Download - F94Early ultrasonographic screening for malformation - how early is too early?

4±7 October 2000, Zagreb, Croatia Free Communications

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U LT R A S O U N D I N G Y N E C O L O G Y

F01Transvaginal sonographic and Color/Power Dopplerevaluation of cervical carcinoma

M. E. Romanini*, C. ExacoustoÁ s, M. Congiu*, D. Arduini,P. Benedetti-Panici* and C. RomaniniDepartment of Obstet. and Gynecol., University of Tor Vergata,Rome, Italy, *Department of Gynecol., Campus BiomedicoUniversity, Rome, Italy

Background: Aim of this study was to assess the accuracy oftransvaginal sonography (TVS) associated to Color or Power Doppler(CFD/PD) for the evaluation of size and spread of disease in cervicalcancer as diagnostic tool in the preoperative evaluation.Method : All patients (pts) affected by cervical cancer were studied byTVS and CFD/PD. TVS probe was used also as a transrectal whendeemed necessary. Tumor size was measured consecutively by gray scalesonography and using CFD/PD. Extension of the tumor to the parametria;to the corpus uteri, to the ovary, the bladder and the rectum was alsoevaluated. TVS findings were compared to gynecologic examinationunder anesthesia, MRI and laparoscopy and pathological specimen.Results: 20 cases were studied. 45% of pts had neoadjuvantchemotherapy. Tumor diameter measured by ultrasound correlatedwell with pathological specimen (r � 0.82). Accuracy of themeasurement was increased when tumor diameter was . 4 cm. TVScorrectly diagnose the extension of disease to the bladder and to thecorpus uteri in 90% of cases. Involvement of the parametria wassupected by sonography in 45% of cases.Conclusions: TVS seems to be an accurate means of evaluation fortumor size and extension to adjacent organs, therefore TVS could beuseful in the perioperative management of cervical cancer.

F02Sonographic preoperative assessment of myometrial invasionin endometrial cancer

C. ExacoustoÁ s, M. E. Romanini*, D. Rinaldo, C. Carusotti,D. Arduini, P. Benedetti-Panici* and C. RomaniniDepartment of Obstet. and Gynecol., University of Tor Vergata,Rome, Italy; *Department of Gynecol., Campus BiomedicoUniversity, Rome, Italy

Background: The purpose of this study was to assess the accuracy oftransvaginal sonography (TVS) and Color/Power Doppler (CFD/PD)in evaluating the depth of myometrial invasion and preoperativestaging of endometrial cancer.Method: All patients (pts) with histological confirmed endometrialcancer were evaluated sonographically before surgery. In all patients theendometrium was scanned by TVS to evaluate thickness, echogenicity,border, intraluminal fluid and intracavitary masses. CFD/PD were usedto evaluate vessels distribution and resistance indices: Myometrialinfiltration was evaluated more or less than 50%. Sonographic resultswere compared to histological staging obtained after surgery.Results: 53 patients were enrolled. All had endometrial thickness. 5 mm, mean thickness 19.5 ^ 10.5 mm. Myometrial invasionwas , 50% in 35 pts, TVS evaluation was exact in 33 cases, with asensitivity of 94% and a positive predictive value (PPV) of 94%. Aninfiltration . 50% was seen with TVS in 12 pts and was histologicallyconfirmed in 11, with a sensitivity of 82% and PPV of 75%. Other 3pts had a cervical infiltration, 3 had stage 3, one had stage 4. TVSevaluated correctly 48 patients with a sensitivity of 91%.Conclusions: TVS seems to be a valuable, noninvasive and unexpen-sive diagnostic method for the assessment of myometrial invasion.

F03Transvaginal sonographic detection of endometrial pathologyin postmenopausal women on HRT

C. ExacoustoÁ s, C. Carusotti, D. Angelozzi, D. Rinaldo, D. Arduiniand C. RomaniniDepartment of Obstet. and Gynecol., University of Tor Vergata,Rome, Italy

Background: The aim of this study was to assess the sonographicaspect of the endometrium in postmenopausal patients receivinghormone replacement therapy (HRT) at different phases of thetreatment and to identify endometrial pathologies on the basis ofabnormal sonographic findings.Method: The study group was composed of 103 women treated withsequential (82) or combined (21) HRT for at least 6 months. Allpatients underwent transvaginal sonography (TVS) with evaluation ofendometrial thickness and echopattern. Patients on seqential regimesunderwent TVS subsequently in the estrogen (phase E) and progesto-gen phases (phase P) and after withdrawal bleeding or immediately5 days after the last progestogen administration (phase 0). Patientswith an endometrial thickness . 5 mm (in phase 0 for patients onsequential HRT) or with TVS anomalies of the endometrial patternunderwent sonohysterography and/or hysteroscopy.Results: In the 82 women on sequential HRT regimes mean endometrialthickness was significantly lower in phase 0 (3.8 ^ 1.2 mm) compared tophase E (5.8 ^ 1.7 mm) and phase P (6.2 ^ 2.1 mm). On 20 patientswith TVS abnormal endometrial findings sonohysterography identified 8benign endometrial polyps which were removed by hysteroscopy and 2simple hyperplasia were diagnosed by histeroscopically guided biopsy.Conclusions: Sonohysterography is useful in HRT patients to detectendometrial polyps. In case of diffuse or focal endometrial thicknesson sonohysterography an office hysteroscopy with guided biopsycould be useful.

F04Prognostic value of Dopplerometry during antirecurrenthormonal therapy in patients with hyperplastic process of theendometrium

E. V. Fedorova, A. D. Lipman, I. D. Khokhlova and N. M. PobedinskiMoscow Medical Academy, Russia

Background: The purpose of study was to find out changes of Dopplerparameters in all uterine arteries during antirecurrent hormonalcourses and to define their role in prediction of outcomes.Method: 53 patients receiving hormonal therapy (Norcolut, Provera,Danazol) after D & C were undergone 6 months monitoring bytransvaginal ultrasound with Color Flow Mapping and Dopplerassessment of the main uterine, arcuate, radial and basal arteries. Themean values of resistance indices (RI) were calculated after retro-spective division into groups with effective (n � 41) and effectless(n � 12) treatment. Investigated RI data were used for statisticalcreation of prognostic upper and lower cut-off levels (for P , 0.05).Results: The resistance indices were:

Ultrasound in Obstetrics and Gynecology 35

HealthyEffectivetreatment

Effectlesstreatment

Cut-off intervalsfor P , 0.05

Uterine arteries 0.88 0.86 0.83 0.83±0.87Arcuate arteries 0.78 0.74 0.72 0.65±0.80Radial arteries 0.71 0.73* 0.65* 0.60±0.75Basal arteries 0.57 0.62 0.57 0.48±0.68

* ± p , 0.10

Conclusion: For predicting effectiveness of hormonal treatment aftertwo months from its beginning Doppler measurements should becarried out in Radial Arteries and RI must exceed 0.75.

F05Is TV-USG detection of myometrial invasion of endometrialcancer predictible?

B. Tekin, S. OÈ zalp, H. Hassa, T. SËener, OÈ . T. YalcËin and E. EtizOsmangazi University, School of Medicine, Department of Obstetricsand Gynecology, Eskisehir, Turkey

Background: The aim of the study is to determine effectiveness oftransvaginal ultrasound (TV-USG) examination in predicting myo-metrial invasion of the endometrial cancer.Method: Some patients of endometrial cancer, were examined underTV-USG examination. All TV-USG procedures were done by the sameperson and by the same ultrasound equipment between 1.9.1998 and31.12.1999. After then, patients were operated, and pathologicalexamination of the specimens were done as routine procedure.Results: Twenty-six cases who were in this research, were in stage 1except 4 who were in stage 4. Histopathologic type of 22 cases wasendometrioid cell cancer and grade-1 in 58.3% cases. Ultrasoundexamination revealed 76.9% similarity with pathological results.Positive predictivity was 94.4% and the negative predictivity was37.5%.Conclusion: TV-USG diagnosis of endometrial invasion of cancer, maybe a useful technique in predetermining the way of treatment while thedepth of invasion is an important key as well as histopathology andgrade of the tumor.

F06Transvaginal sonography, hydrosonography and hysteroscopyfor the investigation of women with postmenopausal bleedingand endometrium $ 5 mm

E.E. Epstein, A. Ramirez, L. Skoog* and L. ValentinDepartment of Obstetrics and Gynecology and Department ofPathology*, University Hospital, Malmo, University of Lund, Sweden

Objective: To determine the ability of transvaginal ultralsound, withor without saline infusion (hydrosonography), to detect focallygrowing lesions in the uterine cavity in women with postmenopausalbleeding and endometrium $ 5 mm, and to determine the accuracy ofconventional ultrasound, hydrosonography and hysteroscopy withregard to diagnosing endometrial polyps, submucous myomas anduterine malignancy.Methods: In a proscpective study 105 women with postmenopausalbleeding and endometrium $ 5 mm, underwent conventional ultra-sound examination and hydrosonography. Diagnostic hysteroscopy, D& C, and hysteroscopic resection were the performed. The presence offocally growing lesions, and the type of lesion (e.g. endometrial polyp,submucous myoma or malignancy) were noted at ultrasoundexamination and at hysteroscopy. The endpoints were focally growinglesions detected at hysteroscopy and final pathological diagnosis.Results: There was almost perfect agreement (96%) betweenhydrosonography and hysteroscopy with regard to detecting focallygrowing lesions. Hydrosonography and hysteroscopy both had asensitivity of around 80% with regard to endometrial polyps (falsepositive rate 24% and 6%, respectively), whereas conventionalultrasound missed half of the polyps (sensitivity 49%, false positiverate 19%). Hysteroscopy was superior to both hydrosonography andconventional ultrasound for discrimination between benign andmalignant lesions in the uterine cavity (sensitivity 84%, 44%, and60%; false positive rate 15%, 6%, and 10%). We found a seven foldincreased risk of malignancy in women with distension problems athydrosonography (odds ratio 7.3, 95% CI 1.9±27.8).Conclusion: Hydrosonography is as good as hysteroscopy at detectingfocally growing lesions in the uterine cavity in women withpostmenopausal bleeding. However, neither hysteroscopy nor hydro-sonography can reliably discriminate between benign and malignant

focal lesions. Distension problems at hydrosonography should raise asuspicion of malignacy.

F07Hysterosonosalpingography ± a new concept of diagnosticprocedures in gynaecology

M. J. Bernardo, C. LeitaÄo, I. Dias, J. Bugalho and I. NetoDona EstefaÃnia Hospital, Lisbon, Portugal

Background: The aim of this study is to find the effectiveness ofhysterosonosalpingography in the diagnosis of the endometrialpathology and in the study of tubal patency.Method: We have studied 550 cases backwards. The women enrolledcame from four departments of our Hospital: Menopause (n � 206),Reproductive Medicine (n � 195), General Gynaecology (n � 125)and Senology 2 Women on Tamoxifen (n � 24). We have analysedepidemiological data, Transvaginal Sonography and hysterosonosal-pingography findings, as well as the conventional Hysterosalpingo-graphy, Laparoscopic, Hysteroscopic and histological data. We havelooked for the concordance rate between the hysterosonosalpingo-graphy and the other diagnostic procedures.Results: Main findings: Round hyporeflective broad-based structuresrepresenting polyps or submucosal myomas, thin endometrium,floating thin or rigid strips, subseptate uterus, unobstructed tubes,uni or bilateral tubal occlusions. High concordance rate (from 85% to95%) was verified between the hysterosonosalpingography and theclassic diagnostic proceedings.Conclusion: Hysterosonosalpingography is a good and valuablecomplement of Transvaginal Sonography in the endometrial study. Itmakes possible appropriate preoperative triage to hysteroscopy. It maybe also a first class exam of screening infertility. The success of thistechnique led us to include it at the diagnostic protocols in ourHospital.

F08Real-time intraoperative ultrasound guidance; the transrectalapproach

I. Bar-Hava, I. Meizner, D. Rabinerson, I. Shalev, R. Mashiach,R. Orvieto, Z. Ben-Rafael and A. DekelDepartment of Obstetrics & Gynecology, Rabin Medical Center,Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, TelAviv, Israel

Background: The aim of this study was to assess the role of real-timetransrectal ultrasound (RT-TRUS) guidance in complicated gynecolo-gical procedures.Method: During the study period RT-TRUS was utilized to directand assist the gynecological surgeon in two complicated gynecolo-gical procedures: Completing the evacuation of the uterine cavityafter identification of uterine wall perforation during termination ofpregnancy and drainage of posthysterectomy infected vaulthematomas.Results: In all, 11 patients were treated by this fashion (6 abortionsand 5 infected vault hematomas). All procedures were completedwithout any further complications and the patients were dischargedthe following day with uneventful follow-up.Conclusion: RT-TRUS is an effective tool that can provide on-lineassistance to the gynecological surgeon in various pelvic procedures.

F09Detection of pelvic recurrent disease with transvaginal color-Doppler analysis in women treated for gynecologicmalignancy

A. C. Testa, M. Ciampelli, C. Mastromarino, R. Lopez, S. Mancusoand G. ScambiaUniversitaÁ Cattolica del Sacro Cuore, Rome, Italy

Background: To evaluate Color Doppler characteristics of small tumor

10th World Congress on Ultrasound in Obstetrics and Gynecology Free Communications

36 Ultrasound in Obstetrics and Gynecology

recurrences detected within the pelvis in follow-up patients treated forgynecologic malignancy.Method: Out of 310 patients monitored for gynecologic malignancy, aselected group of 14 patients, with small size pelvic masses located inthe central region of the pelvis detected by transvaginal ultrasound,underwent a color Doppler evaluation.

A subjective assessment of the vascularization (vascular score), thelowest Resistance Index (RI), the highest Peak Velocity (PV) and thehighest Time Averaged Maximum Velocity (TAMXV) of the vesselsdetected within the lesion were considered for the analysis.Results: Color score of tumor recurrences (No 7) was significantlyhigher in comparison to benign lesions (No 7) (2.6 ^ 0.5 vs. 2 ^ 0,P , 0.05). The malignant lesions showed significantly higher meanvalues of PV and TAMXV when compared to benign ones(17.9 ^ 4.3 cm/s vs. 7.5 ^ 3 cm/sec, P , 0.0001; 9.7 ^ 2.2 cm/svs. 3.5 ^ 3 cm/s, P , 0.01).Conclusions: Color Doppler analysis added to transvaginal ultra-sonography seems to be an helpful tool in the evaluation pelvis at anearly stage of recurring tumor in the pelvis.

F10The sonographic diagnosis of uterine venous plexusthrombosis made by transvaginal B-mode and color Dopplerscanning: two case reports

Z. Leibovitz, S. Degani, I. Shapiro, J. Tal, B. Paz, Z. Levitan,L. M. Schliamser, A. Toubi and G. OhelBnai Zion Medical Center, Haifa, Israel

Background: Transvaginal sonography (TVS) enables a close imagingof the pelvic organs providing a clear imaging of the pelvic vessels. Tothe best of our knowledge ± this is the first report of the diagnosis ofuterine venous plexus thrombosis using this technique.Case reports: 1st case: 38-year-old patient diagnosed as having a lefttubal ectopic pregnancy in the 7th week of gestation. On TVSexamination the ipsilateral uterine plexus thrombosis was found. Theblood clots were demonstrated as elongated echogenic structureswithin the dilated veins. The thrombi showed swinging movementscaused by the surrounding blood flow. This effect could also beprovoked by gentle transducer pressure. On the transverse view of theaffected veins the thrombi appeared as free round structures in thelumen. The blood flow around the thrombi was seen on colorDoppler.

2nd case: 36-year-old patient with fetal death in the 19th week ofgestation. Two days after the induced labor the patient experiencedexcessive vaginal bleeding. A placental residue was confirmed by TVS.Upon examination the engorged uterine venous plexuses were seenwith a thrombus on the right side. The sonographic description of theclot was as in the first case.

There were no signs of thromboembolic disease in both cases. Thedeep leg veins and iliac veins were studied and found to be normal.The uterine plexus thrombi could not be detected by transabdominalsonography and were only seen by TVS. Over 3 months of antic-oagulation therapy the clots gradually disappeared in both cases.Conclusions: In both patients the transvaginal sonographic diagnosisof uterine venous plexus thrombosis was accidental. There is notenough data in the medical literature to determine the evidence basedapproach to such cases. Nevertheless, focusing on the pelvic veins mayreveal important findings with significant clinical implications.

F11Ultrasound evaluation of the uterus after pregnancy

T. Van Den Bosch, D. Van Schoubroeck, D. Timmerman andA. Z. H. HartTienen, and University Hospital Gasthuisberg, K.U. Leuven, Belgium

Objectives: To evaluate the sonographic appearance of the uterus aftera recent pregnancy, with special attention to the occurrence ofplacental rests, hyperechogenic lesions, and areas of enhancedvascularity.Patients and methods: Cross-sectional observational study on 239

consecutive women presenting at follow-up visit after pregnancy. Theuterus was evaluated using ultrasound with color Doppler. In case ofplacental rests, blood was sampled. When indicated a D & C wasperformed.Results: Hyperechogenic areas were seen in 11.3%, mostly spots(85.2%) localized in the (sub)endometrial region. In 4.6% placentalrests were evidenced. In these cases blood sampling revealed bHCGlevels below 30 mIU/ml in 64%; serological infection parameters andhemoglobin concentration were within normal range. In 5% ofwomen areas of enhanced vascularity were detected on color Doppler.Most cases were focal areas of one or more vessels perfusing retainedplacental tissue. There were 2 cases of placenta accreta. In 3 patientsabnormal vascularity extended over the whole of the myometrium.Conclusions: (1) (Sub)endometrial echogenic spots are common inprimigravidas without a history of curettage. (2) Serology proved to beof little help in the diagnosis of retained gestational products. (3)Areas of enhanced vascularity of the uterus can be devised in 3 groups:focal vascular pedicle of a placental rest, placenta accreta, and areas ofabnormal enhanced vascularity over the whole thickness of themyometrium.

F12Diagnosis of ovarian cancer with ultrasound, serum CA125and logistic regression

A. C. Lawrence, N. Aslam, B. Wolfer, C. J. Elson and D. Jurkovic

Background: The aim of this study was to compare the accuracy of alogistic regression model for the diagnosis of ovarian malignancy tosubjective assessment made by experienced ultrasonographers at thetime of the scan.Method: All patients undergoing surgery for known adnexal masseswere assessed preoperatively using transvaginal ultrasound and serumCA125 measurements. A number of demographic, morphological andDoppler parameters necessary for the regression analysis wererecorded. The risk of malignancy was then calculated using apreviously published multivariate regression model. Independentlyto these calculations, an attempt was made to establish the histologicaldiagnosis based on subjective assessment of ultrasound findings byexperienced operators.Results: A total of 161 patients had surgery for adnexal massesbetween August 1997 and June 2000. Of these, 115 had benignmasses, 9 borderline and 37 malignant. The multivariate logisticalregression model diagnosed ovarian malignancy with a sensitivity of68.9% and specificity of 79.7%. The subjective assessment of themalignancy gave a sensitivity of 92.7% with a specificity of 78.2%.The calculated likelihood ratios were 3.4 and 4.3, respectively.Comment: Multivariate logistic regression model is less accurate thansubjective assessment by experienced observers in the diagnosis ofovarian cancer.

F13The influence of angiotenzin converting enzyme inhibitors onadnexal tumor vascularization

A. Jurisic, N. Antic, R. Maglic, P. Tajfl and S. Jankovic`Narodni Front' OB/GYN University Clinic, Belgrade, Yugoslavia

Background: The aim of this study was to investigate the influence ofantihypertensive therapy with angiotenzin converting enzyme inhibi-tors (ACE) on adnexal tumor hemodynamic parameters.Method: Patients were classified into the four groups: ace benign (29),ACE malignant (17), benign (188), malignant (71). Hemodynamicstudies of tumor vascularization were performed by transvaginalcolor/power Doppler and Pourcelot resistance indices (RI) weremeasured in tumor tissue. Statistical analysis was performed byanalysis of variance (ANOVA).Results: A total of 305 patients were examined and 1411 blood vesselswere analyzed. In ACE benign group 125 resistance indices wereanalyzed; in ACE malignant group 136 RIs; in benign group 644 RIsand in malignant group 506 RIs were measured. Mean RI values were



BACE � 0.469 ^ 0.124, MACE � 0.409 ^ 0.096, B � 0.564 ^

0.121 and M � 0.390 ^ 0.095. Analysis of variance showed highstatistical significance between the groups, where RI in ACE benigngroup was significantly lowered.Conclusion: The analyzed data in our study indicate that antihyper-tensive therapy with angiotenzin converting enzyme inhibitors maysignificantly reduce vascular resistance indices (RI) in patients withbenign adnexal tumors who received that therapy at the time ofultrasonographic examination.

