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Use of the mitral valve–tricuspid valve distance as a marker of fetal endocardial cushion defects
SMFM Abstracts S233
Volume 189, Number 6 Am J Obstet Gynecol 639
USE OF THE MITRAL VALVE-TRICUSPID VALVE DISTANCE AS A MARKER OF FETAL ENDOCARDIAL CUSHION DEFECTS CAROLYN ZELOP1, BETH MILEWSKI1, ALAN BOLNICK1, ELISA GIANFERRARI1, LILLIAN KAMINSKY1, ADAM BORGIDA1, JAMES EGAN1, 1University of Connecticut, Maternal Fetal Medicine, Farmington, CT OBJECTIVE: Vettraino (JUM; 2002) showed the clinical utility of the mitraltricuspid valve distance (M-T D) in the prenatal diagnosis of Ebstein anomalies. We compared the M-T D in second-trimester fetuses with normal cardiac anatomy to those with antenatally diagnosed endocardial cushion defects (ECCD). STUDY DESIGN: We searched our ultrasound database (1997-2003) and identified apical four-chamber views at end diastole. Images were enlarged to electronically measure the distance between the insertion of the medial leaflets of the mitral and tricuspid valves for fetuses between 16 and 24 weeks’ gestation with normal cardiac anatomy and in a subset with ECCD. A linear regression curve was generated for M-T D in normals by gestational age. The sensitivity, specificity, positive and negative predictive value were determined using an M-T D less than the 5th %ile of the expected M-T D as a marker of ECCD. Fisher exact and Student’s t test were used. RESULTS: The mean M-T D for 86 fetuses with normal cardiac anatomy was 2.02 mm (1.86-2.18; 95% CI ) compared to 0.37 mm ( 0.033-0.782; 95% CI) in 13 fetuses with ECCD; P = .0001. Linear regression curve correlating M-T D with gestational age showed a gradual slope with an R2 = 0.28, P < .0001. Using M-T D < 5th %ile as a marker for the diagnosis of ECCD gave a sensitivity of 69.2%, specificity of 100%, PPV of 100%, NPV of 95.6%, and FPR of 0%; P = .0001. CONCLUSION: M-T D is clinically useful in the detection of ECCD in second-trimester fetuses. An M-T D >5th %ile is reassuring and diminishes the likelihood of ECCD.
641
IS FUNNELING AT 23-34 WEEKS’ GESTATIONAL AGE PREDICTIVE OF PRETERM DELIVERY? SHERI JENKINS1, JAMES KURTZMAN2, 1University of California, Irvine, Ob/Gyn, Orange, CA 2University of California, Irvine, Ob/Gyn, Laguna Hills, CA OBJECTIVE: To determine if funneling at 23-34 weeks’ (wks’) gestational age (GA) is predictive of preterm delivery (PTD). STUDY DESIGN: Patients at 23-34 wks’ GA underwent a 10-minute transvaginal ultrasound (US) for cervical length with concurrent tocodynamometry. The presence of funneling (any dilation of the internal cervical os with amniotic sac protrusion) was noted. Exclusion criteria were multiple gestation, ruptured membranes, cerclage, or dilation >3 cm. Funneling was prospectively assessed for prediction of PTD at < 37 wks’ GA. RESULTS: 119 pregnancies were analyzed; 21% had PTD at < 37 wks’ GA. Funneling was associated with preterm labor (PTL) symptoms and tocolysis use, but not contractions (Table 1). Funneling was also associated with shorter initial and minimum lengths and greater real-time shortening of cervical length. Patients with funneling had an earlier mean GA at delivery and higher PTD rates (Table 2). However, funneling was not an independent predictor of PTD after controlling for initial length by regression analysis. Table 1. Characteristics of patients with and without cervical funneling Funneling Absent n = 94
Funneling Present n = 25
P Value
46 (49%) 27 (29%) 32 (34%) 28.1 ± 3.0
20 (80%) 14 (56%) 12 (48%) 28.9 ± 3.0
.01* .01* NS NS
PTL symptoms Tocolysis use Uterine contractions EGA at enrollment (wks)
Table 2. Cervical lengths and PTD rates at < 37 weeks’ GA Funneling Absent n = 94
Funneling Present n = 25
P Value
3.8 ± 0.7 3.5 ± 0.8 0.4 ± 0.3 38.4 ± 2.1 15 (16%)
2.4 ± 1.0 1.8 ± 0.7 0.9 ± 0.5 36.8 ± 2.9 10 (40%)
< .01* < .01* < .01* < .01* < .01*
Initial (cm) Minimum (cm) Maximum change (cm) GA at delivery (wks) PTD < 37 wks’
CONCLUSION: Funneling is associated with shortened cervical length and is predictive of PTD, but not after controlling for initial length.
