Pediatrics, San Francisco, California, 5King’s College London, Harris Birthright Research Centre, London, United Kingdom, 6Hospital Universitari Vall Hebron, Obstetrics and Gynecology, Barcelona, Spain, 7University of California, San Francisco, Surgery & Pediatrics, San Francisco, California, 8CHRU Strasbourg, Neonatology, Schiltigheim, France OBJECTIVE: Congenital diaphragmatic hernia (CDH) is associated to high neonatal mortality. Accurate prediction of outcome is crucial in counselling parents about management options. We evaluated Lung-to-Head Ratio (LHR) and liver position in prediction of outcome of isolated Left CDH. STUDY DESIGN: Retrospective review of consecutive patients diagnosed with isolated LCDH %28 weeks, evaluated at 6 tertiairy units from 1995 onwards. Only patients with LHR measurements by experienced sonographers and with known liver position by ultrasound or MRI, both %28 wks, were included. Outcome measure was survival at discharge from NICU. RESULTS: 134 cases had an LHR obtained at 24.4 G 2.8 wks. 11 patients (8%) opted for termination after evaluation, all with LHR !1.4. There were no postnatal diagnoses of chromosomal anomalies. Overall survival was 43% (58/ 134), after substraction of antenatal losses 47% (58/123). In case of liver herniation survival was 35 %. LHR correlated to survival irrespective of liver position but combination of both variables predicted neonatal outcome better: liver up & LHR !1 predicted a survival of 9%. When LHR !0.8 and liver up, there were no survivors, but with liver down (37% of cases) survival was 40%. When LHR !0.6 there were no survivors irrespective of liver position. CONCLUSION: Combination of liver up& LHR !1 at %28 wks predicts a !10 % chance of survival, dropping to 0% if LHR !0.8. 8% of patients opted for termination after second opinion, all with LHR !1.4, but only in half this coincided with the above poor prognostic indicators.
n
Liver LHR
Up n
Up Survival, n (%)
Up TOP (n)
Down n
Down Survival, n (%)
Down TOP (n)
4 27 23 46 34 134
!0.6 0.6-0.8 0.8-1.0 1.0-1.4 R1.4 Total
3 18 16 29 9 75
0/3 0/14 3/15 14/28 7/9 24/69
0 4 1 1 0 6
1 9 7 17 25 59
0/1 4/9 3/6 9/13 18/25 34/54
0 0 1 4 0 5
(0%) (0%) (20%) (50%) (78%) (35%)
(0%) (44%) (50%) (69%) (72%) (63%)
CLINICAL IMPLICATIONS OF PRENATALLY DIAGNOSED MARGINAL PLACENTAL CORD INSERTION DEBORAH FELDMAN1, KATJE KONING1, RENEE BOBROWSKI1, ADAM BORGIDA1, CHARLES INGARDIA1, 1Hartford Hospital, Obstetrics and Gynecology, Hartford, Connecticut OBJECTIVE: To compare pregnancy and neonatal outcomes in marginal placental cord insertion (MPCI) diagnosed by ultrasound to a group of matched controls with a central placental cord insertion (CPCI). STUDY DESIGN: We reviewed our ultrasound database and identified patients with a singleton pregnancy from 1/2002-12/2003 with MPCI, defined as placental cord insertion !2 cm from the placental edge. For each case, two controls with CPCI were matched for maternal age and gestational age (GA) at initial ultrasound. Maternal demographics and pregnancy and neonatal outcomes were compared using Student’s t test, ANOVA, and c2 with Fisher exact test where appropriate. RESULTS: During the study period, 38/3722 patients(1.0%) with a singleton pregnancy had a MPCI documented by ultrasound; 25 had complete data. There was no difference in maternal demographics between the two groups. The incidence of preterm delivery was higher (20% vs 5.4%, P = .042)) in the MPCI group. Although the mean birth weight (BW) was lower in the MPCI group, there was no difference in the rate of BW !2500 g (LBW). There were no differences in the rates of preeclampsia, oligohydramnios, fetal growth restriction, fetal distress, or primary cesarean delivery between the groups. Neonatal outcomes showed similar rates of meconium, nuchal cord, small-forgestational age (SGA), and NICU admission between the groups. Composite maternal and fetal morbidity were also similar for both groups. CONCLUSION: MPCI was associated with earlier delivery and lower birth weight when compared to fetuses with CPCI. While no significant differences were noted with regard to maternal or neonatal morbidity, larger studies are required to elucidate the need for closer surveillance in these pregnancies. Pregnancy outcomes of MPCI versus CPCI Outcome