F14Functional ovarian cysts during the use of levonorgestrelreleasing intrauterine system

E. Ekholm, P. Inki, R. Hurskainen and P. PaloDepartment of Obstetrics and Gynecology, University of Turku andHelsinki, Finland

Background: We wanted to study the effect of a levonorgestrel-releasing intrauterine system (Mirena) on ovarian morphology inhypermenorrheic women.Methods: 236 women suffering from menorrhagia participated in thisstudy. The patients were randomized to two groups: 118 womenreceived mirena and 106 went through hysterectomy. All the subjectswere 35±49-year-old. Transvaginal ultrasound was performed atbaseline, and both six months and one year after mirena insertion/hysterectomy.Results: An ovarian cyst of more than 30 mm in diameter wasdetected in 13 patients at baseline. The mean diameter of the cyst was34 mm (SD 8, range 32 � 19 to 62 � 28 mm). At six month control19 patients had an ovarian cyst of a diameter more than 30 mm and atone year follow-up an ovarian cyst was detected in 23 and two cysts intwo patients using Mirena. In the hysterectomized group the numberof ovarian cysts were 3 and 8, respectively. The mean size of theovarian cysts was similar in both groups. None of the ovarian cystsrequired surgical intervention during the follow-up period. At baseline110 patients (46.6%) were diagnosed as having uterine fibroids with amean diameter of 22 mm. The size of uterine fibroids did not increaseduring the study period.Conclusion: Functional ovarian cysts are more frequent in womenusing mirena compared to hysterectomized women of similar age.However, the ovarian cysts observed during the study did not lead tosurgical intervention.

F15Tubal sterilization by laparoscopic electrocoagulation is notassociated with disturbances in pelvic blood flow velocimetry

R. Hershkovitz, D. Goldstein and M. MazorDepartment of Obstetrics and Gynecology, Soroka University MedicalCenter, Ben-Gurion University of the Negev, Beer-Sheva, Israel

Background: Sterilization by laparoscopic tubal electrocoagulation isa well-known technique. The purpose of the present study was toevaluate pelvic blood flow velocimetry before and after laparoscopictubal ligation and to determine hormonal profile.Methods: Sixteen women underwent laparoscopic tubal electrocoa-gulation. Doppler studies of uterine, arcuate and ovarian arteries wasperformed at early follicular and midluteal phases at the cycles beforeand after the laparoscopic procedure. Serum blood samples wereobtained concordantly.Results: Mean maternal age at the time of procedure was 38 ^ 8 years. Nosignificant differences were noted between all the following parameters:

Conclusion: Laparoscopic tubal electrocoagulation is not associatedwith changes in the pelvic blood flow velocimetry and the hormonalprofile.

E C T O P I C P R E G N A N C Y

F16Natural course of ectopic pregnancy evaluated by transvaginalsonography

O. Okitsu, H. Nakasaka and T. MimuraHanda Municipal Hospital, Tokushima, Japan

Backgorund: Some of the cases with ectopic pregnancy (EP) may havespontaneous resolution without any treatment. Our aim of this studywas to survey natural course of EP with serial sonographic assessment.Method: All patients with EP from 1995 to 2000 were recruited.Inclusion criteria were 1. Positive hCG test, 2. Adnexal mass,suggestive of EP depicted by transvaginal sonography, 3. No fetalactivity, 4. Pelvic fluid less than 300 mL, 5. Minimal symptoms, 6.

Conservative management might be profitable to the patients, and 7Informed consent. Under Hospitalization, the patients underwent atleast one sonographic examination per day. When the amount ofintraperitoneal hemorrhage proved to be increasing during the follow-up, surgical treatment was performed.Results: Of 34 cases with ectopic pregnancy, 13 cases with tubalpregnancy had emergency laparotomy immediately after admission.One case with cervical pregnancy was treated with methotrexate.Other 20 cases were enrolled in this study. Of the cases, 10 hadlaparotomy because of increasing intraperitoneal hemorrhage and/orworsening symptoms. In other 10 cases, spontaneous regression of themass and decline of hCG level were confirmed. They could bedischarged without any surgical treatment.

Early Follicular Phase Midluteal Phase

Pre

Ligation

Post

Ligation

Pre

Ligation

Post

Ligation

Rt. Uterine

artery

2.5 2.3 1.9 2.2

PI-median

(range)

(1.2±3.5) (1.4±3.7) (1.05±3.2) (1.1±3.5)

Lt. Uterine

artery

2.9 2.7 2.5 2.6

PI-median

(range)

(1.5±3.9) (1.6±3.4) (1.3±2.9) (1.4±3.3)

Arcuate artery 2.4 2.6 2.1 2.3

PI-median

(range)

(2.0±2.9) (1.8±3.4) (1.7±2.7) (1.8±2.9)

Rt. Ovarian 3.4 3.5 3.2 3.1

PI-median

(range)

(2.4±4.1) (2.5±4.2) (2.0±3.9) (2.1±3.8)

Lt. Ovarian 3.7 3.5 3.2 3.1

PI-median

(range)

(2.7±4.5) (2.6±4.4) (2.3±4.1) (2.4±3.9)

Estrogen

(pg/ml)

mean ^ SD

32.0 ^ 15.2 29.0 ^ 5.7 209.5 ^ 95.2 187 ^ 72.0

DHEAS

(mg/dl)

mean ^ SD

190.5 ^ 90 215.4 ^ 105 201.2 ^ 48.5 251.1 ^ 120

Progesterone

(ng/ml)

mean ^ SD

0.5 ^ 0.4 0.6 ^ 0.5 15 ^ 5.4 19 ^ 3.9



Conclusion: Expectant management was successful in 10 (50.0%) ofthe patients, in which natural course of EP was followed bytransvaginal sonography.

F17Expectant management of ectopic pregnancy: is it possible topredict successful outcome

J. Elson, S. Banerjee, A. C. Lawrence, B. WoÈ lfer and D. JurkovicKing's College Hospital, London, UK

Background: The aim of this study was to examine the value ofdifferent clinical, ultrasound and biochemical parameters for theprediction of final outcome in women with ectopic pregnancies whichare managed expectantly.Method: Clinically stable women with ultrasound diagnosis of tubalectopic pregnancy were offered expectant management. In all casesthe gestational age, morphology, pregnancy size, serum hCG andprogesterone levels were recorded. Surgery was indicated in womenwith a deterioration of clinical symptoms or rising/nondeclining hCGlevels.Results: 51 out of 114 (45%) tubal ectopic pregnancies were managedexpectantly. The ectopic pregnancy resolved spontaneously in 33 cases(65%). None of the patients suffered tubal rupture and one patientwith low pretreatment haemoglobin received blood transfusion. Therewere no significant differences in the length of gestation, morpholo-gical appearances and mean pregnancy diameter between pregnancieswhich resolved spontaneously and those requiring surgery. However,both serum hCG and progesterone were significantly lower in tubalpregnancies that resolved spontaneously. By combining serumprogesterone at cut-off level of , 10 nmol/L and serum hCG at, 1000 IU/L a successful resolution of the ectopic pregnancy could bepredicted with a sensitivity of 63% and specificity of 93%. Thepositive predictive value of this test was 79% and the accuracy 85%.Conclusions: Serum hCG and progesterone measurements could beused to predict the likelihood of successful expectant management oftubal ectopic pregnancies.

F18Hysterosalpingo contrast sonography in the assessment oftubal patency after ectopic pregnancy treated by methotrexat

M. Odeh, A. Priborkin, Z. Lebovitz, S. Degani and M. OettingerDepartments of ob. & gyn. Regional Hospital of Western Galilee,Nahariya and Bnei Zion Medical Center, Haifa, Israel

Background: The aim of this study was to assess tubal patency inpatients treated by methotrexat for ectopic pregnancy using hyster-osalpingo contrast sonography (HyCoSy).Method: Patients that had ectopic pregnancy treated by methotrexat

and in whom the pregnancy site was confirmed by ultrasound wereincluded in this study. Echovist contrast medium was used to assesstubal patency. Fallopian tube patency was defined as being thevisualization of a steady flow of contrast agent within the fallopiantube and/or the visible contrast spill from the fimbirial end over theovary. In patients who previously underwent HSG the results werecompared.Results: 135 patients were contacted out of 157 but 28 only reportedfor the examination. The ectopic pregnancy was localized in the lefttube in 14 patients and in the right tube in 14. Twenty-four patientsstated that they are still planing future pregnancies and 4 of themdelivered before the examination. Both tubes were patent in 22(78.6%) patients (5 normal HSG) while 3 (10.7%) had one patenttube in the contralateral side (1 normal HSG) and 1 (3.6%) in theipsilateral side (1 normal HSG) and 2 (7.1%) had both tubes occluded(no HSG). The examination was completed in all patients and 6reported on severe pain and 14 on mild discomfort.Conclusion: Our results match the tubal patency rate reported in thisgroup of patients using HSG and we think HyCoSy may replace HSGin the majority of these cases.

F19The use of color Doppler ultrasound in conservativemenagement of ectopic pregnancy

R. Bauman, S. Kupesc, T. Hafner, K. Stilinovic and M. IlijasDepartment of Obstetrics and Gynecology, Sveti Duh Hospital,Zagreb, Croatia

Background: Up to 20% of all patients with ectopic pregnancieslocated in the ampullary part of the tube could be treated by expectantmenagement. Conservative treatment with MTX is a method of choicein cases of cervical or cornual pregnancy. Serum values of ûhCG arecommonly used as an indirect indicator of trophoblastic proliferativeactivity. The aim of this study is to establish the value of color Dopplerultrasound in conservative menagement of ectopic pregnancies.Method: All patients with ectopic pregnancies that have been treatedconservatively in our Department had serial ûhCG measurements andcolor Doppler examinations.Results: From January 1998. to December 1999. total of 21 patientwith ectopic pregnancy had expectant menagement. Spontaneousresolution occurred in 15 patients and in 6 patients we had to performlaparoscopy. One patient with cornual pregnancy and one patientwith cervical pregnancy were successfully treated with MTX. In allpatients color Doppler findings could be correlated with serum ûhCGvalues.Conclusion: Color Doppler ultrasound can be used in addiction tohormone asseys in order to follow the resolution of ectopicpregnancies treated expectantly or with MTX.

M I S C E L L A N E O U S

F20Sonographic tissue characterization based on the parametersderived from computerized processing of gray level data

Z. Leibovitz, S. Degani, I. Shapiro and G. OhelBnai Zion Medical Center, Haifa, Israel

Background: Sonographic tissue characterization is a relatively weakarm of ultrasound diagnosis. There is a great influence of thesonographic machine setup on the B-mode gray level appearance ofthe ultrasound image. Various ultrasound artefacts can producesignificant changes in brightness setting of the details in sono-graphic pictures. Nevertheless, in certain situations, the ability tospecify the sonographic texture of the tissues may reveal interestinginformation.Method: We present measurable parameters for the specification of

the `homogenicity' of the sonographic texture of the scanned tissue.These parameters are derived from the computerized image proces-sing. The processing includes selection of the region of interest, whichis related to the specific tissue in the image plane and distributionanalysis of the gray level of pixels within the selected region.Results: An implication of this algorithm is demonstrated by textureanalysis of the different fetal choroid plexus images as they appear inearly anatomical scans (15±17 weeks).

Of the effects of B-mode presets ± the dynamic range and rejectionlevel had most significant impact on the texture appearance in view ofthe studied parameters.

There was good correlation between the subjective perception of thetissue homogenicity and the computer analysis results.Conclusion: The proposed texture parameters may lead to the newapproach for the sonographic tissue characterization. These



parameters may be used for the standardization of ultrasoundmachine setups as well.

F21Recurrent non inmune hydrops fetalis in parents with sharedHLA DR and DQ

R. PeÂrez FernaÂndez, J. A. De LeoÂn, P. Pintado, M. Orera, J. Carboneand L. Ortiz`Gregorio MaranÄoÂn' General Hospital, Madrid, Spain

Introduction: Non immune hydrops fetalis (NIHF) is defined as theextra cellular accumulation of fluid in tissues and serous cavities,without evidence of circulating antibodies against red blood cellantigens. NIHF is the result of a heterogeneous group of conditionsincluding cardiovascular, pulmonary, chromosomal, haematology,infectious disorders and deposit disease.

A 34-year-old pregnant woman with obstetrical history of two priorperinatal deaths between 29th and 30th weeks of gestation, allassociated with foetal hydrops. In the prior pregnancy we made aexhaustive study of the foetal blood, obtained by cordocentesis, andthe parents' blood. This study included haematology, infectious

serology, hormonal and immune disorders and it was detected ashared HLA DR and DQ. In the current pregnancy, the foetus hasdeveloped hydrops at the 20th week of gestation which has beendiagnosticated by ultrasound. Once again the results of the researchhas been normal and we have tried to correct the hypoproteinemiawith albumen infusion by cordocentesis. The following up has showedthe increase of the hydrops concluding with cardiovascular failure andfoetal death.Discussion: The mortality rate of recurrent NIHF is over the 80% ofthe cases and depends on the ethiology. The epidemiological studieshad demonstrated the association between abortions and parents whoshared HLA DR and DQ but the association with recurrent NIHF isnot a proved fact.

The diagnosis of hydrop fetalis is by ultrasound on detection of skinthickness greater than 5 mm with fluid accumulation in at least one ofthe serous cavities. It is also necessary to obtain a detailed ultrasoundscan for structural defects, echocardiography and Doppler blood flowstudies of mayor foetal vessels. Ultrasound is an important tool used inthe following up of NIHF and it makes possible the use of thecordocentesis therapy in some cases.

I N F E RT I L I T Y

F22Computerized analysis of uterine peristalsis from transvaginalultrasound images after ovulation induction by clomiphencitrate

O. Eytan, I. Halevi, J. Har-Toov, I. Gull, I. Wolman, J. B. Lessing,D. Elad and A. J. JaffaLis Maternity Hospital, Tel-Aviv Sourasky Medical Center andBiomedical Engineering, Tel Aviv University, Tel Aviv, Israel

Background: Uterine peristalsis plays a central role in assisting thetransport of an embryo to a fundal implantation site.Objective: Computerized characterization of the dynamics of intra-uterine fluid±wall interface (IUFWI) from in vivo images of thesagittal cross-sections of the uterus of patients treated with ClomiphenCitrate (CC) and healthy women with normal cycle.Method: Transvaginal ultrasound (TVUS) images of sagittal cross-sections of nonpregnant uterus were scanned. Images at consecutivetimes (1 second apart) were digitized and processed by techniques ofimage processing. The images were compared to evaluate timevariation of the IUFWI with respect to amplitude, frequency andsymmetry.Results: TVUS images from 6 women treated by CC (Group A) and 25healthy volunteers (Group B) during the proliferative phase wereanalyzed. The amplitudes of the IUFWI of Groups A and B yielded0.106 ^ 0.041 mm and 0.082 ^ 0.045 mm, respectively. Thefrequency of Group A, 0.036 ^ 0.017 Hz, was higher than thefrequency of Group B, 0.029 ^ 0.017 Hz, in contrast to reportedobservations. The motility of IUFWI among Group B revealed highersymmetry, 20.712 (21 yields full symmetry), than the symmetry of20.660 of Group A.Conclusions: It may well be that the differences in the amplitude,frequency and symmetry change the pregnancy rate of womenundergoing ovulation induction by CC.

F23Reproducibility of transvaginal three-dimensionalendometrial volume measurements during ovarian stimulationusing virtual organ computer aided analysis (VOCALTM)

B. Salle, A. Affif, A. M. Bory and R. C. RudigozService de GyneÂcologie ObsteÂtrique, Centre Hospitalo-universitaire dela Croix Rousse, Lyon, France

Background: The aim of this study was to document the reproduci-bility of endometrial volume measurements by 3D-ultrasound andVOCALTM.Materials and methods: One three-dimensional endometrial measure-ment was performed on each 79 consecutive infertile patientsundergoing IVF. All scans were obtained using the Voluson 530 D(Kretztechnik AG, Zipf, Austria) the day of the oocytes retrieval andstored on a 540 Mbyte with an integrated magneto optical drive. AfterB mode analysis of the endometrium the system was switched intovolume mode. Endometrial volume was calculated with theVOCALTMsoftware. Volume was calculated by two different obser-vers (O1 and O2) and every 158 and 308 in order to appreciate interand intra observer reliability.Results: Mean endometrial volume was 4.00 cm3for each observer.Intra observer reproducibility was better for volume calculated at 158

(0.9754 for O1 and 0.9683 for O2) than volume calculated at 308

(0.9303 for O1 and 0.9602 for O2). A paired t-test showed that therewas no statistical difference between the two observers for volumecalculated each 158 and significant difference for volume calculatedeach 308.Conclusion: VOCAL permitted an easy and reproducible inter andintra observer calculation of endometrial volume during controlledovarian stimulation for IVF.

F24Assessment of endometrial volume by virtual organ computeraided analysis (VOCALTM) with three-dimensionnalultrasound prior to embryo transfer

R. C. Rudigoz, A. M. Bory, A. Affif and B. SalleService de GyneÂcologie ObsteÂtrique, Centre Hospitalo-universitaire dela Croix Rousse, Lyon, France

Background: The aim of this study was to obtain quantitative data onendometrial volume at the time of the oocyte retrieval in IVF patientsMaterials and methods: 110 consecutive patients undergoing IVF wereincluded. The day of oocyte retrieval, patients were scanned by 3Dultrasound with Voluson 530 D (Kretztechnik AG, Zipf, Austria).Once the uterus was centred in longitudinal section, the volume boxwas superimposed. The volume was captured and stored on a 540Mbyte with an integrated magneto optical drive. Endometrial volumewas calculated with Virtual Organ Computer Aided Analysis(VOCALTM).



Results: Pregnancy rate was 25.45% (28/110). There was no statisticaldifference in age, ampoule of rec FSH, E2 level at the time of theoocyte retrieval, number of oocyte, number of mature oocyte,embryos and embryos transferred between pregnant and non pregnantwomen. Mean endometrial thickness was 10.29 mm in the pregnantgroup and 9.54 mm in the non pregnant group. Mean endometrialvolume was 5.10 cm3in the pregnant group and 4.31 cm3 in the nonpregnant group. A paired t-test showed no statistical difference inendometrial thickness (P � 0.4) and volume (P � 0.08) between thetwo groups of patients.Conclusion: 3D-ultrasound enables easy calculation of the endome-trial volume. Although there is a statistical tendency endometrialvolume cannot be use to appreciate uterine receptivity duringIVF.

F25Changes in the endometrium between the day of oocyteretrieval and embryo transfer. Does it matter?

P. Sladkevicius, K. Ojha, S. Campbell and G. NargundThe Diana, Princess of Wales Centre for Reproductive Medicine, St.George's Hospital Medical School, London, UK

Background: Multiple studies have confirmed a lower implantationand pregnancy rates in women who exhibit a homogenous pattern ofthe endometrium compared to a triple-line pattern on the day of hCGadministration. However, there are no studies comparing the patternof endometrium and its vascularization on the days of oocyte retrievaland embryo transfer.Methods: We prospectively evaluated the endometrium in 97 womenundergoing 116 IVF-ET cycles. Endometrial thickness and pattern,endometrial vascularization and blood flow waveforms in subendo-metrial vessels and uterine arteries were registered on the days ofoocyte retrieval and embryo transfer.Results: There was no difference in age, basal FSH, number ofoocytes, number of embryos transferred and endometrial thicknessbetween pregnant and nonpregnant patients, or between patientswith homogenous endometrium and those with triple-line patternof the endometrium. The ongoing implantation rate was 11%having homogenous endometrium and 23% having triple-linepattern of the endometrium on the day of oocyte retrieval. Bythe day of embryo transfer 89% of endometrium seemed to behomogeneously echogenic. All pregnancies occurred in thepatients who had a homogenous endometrium on the day ofembryo transfer.Conclusion: Endometrial pattern, rather than endometrial thicknesson the day of oocyte retrieval and its changes towards the day ofembryo transfer appear to be important prognostic factors ofendometrial receptivity.

F26Reproductive outcomes in women with arcuate andsubseptate uteri

B. WoÈ lfer, A. C. Lawrence, J. Elson and D. JurkovicKing's College Hospital, London, UK

Background: The effect of congenital uterine anomalies on reproductiveperformance is uncertain. The aim of this study to correlate uterinemorphology with past reproductive outcomes in a large group of womenwith no history of infertility or recurrent pregnancy loss.Method: In a period of three years 1028 women were recruited into thestudy. A detailed history of past pregnancies was obtained first, followedby transvaginal three-dimensional ultrasound examination. The uterus wasclassified as being normal, arcuate or subseptate after the examination ofuterine morphology in the coronal reformatted section. Uterine anomalieswere classified according to the American Fertility Society classifica-tion and the degree of uterine cavity distortion was measured.Results: 884 women had a normal uterus, 72 arcuate and 29subseptate uteri. In the past they had total of 1944 pregnancies. Therisk of miscarriage was significantly increased in both women witharcuate (OR � 1.9; 95% CI 1.1±3.5) and subseptate uteri (OR � 5.8;

95% CI 3.4±10.1) compared to those with normal uterine morphol-ogy. There was no correlation between the depth of uterine septumand the risk of miscarriage.Conclusion: Miscarriage is significantly more frequent in women witharcuate and subseptate uterus. Further research is needed to assesspotential benefits of surgical treatment in these cases.