A-V Canal M-T Distance with 5th, 50th, and 95th percentiles. 640
WHAT IS THE REAL RISK FOR TRISOMY 18? RENEE BOBROWSKI1, JULIA NOETHER1, DEBRA RICHARDSON2, PETER BENN3, 1Hartford Hospital, Maternal-Fetal Medicine, Hartford, CT 2University of Connecticut, Obstetrics and Gynecology, Farmington, CT 3University of Connecticut, Genetics, Farmington, CT OBJECTIVE: To determine if amniocentesis is indicated when the quad screen trisomy 18 risk is >1:100 and targeted ultrasound examination (TUS) is normal. STUDY DESIGN: Women with singleton pregnancies and quad screen trisomy 18 risk >1:100 from January 1, 1995, to February 28, 2003, were identified. Patients evaluated and/or delivered at Hartford Hospital were included. TUSs were performed by a registered sonographer under perinatologist supervision. Patients were offered amniocentesis per standard of care. TUS results, fetal karyotype, when performed, and newborn examination were reviewed. RESULTS: 128 women had a quad screen trisomy 18 risk >1:100. 51 patients had complete TUS records from our unit (average 18.9 weeks). TUS was normal in 33 fetuses, while 18 had at least one finding on TUS. Eleven of 18 fetuses (61%) were abnormal: 4 trisomy 18, 1 triploidy, 1 deletion Xp22.3, 1 anencephaly, 3 fetal demises, and 1 spontaneous abortion. The quad screen risk was 1:10 or higher in 10 of 11 patients. Of the 6 abnormal karyotypes, 5 fetuses had structural abnormalities and 1 fetus had an ultrasound marker. Thirty-seven of 128 patients delivered at our institution: 36 normal newborns and 1 trisomy 18 diagnosed at 18 weeks. Thirty fetuses had a normal TUS and 6 fetuses had an ultrasound marker but no structural abnormality; all 36 newborns were normal at birth. CONCLUSION: When the quad screen trisomy 18 risk is >1:100 and: (1) a structural abnormality is present on TUS, amniocentesis should be recommended; (2) a single marker is present, amniocentesis should be discussed and offered; (3) the TUS is normal, amniocentesis does not appear to be indicated.
642
DECREASED ENDOVASCULAR TROPHOBLAST INVASION IN FIRSTTRIMESTER PREGNANCIES WITH HIGH-RESISTANCE UTERINE ARTERY DOPPLER INDICES FEDERICO PREFUMO1, NEIL J. SEBIRE2, BASKARAN THILAGANATHAN1, 1St. George’s Hospital Medical School, Fetal Medicine Unit, London, United Kingdom 2Great Ormond Street Hospital, Department of Pathology, London, United Kingdom OBJECTIVE: Defective trophoblastic invasion in early pregnancy is involved in the pathogenesis of preeclampsia. This study investigates the relationship between Doppler assessment of uterine artery resistance and endovascular trophoblastic invasion in the first trimester of pregnancy. STUDY DESIGN: Patients undergoing termination of pregnancy for nonmedical reasons were categorized as having a low- or high-resistance uterine artery blood flow pattern by transabdominal Doppler ultrasound. Products of conception were examined histologically with regard to decidual endovascular trophoblast invasion. RESULTS: There were 14 low-resistance and 17 high-resistance uterine artery blood flow pregnancies identified at 10-14 weeks of gestation. Normal intradecidual endovascular trophoblast invasion was identified with a similar frequency in both groups. However, the proportion of decidual vessels with endovascular trophoblast invasion was significantly higher in the low-resistance pregnancies compared to the high-resistance ones. CONCLUSION: The findings of this study support the use of uterine artery Doppler investigation for the non-invasive assessment of trophoblast invasion in early pregnancy. Further studies are necessary to clarify the biological significance of these observations and their potential clinical applications. Histological findings in products of conception from pregnancies with highand low-resistance uterine artery blood flow examined in the late first trimester
Implantation site identified Endovascular trophoblast invasion present No. of implantation site vessels per case No. of implantation site vessels with endovascular trophoblast invasion
High-resistance (n = 17)