MPCI (n = 25)
CPCI (n = 50)
P value
PTD (%) BW (g) LBW (%) NICU (%)
20 3168 699 8.0 4.0
5.4 3486 510 4.0 0.0
.04 .016 .427 .250
628
FIRST TRIMESTER SCREENING (FTS) IN THE DETECTION OF DOWN SYNDROME JOANN JOHNSON1, BARRY HOFFMAN2, DAVID CHITAYAT3, ELIZABETH WINSOR2, KENNETH PRITZKER4, 1University of Calgary, Obstetrics and Gynecology, Calgary, Alberta, Canada, 2University of Toronto, Pathology and Laboratory Medicine, Toronto, Ontario, Canada, 3University of Toronto, Paediatrics, Toronto, Ontario, Canada, 4University of Toronto, Laboratory Medicine & Pathobiology, Toronto, Ontario, Canada OBJECTIVE: The aim of this study was to evaluate the performance of first trimester screening (FTS) in the detection of fetal Down syndrome (DS). STUDY DESIGN: The study population consisted of unselected patients (single site) between 11-13.6 weeks gestation who consented to FTS (maternal age, nuchal translucency (NT) and biochemical markers (free b-human chorionic gonadotropin [hCG], pregnancy-associate plasma protein-A [PAPP-A]) and follow-up of pregnancy outcome. All NT measurements were performed by sonographers trained according to the standards set by the Fetal Medicine Foundation, UK. A screening result was considered positive for Down syndrome if the calculated risk was greater than or equal to 1:350 (term risk). RESULTS: Between January 2002 and Jan 2004, 8805 women underwent FTS. The detection rate for DS was 87.8% (27/31) and false positive rate (FPR) 4.7%. During the same time period, the amniocentesis rate decreased by 22%. CONCLUSION: FTS is associated with a higher DR and lower FPR compared with second trimester maternal serum screening. A decrease in the number of invasive tests (mainly amniocentesis) has also been observed since the introduction of the program.
629
THE HAZARDS OF OBSTETRICS AND GYNECOLOGICAL ULTRASOUND TO PRACTITIONERS RINAT HACKMON1, EYAL SHEINER2, RUTH BEER-WEISEL3, ISRAEL MEIZNER4, 1Tel Aviv University, Ob/Gyn, NYC, New York, 2Soroka University Medical Center, Ob/Gyn, Beer-Sheva, Israel, 3Soroka University Medical Center, Ob/Gyn, Beer- Sheva, Israel, 4Beilinson University Medical Center, OB/GYN, Petach Tiqwa, Israel OBJECTIVE: In the practice of Obstetrics and Gynecology (Ob/Gyn), the ultrasound examination has become so common that it is considered as an integral part of the physical examination.New unexpected symptoms such as myalgia and arthralgia among sonographers have arisen. The aim of this study is to investigate the complains of physicians and technicians performing Ob/Gyn ultrasound examinations. STUDY DESIGN: A cross sectional retrospective survey was performed between 2002 and 2003. Questionnaires were distributed to members of the Society of Gynecological Ultrasound. Statistical analysis included c2, Fisher’s exact, or Student’s t test, Pearson’s correlation coefficient and Multivariable analysis. P ! .05 was considered significant. RESULTS: One hundred thirty three (66.5%) of 200 surveys distributed, were filled out. Sixty nine were female 64 were male. The vast majority of technicians were female 97.3%, while 89.6% of physicians were males. The average number of examination per day for technicians was 29 as compared to 20 for physicians. Joint pain (JP) was reported by 51.7% technicians compared to 25.3% of the physicians (OR = 3.16; 95% CI 1.4-7.0; P = .002). JP complains were more common in females as compared to males (44.9% vs 28.1%, P = .04) and among those who performed abdominal ultrasound more frequently than the transvaginal procedure (mean 21 vs 19, P = .004). A significant association was found between the performance of abdominal ultrasound and back pain (BP), using the Pearson’s correlation coefficient (P = .05). Visual deterioration was the most common complain (3.8%) answered to the open question of symptoms. Surgical procedures were performed more often among male as compared to female technicians (12.5% vs 2.9%, P = .05). CONCLUSION: There is a direct correlation between the number of abdominal ultrasound examinations and JP or BP. In addition, gender differences in pain perception and therapy exist. Attention should be focused on the mobility, angulation, shape and weight of the various equipment in order to prevent physiological damage to the performers.