F27A correlation of the uterine and ovarian perfusion with parityof women having a history of recurrent spontaneous abortions

J. Jirous*, M. Diejomaoh², S. Al-Othman*, F. Al-Abdulhado*,N. Al-Xmarzouk³ and T. Sugathan²*Department of Obst. and Gynecology, Maternity Hospital, Kuwait;²Department of Obstetrics and Gynecology, Faculty of Med, KuwaitUniversity, Kuwait; ³Department of Radiology, Sabah Hospital,Kuwait; ²Department of Community Medicine, Faculty of Med.,Kuwait University, Kuwait

Background: To explore a relationship between the incidence ofrecurrent spontaneous abortions (RSA) and values of Doppler indicescharacterizing the uterine and ovarian perfusion in women withhistory of Primary and secondary RSA.Method: A prospective study was carried out in which color Dopplertransvaginal ultrasonography was used to estimate the endometrialthickness (ETH), the uterine pulsatility index (UTAP) and theintraovarian arterial resistance index (IOARI) on the 21st day of aregular 28-day menstrual cycle in a control group of 19 healthy fertilenonpregnant parous women and 81 cases of nonpregnant womenhaving a history of RSA.Results: A highly significant difference (P , 0.001) was observedbetween UTAPI and IOARI values of control group and women withprimary RSA. The same results were obtained for secondary RSAwomen who had some more 3 abortions. No difference was found forETH values in control and study groups.Conclusion: Our study has demonstrated the presence of a significantlydecreased uterine and ovarian perfusion in nonpregnant women withprimary RSA and secondary RSA if more than 3 abortions occurred. Thesignificance of this result in the management of RSA requires furtherstudy. There was no difference between UTAPI and IOARI values in thecontrol group and secondary RSA women with only 3 abortion.

F28Correlation of saline hysterosonographic and hysteroscopicdiagnosis

B. Tekin, H. Hassa, A. Yildrim and T. SËensesOsmangazi University, School of Medicine, Department of Obstetricsand Gynecology, EskisËehir, Turkey

Objective: To investigate correlation of an office procedure salinesonohysteroscopic analysis with an invasive procedure diagnostichysteroscopy.Intervention: Diagnostic analysis of infertile patient in OsmangaziUniversity Reproductive Health Center.Materials and methods: In Osmangazi University, ReproductiveHealth Center, saline hysterosonographic analysis of the uterus, asan office procedure is done to all seconder infertile patient andprimer infertile patients who have any suspicion to have an uterineanomaly or adhesion. Also if ultrasound examination of the uterusshow endometrial thickness more than 5 mm after the end ofmenstruation saline hysterosonographic analysis (SHG) wasperformed.Results: SHG is an easy and speedy method to use in office procedure.There were 38 cases of SHG showing disturbance of uterine cavity; 28had polyp like lesions, 7 cases of suspected synechia. There were 11patients who had normal SHG but recurrent pregnancy loss; thesepatients had normal findings in hysteroscopic analysis. After endo-scopic procedures, 7 cases of synechia were verified, 5 cases out of 28had submucous myomas, the others polyps. Effectiveness of the shgaccording to the hysteroscopic analysis is thus excellent. Correlation



between the two methods, shows us that SHG can replace diagnostichysterocopic analysis.Conclusion: In case of doubt, diagnostic analysis of the uterine cavity,can be done by SHG; hysteroscopy is superior to the SHG by itscapability of treatment (surgery).

F29Vascular network in LUF syndrome

U. Marton, S. KupesÏicÂ and A. KurjakOutpatient Clinic Dr Marton, Department of Obstetrics andGynecology Sveti Duh Hospital, Zagreb, Croatia

Background: The principal aim was to reveal additional informationand comprehension's on physiology of the normal and pathophsysiol-ogy of disturbed cycles, that may lead towards the new diagnosticapproaches and treatments in infertile patients.Method: The group of 22 patients included women with LUFsyndrome. The emphasis was put on the intraovarian vascularityand especially on vascularity from inner vessels of ring of the follicle.Scans were performed on 5th, 10th, 12th, 21st and 24th day ofmenstrual cycle. A control group of 38 patients with regular menstrualcycles was selected on the basis of the normal gynecological,

sonographical and hormonal findings. These patients had normalovulatory cycles but were investigated for infertility due to the malefactor.Results: Doppler studies of the uterine artery and its evaluatedbranches have suggested significant decrease of the velocities at 12thand 15 h day of MC compared to control group. The RI of ovarianartery were around 0.84 ^ 0.016 during the MC and exceptedlowering of the RI has not occurred during the preovulatory period asin the control group. Velocity of ovarian artery of the dominant sideshowed significantly lower values, with the mean values of 34 cm/s^ 1.1 in the patients with LUF sy. compared to controls. Thedevelopment of the RI of the intraovarian stromal vessels in LUF sy.were similar to that of anovulatory cycles, showing the loss in thecycling rhythm and post peak LH values similar to those of thefollicular growth phase.Conclusion: The results of this study showed again that there isclear relationship between hormone mediators, primarily thesteroids and velocimetric indices taken during the observedcycles. It also would seem that the hormones, with itsmediators and hemodynamic factors play an important rolethrough systemic and local action, in regulating uterine andovarian blood flow.

C H R O M O S O M O PAT H I E S

F30The clinical impact of increased nuchal translucency

E. Pajkrt, M. A. Muller, O. P. Bleker and C. M. BilardoMedical Centre Alkmaar, Alkmaar, and Academic Medical Centre,Amsterdam, The Netherlands

Background: The aim of this study was to examine the relationshipbetween nuchal translucency measurements and outcome of preg-nancy.Method: Fetal nuchal translucency measurements were performed on6300 consecutive women attending the prenatal diagnosis centre ofour Hospital.Results: Of the 384 fetuses (6.1%) with an enlarged ($ p95) nuchaltranslucency 104 (27%) had an abnormal karyotype. Ten (2.6%)pregnancies ended in a spontaneous abortion before karyotyping wasperformed. In the remaining 270 eukaryotic fetuses with enlargednuchal translucency 22 (8.2%) had a structural anomaly or geneticsyndrome detected by ultrasound later in pregnancy and 3 (1.3%)after birth. The total incidence of an unfavourable outcome in thegroup of fetuses with enlarged nuchal translucency was 40%. Incontrast, in the group with a normal nuchal translucency (, p95), theincidence of an unfavourable outcome was 4.0%.Conclusion: When counselling parents in case of an increased nuchaltranslucency fetal karyotyping is the first step. If the karyotype isnormal detailed ultrasound examination around 20 weeks' gestationis the second step. When both the fetal karyotype and the anomalyscan are normal there is still a 1.3% risk that the fetus will be affectedby a congenital abnormality or genetic syndrome.

F31Implementation of nuchal translucency screening in the Dutchprenatal care system: evaluation of screening performance andacceptance

M. A. MuÈ ller, G. J. Bonsel, O. P. Bleker and C. M. BilardoDepartment of Prenatal Diagnosis, Obstetrics and Gynaecology,Academic Medical Centre, Amsterdam, The Netherlands

Background: The aim of this study was to determine the performanceof nuchal translucency screening and its uptake in a low-risk populationMethod: For a period of 18 months all women attending midwifepractices of two health regions were informed on the possibility of

having nuchal translucency screening for Down's syndrome. Reasonsfor opting in or out were recorded and nuchal translucencymeasurement was performed on request. A risk of more than 1:200,based on gestational age, maternal age and NT, was used as cut-off forincreased risk.Preliminary results: screening was offered to 6000 pregnant women,of which 83% accepted (n � 4980). The main reason for declining thescreening was not considering termination in case of an affectedpregnancy. NT measurement failed in 179 cases (3.6%), mainlybecause of a gestational age of more than 14 weeks or because of anon viable pregnancy at ultrasound. Of the 4801 women in whom NTmeasurement was performed, 1.4% had an increased risk. Of these 40%were found to have a chromosomal anomaly and in 4% a structuraldefect was diagnosed at subsequent scans. In total an unfavourableoutcome was recorded in 48% of cases with increased risk.Conclusion: Women of all ages accept nuchal translucency screening.This is an effective screening method for chromosomal abnormalitieswith a low false positive-rate.

F32Comparison of conventional two-dimensional and three-dimensional multiplanar analysis for evaluation of fetalnuchal translucency

M. Koudelka, Z. MalyÂ and NovotnaÂMasaryk University Hospital, Department of Obstet.Gynecol., Brno -Bohunice, Czech Republic

Backround: One of the most useful US markers for fetal aneuploidyand other structural anomalies is measurement of nuchal translucency(NT). Using conventional 2D ultrasound, irrespective of high qualityof current devices, brings problems connected with fetal intauterinepossition. Unfavourable position increases intra-and interobservervariability of measurement or can even disables the evaluation.Method: In this study the fetal textbook `standard' position formeasurement of NT using konventional 2D and 3D was performed in105 cases in 11th 2 14th week of pregnancy, 3x in each case. Twoaspects were evaluated: succes of achieving standard position andvariability of individual measurement.Results: The nuchal translucency with 2D scanner was measurable in63% of cases. With 3D vaginal scanner, using computed 2Dmultiplanar analysis the correct and standart plane was achieved in



97% the cases. The exactness of 3D measurement is significantlyhigher.Conclusions: The problems with fetal position seems to be solvedusing 3D computer sonography with its electronic tools as multiplanar2D and possibility of electronic rotational display of embryo. 3Ddecreased the interobserver and intraobserver error to minimum. The3D multiplanar analysis was found to be superior.

F33Application of early sonographic markers of Down syndrometo pregnancies achieved by assisted reproduction techniques

C. Lara, J. Bellver, G. Iberico, J. RemohõÂ, A. Pellicer and V. Serra-SerraInstituto Valenciano de Infertilidad & Departamento P.O.G. Facultadde Medicina, Universidad de Valencia, Spain

Background: Biochemical markers need to be adjusted in pregnanciesfollowing assisted reproduction techniques (ART) for properinterpretation of second trimester Down syndrome screening results.However, little information is available on the application of firsttrimester sonographic markers of Down syndrome to ARTpregnancies.Methods: The crown-rump length (CRL), nuchal translucency (NT),fetal heart rate (FHR), femur length (FL) and humerus length (HL)were measured transvaginally in 301 normal fetuses (159 singletonsand 142 twins) between 10 and 14 weeks gestation. A control groupof naturally conceived fetuses (n � 91) was compared to thoseobtained after intrauterine insemination (n � 35), in vitro fertilization(IVF) (n � 35), intracytoplasmic sperm injection (ICSI) (n � 47),combined IVF-ICSI (n � 25) and ovum donation (n � 68). Adjust-ment for gestational age was performed by dividing the sonographicmeasurement by the CRL in each fetus.Results: Naturally conceived fetuses showed similar NT/CRL, FHR/CRL, FL/CRL and HL/CRL ratios than ART fetuses (P � NS). Nodifferences were observed either between the various ART pregnancies(P � NS).Conclusion: Our preliminary results suggest that no adjustments areneeded for the application of early sonographic markers of Downsyndrome to pregnancies achieved by ART.

F34Early prenatal diagnosis of chromosomal defects: value ofsonographic markers

A. Galindo, J. M. Puente, M. J. GoÂmez, A. Moreno, J. FernaÂndez,C. Alvarez, A. GranÄ eras and E. BarreiroHospital `12 de Octubre' de Madrid, Department of Obstetrics andGynecology, Spain

Aim: To evaluate the role of early sonographic markers (SM) ofchromosomal defects combined with maternal age (MA).Methods: Retrospective study of 1470 amniocentesis performed inhigh-risk patients mainly because of advanced MA from Jan.97-Dec.99. SM of chromosomal defects are routinely searched for at firstscan at 11±14 weeks. We analyze the association between chromo-somal defects and MA regarding the existence of SM.

Results: Overall chromosomal defects rate was 4.6% (66/1470). SMwere detected in 147 cases (10%) and, regardless of MA, achromosomal defect was diagnosed in 44 of these cases (30%). Ofthe 1323 cases without SM the rate of chromosomal abnormalitieswas 1.5% (20 cases) (P , 0001). When MA was � 35 years, the rateof chromosomal defects in cases with SM was 35.2% (19/54) and inthose without SM 1.8% (20/1125) (P , 0001). No significantdifferences were found in cases with SM as a function of MA neither

in cases without SM. The number and percentage of chromosomaldefects according to MA and SM are expressed in the Table.

14 out of the 20 cases of chromosomal defects (70%) diagnosed infetuses without SM were sexual aneuploidies or structural defectswhile the remaining 6 were trisomies 21 (30%). By contrast, in caseswith SM were mainly trisomies 21, 18, 13 and 45X0.Conclusions: SM are best correlated with chromosomal defects thanother risk factors (RR � 15). However, when risk factors other thanSM are present, fetal karyotype analysis is still also indicated.

F35Trade-off of different combining methods of ultrasound andbiochemical screening tests for Down syndrome

A. Herman, E. Dreazen, I. Bukovsky, Z. Weinraub and R. MaymonAssaf Harofeh Medical Center, Tel Aviv University, Israel

Aim: To assess the efficacy of different combining methods of 1sttrimester nuchal translucency and 2nd trimester triple test.Methods: Results of both NT and TT were obtained in 706 euploidfetuses and in 16 DS cases. The net effect of each test was evaluated byusing its likelihood ratio (LR). A combined risk for DS live birth. 1:400 was used to assess false-positive rate (FPR) and detection rate(DR), adjusted to different age groups.

The tests were combined using the following methods:a. Summation ± all cases with a risk . 1:400 by either NT or TT;b. Calculated risk ± derived from combined LR (LRNT x LRTT).

Results: In normal pregnancies the overlap of cases with a LR . 1.5 ±by both tests ± was negligible (P , 0.001), whereas in DS cases theoverlap was 33%. The table at the foot of the page shows betterefficacy of the calculated risk vs. the summation method (e.g. for 30-year-old group yield of 1:26 and 1:78, respectively).Conclusions: The FPRs derived from the summation method seems tobe a reasonable trade-off for the high DR obtained by this method.Also, the yield of the summation combining method is much moreefficacious than that obtained by the worldwide policy of karyotypingpatients at 35, 37 or even 40 y.

Age , 35 35 36 37 38 39 � 40

SM1 25/91 1/7 2/13 1/5 ± 5/6 10/2327% 14% 15% 20% 83% 43%

SM± 2/198 3/102 5/207 1/262 6/204 2/158 3/1921% 3% 2% 0,4% 3% 1% 2%

Summation(NT or TT risk . 1:400)

Calculated risk(Combined risk . 1:400)

Age Years Yield* by age only Yield* FPR DR Yield* FPR DR

20 1:1529 4.5% 81% 1:85 1.0% 56% 1:2725 1:1351 4.5% 81% 1:75 1.0% 56% 1:2430 1:910 6.9% 81% 1:78 2.0% 69% 1:2635 1:384 15.7% 94% 1:65 4.3% 81% 1:2040 1:112 44.7% 100% 1:50 10.6% 94% 1:13

* Number of invasive procedures required to detect 1 case of DS.



F36Abstract withdrawn

F37Serial measurements of ductus venosus flow velocitywaveforms and nuchal translucency thickness: relationshipwith fetal outcome

C. M. Bilardo, M. A. MuÈ ller, E. Pajkrt and O.P. BlekerDepartment of Prenatal Diagnosis and Obstet & Gynaecol, AcademicMedical Centre, Amsterdam, the Netherlands

Background: In a previous study we have demonstrated that astatistically significant relationship exist between nuchal translucency(NT) thickness and ductus venosus flow measurements. Moreover wehave shown that a decrease in NT thickness at a subsequentexaminationl reduces the chance of an abnormal outcome. The aimof this study was to investigate the interrelationship between NTthickness and ductus venosus Doppler measurement (a-wave, pulsa-tility index PI) at repeated examinations and their relationship withfetal outcome.Method: Ductus venosus flow velocity waveforms and NT thicknesswere measured twice (median 4 days range 2±7) in 36 fetuses withincreased nuchal thickness.Results: According to the behaviour in the two parameters the fetuseswere divided into three categories: unchanged both abnormal (1),unchanged only NT persistently abnormal (2) and changed NTdecreased. The fetuses in group 1 had a 20 fold increase chance of anabnormal outcome (chromosomal anomalies, unexplained intrauter-ine death, congenital anomalies, cardiac defects n.). Conversely fetusesin group 3 had a lower chance of an abnormal outcome than group 1and 2.Conclusion: In fetuses with normal karyotype the finding ofpersistently increased NT and ductus venosus flow represents a poorprognostic factor, more than when nuchal translucency alone ispersistently abnormal.

F38Normogram of nuchal fold thickness during 14±16 weeks'gestation of 195 normal fetuses by transvaginal ultrasound

Y. Perlitz, M. Mukary and M. Ben-AmiDepartment of Ob/Gyn, Poriya Hospital, Tiberias, and the RappaportFaculty of Medicine, Technion, Israel Institute of Technology, Haifa,Israel

Background: The aim of this study was to establish normal values ofnuchal fold thickness during 14±16 weeks' gestation by transvaginalsonography (TVS).Method: Singleton fetuses of 195 women with normal pregnancieswere studied by TVS at 14±16 weeks' gestation. Gestational age wasdetermined by last menstural period and confirmed by biometry.Nuchal fold thickness was measured by the modified axial view of thehead, cerebellum and the nuchal fold. All women delivered normalinfants with no evidence of anomalies. t-testing was performed todetermine any correlation between nuchal fold thickness andgestational age.Results: Mean value of nuchal fold thickness during 14±16 weeks'gestation was 2.2 ^ 0.5 mm (mean ^ SD). The mean values for 14,15 and 16 weeks' gestation were 2.1 ^ 0.5 mm, 2.2 ^ 0.4 mm and2.4 ^ 0.9 mm, respectively. There was only a marginally significantincrease of the nuchal fold thickness between 15 and 16 weeks'gestation (P � 0.054, t-test).Conclusions: Normal values of nuchal fold thickness at 14±16 weeks'gestation for normal fetuses were constructed by TVS. The mean valueof nuchal fold thickness only slightly increased during 14±16 weeks'gestation. Therefore, the same mean value (2.2 ^ 0.5 mm) may beused throughout this period.

F39Chorionic villus sampling after the first trimester

M. Podobnik, ZÏ . DuicÂ, D. Skalak, M. Podgajski, S. Ciglar and B. GebauerDepartment of OB/GYN, University Hospital Merkur, Zagreb,Croatia

Objectives: The purpose of this article was to evaluate the associationbetween late CVS (placental biopsy) and complications betweensampling and delivery.Method: Late chorionic villus sampling under ultrasound guidancewas carried out in 2600 (86.7%) cases in the second trimester and400 (13.3%) cases in the third trimester of pregnancy. Out of 3000late CVS, 684 (22.8%) were performed because of suspiciousultrasonographic findings. In the 500 patients between 13 and16 weeks of gestation color Doppler was used to investigate theuteroplacental and fetal vessels before and after late chorionic villussampling.Results: In 24 patients (0.8%), complications between samplingand delivery were found. There were only nine (0.35%)spontaneous abortions four to six weeks after late chorionic villussampling. We found 156 (5.2%) chromosomal abnormalities. Inthe group with suspicious ultrasonic findings (684 cases) we foundsignificant oligohydramnios in 300 (43.8%) and significantpolyhydramnios in 150 (21.9%), and 105 (15.4%) had chromo-somal abnormalities. Among the 156 patients with chromosomalabnormalities, ultrasonographic findings in 85 (54.4%) weredetected after 20th week of pregnancy. There were no significantdifferences in mean pulsatility indices between uteroplacental andfetal vessels before and after late chorionic villus sampling.Preliminary data for 20 trisomic fetuses indicate an abnormallyincreased umbilical PI and abnormally decreased middle cerebralartery PI.Conclusions: Late CVS is a safe method of prenatal diagnosis for high-risk couples and does not significantly affect the outcome ofpregnancy.



F40Response of the fetal pupil in the chromosomal anomalies

C. LoÂpez RamoÂn y Cajale-mail: [email protected]. Unidad de DiagnoÂ stico Prenatal. Serviciode obstetricia y GinecologõÂa, Hospital Xeral, Vigo, Spain

Background: We studied sonographically the response of the fetalpupil to the stimulus of color Doppler (CD) in fetuses withchromosomal anomalies below 22nd weeks.Method: The pupils of 28 fetuses were studied sonographically

between 15 h-21 weeks' gestation, diagnosed of a chromosomalalteration through of genetic amniocentesis. The areas of the pupiland iris were compared before and after CD imaging.Results: The great majority of the fetuses have some data out of rangein the relationship pupil/iris in basal conditions or after CD. Usually,we observed an atypical response (mydriasis before the 19 weeks ormiosis after this) and/or an exaggerated response (hyperreflexia).Conclusion: These results affirm that this type of test increases thepossibilities in a fetal study of high resolution performed before the 22ndweeks of gestation and it can be auseful indicator like an aneuploidy marker.