Low-resistance (n = 14)
P value
13/17 (76%)
12/14 (86%)
0.52
8/13 (62%)
8/12 (67%)
0.79
9 (1 to 17)
7.5 (3 to 32)
0.44
39/114 (34%)
70/143 (49%)
0.02
Volume 189, Number 6 Am J Obstet Gynecol 639
USE OF THE MITRAL VALVE-TRICUSPID VALVE DISTANCE AS A MARKER OF FETAL ENDOCARDIAL CUSHION DEFECTS CAROLYN ZELOP1, BETH MILEWSKI1, ALAN BOLNICK1, ELISA GIANFERRARI1, LILLIAN KAMINSKY1, ADAM BORGIDA1, JAMES EGAN1, 1University of Connecticut, Maternal Fetal Medicine, Farmington, CT OBJECTIVE: Vettraino (JUM; 2002) showed the clinical utility of the mitraltricuspid valve distance (M-T D) in the prenatal diagnosis of Ebstein anomalies. We compared the M-T D in second-trimester fetuses with normal cardiac anatomy to those with antenatally diagnosed endocardial cushion defects (ECCD). STUDY DESIGN: We searched our ultrasound database (1997-2003) and identified apical four-chamber views at end diastole. Images were enlarged to electronically measure the distance between the insertion of the medial leaflets of the mitral and tricuspid valves for fetuses between 16 and 24 weeks’ gestation with normal cardiac anatomy and in a subset with ECCD. A linear regression curve was generated for M-T D in normals by gestational age. The sensitivity, specificity, positive and negative predictive value were determined using an M-T D less than the 5th %ile of the expected M-T D as a marker of ECCD. Fisher exact and Student’s t test were used. RESULTS: The mean M-T D for 86 fetuses with normal cardiac anatomy was 2.02 mm (1.86-2.18; 95% CI ) compared to 0.37 mm ( 0.033-0.782; 95% CI) in 13 fetuses with ECCD; P = .0001. Linear regression curve correlating M-T D with gestational age showed a gradual slope with an R2 = 0.28, P < .0001. Using M-T D < 5th %ile as a marker for the diagnosis of ECCD gave a sensitivity of 69.2%, specificity of 100%, PPV of 100%, NPV of 95.6%, and FPR of 0%; P = .0001. CONCLUSION: M-T D is clinically useful in the detection of ECCD in second-trimester fetuses. An M-T D >5th %ile is reassuring and diminishes the likelihood of ECCD.
641
IS FUNNELING AT 23-34 WEEKS’ GESTATIONAL AGE PREDICTIVE OF PRETERM DELIVERY? SHERI JENKINS1, JAMES KURTZMAN2, 1University of California, Irvine, Ob/Gyn, Orange, CA 2University of California, Irvine, Ob/Gyn, Laguna Hills, CA OBJECTIVE: To determine if funneling at 23-34 weeks’ (wks’) gestational age (GA) is predictive of preterm delivery (PTD). STUDY DESIGN: Patients at 23-34 wks’ GA underwent a 10-minute transvaginal ultrasound (US) for cervical length with concurrent tocodynamometry. The presence of funneling (any dilation of the internal cervical os with amniotic sac protrusion) was noted. Exclusion criteria were multiple gestation, ruptured membranes, cerclage, or dilation >3 cm. Funneling was prospectively assessed for prediction of PTD at < 37 wks’ GA. RESULTS: 119 pregnancies were analyzed; 21% had PTD at < 37 wks’ GA. Funneling was associated with preterm labor (PTL) symptoms and tocolysis use, but not contractions (Table 1). Funneling was also associated with shorter initial and minimum lengths and greater real-time shortening of cervical length. Patients with funneling had an earlier mean GA at delivery and higher PTD rates (Table 2). However, funneling was not an independent predictor of PTD after controlling for initial length by regression analysis. Table 1. Characteristics of patients with and without cervical funneling Funneling Absent n = 94
Funneling Present n = 25
P Value
46 (49%) 27 (29%) 32 (34%) 28.1 ± 3.0
20 (80%) 14 (56%) 12 (48%) 28.9 ± 3.0
.01* .01* NS NS
PTL symptoms Tocolysis use Uterine contractions EGA at enrollment (wks)
Table 2. Cervical lengths and PTD rates at < 37 weeks’ GA Funneling Absent n = 94
Funneling Present n = 25
P Value
3.8 ± 0.7 3.5 ± 0.8 0.4 ± 0.3 38.4 ± 2.1 15 (16%)
2.4 ± 1.0 1.8 ± 0.7 0.9 ± 0.5 36.8 ± 2.9 10 (40%)
< .01* < .01* < .01* < .01* < .01*
Initial (cm) Minimum (cm) Maximum change (cm) GA at delivery (wks) PTD < 37 wks’
CONCLUSION: Funneling is associated with shortened cervical length and is predictive of PTD, but not after controlling for initial length.