627
LUNG-TO-HEAD RATIO AND LIVER POSITION TO PREDICT OUTCOME IN EARLY DIAGNOSED ISOLATED LEFT SIDED DIAPHRAGMATIC HERNIA FETUSES: A MULTICENTER STUDY JACQUES JANI1, ALEXANDRA BENACHI2, RENE´ FAVRE3, ROBERTA KELLER4, HILDE VANDECRUYS5, JULIAN DELGADO6, MICHAEL HARRISON7, JACQUELINE MATIS8, EDUARD GRATACOS6, KYPROS NICOLAIDES5, JAN DEPREST1, 1 University Hospital Gasthuisberg, Obstetrics and Gynecology, Leuven, Belgium, 2Hoˆpital Necker-Enfants Malades, Obstetrics and Gynaecology, Paris, France, 3CHRU Strasbourg, Obstetrics and Gynecology, Schiltigheim, France, 4University of California, San Francisco, Neonatology/Pediatrics, San Francisco, California, 5King’s College London, Harris Birthright Research Centre, London, United Kingdom, 6Hospital Universitari Vall Hebron, Obstetrics and Gynecology, Barcelona, Spain, 7University of California, San Francisco, Surgery & Pediatrics, San Francisco, California, 8CHRU Strasbourg, Neonatology, Schiltigheim, France OBJECTIVE: Congenital diaphragmatic hernia (CDH) is associated to high neonatal mortality. Accurate prediction of outcome is crucial in counselling parents about management options. We evaluated Lung-to-Head Ratio (LHR) and liver position in prediction of outcome of isolated Left CDH. STUDY DESIGN: Retrospective review of consecutive patients diagnosed with isolated LCDH %28 weeks, evaluated at 6 tertiairy units from 1995 onwards. Only patients with LHR measurements by experienced sonographers and with known liver position by ultrasound or MRI, both %28 wks, were included. Outcome measure was survival at discharge from NICU. RESULTS: 134 cases had an LHR obtained at 24.4 G 2.8 wks. 11 patients (8%) opted for termination after evaluation, all with LHR !1.4. There were no postnatal diagnoses of chromosomal anomalies. Overall survival was 43% (58/ 134), after substraction of antenatal losses 47% (58/123). In case of liver herniation survival was 35 %. LHR correlated to survival irrespective of liver position but combination of both variables predicted neonatal outcome better: liver up & LHR !1 predicted a survival of 9%. When LHR !0.8 and liver up, there were no survivors, but with liver down (37% of cases) survival was 40%. When LHR !0.6 there were no survivors irrespective of liver position. CONCLUSION: Combination of liver up& LHR !1 at %28 wks predicts a !10 % chance of survival, dropping to 0% if LHR !0.8. 8% of patients opted for termination after second opinion, all with LHR !1.4, but only in half this coincided with the above poor prognostic indicators.
n
Liver LHR
Up n
Up Survival, n (%)
Up TOP (n)
Down n
Down Survival, n (%)
Down TOP (n)
4 27 23 46 34 134
!0.6 0.6-0.8 0.8-1.0 1.0-1.4 R1.4 Total
3 18 16 29 9 75
0/3 0/14 3/15 14/28 7/9 24/69
0 4 1 1 0 6
1 9 7 17 25 59
0/1 4/9 3/6 9/13 18/25 34/54
0 0 1 4 0 5
(0%) (0%) (20%) (50%) (78%) (35%)
(0%) (44%) (50%) (69%) (72%) (63%)
CLINICAL IMPLICATIONS OF PRENATALLY DIAGNOSED MARGINAL PLACENTAL CORD INSERTION DEBORAH FELDMAN1, KATJE KONING1, RENEE BOBROWSKI1, ADAM BORGIDA1, CHARLES INGARDIA1, 1Hartford Hospital, Obstetrics and Gynecology, Hartford, Connecticut OBJECTIVE: To compare pregnancy and neonatal outcomes in marginal placental cord insertion (MPCI) diagnosed by ultrasound to a group of matched controls with a central placental cord insertion (CPCI). STUDY DESIGN: We reviewed our ultrasound database and identified patients with a singleton pregnancy from 1/2002-12/2003 with MPCI, defined as placental cord insertion !2 cm from the placental edge. For each case, two controls with CPCI were matched for maternal age and gestational age (GA) at initial ultrasound. Maternal demographics and pregnancy and neonatal outcomes were compared using Student’s t test, ANOVA, and c2 with Fisher exact test where appropriate. RESULTS: During the study period, 38/3722 patients(1.0%) with a singleton pregnancy had a MPCI documented by ultrasound; 25 had complete data. There was no difference in maternal demographics between the two groups. The incidence of preterm delivery was higher (20% vs 5.4%, P = .042)) in the MPCI group. Although the mean birth weight (BW) was lower in the MPCI group, there was no difference in the rate of BW !2500 g (LBW). There were no differences in the rates of preeclampsia, oligohydramnios, fetal growth restriction, fetal distress, or primary cesarean delivery between the groups. Neonatal outcomes showed similar rates of meconium, nuchal cord, small-forgestational age (SGA), and NICU admission between the groups. Composite maternal and fetal morbidity were also similar for both groups. CONCLUSION: MPCI was associated with earlier delivery and lower birth weight when compared to fetuses with CPCI. While no significant differences were noted with regard to maternal or neonatal morbidity, larger studies are required to elucidate the need for closer surveillance in these pregnancies. Pregnancy outcomes of MPCI versus CPCI Outcome