M U LT I P L E P R E G N A N C Y

F41Early versus late multifetal pregnancy reduction, comparisonof pregnancy outcome

A. J. Jaffa*, J. Hat-Toov*, G. Fait*, I. Wolman*, I. Gull*, R. Achiron²and S. Lipitz²*U.S. Unit Ob/Gyn, Lis Maternity Hospital, Tel-Aviv Medical Center,²U.S. Unit Ob/Gyn, Department of Ob/Gyn, Shiba Medical CenterIsrael

Background: To evaluate the pregnancy outcome of selective second-trimester multifetal pregnancy reduction (MFPR) compared to latefirst-trimester and early first-trimester MFPR in triplets and quad-ruplets.Method: The study groups comprised of 46, 47, and 48 patients whounderwent MFPR at mean gestational of 11.2 (group A), 13.6 (groupB), and 18.5 (group C) weeks, respectively. Patients of groups B and Cunderwent ultrasonographic fetal malformation screening. Somepatients of group C had amniocentesis for chromosomal evaluation.Results: No statistically significant difference was found betweenGroup A, B, C regarding Pregnancy loss (4%, 4.3%, 2.5%,respectively), mean gestational age at delivery (35.8, 35.7, 35.8,respectively), and mean birth weight (2190, 2140, 2190, respectively).In group C fetal structural anomalies and chromosomal abnormalitieswere found in 4.2%, and 4.2% of pregnancies, respectively.Conclusion: Pregnancy outcome was similar after MFPR at differentstages of pregnancy. Selective second-trimester MFPR is associatedwith favorable perinatal outcome and may facilitate detection ofstructural and chromosomal anomalies before the procedure andselective reduction of the affected fetus.

F42Doppler assessment of the intervillous blood flow before andafter selective twin reduction in the reduced twin placenta

A. Antsaklis, D. Miliu-Paulescu, D. Doublis, G. Daskalakis andG. TheodhosiAlexandra Maternity Hospital, University of Athens, Athens, Greece

Background: The aim of this study was to compare the Dopplerparameters (PI, RI) from the intervillous blood flow of the reducedtwin placenta before and after the selective twin reduction.Method: We studied 21 patients with triplets (trichorionic triamniotic)who underwent selective twin reduction (to twin pregnancy) at10 weeks gestation from the last menstrual period. The intervillousblood flow of the reduced twin placenta was studied using pulsedcolor Doppler before and 10 days after the selective reduction. Thearterial waveform signals were assessed by resistance index andpulsatility index.Results: Arterial blood flow signals isolated from the intervillous spacebefore the selective reduction did not show significant difference in RI(0.35 ^ 0.03) and PI (0.78 ^ 0.04) comparing with the valuesobtained 10 days after the reduction (RI 0.36 ^ 0.03 and PI0.73 ^ 0.02).

Conclusions: The impedance to flow did not show significantdifference after a relatively short period from the embryos death.

F43Feto-placental Doppler measurements pre and post lasercoagulation in severe twin±twin transfusion syndrome

E. Carreras, J. Deprest*, D. Van Schoubroeck*, L. Roma,A. Van Assche*, L. Cabero and E. GratacosDepartment of Obstetrics & Gynaecology, H. Vall d'Hebron,Barcelona, Spain *Department of Obstetrics & Gynaecology, UZGasthuisberg, Leuven, Belgium

Objective: The aim of the study was to know what fetal hemodynamicresponse to therapeutical fetoscopic laser was, specially in the donor.Material and methods: Patients with severe TTS undergoing lasercoagulation of placental anastomoses (n � 25) were included. Dopplermeasurements (Accuson Aspen) were performed in the Umbilicalartery, Middle cerebral artery, ductus venosus and Umbilical vein ofboth fetuses preoperatively and on days 1, 3 and 5 postlaser.Results: Venous pulsatility indices tend to decrease in the recipientwhile they increase in the donor. Increased PI and/or appearance ofpulsations in the UV was observed in 75% of donors, which wasaccompanied but one or more signs of hydrops in 20% of cases. Thesedid not constitute signs of poor prognosis.Conclusions: We hypothesize that venous return in the donor fetusincreases after laser coagulation, which could explain a transientoverload phase, which in any case does not imply a poorer prognosis.

F44Serial amniocentesis in twin Transfusion syndrome

K. Szaflik, D. Borowski, J. WilczynÄ ski, D. Wyrwas, A. Kunert,P. Hincz and A. CiesielskiInstitute `Polish Mother's Memorial Hospital', èoÂdzÂ, Poland

Background: The aim of our study was to estimate the efficiacy ofserial amniocentesis in cases of acute polyhydramnion in TTS.Method: The study group consisted of 13 pairs of twins withsonographically confirmed hydramnios. After the examinationpatients were prepared for amnioreduction. During the procedurethe excess of amniotic fluid was removed through the punction needle.Results: The mean gestational age was 24.3 ^ 2.9 weeks in the range22±29 weeks. In 6 cases polyhydramnion/oligohydramnion wasfound. The therapy of TTS was based mainly on serial amniocente-sis.The mean gestational age during delivery was 27.6 ^ 3 weeks.The mean interval between the diagnosis and delivery was 3.3 weeks.In all cases the deliveries were preterm. The mean donor weight was730 ^ 290 g and the mean recipient weight was 1145 ^ 435 g. Thedifference between the recipients and donors was approximately 37%.In 7 cases we observed an intrauterine demise of one fetus. The 5thmin Apgar score was 1 pt (median). When the analysis was performedafter exclusion of stillborns, the median Apgar score for donors andrecipients was 4 and 2 pt, respectively.



Conclusion: Serial amniocentesis are effective in significant prolonga-tion of gestation (the mean interval between diagnosis and delivery24 days). The improvement of perinatal outcomes in twin gestationscomplicated by TTS can be achieved by the combination of serialamniocentesis and the laser ablation.

F45Acquired right heart outflow tract anomaly in twin±twintransfusion syndrome: not such a bad prognosis

J. Nizard*, M. C. Vaillant², G. GrangeÂ³, D. Bonnet§, F. Audibert¶,L. Fermont¶ and Y. Ville**HoÃpital de Poissy-Saint Germain en Laye, Yvelines, France.²HoÃpitaux de Tours, Tours, France. ³HoÃpital Port-Royal, Paris,France. §HoÃpital Necker-Enfants-Malades, Paris, France. ¶Institut dePueÂriculture de Paris, Paris, France

Background: Significant hemodynamic changes are commonly

observed in both fetuses in twin±twin transfusion syndrome. Cardiacdysfunction is common and well known in the donor twin withhypertrophy of the left ventricle and overall enlargement of the heart,whereas there is dilatation of the right ventricle with tricuspidregurgitation in the recipient twin.Cases: We report 3 cases of twin±twin transfusion syndrome withright ventricle outflow tract obstruction acquired in utero in therecipient twin which are likely to have developed as a cardiacdysfunction. Two of the tree recipient twins survived and are wellbeing with more than one year of follow-up due to correct surgicaltreatment.Analysis: These acquired anomalies of the right heart are probablyrelated to the very particular hemodynamic conditions and the volumeshifted between the twins.Conclusion: Right heart anomaly in the recipient twin should beknown of all ultrasonographers since it calls a particular neonataltreatment.

S E C O N D A N D T H I R D T R I M E S T E R D O P P L E R

F46Fetal cerebral and adrenal blood velocimetry in predictinghypoxia of the fetus

G. H. Breborowicz*, M. Dubiel*, K. Marsal² and S. Gudmundsson²*Department of Perinatology and Gynecology, University School ofMedical Sciences, Poznan, Poland, and ²University of Lund,Department of Obstetrics and Gynecology, University HospitalMalmoÈ , Sweden

Background: Animal studies have shown that hypoxic fetusesredistribute their blood flow, giving preferential supply to the brain,heart and adrenal glands. The aim of this study was to evaluate bloodvelocity waveforms in the fetal middle adrenal artery and cerebralarteries in relation to the outcome of high-risk pregnancy.Methods: Middle adrenal artery and anterior, middle and posteriorcerebral arteries were recorded in 102 pregnancies complicated bypregnancy induced hypertension between 27 and 41 weeks ofgestation. Signs of the fetal `adrenal-sparing' were considered presentwhen pulsatility index (PI) was below the 95% confidence interval.Signs of fetal brain-sparing were considered present when the cerebralarterial PI were , mean 22 SD of the normals and cerebroplacental PIratio , 1.08. The blood velocimetry results were related to perinataloutcome.Results: Adrenal velocimetry was strongly associated with aDVerseperinatal outcome, being significant for all studied parameters. Allperinatal mortality showed signs of adrenal sparing. Adrenal sparing,but not brain sparing, was correlated with fetal acidosis. Combiningadrenal velocimetry with brain velocimetry shown worser predictiveresults than adrenal velocimetry itself.Conclusion: Fetal adrenal sparing is more predictive of perinataloutcome in high-risk pregnancies and might be maintained longerthan the brain-sparing sign.

F47The flow redistribution toward the brain: beneficial andadverse effects on the fetal outcome in htypertensivepregnancies

A. Salihagic*, N. Tobal*, F. Perrotin², V. Imily*, J. Lansac² andP. Arbeille**Inserm. 316. Department of Med NucleÂaire & Ultrasons. CHUTrousseau, Tours, ²Sce Obstetrique & GyneÂcologie. CHUBretonneau, Tours, France

Objective: To predict fetal outcome (abnormal FHR to cerebral lesion)from the degree and the duration of the hypoxia.Method: Pregnancies complicated with hypertension and IUGR were

submitted to a daily umbilical and cerebral Doppler from first day ofadmission until delivery. The umbilical (URI), and cerebral (CRI)resistance indices, cerebral-umbilical ratio (C/U � CRI/URI), and thehypoxia index (HI) were calculated. The HI expresses as themaximum C/U change between admission day and delivery day (inpercentage of C/U at admission, or in percentage of C/U cut-off limit(� 1) if C/U admission , 1) multiplied by number of days ofobservation.Results: 68 pregnancies investigated (age: 25 ^ 5 years, primipar:35%, admission date: 30.8 ^ 2.5 weeks, delivery at 33.2 ^ 2.8,mean weight: 2300 ^ 457g. The combination (HI . 200 and C/U , 1) was associated with abnormal FHR in 75% cases, whereas 1or 2 of these parameter normal was associated with normal FHR in85% cases (PPV 75% ± NPV 85%). The minimal C/U and the HIduring the period of observation allowed to predict abnormal FHR atdelivery. On 5 pregnancies the period of hypoxia extended over 10±20 days (C/U ,, 1, HI .. 200), the fetuses died or were handi-caped at delivery. The daily cerebral index recording showed a loss offluctuation from one day to another, which could correspond to adeterioration of the cerebral regulation (vasoplegia). We suggest thatthe loss of fluctuation could be considered as the last limit before thecerebral lesion have serious chances to develop. In these 5 cases thefetal heart rate abnormalities appeared several days after this limit waspassed.

F48Vasoconstrictor effect of the proximal segment of the fetalmiddle cerebral artery after an external partial occlusion ofthe umbilical vein (vasoconstrictor reflex)

C. LoÂpez RamoÂn y CajalE-mail: [email protected]. Unidad de DiagnoÂ stico Prenatal.Hospital Xeral, Vigo, Spain

Background: We studied the repercussion of the nuchal cords on theproximal segment of the middle cerebral artery (pMCA) (segmentwith a rich innervation).Method: We performed an external partial occlusion of the umbilicalvein (through maternal abdominal wall) during 1±2 s to stimulate thebaroreflex (pressure test or PT). We performed 76 PT in 36 fetuses.The pMCA was studied sonographically before, during and after thePT through pulsed Doppler and color Doppler energy (CDE).Results: During the PT we observed stop the whole of the umbilicalvein flow while maintaining the flow of the umbilical arteries. Weobserve a vasoconstrictor effect on the pMCA using CDE. This effectreflected a moderate-severe segmental stenosis in the pMCA, however,flow in the remaining MCA was maintained. Sometimes, the effect



vasoconstrictor produced a reverse flow on the pMCA to pulsedDoppler study. Post occlusion a cerebral vasodilatation took place,although in occasions an increased vascular tone persisted. Some fetalmovements also could produce a similar effect in the pMCA(spontaneous PT).Conclusion: The PT produces an effect vasoconstrictor in the pMCA.Variations of this reflex can be the origin of some perinatal motorinjury of intrauterine origin.

F49Subclassification of small-for-gestational-age fetus using fetalDoppler velocimetry

K. Kanenishi, C. Yamashiro, H. Tanaka, A. Kuno, T. Yanagihara andT. HataDepartment of Perinatology, Kagawa Medical University, 1750±1Ikenobe, Miki, Kagawa 761±0793, Japan

Background: Our purpose was to determine whether small-for-gestational-age (SGA) fetus can be divided to subclassified groupsusing fetal Doppler velocimetry.Method: Fifty-four pregnant women with SGA infant delivered after37 weeks of gestation were studied. After 24 weeks of gestation, fetalmiddle cerebral artery pulsatility index (MCAPI) and umbilical arterypulsatility index (UAPI) were measured at 2-to 3-week intervals usingDoppler ultrasound. Perinatal outcomes were compared in subclassi-fid SGA groups using fetal Doppler velocimetry.Results: The number of SGA fetuses with normal MCAPI and UAPI(normal SGA group) was 39, and those with significantly low MCAPIbut normal UAPI (eventful SGA group) 15, respectively. Birth age andbirth weights in eventful SGA group were significantly earlier andlower than those in normal SGA group, respectively (P , 0.05, andP , 0.005). There were significant increases in operative deliveries,abnormal FHR patterns and decreased amniotic fluid in eventful SGAgroup. However, there were no significant differences in meconiumstaining of amniotic fluid, low Apgar score, neonatal acidosis, andNICU admission between the two groups.Conclusion: These results suggest that SGA fetus with abnormally lowMCAPI but normal UAPI has more poor perinatal outcomes,compared with that with normal MCAPI and UAPI.

F50Short-term variation (STV) in centralized fetuses

S.C. Cha, O.T. Toma, G.O. Braia, M.A. Lopes and M.B. CarvalhoFetal Medicine Unit, Laboratorio Fleury, SaÄo Paulo, Brazil

Aim: To evaluate the importance of STV in centralized fetuses.Material and method: 43 centralized fetuses were evaluated bycomputorized cardiotocography (CCT) (System 8002 ± Oxford). Asgroup control, 1235 computorized cardiotocography trace fromfetuses with normal Doppler were analysed.Result: At 10 min of CCT, 15/43 (35%) of centralized fetuses showedSTV , 4 msec. At the end of CCT 4 (9.4%) centralizad fetusesmaintainned STV , 4 msec against only 12 (1%) fetuses in thenormal group. The duration of CCT in centralized fetuses was30 ^ 10 min and 20 ^ 9 min in the normal group. The mean STV ofcentralized fetuses was significantly lower than normal fetuses at anytime of the trace. At the end of the trace, STV in centralized fetuseswas 5.5 ^ 1.5 msec and in normal fetuses was 8.7 ^ 2.5 msec(P , 0.05). However, 90% of centralized fetuses showed normal CCT(STV . 4 msec. or presence of two or more transitory acceleration).Conclusion: This preliminary study shows that short-term variationseems to be earliest abnormal finding at CTC in centralized fetuses.Since 90% of centralized fetuses had normal CCT (STV . 4 msec.),this parameter can be used to avoid premature interruption of thepregnancy due to abnormal Doppler.

F51Development of power Doppler as a quantifiable tool forassessing fetal perfusion: fractional renal vascular volume

A.W. Welsh*, R. Eckersley², M. Blomley², D. Cosgrove² andN.M. Fisk**Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital and²Hammersmith Hospital, ICSM, London, UK

Background: Power Doppler allows the display dynamic range to beincreased by up to 10±25dB by coding the amplitude rather than thevelocity component of the Doppler frequency shift. Though this meansan improvement in image quality, the real advantage of the additionalinformation coded within this signal lies in the potential forquantification of flow (as vascular volume).Method: Isolated measurements of amplitude do not have meaningunless they can be standardised to remove the effects of machinesettings and attenuation. Two important functions are necessary forthis: 1. Correction of the nonlinearities of the energy scale bar(purpose-designed software -CQ Analysis, Kinetic Imaging Ltd,Liverpool). 2. Standardisation to a local area of 100% blood flow(the fetal aorta) to define a fractional regional vascular volume.Multiple clips of fetal renal perfusion were stored to mo disk using theAcuson SequoiaTM for offline computer analysis.Results: 150 fetuses were examined (24±40 weeks). Fetal vascularbranching could be seen throughout the renal parenchyma in . 80%of fetuses, with clear fluctuations in the fetal cardiac cycle andstatistically significant energy values to the aorta and renal parench-yma. Standardising the peripheral volume flow to the aorta gives afractional vascular volume of approximately 10±20%.Conclusions: Further work is underway to improve reproducibility ofthis technique, to develop an accurate index of fetal renal perfusion.Acknowledgements: Alec Welsh is supported by a Research TrainingFellowship from RCOG/WellBeing.

F52Evidence of unidirectional pulsatile flow in the umbilicalinterarterial anastomosis

L. Raio, F. Ghezzi, E. Di Naro, M. Franchi, D. Bolla, B. Lischetti,D. Balestreri, P. DuÈ rig and H. SchneiderUniversity of Bern, Switzerland, University of Insubria, Varese andBari, Italy

Background: An anastomosis between umbilical arteries (UAS),located within 1±3 cm from the placental insertion, has beenpreviously described at delivery and in utero. However, the prenatalinvestigation of this vessels is limited to case reports. We report aseries of antenatal functional evaluation of this vessel.Method: 41 women underwent a target ultrasonography to evaluatethe blood flow characteristics of UAS and UAS anastomosis. Theresistance index (RI) of the anastomosis and the UAS RI before andafter the anastomosis was obtained. The direction of the blood flow inthe anastomosis was determined by color Doppler evaluation.Results: An anastomosis between the two stems of the UAS waspresent in 36 cases while a fusion of the two UAS was found in theremaining 5 cases. The median (range) gestational age at diagnosiswas 33.1 weeks (25.5±40.1). The median (range) diameter of theanastomosis was 2.3 mm (1.3±7.1). The blood flow in the anasto-mosis was pulsatile with a median (range) RI of 0.62 (0.45±0.85). Thedifference between UAS RI was higher after than before theanastomosis [0.07 (0±0.3) vs. 0.04 (0±0.17), P � 0.051]. The ana-stomosis blood flow was always unidirectional.Conclusion: During fetal life, the UAS anastomosis acts as a pressure-equalizing system between UAS and the placental lobes.

F53Umbilical venous volume flow: reproducibility anddevelopmental data

S. Boito, P. C. Struijk, H. R. Stijnen and J. W. WladimiroffDepartment of Ob/Gyn, University Hospital Rotterdam, TheNetherlands



Background: To determine reproducibility of volume flow compo-nents; to calculate volume flow in normal and growth restrictedfetuses in a cross-sectional study design.Method: Using Labview and Imaq-vision software, the cross-sectionalinner vessel area was traced. Vessel area (mm2) and mean flowvelocity (cm/s; Doppler) were multiplied to calculate volume flow (ml/min) including flow/kg fetus. The coefficient of variation (CV) forvessel area and flow velocity scans and tracings was determined (n:13;26±35 weeks). Normal charts for components and volume flow wereconstructed (n:72; 20±36 weeks) and related to data from growthrestricted fetuses (birthweight , P5) (n:20; 23±36 weeks).Results reproducibility: CV was 5.4% (vessel area) and 7.3% (meanvelocity) for scans and 6.6% and 10.5% for tracings resulting in a CVof 8.1% (scans) and 11.9% (tracings) for volume flow. Gestationalage related increase exists for vessel area, mean flow velocity, andvolume flow: 47.5 ^ 19.3(SD) ml/min at 20 week and 229.6 ml/min^29.6(SD) ml/min at 36 week, but not per kg/fetus. In fetal growthrestriction, volume flow was reduced (P , 5) in 18/20 cases, but forvolume flow/kg fetus only in 11/20 cases.Conclusion: Measurements of vessel area results in acceptablereproducibility of volume flow calculations, which show a 5-foldincrease at 20±36 week. In fetal growth restriction, volume flow issignificantly reduced but equally distributed between normal andreduced values when calculated per kg/fetus.