A-V Canal M-T Distance with 5th, 50th, and 95th percentiles. 640
WHAT IS THE REAL RISK FOR TRISOMY 18? RENEE BOBROWSKI1, JULIA NOETHER1, DEBRA RICHARDSON2, PETER BENN3, 1Hartford Hospital, Maternal-Fetal Medicine, Hartford, CT 2University of Connecticut, Obstetrics and Gynecology, Farmington, CT 3University of Connecticut, Genetics, Farmington, CT OBJECTIVE: To determine if amniocentesis is indicated when the quad screen trisomy 18 risk is >1:100 and targeted ultrasound examination (TUS) is normal. STUDY DESIGN: Women with singleton pregnancies and quad screen trisomy 18 risk >1:100 from January 1, 1995, to February 28, 2003, were identified. Patients evaluated and/or delivered at Hartford Hospital were included. TUSs were performed by a registered sonographer under perinatologist supervision. Patients were offered amniocentesis per standard of care. TUS results, fetal karyotype, when performed, and newborn examination were reviewed. RESULTS: 128 women had a quad screen trisomy 18 risk >1:100. 51 patients had complete TUS records from our unit (average 18.9 weeks). TUS was normal in 33 fetuses, while 18 had at least one finding on TUS. Eleven of 18 fetuses (61%) were abnormal: 4 trisomy 18, 1 triploidy, 1 deletion Xp22.3, 1 anencephaly, 3 fetal demises, and 1 spontaneous abortion. The quad screen risk was 1:10 or higher in 10 of 11 patients. Of the 6 abnormal karyotypes, 5 fetuses had structural abnormalities and 1 fetus had an ultrasound marker. Thirty-seven of 128 patients delivered at our institution: 36 normal newborns and 1 trisomy 18 diagnosed at 18 weeks. Thirty fetuses had a normal TUS and 6 fetuses had an ultrasound marker but no structural abnormality; all 36 newborns were normal at birth. CONCLUSION: When the quad screen trisomy 18 risk is >1:100 and: (1) a structural abnormality is present on TUS, amniocentesis should be recommended; (2) a single marker is present, amniocentesis should be discussed and offered; (3) the TUS is normal, amniocentesis does not appear to be indicated.
642
DECREASED ENDOVASCULAR TROPHOBLAST INVASION IN FIRSTTRIMESTER PREGNANCIES WITH HIGH-RESISTANCE UTERINE ARTERY DOPPLER INDICES FEDERICO PREFUMO1, NEIL J. SEBIRE2, BASKARAN THILAGANATHAN1, 1St. George’s Hospital Medical School, Fetal Medicine Unit, London, United Kingdom 2Great Ormond Street Hospital, Department of Pathology, London, United Kingdom OBJECTIVE: Defective trophoblastic invasion in early pregnancy is involved in the pathogenesis of preeclampsia. This study investigates the relationship between Doppler assessment of uterine artery resistance and endovascular trophoblastic invasion in the first trimester of pregnancy. STUDY DESIGN: Patients undergoing termination of pregnancy for nonmedical reasons were categorized as having a low- or high-resistance uterine artery blood flow pattern by transabdominal Doppler ultrasound. Products of conception were examined histologically with regard to decidual endovascular trophoblast invasion. RESULTS: There were 14 low-resistance and 17 high-resistance uterine artery blood flow pregnancies identified at 10-14 weeks of gestation. Normal intradecidual endovascular trophoblast invasion was identified with a similar frequency in both groups. However, the proportion of decidual vessels with endovascular trophoblast invasion was significantly higher in the low-resistance pregnancies compared to the high-resistance ones. CONCLUSION: The findings of this study support the use of uterine artery Doppler investigation for the non-invasive assessment of trophoblast invasion in early pregnancy. Further studies are necessary to clarify the biological significance of these observations and their potential clinical applications. Histological findings in products of conception from pregnancies with highand low-resistance uterine artery blood flow examined in the late first trimester
Implantation site identified Endovascular trophoblast invasion present No. of implantation site vessels per case No. of implantation site vessels with endovascular trophoblast invasion
High-resistance (n = 17)
Low-resistance (n = 14)
P value
13/17 (76%)
12/14 (86%)
0.52
8/13 (62%)
8/12 (67%)
0.79
9 (1 to 17)
7.5 (3 to 32)
0.44
39/114 (34%)
70/143 (49%)
0.02