MPCI (n = 25)
CPCI (n = 50)
P value
PTD (%) BW (g) LBW (%) NICU (%)
20 3168 699 8.0 4.0
5.4 3486 510 4.0 0.0
.04 .016 .427 .250
628
FIRST TRIMESTER SCREENING (FTS) IN THE DETECTION OF DOWN SYNDROME JOANN JOHNSON1, BARRY HOFFMAN2, DAVID CHITAYAT3, ELIZABETH WINSOR2, KENNETH PRITZKER4, 1University of Calgary, Obstetrics and Gynecology, Calgary, Alberta, Canada, 2University of Toronto, Pathology and Laboratory Medicine, Toronto, Ontario, Canada, 3University of Toronto, Paediatrics, Toronto, Ontario, Canada, 4University of Toronto, Laboratory Medicine & Pathobiology, Toronto, Ontario, Canada OBJECTIVE: The aim of this study was to evaluate the performance of first trimester screening (FTS) in the detection of fetal Down syndrome (DS). STUDY DESIGN: The study population consisted of unselected patients (single site) between 11-13.6 weeks gestation who consented to FTS (maternal age, nuchal translucency (NT) and biochemical markers (free b-human chorionic gonadotropin [hCG], pregnancy-associate plasma protein-A [PAPP-A]) and follow-up of pregnancy outcome. All NT measurements were performed by sonographers trained according to the standards set by the Fetal Medicine Foundation, UK. A screening result was considered positive for Down syndrome if the calculated risk was greater than or equal to 1:350 (term risk). RESULTS: Between January 2002 and Jan 2004, 8805 women underwent FTS. The detection rate for DS was 87.8% (27/31) and false positive rate (FPR) 4.7%. During the same time period, the amniocentesis rate decreased by 22%. CONCLUSION: FTS is associated with a higher DR and lower FPR compared with second trimester maternal serum screening. A decrease in the number of invasive tests (mainly amniocentesis) has also been observed since the introduction of the program.
629
THE HAZARDS OF OBSTETRICS AND GYNECOLOGICAL ULTRASOUND TO PRACTITIONERS RINAT HACKMON1, EYAL SHEINER2, RUTH BEER-WEISEL3, ISRAEL MEIZNER4, 1Tel Aviv University, Ob/Gyn, NYC, New York, 2Soroka University Medical Center, Ob/Gyn, Beer-Sheva, Israel, 3Soroka University Medical Center, Ob/Gyn, Beer- Sheva, Israel, 4Beilinson University Medical Center, OB/GYN, Petach Tiqwa, Israel OBJECTIVE: In the practice of Obstetrics and Gynecology (Ob/Gyn), the ultrasound examination has become so common that it is considered as an integral part of the physical examination.New unexpected symptoms such as myalgia and arthralgia among sonographers have arisen. The aim of this study is to investigate the complains of physicians and technicians performing Ob/Gyn ultrasound examinations. STUDY DESIGN: A cross sectional retrospective survey was performed between 2002 and 2003. Questionnaires were distributed to members of the Society of Gynecological Ultrasound. Statistical analysis included c2, Fisher’s exact, or Student’s t test, Pearson’s correlation coefficient and Multivariable analysis. P ! .05 was considered significant. RESULTS: One hundred thirty three (66.5%) of 200 surveys distributed, were filled out. Sixty nine were female 64 were male. The vast majority of technicians were female 97.3%, while 89.6% of physicians were males. The average number of examination per day for technicians was 29 as compared to 20 for physicians. Joint pain (JP) was reported by 51.7% technicians compared to 25.3% of the physicians (OR = 3.16; 95% CI 1.4-7.0; P = .002). JP complains were more common in females as compared to males (44.9% vs 28.1%, P = .04) and among those who performed abdominal ultrasound more frequently than the transvaginal procedure (mean 21 vs 19, P = .004). A significant association was found between the performance of abdominal ultrasound and back pain (BP), using the Pearson’s correlation coefficient (P = .05). Visual deterioration was the most common complain (3.8%) answered to the open question of symptoms. Surgical procedures were performed more often among male as compared to female technicians (12.5% vs 2.9%, P = .05). CONCLUSION: There is a direct correlation between the number of abdominal ultrasound examinations and JP or BP. In addition, gender differences in pain perception and therapy exist. Attention should be focused on the mobility, angulation, shape and weight of the various equipment in order to prevent physiological damage to the performers.