F54Different types of umbilical venous pulsations and clinicalimplications

S. Gudmundsson*, C. Hofstaetter² and M. Dubiel³*Department of Obstetrics and Gynecology, University Hospital MAS,MalmoÈ , Sweden, ²Division of Perinatal Diagnosis & Therapy,University of Bonn, Germany; ³University School of Medical Sciences,Department of Perinatology, University Hospital Poznan, Poland

Objective: Normally, blood flows evenly in the umbilical vein, withoutfluctuation. A pulsating pattern has been reported during fetal heartfailure and asphyxia. Recently we have noticed different types ofpulsating pattern, its physiological implication and relationship tooutcome of pregnancy was analysed.Study design: In a prospective multicenter study, recording ofumbilical cord venous blood flow was conducted in high-riskpregnancies admitted for umbilical artery Doppler. In cases ofpulsating flow or signs of vascular resistance in the umbilical artery,the examination was extended to the intra-abdominal part of theumbilical vein. Venous pulsation, single or double, were noted andcorrelated to perinatal outcome.Results: Venous flow pulsatility was noted in 83 fetuses during twoyears, 26 had a double pulsating pattern, which was closely related toincreased vascular resistance in the umbilical artery and perinatalmortality. A single end-diastolic pulsation only in the cord was notedin some of the fetuses with absent or reversed flow in the umbilicalartery, probably due to decreased forward flow over the placenta. Asingle pulsating venous pattern in one location had good prognosis.Conclusion: A double pulsating venous pattern, especially if extendingto the cord, is an ominous finding associated with poor perinataloutcome in high-risk pregnancy. A single pulsating pattern predicted amuch better outcome and might be an indication for delivery in thehigh-risk case.

F55Venous velocimetry in the surveillance of severelycompromised fetuses. Where is the point of no return?

C. Hofstaetter and M. HansmannDivision of Prenatal Diagnosis and Therapy, Department ofObstetrics and Gynecology, University of Bonn, Germany

Objective: To investigate special changes in venous velocimetry ofseverely compromised fetuses and to determine signs of cardiacdecompensation prior fetal demise.Methods: A prospective study in 154 growth-restricted fetuses. 37

were severely compromised with reverse flow in the umbilical artery.The velocimetry of right hepatic vein and ductus venosus wereinvestigated and the presence of umbilical venous pulsations wereregistered. The final examination prior to birth or fetal demise weretaken for analysis and related to obstetrical outcome defined asgestational age at birth, birthweight and rate of perinatal mortality.Secondly the velocimetry of 15 nonsurvivors was pared with 22survivors.Results: There were a significant (P , 0.05) decrease of the S- and ES-,increase of the A-velocity and pulsatility in the RHV and a significant(P , 0.05) decrease of all velocities and increase of pulsatility in DV.24% had a reversed flow in DV and 75% had pulsations. Thenewborn were significantly premature and small for gestational age.15 fetuses died perinatally. Special predictors of fetal demise were afurther increase or decrease of A-velocity in RHV and DV. 8/15fetuses had a reversed flow in DV and 11/1 5 had mainly doublepulsations as signs of cardiac decompensation.Conclusions: Venous velocimetry changes significantly in compro-mised fetuses. Prior to fetal demise the A-velocity decreasesspecifically in DV. Especially a reversed flow in DV and doubleumbilical venous pulsations are omnious signs of left heart decom-pensation.

F56Blood velocity in fetal Galen vein and outcome of pregnancy

S. Gudmundsson³, M. Dubiel*, G. H. Breborowicz* and R. Laurini²*Department of Perinatology and Gynecology, University School ofMedical Sciences, University Hospital Poznan, Poland; ²Division ofDevelopmental Pathology, University Hospital, Lausanne,Switzerland; ³Department of Obstetrics and Gynecology, UniversityHospital MAS, MalmoÈ , Sweden

Background: Pulsating blood velocity in the umbilical vein is anindicator of fetal compromise with poor outcome. Blood velocity inthe fetal vein of Galen is normally even and without fluctuation. Thepropose of this study was to establish whether blood flow velocitypulsations in the Galen vein seen in high-risk pregnancies were alsorelated to adverse outcome of pregnancy.Methods: The vein of Galen was located by color Doppler ultrasound in102 pregnancies complicated by pregnancy-induced hypertension andblood velocity recorded by pulsed Doppler within 2 days of delivery. Thepresence of blood velocity pulsation's was noted and correlated toperinatal outcome, including emergency operative intervention and/orneonatal distress. Umbilical artery and venous, uterine and middlecerebral artery blood velocity was also recorded at the same time.Results: Pulsating blood velocity in the vein of galen was found in 68cases and in the umbilical vein in 21. Venous pulsations were highlysignificantly related to adverse outcome of pregnancy. Pulsations inthe Galen vein were three times more frequent than in the umbilicalvein, suggesting that it appears earlier than in the umbilical vein. In allthe 7 perinatal deaths there were pulsations in the Galen vein. Signs ofbrain sparing in the middle cerebral artery were seen in only 32fetuses.Conclusion: Venous pulsations in the umbilical and Galen vein wereboth significantly correlated to adverse outcome of high-riskpregnancy. Pulsations in the vein of Galen seem to occur earlierthan in the umbilical vein, which might be helpful when deciding thetiming of delivery of a high-risk case with minimal neonatalmorbidity.

F57Intra-observer and inter-observer variability of DuctusVenosus blood flow indices in fetuses between 10 and14 weeks of gestation

E. Mavrides, D. Holden, B. Hollis, A. Tekay and B. ThilaganathanFetal Medicine Unit, St George's Hospital Medical School, London,UK

Background: The aim of this study is to assess the intra-observer andinter-observer variability of transabdominal Doppler velocity



measurements of ductus venosus (DV) blood flow in fetuses at 10±14 weeks.Method: Doppler indices in the DV of first trimester fetuses wererepeated three times by the same trained observer in 67 pregnanciesand by a second trained observer in 24 pregnancies. In addition, bothobservers documented the presence of normal/abnormal blood flowduring atrial contraction.Findings: Intra-observer reproducibility of measurements of peaksystolic velocity, end-diastolic velocity and systolic to diastolic ratiowere poor. Intra-observer pulsatility index (PI) repeatability wasadequate (CC 0.60, CV 8.9%). Inter-observer agreement for all theDoppler measurements was unsatisfactory (CC 0.18±0.44; CV 11.5%to 47.2%).Conclusion: There is significant variability in all Doppler indices,except for the intra-observer repeatability of PI. Determination ofnormal/abnormal atrial flow is a repeatable measurement.

F58Anatomical variation of the fetal venous system

C. Hofstaetter and M. HansmannDivision of Prenatal Diagnosis & Therapy, University of Bonn, Germany

Objective: This report presents our experience in the prenataldiagnosis of anomalies of fetal veins using high-resolution and colorDoppler ultrasound.Design: In an observatorial study 15 cases of abnormalities of theumbilical, portal, hepatic and caval venous system have beendiagnosed at our division over the past 5 years. The abnormality,the underlying embryologic disorder and the outcome of thepregnancy are presented.Results: In group A, 8 fetuses had an abnormal course of theumbilical vein with a patent (n � 3) or absent (n � 5) ductusvenosus. No portal veins and absent or abnormal hepatic veinswere visualized. Six fetuses (75%) did not have an associatedmalformation and have survived. Two pregnancies were termi-nated or ended in fetal demise. In group B, 7 fetuses with anabnormal caval system had a left (n � 5) and right (n � 2) atrialisomerism with a cardiac defect in 6 cases (86%). Thepregnancies ended in 4 terminations of pregnancy and two infantdeaths. Only an infant with a left atrial isomerism and a normalheart has survived.Conclusion: In a targeted fetal scan the course of the venous systemshould be carefully examined using color Doppler. Any suspiciousfinding should be followed by a detailed assessment of the specifity ofthis abnormality considering the embryological development as wellas the associated malformations.

F59Fetal venous Doppler in the normal first and second stage oflabor

M. Krapp, S. Denzel, U. Germer and U. GembruchDivision of Prenatal Medicine, Department of Obstetrics andGynecology, Medical University of LuÈbeck, Germany

Background: The aim of the study was to evaluate, whetherdifferences in fetal venous flow velocity waveforms can be seen infetuses during labor compared to fetuses before labor.Method: The Pulsatility index for veins (PIV) of the ductus venosuswas analysed in 127 fetuses (37th to 41th weeks) before labor by colorDoppler sonography (control group). Identically 42 fetuses withnormal cardiotocogram were analysed during and between contrac-tions consecutively in the early first stage of labor, at 2±4 cm and 6±8 cm and at full dilatation of the cervix (study group).Results: The control group showed a normal PIV of 0.59 (SD 0.24). Inthe study group between contractions the PIV was normal during allstages of labor with average values of 0.55 2 0.68 (SD 0.26 2 0.42).During contraction the average values of the PIV were 1.64 ± 2.48 (SD0.76 ± 1.16). These values were significant elevated (P , 0.001)during contraction compared to the values of contraction free episodes as

well as to the control group. The increase of the PIV during contractionswas not related to any fetal heart rate deceleration.Conclusion: During contractions the fetal venous pressure issignificantly elevated in normal labor. Reference ranges for the ductusvenosus should be established and compared to values in compro-mised fetuses.

F60Umbilical vein blood flow in growth restricted fetuses

S. Rigano, E. Ferrazzi, Bozzo², N. Giovannini², M. Bellotti², H.Galan* and F.C. Battaglia*Departments of Ob/Gyn ISBM L. Sacco and DMCO San Paolo²,Milan, Italy, Department of Ob/Gyn and Pediatrics UCHSC Denver*,CO, USA

Objective: The present study was designed to determine whetherspecific umbilical blood flow is reduced in IUGR fetuses.Subjects: Thirty-seven IUGR fetuses of different clinical severity wereexamined by Doppler ultrasound within four hours of the lastnonstress test prior to delivery.Method: Absolute and weight specific umbilical vein (UV) flow werecalculated from measurements of UV diameter and UV mean velocity.UV diameter, velocity and UV flow were calculated also per unit head(HC) or abdominal circumference (AC) and correlated with gesta-tional age.Results: UV flow per kilogram was significantly lower in the moresevere IUGR fetuses (abnormal umbilical arterial p.i.) than in normalcomparable fetuses (P , 0.001). UV flow per unit head circumferencewas significantly lower in the three groups (P , 0.001) than in thecontrol population. The UV diameter/HC was normal whereas UVvelocity/HC was significantly lower in IUGR fetuses than incomparable controls.Conclusions: The present study clearly establishes that umbilicalvenous blood flow is reduced in IUGR fetuses on a weight specificbasis. The sonographic growth parameter which best distinguishesumbilical flow differences of IUGR fetuses from normal fetuses is thehead circumference.

F61The ductus venosus blood flow velocity waveforms duringlabour in 42 singleton fetuses at term

S. A. Denzel, M. Krapp, U. Germer and U. GembruchDivision of Prenatal Medicine, Department Obstetrics andGynaecology, University of LuÈbeck, Germany

Background: The aim of this study was to learn about thephysiological changes in the ductus venosus blood flow velocitywaveforms during labour.Method: Ductus venosus flow curves were obtained by Dopplerultrasonography during and in-between uterine contraction duringthe first and second stage of labour in 42 singleton fetuses at term.In every patient we tried to measure at four different times ofdilatation of the cervix (0±2 cm, 2±4 cm, 6±8 cm, fully dilated). Inaverage we obtained 3.76 measurement periods. At every period theductus was continuously recorded on video tape throughout 5±10 min.Results: Changes in the ductus venosus blood flow were observedduring labour. The flow profiles did not change with increasing cervixdilatation, but they changed during contraction compared to inabsence of contractions. The peak velocity index (PVIV) and thepulsatility index for veins (PIV) within uterine contraction differedsignificantly (P , 0.001) compared to pviv and piv in absence ofcontractions in all four stages of cervix dilatation.Conclusions: The ductus venosus blood flow velocity waveformsundergo great changes intrapartum in cases of uneventful pregnancyand delivery. It has to be further evaluated which subgroup ofpregnancies will benefit from Doppler velocimetry of the ductusvenosus for intrapartum surveillance.



I N T E RV E N T I O N A L P R O C E D U R E S

F62Interventional ultrasound based on national registrations offetal interventions in Japan

Y. Chiba and H. NakanoCommittee of Perinatal Medicine, Japan Society of Obstetrics andGynecology

Methods: Japanese Society of Obstetrics and Gynecology conductedthe Registration of Fetal Therapy. One hundred 62 Institutes in Japanjoin the registration. From 1966 to 1999, totally 584 fetuses treatedinutero including interventional procedures were registered from 86Institutes. Effects of fetal therapies were determined by self-judgements of reporters.Results: One hundred 81 cases of hydrops aspirated their pleuraleffusion or ascites. The mortality of this group was 38.7%. Totally 47cases of hydrops were medicated through maternal vein or directly.Thirty-four (72.3%) cases in 47 of this group judged ineffective orunknown effect. The mortality of the group was 68.1%. Sixteen fetaltransfusions were reported, effectiveness of that was 62.5% and themortality was 31.2%. Shunting operations for hydrothorax or asciteswere performed on 28 fetuses. The effectiveness of feto-amnioshunting for hydropic fetuses was high as 82.1% and the mortalitywas 46.4%. Medical therapies for tachycardia were performed for 31fetuses. The effectiveness was 67.7% and the mortality was 12.9%.There were 21 cases of shunting operation for obstuctive uropathies.The effectiveness of urinary shunting operation was 71.4% and themortality was 47.6%. One hundred 60 fetuses of the amnio-aspirationfor TTTS, 16 fetuses of the rupture of septal membrane, 2 fetuses ofclosure blood flow and 2 fetuses of selective delivery were reported.After the period of the registration, we performed successfullyendoscopic closure of umbilical cord for acardiac twin by the goodguidance of ultrasound.Conclusions: There are some fetal interventions which we can acceptas the general therapy for fetus. They are shunting operation forobstructive uropathy, medication for tachy-arrythmia, and fetaltransfusion. Shunting operation for hydrothorax will be accepted.

F63Ultrasound guided fetal cystoscopic therapy for posteriorurethral valves (PUV)

A. W. Welsh, S. Agarwal and N. M. FiskQueen Charlotte's and Chelsea Hospital, ICSM, London, UK

Background: The commonest cause of obstructive uropathy in malesis PUV, with well-recognised ultrasonographic features and amortality of up to 95% if associated with oligohydramnios. Palliativetreatment (vesicoamniotic shunting) has increased survival, but with ahigh complication rate and significant incidence of long-term renalimpairment. We evaluated the diagnostic and therapeutic role of thingauge embryofetoscopy in suspected PUV.Method: A joint fetal medicine and paediatric urological teamperformed the procedures under local anaesthetic. Nine fetuses wereassessed, mean gestation 22 weeks (7 subsequently confirmed PUV, 1unconfirmed, 1 suspected urethral atresia). After confirmation ofurinary electrolyte normality, a 1.3-mm semirigid fetoscope (KarlStorz Ltd) was inserted under ultrasound guidance into the dilatedfetal bladder. Fetoscopic features were documented and an attemptmade to enter the dilated upper posterior urethra. Two therapeuticprocedures were assessed: valvular flushing under pressure andguidewire passage.Results: The hypertrophied bladder neck was seen in 7 cases, theposterior urethra entered in 4 and the obstruction visualised in 2. Fivetherapeutic procedures were attempted (2 flushing, 3 guidewire). Onecase flushed therapeutically was confirmed after delivery to have apatent urethra.Conclusions: Some cases of PUV may be treated in utero. Furtherstudies are indicated to explore fetoscopy as a therapeutic tool.

Acknowledgements: Alec Welsh is supported by a Research TrainingFellowship from RCOG/WellBeing.

F64Intrauterine therapy of fetal obstructive uropathy

K. Szaflik, D. Borowski, M. Kozarzewski and A. KunertInstitute `Polish Mother's Memorial Hospital', èoÂdzÂ, Poland

Background: The aim of our study was the evaluation of theusefulness of fetal bladder drainage in cases of obstructive uropathybefore the 24th week of gestation.Methods: Since January 1997 we have diagnosed 9 cases of fetalobstructive uropathy before the 24th week of gestation. In all cases,oligohydramnios or ahydramnios was also diagnosed. After evalua-tion of kidneys function on the basis of fetal urine samples, obtainedfrom punctures of fetal bladder (three times in each fetus) we selected7 fetuses for in-utero shunting. 2 fetuses presented features of renalcystic dysplasia and its renal function prognostic factors were poor.Those fetuses were not offered intrauterine decompression.Results: All the newborns in which intrauterine decompression of theobstructive uropathy was made have had a good perinatal outcome.The mean apgar score was 8 (7±10 points). The weight at delivery wasbetween 1700 and 3300 g. No pulmonary hypoplasia was observed.All the deliveries took place after the 33rd week of gestation (33±38hbd). The minimum time of drainage was 11 weeks, the maximum18 weeks.Conclusions: Early bladder drainage enables delivery of newbornswithout pulmonary hypoplasia. Drains with a good `shape memory'enable good results, because they are not prone to migration. Shuntingshould be performed only in selected cases which would not be bettermanaged by early delivery, but who have not yet developed renaldysplasia.

F65Abstract withdrawn

F66Learning ultrasound-guided invasive procedures in fetalmedicine: the learning curve with an automated system

J. Nizard and Y. VilleHoÃpital de Poissy Saint-Germain en Laye, France

Background: Learning ultrasound-guided invasive procedures in fetal



medicine can be done either on training models or directly on patients.Amniocenteses, cordocentesis, and chorionic villous sampling areassociated with more complications at the beginning of the learningcurve. It is therefore essential to optimise the teaching and reduce thelength of the learning curve. We studied the learning curves of 8inexperienced registrars in ObGyn with and without the use of a newelectronic guidance system.Method: 8 medical students performed 100 invasive procedures(cordocentesis) using a specially designed training model. Fourstudents used the ultrasound-assisted free hand technique and four

students used the same technique but assisted by the electronicguidance system. We studied the overall duration of the procedure andthe proportion of this time the student is in control of the needle (theentire needle is visualised on the ultrasound screen).Results: The new electronic guidance system reduces the learningcurve of ultrasound-assisted invasive procedures on training models,but increases the length of the procedure.Conclusion: The new electronic guidance system can help teachingjunior doctors in ultrasound-assisted invasive procedures in fetalmedicine.

T H R E E - D I M E N S I O N A L P O W E R D O P P L E R I N O B S T E T R I C S A N D G Y N E C O L O G Y

F67Three dimensional follicular and endometrial volumeassessment and pregnancy rate in in vitro fertilization patients

D. Bjelos, S. Kupesic and A. KurjakDepartment of Obstetrics and Gynecology, Medical School Universityof Zagreb, Sveti Duh Hospital, Zagreb, Croatia

The aim of this study was to assess the role of three-dimensional (3D)follicular and endometrial volume measurements in predicting thepregnancy outcome of the in vitro fertilization (IVF) programme. Forthe purpose of this study we evaluated 52 patients on the day ofoocyte retrieval and embryo transfer. Follicular volume and endo-metrial volume were main outcome measures related to the occurrenceof a successful implantation. The overall pregnancy rate was 30.8%(16/52). Sixteen pregnant patients demonstrated mean follicular andendometrial volume measurements 4.81 ^ 1.92 mL and 5.2 ^

1.9 mL, respectively. In the same time, 36 nonpregnant patients hadcorresponding measurement of 3.82 ^ 1.7 mL and 5.6 ^ 2.1 mL,respectively.

Presented data demonstrate that 3D volume measurements of thefollicles and endometrium on the days of oocyte retrieval and embryotransfer are not predictive of IVF outcome. However, follicularvolume measurements are clearly related with the number and qualityof the oocytes collected on the day of pick-up.

F68Changes in ovarian vascularization during the menstrual cycleas assessed by three-dimensional Power Doppler imaging (3D-PDI)

P. Sladkevicius, K. Ojha, S. Campbell and G. NargundThe Diana, Princess of Wales Centre for Reproductive Medicine, St.George's Hospital Medical School, London, UK

Background: The study was conducted to determine the pattern of thevascular changes during the normal menstrual cycle in the ovariesusing the 3D Power Doppler imaging technique.Methods: Observations were made during 19 normal menstrualcycles. Women were scanned transvaginally using VOLUSON 530Dultrasound machine during midfollicular, perifollicular and midlutealphases. The presence of a dominant follicle was recorded and ovarieswere classified as dominant or nondominant based on these findings.The volume of the ovaries was acquired using 3D-PDI. Thevascularization index (VI), flow index (FI) and vascular flow index(VFI) were calculated using VOCAL software.Results: The dominant ovary VI 4.6 ^ 2.5, FI 51.6 ^ 4.8, VFI2.5 ^ 1.5 in the midfollicular phase were significantly lower thanthose in the midluteal phase (VI 19.8 1 10.5; FI 61.1 1 1 1 3.8; VFI12.2 1 6.3). These parameters in the perifollicular phase hadintermediate values, although being significantly higher than inmidfollicular phase and significantly lower than in the luteal phase.In the contralateral nondominant ovary, no cyclical changes were seenin the values of VI, FI, VFI. There were significant differences betweendominant and nondominant ovaries in all phases investigated. The

most prominent midluteal increase of VI, FI and VFI in the dominantovary were 6.6, 1.3 and 9.2 folds, respectively.Conclusion: These data indicates that there are significant vascular-ization and blood flow changes in the dominant ovary.

There were no changes observed on the nondominant ovary.

F69Three-dimensional ultrasound in the diagnosis of uterinemalformations

C. A. B. Montenegro, S. P. Leite, M. L. Mathias and J. Rezende-FilhoClõÂnica de Ultra-Sonografia Botafogo and Departamento deGinecologia e ObstetrõÂcia da UFRJ, Rio de Janeiro, Brazil

Uterine evaluation by means of 3D US is useful in classifying the mainmalformations, as it allows the visualisation of the frontal plane,impossible to obtain with conventional sonography. In the frontalplane it is possible to classify the uterine abnormalities, according tothe fundal surface, the endometrial cavity and the uterine cervix.

Arcuate uterus presents with a normal fundal surface, but theendometrial cavity is concave, different from the normal uterus, where itis convex or rectilinear. Septate uterus also shows a normal fundus, but 2endometrial cavities, due to the septum. Bicornuate uterus is char-acterised by a fundal indentation ($ 1 cm) and 2 endometrial cavities.Didelphic uterus is identical to complete bicornuate uterus, but theduplication extends to the cervix, which is doubled. Unicornuate uterusexhibits only one half of the uterus and does not seem to present anydiagnostic pitfall, although it may present with a rudimentary cornus,that may or not communicate with the main cavity.

Septal vascularization may be identified in slightly over 70% of thecases with this abnormality. Power Doppler is helpful in identifyingthose cases, and differentiate them from bicornuate uterus.

17 patients with suspected uterine malformation were examined. 4bicornuate, 6 septate, 6 arcuate, and 1 didelphic uterus were found.3D US was concordant in 11 cases.

F70Evaluation of adnexal masses with three-dimensionalultrasound

M. Simic, M. Kopjar, M. Zadro, T. Viskovic, N. Knezovic, I. Maricicand I. AlvirGeneral Hospital Zabok, Zabok, Croatia

Study objective: To evaluate the use of 3D ultrasound in preoperativepreparation for the laparoscopic operation of adnexal masses.Methods: In last two years we have started with 3D ultrasound inpreoperative evaluation of adnexal masses. Over that period we havehad 187 adnexal masses evaluated with 3D ultrasound.Results: At the period of first two years since we have performed 3Dultrasound we have had 14 tecofibroma ovarii, 2 Brener tumours, 10cystadenoma, 14 ovarian carcinoma in different stages, 9 teratomas,21 dermoid cysts, 62 endometrioid cysts and 55 simplex cysts of theovary.

All of those finding were confirmed at the time of operation (frozen



section). Two dermoid cysts were estimated on ultrasound as amalignant disease of the ovary and frozen section finding was benigncystic teratoma.Conclusion: Since we started to perform 3D ultrasound in estimationof adnexal masses before surgery (mostly laparoscopy) we have foundthat adnexal masses with 3D ultrasound verification of intracysticpapilla for the patient in fertile period greater than 1.0 cm and forpostmenopausal patient greater than 0.5 cm can be of clinical value inearly diagnosis of ovarian carcinoma and appropriate therapy.

F713D CDS of fibroid pre- and post-embolization

A.C. Fleischer*, E. Donnelly*, M. Campbell*, M. Mazer* andN. Lipsitz²Vanderbilt University Medical Center, *Department of Radiology,²Department of Obstetrics and Gynecology, Nashville, TN USA37232±2675

Objective: Evaluate and quantitate changes in fibroid vascularity andvolume preand postembolization with 3D Color Doppler sonography(CDS).Method: Quantitative 3D CDS was performed immediately prior to,1 day, 3 months, and 6 months postembolization in 20 patients.Results: All patients had symptomatic relief. Changes in vascularitywere greatest 1 day postembolization whereas the most significantchanges in volume occurred on the 3 month follow-up scan.Conclusion: Quantitative 3D CDS provides accurate informationregarding fibroid vascularity and volume postembolization. This datamay be helpful in monitoring response to treatment as well asdetection of complications.

F72Visualization of anal sphincter disruptions with transperinealthree-dimensional ultrasound following vaginal delivery inprimiparous women

G. Bader, P. Rozenberg and Y. VilleHoÃpital de Poissy Saint-Germain en Laye, France

Objective: To visualize the anal sphincter disruptions followingvaginal delivery in primiparous women using 3D ultrasound tocorrelate damage to obstetrical factors.Methods: We have studied prospectively 150 consecutive primiparouswomen. Axial and sagittal images of the anal sphincter were performed48 h after vaginal delivery using a 7.5-MHz convex transducer placedon the perineum (Voluson 530 D Kretz) and repeated in the 30 womenwith anal sphincter disruption at a median of six months post natally.Obstetrical characteristics were analysed in all cases.Results: Anal sphincter defect and its location were detected in 30women (20%). None of the 24 women (16%) who underwentcesarean section had a sphincter disruption even in the 10 womendelivered by cesarean section in labor. Head circumference, birthweight, maternal age, the duration of each stage of labor and theduration of active pushing were not significantly related to analsphincter disruptions after vaginal delivery. Instrumental delivery,epidural analgesia and posterolateral episiotomy were associatedwith a sphincter defect but the only single independent factorrelated to the development of sphincter defects was instrumentaldelivery. The 3D sonography revealed sphincter injuries in 70% ofthe cases in the forceps delivery group (7 of 10), 13.3% of thecases in the vacuum delivery group (2 of 15) and 9.9% of thecases in the normal vaginal delivery group (10 of 101). 12 women(8%) had anal incontinence of faecal urgency when studied twomonths after vaginal delivery. The anal function was not altered aftercesarean section.Conclusions: Transperineal 3D ultrasound of the anal sphincter is areliable method for evaluating the anal sphincter. It is quicklyperformed and well tolerated by patients. Besides forceps delivery,commonly measured delivery variables are not useful predictors oflatent anal sphincter injury.

F73New modes of capture by freehand three-dimensionalultrasound in the prenatal diagnosis of fetal anomalies

F. Guerra, R. GutieÂrrez, L. Herrera, C. Anwandter, J. Caro, R. Aguilarand A. IslaDepartment of Obstetrics & Gynecology, Universidad Austral,Valdivia, Chile

Background: The aim of this study was to see the contribution of threedifferent modes of capture of data by the freehand three-dimensionalultrasound (3D US) in the prenatal diagnosis of fetal anomalies.Method: We studied a total of 34 pregnant women. In all of them afetal anomaly was previously assessed by 2D US. Planar US probesand a 3D software (3D-ViewTM) were used on a digital Gaia 8800scanner. Three modes of data capture were employed: volume capture(to capture a volume), static capture (to capture motion; acombination of B-mode and M-mode), and free style capture (tocapture a big region of interest; ROI), then the most suitable screenpresentation was used according to the mode of capture.Results: We found a total of 41 anomalies on 34 fetuses which are:Heart (17), abdomen (8), central nervous system (6) and miscella-neous (10). We were able to see all anomalies previously detected by2D US. By using volume capture and rendering image we were able todetect also anomalies of fingers and face, no previously detected by2D. However volume capture was the most difficult mode to perform.Static capture was the most suitable to study fetal heart malformations(as A-V canal) and arrhythmias. Free style capture give us a B-modedigital video of the ROI (hydrocephalus, spina bifida, gastroschisis,omphalocele, adominal cysts, kidney malformations). Good picturesby using the last two modes of capture were easy to obtain. We alsobenefit of all the advantages of using digital technology, like to havethe information as a virtual patient.Conclusion: The appropriate use of different modes of capture of databy free hand 3D US in combination with 2D US gives a newperspective of using this new technology in the diagnosis of fetalanomalies.

F74Live 3D ± dynamic prenatal three-dimensional-sonography

M. Brauer and J. W. DudenhausenKlinik fuÈ r Geburtsmedizin, ChariteÂ Campus Virchow, Humboldt-UniversitaÈ t, Berlin, Germany

Background: 3D-Ultrasound (3D-US) was lacking a mode of dynamicvisualisation in the past. Recently a new method for dynamic 3D-Sonography (Live-3D) was developed. Live-3D was evaluatedconcerning feasability and relevance in fetal sonography. The resultswill be demonstrated by short video sequences.Method: The technical principle of Live-3D is based on the Voluson-technique, developed by Kretztechnik (Zipf/Austria). Special mod-ifications enable the machine to perform a continuous serial volume-scanning and image-rendering. The result is a dynamic visualisation oftomographic images or surface renderings with a maximum speed of 3images/second. Recent improvements even permit image-frequenciesup to 12 images/second.Results: Live-3D allows a 3-dimensional visualisation of the movingfetus. Low image-frequencies cause certain limitations but thisproblem has been improved tremendously and will be completelysolved in near future. A still remaining problem is the lack of aselective elimination of artefacts.Conclusions: Integrating motion into 3D-US the development of Live-3D is comparable to the step from Compound-Scan to Realtime-B-Mode. Fetal behaviour (e.g. mimic) can be visualized 3-dimensionally,which might be useful for fetal assessment. Furthermore realtime-3-dimensional-guidance will allow a more precise performance ofinvasive procedures. Further modifications such as the accelerationof image-frequencies and the improvement of the artefact-eliminationare necessary to optimize the method.



F75Determining fetal lung volume using three-dimensional-ultrasonography

D. Miric-Tesanic and E. MerzCenter for Diagnostic Ultrasound and Prenatal Therapy, Departmentof Obstetrics and Gynecology, University of Mainz, Mainz, Germany

Background: The aim of the study was to establish fetal lung, thoracicand heart volume nomograms using 3D-ultrasonography.Method: For this purpose 115 fetuses were examined (between 18 and33 weeks of gestation) using Voluson 530D (Kretztechnik, Austria)ultrasound device and 5 MHZ three-dimensional annular volumetransducer. Lung volumes of 15 fetuses suffering from skeletaldysplasia, renal agenesis or hydrothorax and secondary pulmonaryhypoplasia were compared with previously established nomograms.Results: Lung volumes in the pathologic group of fetuses compared tothe nomograms were below the 5% for gestational age.Conclusion: The encouraging first results suggest that this methodcould be a method of choice for the early detection of pulmonaryhypoplasia, even before 24 weeks of gestation.

F76Patients undergoing three-dimensional ultrasound: review ofreferrals for 111 patients

D. H. Pretorius, A. D. Hull, T. R. Nelson, M. Coffler andS. DaneshmandUniversity of California, San Diego, La Jolla, CA, USA

Background: Three-dimensional ultrasound (3DUS) is a rapidlyemerging imaging technology offering improved visualization ofpatient anatomy. The purpose of this project was to identify thedistribution of patients referred for 3DUS on a clinical service andassess the potential impact on care and management strategies.Method: Charts from 111 patients having 3DUS studies in our clinicalobstetrical and gynecological service were reviewed for indications.Patients were categorized as:

1) 3DUS specific referrals based on 2DUS findings, 2) value addedDUS studies to

2) trouble shoot problems identified with 2DUS, 3) physicianrequested 3DUS studies to enhance patient reassurance and 4) patientinitiated 3DUS studies for reassurance.Results: Indication for 3DUS studies were: 3DUS specific referrals (30)(e.g. facial anomalies, sonohysterogams), trouble shoot problemsidentified with 2DUS (45) (e.g. club feet, vasa previa), physicianrequested studies to enhance patient reassurance (e.g. prior anomalies)and patient initiated 3DUS for reassurance (15) (e.g. prior anomalies,surrogate parents, hospice patients). Availability of 3DUS imagingresulted in new models of patient referral (internet, patient initiated,distant to the community).Conclusion: As new technology (e.g. 3DUS) enters the clinical arena,new pathways for patients to access technology develop (outsidereferrals, patient referrals, internet).

Improved information alters and improves patient responses(comprehension, decision making, reassurance) to their medicalsituation.

F77Application of `Live 3D' ultrasound in the detection of fetalmalformation of extremities

A. Lee, M. PoÈhl and G. BernaschekDepartment of Prenatal Diagnosis and Therapy, University Vienna,Austria

Background: 3D ultrasound can produce images comparable tophotographs. However, they only represent about a second of thehole examination. Artifacts due to fetal movements can makeinterpretation difficult. Sequential rescanning, a technique which isalso called `Live 3D' may overcome these limitations.Method: Patients who underwent 3D ultrasound examination becauseof suspicious of fetal skeleton malformation were included into this

study. Live 3D ultrasound was performed with a commerciallyavailable machine (Combison C530, Kretztechnik, Zipf, Austria)Results: In 32 out of a total from 70 patients malformation of the fetalextremities have been postulated in 2D ultrasound. Sufficient surfacerendering of the region of interest could be achieved within 85% of allpatients. Malformations of the fetal extremities could be visualized in93%. Discrepancy between 2D and 3D findings could be found inonly 2 cases.Conclusion: Live 3D ultrasound can give confirmation and newdiagnosis in cases of fetal malformation of extremities compared to2D ultrasound examination.

F78Three-dimensional sonographic features of fetal centralnervous system anomaly

A. Kuno, M. Ueta, U. Hanaoka, Y. Tanaka, M. Matsumoto,K. Kanenishi, C. Yamashiro, H. Tanaka, K. Hayashi, T. Yanagihara,K. Hara and T. HataDepartment of Perinatology, Kagawa Medical University, Japan

Background: Our aim was to visualize an intracranial structure of thefetal central nervous system (CNS) anomaly using transabdominalthree-dimensional (3D) sonography.Methods: A total of 18 cases with fetal cns anomalies (one unilateralventriculomegaly; 6 hydrocephalus; 3 anencephaly; 4 holoprosence-phaly; one Dandy-Walker cyst; and 3 enlarged cisterna magna) from17 to 37 weeks of gestation were studied with transabdominal 3Dsonography (3.5 MHZ).Results: In unilateral ventriculomegaly, insight view of dilated lateralventricle, especially dilated atrium was depicted. In hydrocephalus,severely dilated bilateral ventricles and thin brain mantle werebeautifully shown. In anencephalus, an absence of the brain anddefect of the vault of the skull was clearly noted. In holoprosence-phaly, absent interhemispheric fissure, common ventricle, and theextent of thalamic fusion were evident. In Dandy-Walker cyst,cerebellar hemisphere was clearly depicted due to the agenesis ofcerebellar vermis. In enlarged cisterna magna, posterior intracranialview of the fetus showed a large space of cisterna magna. Although thediagnosis of each CNS anomaly was made using conventional two-dimensional sonography, 3D sonography proved most helpfuldelineating the exact nature and anatomic level of the anomaly.Conclusion: Our results suggest that 3D sonography provides a novelmeans of visualizing fetal CNS anomalies in utero.

F79Real-time three-dimensional fetal echocardiography

B. Tutschek*, T. Buck², T. Reihs*, H. F. Staiger³, W. Henrich§,H. G. Bender* and R. Erbel²Obstetrics and Gynecology*, Duesseldorf University, Cardiology² andOb. & Gyn.³, Essen University, Obstetrics§, ChariteÂ Virchow, Berlin

Background: Fetal echocardiography employs high resolution two-dimensional ultrasound (2DE) to detect structural heart disease.Three-dimensional echocardiography (3DE) using reconstruction of aseries of 2D images of the fetal heart has been hampered by technicalproblems. Real-time 3DE (rt3DE) acquires volume data sets ratherthan 2D images.Method: The rt3DE system (Volumetrics, Durham) uses a 2.5-MHzmatrix phased-array transducer scanning a pyramidal volume. Amultipanel screen displays cross-sectional images of the same volumein real-time: two perpendicular 2D images that can be freely orientedthroughout 3-D space plus up to three calculated sections notobtainable by 2DE.Results: rt3DE could visualize the fetal heart satisfactorily. Due toreal-time volumetric scanning gating with the fetal cardiac cycle wasnot necessary. The image quality with regard to resolution was inferiorto current high end 2D machines, but is bound to improve withtechnology. Volumes can also include color Doppler, but at the cost oflow frame rates.Conclusion: With advancing technology volume rather than 2D data



acquisition may emerge as a standard in fetal echocardiography. Whileexamining one or two technically and physically optimized 2D views,the entire pyramidal volume surrounding these planes is acquired inreal time. The dissociation of rapid data acquisition from itsinterpretation may be advantageous, enabling `virtual scanning' fordifferent aspects even without the patient present.

F80Three dimensional ultrasound reconstruction ofmonochorionic placental anastomoses

A. W. Welsh, M. J. Taylor and N. M. FiskQueen Charlotte's and Chelsea Hospital, ICSM, London, UK

Background: Feto-fetal transfusion syndrome is characterized by apaucity of bi-directional superficial vascular anastomoses whichprotect against haemodynamic imbalance built up by deep unidirec-tional arterio-venous (AVA) anastomoses. Vascular identification and`mapping' is a necessary prerequisite to selective therapy for FFTS.Method: The sites of arterio-arterial (AAA) and an arterio-venousanastomoses were identified by colour flow mapping and character-

istic doppler waveforms (Acuson SequoiaTM5C2 MHz curvilinearprobe). Having identified these sites, freehand 2D image storage todisk was performed, and images transferred to a personal computer.Purpose-designed software (CQ Analysis, Kinetic Imaging Ltd, Liver-pool, UK) was used to segment the colour information from theseimages and the resulting greyscale images were saved as TIFF imageformat files. These files were fed as a parallel data set into VoxBlastsoftware (Vaytek Inc, Iowa, USA) for 3D rendering and rotationalmovie generation.Results: This technique allowed perfect reconstruction of 3D vascularand placental anatomy for both AAA and AVA. Dual rendering withoriginal greyscale images allowed accurate visualisation of anastomo-tic location within the placenta.Conclusions: It is now technically feasible to gain an understanding ofmonochorionic placental microvasculature in 3D. Prospective evalua-tion is underway to compare the predictive ability of 3D vs. 2Dultrasound placental mapping.Acknowledgements: Alec Welsh is supported by a Research TrainingFellowship from RCOG/WellBeing.

M E D I A

F81OBGYN.net and internet

S. BanovicÂZagreb, Croatia

The web site is the largest specialized women's health care suite in theworld, diversified by more than 50% of its visitors being women andpatients looking for medical information and over 40% beingphysician and other medical professionals.

Every month, the web site is recording over 7000 forum entrieswhich are read more than 350 000 times monthly. Thus each postedcomment or question is read on average of 50 times, confirming thepopularity and relevance of the content being addressed. Some ofOBGYN.net's most popular forums deal with topics like endome-triosis, pregnancy and birth and ultrasound.

The average time visitors spend on the OBGYN.net web site is11.5 min. OBGYN.net also welcomes over 12 000 visitors every day,a number that is growing every week. OBGYN.net creates originalcontent with cooperation of staff employees and over 200 medicalprofessionals who contribute on a world-wide basis located at http://www.obgyn.net on the web. OBGYN.net is a physician-reviewedservice providing women physicians and industry professionals a placeto publish articles, participate in discussion groups, access informationand communicate online. OBGYN.net web site operates on a globallevel and offers three main sections, each focusing on differentsegments of the woman's health community; Medical Professionals,the Medical Industry and women and Patients.

F82Detailed three-dimensional fetal echocardiography facilitatedby an internet link

G.D. Michailidis*, J.M. Simpson², C. Karidas* and D.L. Economides*

*Fetal Medicine Unit, Department of Obstetrics and Gynaecology,Royal Free Hospital, Pond St, London, U.K. NW3 2QG, ²FetalCardiology Unit, Department of Congenital Heart Disease, Guy'sHospital, St Thomas Street, London SE1 9RT, UK

Objectives: To assess whether a complete virtual cardiologicexamination can be achieved in stored three-dimensional volumes ofthe fetal heart, transmitted to a tertiary fetal cardiology centre via theInternet.Methods: Twenty-one sequential normal singleton pregnancies. 1±4cardiac volumes were acquired using a Kretz Voluson 530D scanner.The volumes were sent via the internet to a fetal cardiologist. Adetailed fetal cardiac examination, was attempted using the 3Dvolumetric dataset.Results: The mean gestational age was 24 weeks and 3 days. Acomplete heart examination was accomplished in 81% (95%C.I. 58%to 94%) of cases. The four-chamber view, and the right ventricleoutflow tract were seen in all cases. The `three vessel' view was seen in91% of the cases, while the left ventricle outflow, long axis view of theaortic arch, SVC/IVC and pulmonary veins in 81% of the cases. Themean time of volume acquisition was 10 min (SD: 2 min) and it wasmainly influenced by fetal movements and the transfer time to themain computer. The mean examination time by the fetal cardiologistwas 17.8 min (SD 6 min).Conclusion: These preliminary results demonstrate that 3D virtualexamination of the heart is possible. Although there are limitationssuch as the lack of flow and functional information, completeascertainment of the main cardiac connections was possible in themajority of cases. The use of an internet link has major implications,particularly in situations where the scanning centre is geographicallyremote from the cardiological centre.

B R E A S T

F84The estrogen environment and Doppler parameters of breastlesions

U. Germer, A. Tetzlaff, A. Geipel, U. Gembruch and K. Diedrich

Department of Gynecology and Obstetrics, Medical University ofLuÈbeck, Germany

Background: A high physiological variation of blood flow duringmenstrual cycle was found by examining breast vascularity with



CW-Doppler and is influenced by endocine therapy. In this studythe correlation between the vascularity of breast lesions tomenopausal status, phase of menstrual cycle and endocrine therapyis analysed.Method: 249 breast lesions in 91 premenopausal patients and 152postmenopausal patients (142 malignant and 105 benign tumors)were demonstrated in B-mode ultrasound and intratumoral vesselswere visualized by color Doppler imaging. Bloodflow velocitywaveforms were detected by pulsed Doppler. Correlations betweenthe Doppler parameters Vmax, RI, PI, S/D and the number ofintratumoral vessels (n) to the endocrine factors mentioned abovewere analysed.Results: The means of Doppler parameters in the group ofpremenopausal patients were: n � 1.38 (^1.53), RI � 0.69(^0.09), PI � 1.25 (^0.36), S/D � 3.64 (^1.78), Vmax � 11.11(^9.6) cm/s and in the postmenopausal group: n � 1.36 (^1.72),RI � 0.77 (^0.08), PI � 1.61 (^0.47), S/D � 5.08 (^3.21), Vmax �11.04 (^6.4) cm/s. RI, PI and S/D-values were significantly(P , 0.05) different between these two groups. The Dopplerparameters of tumors examined in the follicular phase were similarto those in the luteal phase. During treatment with oral contraceptivesthe number of intratumoral vessels was higher n � 1.80 (^1.23) thanduring spontanous menstrual cycle n � 0.86 (^0.86).Conclusion: Menopausal status and endocrine therapy have a robustinfluence on Doppler parameters of breast lesions.

F85Impact of ultrasound-guided large-core needle biopsy withfrozen section on surgical management of breast cancer

K. Pohlodek*, L. Janek Jr, V. Ferianec*, SÏ. GalbavyÂ² and K. HolomaÂnÏ ;**Department of Obstetrics and Gynecology II and ²Department ofPathology, Comenius University, Bratislava, Slovak Republic

The authors have undertaken to establish the ultrasound-guided large-core needle (14 G) biopsy with frozen section in preoperativehistologic examination of palpable and nonpalpable breast tumorsas well as to investigate the diagnostic reliability and significance ofthis procedure in breast cancer surgery. In 1998/99, 125 patients weresurgically treated for breast lesions at the Department of OB/GYN II,Comenius University School of Medicine, Bratislava. 55 patients wereoperated for malign tumors. 38 of them (69%) were preoperativeexamined by ultrasound-guided core-cut biopsy. The core biopsyspecimens were evaluated by frozen section and paraffin section. Theresults were then correlated with definitive paraffin sections from thesurgical specimens. The correlation has not revealed any falselypositive or negative results. Therefore, the authors state that incorrectly indicated cases, this procedure apparently represents areliable method for preoperative histologic examination of breasttumors. Examination of core breast biopsy specimens with frozensection can minimize the interval between diagnosis and treatment,decrease the number of open diagnostic biopsies and reduce the timeof surgery by period necessary for per-operative frozen-section.

C O M P L I C AT I O N S I N P R E G N A N C Y

F86Mullerian anomalies: prospective follow-up with transvaginalultrasound of the cervix

V. Berghella, M. Talucci, A. Odibo and J. ChenJefferson Medical College of Thomas Jefferson University,Philadelphia, PA, USA

Introduction: Patients with mullerian anomalies have higher rates ofpreterm delivery (PTD), but the true reason for PTD has not beenelucidated. Transvaginal ultrasound (TVU) has proven an accuratetest for the prediction of PTD, but has not been studied in this patientpopulation.Methods: Patients with known mullerian anomalies were followedprospectively in pregnancy with TVU of the cervix between 14 and24 weeks. The predictive value of TVU was evaluated using , 25 mmcervical length and/or . 25% funneling as definition for a shortcervix. The primary outcome was PTD , 35 weeks.Results: 45 patients with mullerian anomalies were identified. 16 wereexcluded from analysis because of: prophylactic cerclage (6), twins(3), induced PTD (4), no follow-up (1), still pregnant (2). Of the 29pregnancies available for analysis, there were 8 with septate uterus (5corrected), 7 with bicornuate uterus, 6 with didelphus uterus, and 5with unicornuate uterus (3 were unknown type). 6 (21%) had a shortcervix (3 of these received a therapeutic cerclage because of TVU shortcervix), with 2 (33%) having PTD despite both receiving therapeuticcerclage. 23 (79%) did not have a short cervix, with 2 (9%) havingPTD. Both of these patients had a didelphus uterus. The sensitivity,specificity, positive and negative predictive values for PTD were 50,88, 40, 92%, respectively (RR 4.8, CI 0.9±26.5).Discussion: TVU seems to be predictive of PTD in patients withmullerian anomalies, with the possible exception of didelphus uterus.Therapeutic cerclage in patients with a mullerian anomalies with ashort cervix on TVU may not prevent PTD.

F87Transvaginal sonography in prediction of preterm delivery inpatients presenting with signs and symptoms of preterm labor

P. Hincz, J. WilczynÂ ski, D. Borowski, M. Kozarzewski and K. SzaflikInstitute `Polish Mother's Memorial Hospital', èoÂdzÂ, Poland

Background: The purpose of the study was to assess the clinical valueof transvaginal sonography in the group of women presenting withpreterm contractions and cervical changes.Methods: We prospectively evaluated 82 patients between 23 and34 weeks of gestation presenting in our Department with signs andsymptoms of preterm labor, intact membranes and cervical dilatation, 3 cm. In all cases transvaginal sonography was performed.Results: The rate of preterm delivery (, 37 weeks) was 25.6% and17.1% of the patients delivered # 28 days from the examination.Among the analyzed parameters, the significant difference betweenpatients delivered # 28 and . 28 days from examination, was noticedonly for the functional canal length (21.6 mm vs. 30.1 mm;P , 0.001). The analysis of ROC curves showed that functionalcanal length had the highest diagnostic capability. Two importantthresholds were found ± 20 mm and 31 mm. For predicting delivery# 28 days the functional canal length # 20 mm had sensitivity of57.1%, specificity of 92.6%, PPV of 61.5% and NPV of 91.3%. Thecutoff value of 31 mm had sensitivity of 100%, specificity of 47.1%,PPV of 28% and NPV of 100%. In multiple logistic regression analysisonly FCL # 20 mm (OR 8.18; P � 0.027) was independentlyassociated with PTD.Conclusions: The shortening of the functional canal length (# 20 mm)is predictive of impending preterm delivery and the functional canallength . 31 mm is the indicator of the absence of labor.

F88The value of cervical length measurement in the prediction ofpreterm delivery prior to 34 weeks gestation in womenpresenting with threatened preterm labour

E. Mavrides, A. Georgakopoulou, A. Tekay and B. ThilaganathanFetal Medicine Unit, St. George's Hospital, London, UK

Aim: The aim of this study is to evaluate whether cervical length andmorphology assessed by transvaginal ultrasound in women admittedin threatened labour, can predict preterm delivery prior to 34 weeksgestation.Method: Over a six-month period, 25 women presenting withthreatened preterm labour were prospectively recruited into thestudy. Women with ruptured membranes, chorioamnionitis or heavyvaginal bleeding requiring delivery were excluded. Transvaginal



sonography for cervical length and morphology was performedshortly after admission. Demographic data, medical observationsand interventions were recorded. Pregnancy outcomes were collectedafter delivery.Results: The mean gestation at recruitment was 2714 weeks (range211823216 weeks). 16% (4/25) of patients delivered before 34 weeksgestation. In the latter cases, the cervical lengths were all # 25 mmand the interval between presentation and delivery was , 2 weeks.All pregnancies with a cervical length . 25 mm delivered after34 weeks gestation.Conclusion: Transvaginal ultrasound assessment of cervical length inwomen presenting with threatened preterm labour is useful inpredicting the likelihood of preterm delivery. This investigation maybe useful in optimising the management of these women and reducingthe risks of unnecessary tocolysis in women that are unlikely to deliverpreterm.

F89Retrospective case control study evaluating the outcome ofpregnancy and delivery in patients with myomas

J. Sandberg, A. Herbst and E. AndolfDepartment of Obstetrics and Gynecology, University Hospital,Lund, Sweden

Background: The aim of the present study was to compare theoutcome of pregnancy and delivery of patients with myomas tonormal controls.Method: The cases were found by searching for the diagnosis `myomain pregnancy' on the ultrasonography data base from the period ofAugust 1992 to November 1999. Cases were followed up in thedelivery data base. The control group was matched for age, parity andpregnancy complications.Results: Seventy cases with the diagnosis were found among21 925 deliveries giving an incidence of 3.2 per 1000. Seventeen(26.6% of the cases) were delivered by Caesarian section,compared to 22 out of 128 (17.2%) in the matched controlgroup. The difference was not statistically significant. The rate ofCaesarian section and maternal age was higher than in the generalpopulation. There was no difference in Apgar score betweenbabies delivered from cases and controls. Neither was there anynotable difference in the amount of bleeding between the twogroups. No mentionable difference could be seen in the length ofgestations.Conclusion: In this study no difference could be seen in the outcomeof pregnancy and delivery in cases with myomas. Cases were olderand had a higher rate of Caesarian section than the generalpopulation.

F90Sonography of bladder flap hematoma in cesarean sectionwith open and closed peritoneum: a prospective randomizedstudy

A. Malvasi, P. Totaro, I. Casiero and V. TrainaDepartment of Obstetrics, Center of Ultrasonography and PrenatalDiagnosis, Casa di Cura Santa Maria, Bari, Italy

In our randomized study, we've examined sonographically 238 firstc.s. carried out through Stark technique and 46 traditional repeatc.s. with open peritoneum (284 with open peritoneum), comparedto 253 women who underwent a first c.s. with the classictechnique and 51 previous traditional c.s. (304 c.s. with closedperitoneum) the aim of our investigation is the sonographicevaluation of patients with open peritoneum and those withclosed peritoneum to discriminate the frequency of bladder flaphematomas in the two techniques. The statistical analysis has beenconducted with the test of Student considering significant a valueof P , 0.05. C.s. with PROM, abruptio placentae, and placentaprevia have been excluded from our study. For this reason all thepatients of the two groups were examined by transvaginal and

transabdominal sonography, on the 3rd and 12th postoperativeday, to demonstrate the possible presence of retrovescical collec-tions/hematomas, assuming as sonographic criterion the presenceof a fluid or mixed mass on the lower-uterine-segment (L.U.S.), ofthree or more centimetres, clean wall, with reinforcement of distalechoes. It has been observed that in the group with openperitoneum c.s., there were masses of mixed ecostructure referringto hematomas on the 12th day in 9 cases (3.16%), while in thegroup with closed visceral peritoneum in 48 cases (15.78%)(P , 0.05). Sonography, which is a simple reliable riproducibleand low cost technique let us confirm previous experiences madeby TAC and MR whic indicate that bladder flap hematomas areusual in post-c.s. In 39 cases (81.25%), they were collections onthe L.U.S. from 3 to 4.2 cm, in 6 (12.50%) from 4.2 to 5 cm(4.16%) and only in one case it was a lateral collection of 6 cm(2.08%) which did not require surgical treatment anyway (the last3 cases have been observed by MR which which confirmedsonographic findings). In addition in 104 patients (36.61%), therewas the presence of a fluid collection in Douglas region due to theamniotic liquid usually not removed according to the Starktechnique. Besides in 22 patients (45.83%) the bladder-flaphematoma was associated with fever (values . 38.5 8C), in thisgroup other causes of febrile morbidity were obviously excluded.The characteristic of these c.s. was a significant intraoperativeblood loss, evaluated with a drop in Hb of 3 or more g/dL. Onthe contrary it was observed a significant differences of theintestinal functionality restarting 8.6 h at c.s. with open perito-neum and 42.7 h (P , 0.05) at c.s. with closed peritoneum but acareful examination confirms that therapid resumption is favouredby regional anaesthesia as regards general anaesthesia, rather thanby surgical technique. Subsequently 82 women undergoing the firstStark c.s., have been reoperated with the same technique, withopen peritoneum, but not significant differences have beenobserved in comparison to c.s. with closed peritoneum from apostsurgical adhesion profile. According to the data of literature,peritoneum closure in c.s. lengthens operative time and in somecases favours hematomas on the L.U.S. which increase post-operative morbidity, antibiotics use 2.6 and 4.8 (P , 0.01), lengthof Hospital staying and costs.

F91The role of ultrasonography in the management of gestationaltrofoblastic disease: diagnostic, treatment and follow-upmodality

M Hrehorcak, L. Rob and E. KulovanyÂUniversity Hospital Motol, Prague, Czech Republic

Since hysterectomy is no longer considered standard procedure in thetreatment of malignant gestational trofoblastic disease (GTD),ultrasonography plays a major role in the detection of themyometrial involvement. The Ultrasonography is standardly usedas one of the main diagnostic tools when GTD is suspected. It seemsthat the size of the mola is no longer considered predictive markerfor malignant change. We demonstrate the role of ultrasonographyas an excellent method in the treatment of presumed GTDparticularly in the evacuation of possibly invasive mole orchoriocarcinoma. The specimen for the diagnosis is obtained securelyunder the ultrasound supervision enabling us to control thediagnostic curettage and to prevent the possible uterine wallperforation. Together with serum hCG levels US and Doppleranalysis are useful tools in the monitoring of the tumor regression inthe course of chemotherapy. We demonstrate that possible ultra-sonographic features of the tumor like intramyometrial signals andhypoechogenic areas (representing mainly arteriovenous malforma-tions) may remain in the long term follow up of successfully treatedGTD with negative hCG serum levels. Concluding that monitoringof serum hCG is of major clinical interest in the treatment of GTDsuggesting the limited interpretation value of ultrasonographicfinding.



P R E N ATA L D I A G N O S I S

F92Fetal biometry from 10 to 14 weeks of gestation

I. Chatzipapas, Y. Spathopoulos, B. Whitlow, M. Lazanakis, R. Kadir,S. Verdin and D. EconomidesRoyal Free Hospital, Fetal Medicine Unit, London, UK

Background: To determine fetal biometrical reference ranges from 10to 14 weeks' gestation.Methods: A prospective cross-sectional study in a University Depart-ment of Obstetrics and Gynaecology, London. Four hundred andseventy women from an unselected population underwent a detailedassessment of fetal anatomy at 101821416 weeks' of gestation(confirmed by crown-rump length) using transabdominal sonography(TAS), and transvaginal sonography (TVS) (35.3%: 166/470) whennecessary. Biparietal diameter (BPD), occipito-frontal diameter(OFD), head circumference, humerus (HU), abdominal circumference(AC), femur (FL) and foot lengths (FL) were measured and charts forcentiles derived using regression analysis and a model of best fitconstructed. HC/AC, BPD/OFD, BPD/FL and BPD/FL ratios werederived for each gestational age. Differences in measurements of BPD,HL and FL using TAS and TVS were examined in 39 cases usingregression and t-test analyses.Results: Centiles (2.5th, 5th, 50th, 95th, 97.5th) were derived for eachbiometrical parameter. New charts and tables for each biometricalparameter are presented and compared with previously publisheddata. As expected all parameters increased with gestational age.However the BPD/FL ratio decreased significantly at 10±13 weeksand the BPD/OFD and HC/AC ratio did not change. There was nosignificant difference between TAS and TVS measurements of BPD(T � 0.18, P � 0.86, R2 � 0.846), FL (T � 20.03, P � 0.98, R2 �0.764) and HL (T � 0.17, P � 0.87, R2 � 0.633), therefore theresults were combined.Conclusion: We have constructed new reference ranges for biparietaldiameter (BPD), occipito-frontal diameter (OFD), head circumference(HC), humerus (HU), abdominal circumference (AC), femur (FL) andfoot lengths (Fo) from 1018 to 1416 weeks gestation. These data maybe useful in the diagnosis of skeletal dysplasias and chromosomalabnormalities in early pregnancy.

F93Feasibility of the second trimester fetal ultrasoundexamination in an unselected population at 18, 20 or22 weeks of pregnancy: a randomized trial

P. SchwaÈrzler and Y. VilleDepartment of Obstetrics and Gynecology, University of Innsbruck,Fetal Medicine Unit, St. George's Hospital Medical School, London,UK

Objective: The purpose of this study was to investigate whether ofthree gestational ages (18, 20 and 22 weeks) any one was associatedwith a significant advantage in terms of identification of abnormal-ities, or need for further ultrasound assessment.Subjects and methods: 1206 women were randomised into 3 mutuallyexclusive groups: group 1 at 18±18 1 6 weeks, group 2 at 20±20 1 6 weeks and group 3 at 22±22 1 6 weeks. The main end-pointswere (i) need for rescan of all or part of the fetal anatomy, (ii) fetaloutcome, (iii) placental localisation and (iv) incidence of notches in theuterine artery waveform.Results: There was a significantly higher percentage of completedscans in group 2 (90%) and 3 (88%) than in group 1 (76%,P , 0.001), but no significant difference between those scanned at 20and at 22 weeks. This was associated with a higher incidence ofnoncephalic presentation in group 1 (46%) than in the other twogroups (36%, P , 0.001). Significant differences in completing theassessment of the thorax, heart, spine and skeleton were alsoobserved. The incidence of low lying placenta and of abnormaluterine artery Doppler screening were also higher at 18 weeks than at

20 and 22 weeks (P , 0.001 for both variables), with no differencebeing seen between groups 2 and 3. The number of fetal anomaliesdetected in the three groups were, respectively, 3, 2 and 2, and did notdiffer significantly between the groups.Conclusions: This study suggests that among an unselected pregnantpopulation, second trimester ultrasound screening is easier to performand less likely to require an additional scan appointment at 20222 weeks than at 18 weeks.

F94Early ultrasonographic screening for malformation ± howearly is too early?

I. Gull, I. Wolman, J. Har-Toov, G. Fait, R. Amster, J. B. Lessing andA. J. JaffaUS Unit Ob/Gyn, T.A.M.C, Israel

Background: Early ultrasonographic screening for malformation isperformed between 14 and 17 weeks of gestation.Aims: To analyze the effect of the gestational age on the screeningefficacy of specific organs and to assess the optimal date for screening.Methods: We analyzed 427 ultrasound screening performed between14 and 18 weeks of gestation. The efficacy of screening for eachstructure at certain week was calculated. Then, we analyzed the datato obtain the best date in which the need for repeated screening wasminimal.Results: The lips, posterior fossa, heart and gall bladder were the mainstructures that could not be optimally visualized during the 14th weekof gestation. The lips, Gall bladder and the VA valves and the greatvessels were the structures that were not visualized optimally during15±16 weeks of gestation. The ears and the fingers were the mainstructures that could not be optimally visualized during 17±18 weekof gestation. The need for repeated screening at the 14th week ofgestation was ,65%, and at the first half of the 15th week ,20%.The need for repeated screening from the end of the 15th week ofgestation to the 17th week was ,8% and rose to 11% at the 18thweek.Conclusion: The optimal date for early screening for malformation isthe end of the 15th week of gestation to the 17th week.

F95Cerebral tissue and vessels growth, during normal pregnancies

F. Perrotin*, F. Landre², C. Paillet*, M. Philippot*, J. Lansac³,E. Janky² and P.H. Arbeille**Inserm 316, Sce Med Nucleaire & Ultrasons, CHU Trousseau,37044, Tours, France. ²Department of Obstetrique & Gynecologie,CHU de pointe a Pitre, 96547, Guadeloupe, France. ³Department ofObstetrique & Gynecologie, CHU Bretonneau, 37044, Tours, France

The objective was to study the kinetic of development of the maincerebral structures and vessels from 20 to 39 weeks.Method: 30 normal pregnancies were included into the study. Theconventionnal parameters used for fetal growth assessment weremeasured: biparietal and, abdomen diameters, skull and abdomentransverse cross section area, femur length. In addition the transversecross section of the main intracranial structures were measured:Thalami, cerebral ventricles, cerebral peduncles, cerebellum. Thediameter of the middle cerebral artery and the flow velocity were alsomeasured at the same rate. These parameters were measured every3 weeks from 20 to 40 weeks. The fetal weight was evaluatedfrom a simple index checked at delivery against the fetal actualfetal. All these parameters were displayed against time in order tostudy and compare the kinetic of their progression during normalpregnancies.



F96A discrepancy between gestational age estimated by lastmenstrual period and biparietal diameter may indicate anincreased risk of fetal death and adverse outcomes ofpregnancy

T. Nguyen*, T. Larsen*, G. Engholm² and H. Mùller³*Departments of Ultrasound, Herlev Hospital, Copenhagen, ²Centrefor Research in Health & Social Statistics, The Danish NationalResearch Foundation, ³Thames Cancer Registry, London, UK

Objective: To analyse the association between the discrepancybetween gestational age estimated by last menstrual period and bybiparietal diameter (GALMP ± GABPD) and adverse outcomes ofpregnancy.Design: Population based follow-up study based on registry data.Material: Singleton pregnancies with a reliable date of last menstrualperiod and biparietal diameter measured between 12 and 22 weeks ofgestation were studied (n � 16 469).Method: Logistic regression analysis and Kaplan-Meier survivalanalysis was used to analyse the association between (GALMP ±GABPD) and adverse outcomes of pregnancy.Main outcome measure: Adverse outcomes were defined as: abortionafter 12 weeks of gestation, stillbirth and postnatal death within1 years of birth, prematurity, birth weight lower than 2500 g andbirth weight lower than 22% below the sex-specific expected.Result: The risk of death was more than doubled if (GALMP ± GABPD)was eight days or more compared to (GALMP ± GABPD) of lessthan eight days (odds ratio, 2.2; 95% ci 1.6±3.1). The correspondingrisks for other adverse outcomes were approximately 1.5 times higher.The risk of death was further factor of 6.1 higher if (GALMP ± GABPD)of $ 8 days was associated with multiple of median of maternalalpha-fetoprotein (AFP-MOM) measured in the 2nd trimester overtwo.Conclusion: A discrepancy between GALMP and GABPD generallyreflects the precision of the two methods used to predict term.However, a positive discrepancy of more than seven days, particularlywith high AFP-MOM, might indicate that a foetus is intrauterinegrowth-retarded and at increased risk of adverse outcomes.

F97Preterm fetal behaviour and the risk of sudden infant deathsyndrome

J. S. Smoleniec and D. JamesLiverpool Hospital, NSW, Australia; Nottingham, UK

Objective: To look for differences in fetal behavioural statecoincidence between two groups categorised into a high and a lowSIDS risk by the Oxford SIDS risk scoring system.Patients and methods: The study population comprised low riskwomen with singleton pregnancies booked at St Michael's MaternityHospital, Bristol, Avon. The `Oxford SIDS risk scoring system (Peters& Golding 1986) was used to recruit pregnancies into a high and alow SIDS risk group. The study involved performing two fetalbehavioural studies (Nijhuis et al. 1982) at 30 and 36 weeksgestational age on the same fetuses. The unpaired t-test was used tocompare values for the low and the high SIDS risk groups.Results: Fetal behavioural state coincidence results were analysedfor a group of 58 fetuses. There were 39 in the low SIDS riskgroup and 19 in the high SIDS risk group. A cross-sectionalanalysis of the fetal behavioural state coincidence results for thehigh and the low SIDS risk groups showed no significant difference(P , 0.05). A longitudinal comparison of the intrafetal change incoincidence with increasing gestational age also showed nosignificant difference.Conclusion: The cross-sectional and longitudinal comparison ofFBS coincidence results failed to show a significant differencebetween the high and low SIDS risk groups. The results suggestthat fetal behavioural state study based on the Nijhuis (1982, p.182±4) criteria did not show any association with the OxfordSIDS risk score.

F98Sonographic assessment of fetal disproportion and perinataloutcome in small for gestational age fetuses

M. Mimica, D. KarelovicÂ, I. Tadin and Z. BenzonDepartment of Obstetrics and Gynecology, Clinical Hospital Split,Croatia

Background: To assess the possibility of sonographic prediction ofperinatal outcome in small for gestational age (SGA) fetuses accordingto the presence of fetal disproportion.Method: SGA children (n � 138, birth weight for gestationalage , 10th percentile) were classified by their neonatal ponderalindex (PI) as proportional or disproportional (PI , 3rd centile forgestational age). Adverse perinatal outcome was considered in thepresence of abnormal fetal heart rate (FHR), Apgar score , 7,respiratory and neurological complications in neonatal period.Results: 18 children (13%) were disproportionally small for age,having significantly higher incidence of abnormal FHR (50%),oligohydramnios (44%), neurological complications (22%) andperinatal mortality (17%) compared with proportionally SGAchildren. Multiple logistic regression analysis with perinatal complica-tions as dependent variable revealed a significant effect of ponderalindex (beta � 2 0.17). Among sonographic parameters only umbilicalartery resistance index was significantly associated (beta � 0.50).Oligohydramnios and FL/AC ratio did not reach statisticallysignificant level of influence on perinatal complications.Conclusion: Body disproportion is a significant factor of perinatalmorbidity and mortality in growth retarded children. Abnormalumbilical artery blood flow is the best sonographic predictor ofperinatal complications in this group. FL/AC ratio as antenatalequivalent of neonatal ponderal index is not enough sensitive to beused in prediction of perinatal complications.

F99The influence of maternal hematocrit on placental size andgrowth from the first to mid-second trimesters of pregnancy

G. D. Michailidis, A. Mamopoulos, P. Papageorgiou andD. L. EconomidesFetal Medicine Unit, Department of Obstetrics and Gynaecology,Royal Free Hospital, London, UK

Objectives: To study the association of maternal hematocrit (Ht) levelswith placental size and growth in the first and mid-second trimestersof pregnancy.Subjects/methods: One hundred and forty pregnant women with asingleton pregnancy were recruited at 11±14 weeks' gestation. Foreach case we performed three scans of the placenta the first atrecruitment and the following two in three weeks intervals. Thevolume of the placenta was measured at each visit using a threedimensional ultrasound scanner. The Hb and Ht were measuredwithin two weeks from the first scan.Results: The placental growth from early second (14±17 weeks) tomid-second (17±20 weeks) trimesters was inversely related to the Htlevels (r � 20.263, P , 0.01). Similar results were observed for theoverall placental growth (r � 20.27, P , 0.01). The placentalvolume at mid second trimester* (17±20 weeks) was also inverselyrelated to Ht (r � 20.18, P , 0.05). However, the placental volumeat the first trimester*, early second trimester* and the placentalgrowth from 11 to 17 weeks were not found to be associated with htlevels.Discussion: This study demonstrates the effects of maternal environ-ment on placental growth. Our data suggests that the levels of Htappear to affect the placental size mainly at the second trimester.Further studies about the factors that regulate placental growth areneeded to elucidate the pathophysiology of these interactions and theireffect to the pregnancy outcome.

*(Corrected for gestational age)



F100Dopplerometry at the prenatal diagnosis of congenital defects

J. Santavy, M. Lubusky, P. Polak and J. HyjanekDepartment of Medical Genetics and Fetal Medicine, PalackyUniversity, Olomouc, Czech Republic

Background: Pulse and colour Dopplerometry is going to be more andmore routine investigation in the frame of specialised prenatalinvestigation. Despite the huge number of the works in this field inthe past years we have found only very limited information aboututilisation of these both methods at the cases of congenital defectsfound in utero, especially in the first trimester of pregnancy.Method: During the past two years we have investigated both by pulseand colour Doppler mostly cord vessels, art. cerebri media, art. renalisand truncus arteriosus. By the colour Doppler we evaluated heart,moving of the chest and we assessed placental blood circulation inlacunas.Results: Our collection consists from 28 pregnant women, where wehave found congenital defects. There were chromosomal aberrations,morphological defects, serious intrauterine hypoplasias and Rhincompatibility there. Evaluation was not possible by the absolutevalues and so we divided the curves into four groups: higher, normaland lower levels, and zero flow. The results are not specific forindividual defects, as we expected, but it is an option to utilise them ata suspicion for abnormal intrauterine findings.Conclusion: Dopplerometry at the congenital defects has its limitedvalue but it is helpful at the complex evaluation of the foetus healthcondition.

F101Evaluation of a new and noninvasive method fordetermination of fetal lung maturity and risk to RDS

E. V. Cosmi, R. L. A. Torre and J. J. Piazze2nd Institute of Ob/Gyn. University `La Sapienza', Rome, Italy

Based on our observations in humans (AJOG 1999; 180:s86) thatfetal breathing movements (FBMS) are associated progressively withnasal fluid flow velocity waveforms (NFFVW) as the fetus matures,we now assess this phenomenon relative to the development ofneonatal RDS. In effect, we present the possibility that evaluation ofFBMS by M-mode US with simultaneous determination of NFFVW byDoppler flow analysis, may permit diagnosis of fetal lung maturity(FLM) and, thus, risk to NRDS by rapid and reliable noninvasivemethods. To the purpose of the study, the FBMS and the NFFVW datawere compared with conventional data from amniotic fluid (AF). 39high-risk pregnancies were enrolled; all babies were delivered by CSwithin a week. Each fetus was surveyed for 30 min for thoracicmovements (TM), indicative of regular FBMS, by M-mode and at thesame time for NFFVW. Amniocentesis was then performed. The AFsample was analyzed for L/S, lamellar bodies and presence of PG. Ofthe 39 pregnancies studied, 25 of the neonates had no RDS. Of thelatter, only 3 registered no FBMS and NFFVW in utero; they alsofailed each of the AF tests, while 2 registered only FBMS andequivocal AF tests. 14 neonates developed RDS and none registeredNFFVW in utero and each failed the AF tests for FLM. Only 2 of theRDS group had no FBMS. The study indicates that the presence ofboth FBMS and NFFVW indicates no risk to RDS. Absence ofNFFVW, with or without FBMS, has the opposite connotation. Thediagnostic accuracy of the noninvasive tests was: sensitivity, 100%;NPV (`no-RDS'), 100%; specificity, 80% and PPV (`RDS'), 73%. Theresults strongly encourage further evaluation of the noninvasivemethods as reliable approaches for evaluating FLM, particularly incases where af sampling is undesirable or impossible (Supported byEURAIL, Europe Against Immature Lung).

F102The prenatal ultrasonographic diagnosis of migrationaldisorders

G. Malinger, T. Lerman-Sagie, L. Ben-Sira and M. Glezerman

The Edith Wolfson Medical Center, Holon, and Tel Aviv MedicalCenter, Sackler School of Medicine, Tel Aviv University, Tel-Aviv,Israel

Background: Neuronal migration occurs between the third to fifthmonth of pregnancy, during this time neurons migrate from theventricular zone to the cortical mantle. The hallmark of themigrational disorders is an aberration of gyral and sulcal develop-ment. The aim of this study was to report on prenatal diagnosis,management and outcome of 6 cases with migrational disorders.Method: The records of all the fetuses that were scanned for a possiblemigrational disorder during a 7-year period ending in May 2000 werereviewed.Results: Six fetuses with migrational disorders were identified at agestational age ranging from 22 to 34 weeks (mean 27.5 weeks), onewith lissencephaly, one with pachygyria, two with polymicrogyria andtwo with neuronal heterotopia. In 3 cases corpus callosum hypoplasiawas also present. One of the fetuses had 2 magnetic resonance studiesperformed in utero and only the second one performed 4 weeks afterthe index US was diagnostic.Conclusion: Migrational disorders, although uncommon may bediagnosed prenatally. The very bad prognosis in most cases justifiesthe effort of early detection.

F103Response of the fetal pupil in the chromosomal anomalies

C. LoÂpez RamoÂn y Cajale-mail: [email protected]. Unidad de DiagnoÂ stico Prenatal. Serviciode obstetricia y GinecologõÂa, Hospital Xeral, Vigo, Spain

Background: We studied sonographically the response of the fetalpupil to the stimulus of color Doppler (CD) in fetuses withchromosomal anomalies below 22nd weeks.Method: The pupils of 28 fetuses were studied sonographicallybetween 15 h-21 weeks' gestation, diagnosed of a chromosomalalteration through of genetic amniocentesis. The areas of the pupiland iris were compared before and after CD imaging.Results: The great majority of the fetuses have some data out ofrange in the relationship pupil/iris in basal conditions or after CD.Usually, we observed an atypical response (mydriasis before the19 weeks or miosis after this) and/or an exaggerated response(hyperreflexia).Conclusion: These results affirm that this type of test increases thepossibilities in a fetal study of high resolution performed before the22nd weeks of gestation and it can be a useful indicator like ananeuploidy marker.

F104Prenatal diagnosis and follow-up of 38 cases of cleft lip ±5-year experience of a Brazilian specialized center

R. Ruano, B. Hanaoka, M. L. M. Iglesias, V. Bunduki,R. M. Yamamoto, S. Miyadahira and M. ZugaibDepartment of Obstetrics, Medical School, University of SaÄo Paulo,Brazil

Background: Sonographic aspects of prenatally diagnosed cleft-lipwere reviewed and compared with postnatal findings.Method: 38 cases of prenatally diagnosed fetal cleft lip were reviewedand the following was recorded: gestational age at diagnosis, maternalage, malformation history, associated palate clift, associated aneu-ploidies and malformations and postnatal follow-up. Kariotyping wasperformed in all cases.Results: Maternal age was 28.37 years and only one case had historyof cleft lip. Gestational age at diagnosis was 28 weeks. Isolated cleftlip were observed in 7 cases (18.42%): 5 fetuses (71.43%) with leftlesion and 2 (28.57%) with right lesion. One case (2.63%) wasassociated with cleft palate. Aneuploidy associated with structuralmalformations was identified in 9 cases (23.68%): trissomy 13(n � 6); trissomy 18 (n � 2) and 47XXY (n � 1) In 66% of those



cases associated cleft palate was found. Associated malformationswith normal karyotype were found in 22 cases with associated cleftpalate in 50% of those cases.Conclusion: In this series, fetal cleft lips were frequently associatedwith structural malformations and cromossomal, especially when cleftpalate was associated. Cleft lip is an indication for fetal karyotypingand associated malformations must be discarded by level three ultra-sound scan.

F105Transvaginal sonographic appearance of the cerebellar vermisat 14±16 weeks' gestation

Y. Perlitz, D. Peleg and M. Ben-AmiDepartment of Obstetrics & Gynecology, Poriya GovernmentHospital, Tiberias, The Rappaport Faculty of Medicine, Technion,Israel Institute of Technology, Haifa, Israel

Background: The aim of this study was to evaluate the normaldevelopment of the fetal cerebellum at 14±16 weeks' gestation usingtransvaginal sonography (TVS).Method: 195 low risk women who had structurally normal fetusesdetermined by a detailed anomaly scan, were included in the study.The sonographic image of the cerebellar hemispheres and the vermiswas evaluated by the modified axial view of the fetal head. All womenunderwent a follow up scan at 20±24 weeks' gestation to determinethe status of the cerebellar vermis.Results: All fetuses had an open vermis at 14±16 weeks' gestation. Onthe follow up scan at 20±24 weeks' gestation, closure of the vermiswas demonstrated in all fetuses.Conclusions: At 14±16 weeks' gestation the cerebellar vermis isdemonstrated to be open by TVS. This is a normal finding, andtherefore, the prenatal diagnosis of Dandy-Walker variant should bemade only later than 16 weeks' gestation.

F106Prenatal diagnosis of syndromic and nonsyndromiccraniosynotosis by ultrasound

J.P. Bernard, S. Delahaye, M.V. Senat, B. De Keersmaecker, D. Renierand Y. VilleHoÃpital de Poissy-Saint Germain en Laye, Yvelines, France

Background: Prenatal diagnosis of cranyosynostosis are rare. Most ofthem are syndromic synsostosis (Apert, Crouzon.) and ultrasounddiagnosis is done on associated lesions. Very few publicationsdescribed nonsyndromic craniosynostosis and the diagnosis is madeon skull deformation. Some animal experimentations have proven thatsynostosis have different sonographic features than normal sutures.Material: For 5 years we examined 32 fetuses, referred in ourinstitution with a high risk of craniosynostosis. Some because of afamily history of previous craniosynostosis, others because of anabnormality of the cephalic index or skull deformations.

The diagnosis of craniosynostosis was only made when the suturesseemed abnormal.Results: Nine fetuses had a very high risk of craniosynostosissecondary to a previous autosomic craniosynostosis. In 5 of them,the sonographic appearance of the suture was abnormal and thenewborn presented a recurrent craniosynostosis. In 4 of them, thesonographic appearance of the sutures was normal and the newbornwere healthy.

Twenty-three fetuses had an increased risk of craniosynostotsissecondary to the appearance or biometry of the skull on the routinesecond trimester scan. In 20 of them, sutures were normal andnewborns were healthy. Three fetuses presented abnormal sono-graphic features, two of them presented a craniosynostosis, however,one was a healthy newborn.Conclusion: Ultrasound seems to be a very good tool for the diagnosis ofcraniosynostosis even isolated in a very high risk population (risk of 1/2).In lower risk the negative predictive value can be used to rassure parentswhen the biometry or the appearance of the skull seems abnormal.

F107Ultrasonographic diagnosis of spina bifida at 12 weeks:heading towards new indirect signs

B. De Keersmaecker, O. Buisson, J. P. Bernard and Y. VilleHoÃpital de Poissy-Saint-Germain en Laye, Yvelines, France

Background: The diagnosis of spina bifida before 14 weeks' remainsdifficult to achieve.

We believe that the cephalic markers are accessible to an orientedsonogram at 12 weeks' if these signs are specially looked for.Improvements are necessary since prenatal diagnosis is movingtowards the first trimester.Method: Retrospective analysis of ultrasound pictures taken at around12 weeks in 2 cases of spina bifida diagnosed at 12 and 22 weeks,respectively, and 10 controls.Results: Cerebral peduncles appear to be parallel and some degree ofretraction of the frontal bones give the head an acorn shape. Thisparallelism might be the first and only sign amenable for prenataldiagnosis. A sagittal plane of the brain and spine can also visualise alarge part of the myelencephale on the same plane as themetencephale, which cannot be seen in normal controls.Conclusion: Very subtle signs as peduncular parallelism and alignment ofmetencephale and myelencephale could be the earliest signs of spina bifidain first trimester. No special skill is necessary to obtain the diagnosisbecause the plane of the peduncles is part of the routine examination.

F108Correlation between prenatal ultrasound findings andpostnatal outcome in 37 cases of isolated spina bifida aperta

C. F. A. Peralta, V. Bunduki, J. P. Plese, R. M. Yamamoto,S. Miyadahira and M. ZugaibDepartment of Obstetrics, Medical School, University of SaÄo Paulo,Brazil

Background: The aim of this study was to find prenatal prognosispredictors in spina bifida aperta.Method: Thirty-seven cases of isolated Spina Bifida Aperta wereprospectively evaluated from 1995 to 2000. Prenatal ultrasoundfindings such as hydrocephaly, talipes, site of the lesion and prenatalevolution were correlated with postnatal neurological outcome.Minimum postnatal follow up was one year.Results: Mortality rate was 24% (9/37). Among 28 survivors, 21(71%) had normal intellectual development. Six (6/28±21%) hadnormal intellectual and motor development Fourteen (14/28±50%)had normal intellectual development but severe motor impairment.Severe motor and intellectual impairment were present in 8/28survivors (29%). All of them had hydrocephaly (mean ventriculo-hemisphere ratio � 0.75), and 5(5/8±63%) had talipes. Site of spinawas higher in this group with no case of sacral meningomielocele. All28 patients had problems in controlling sphincters which was analysedseparately from inferior limbs motor development.Conclusions: The group with small sacral lesions without hydrocephalynor talipes had good prognosis, with normal intellectual and inferior limbmotor development but no sphincter control. In any other situation apoor prognosis was observed with a high mortality rate. Longer followup is needed to better ascertain and confirm these prognostic factors.

F109The management and outcome of fetal hydrothorax inTaiwan

An-Shine Chao, Chao-Lung Chung, Reyin Lien* and Jer-Nan LinDivision of Obstetrics, Department of Obstetrics and Gynecology,Chang Gung Memorial Hospital, Tao-Yuan, Taiwan; *Division ofNeonatology, Department of Pediatrics; ²Department of PediatricsSurgery

Background: To evaluate the outcome and management of thecomplications encountered in the cases of fetal hydrothorax.Method: 14 cases of fetal hydrothorax were enrolled. Completeprenatal work-up were done. Thoracocentesis were performed



24±48 h prior to the thoracoamniotic shunting (T-A shunt). Thor-acoamniotic shunting was performed when (i) the age of diagnosiswas less than 34 weeks (ii) presence of hydrops fetalis (iii) progressionof pleural effusion even after thoracocentesis.Results: Among the 14 cases, 10 cases received T-A shunts with 1 casetechnically failed to insert who subsequently had distress and demised.The remaining 9 cases (except a case of trisomy 21 & a case ofpersistent hydrops) had resolved hydrops and pleural effusion after theshunting and survive with good neonatal outcome although 5/8 hadpreterm delivery. For the 4 cases who did not receive T-A shunt, onlyone had pulmonary and gastroenterology sequales. The majorunderlying cause of effusion was chylothorax. There were 2 dislodgedshunts into fetal pleural cavity which had to be removed postnatally.Conclusion: The thoracoamniotic shunting is an potentially correctiveand effective method for the chronic drainage of massive fetal pleuraleffusion by reversal of hydrops and prevention of pulmonaryhypoplasia. Conservative managements are preserved for the slow-accumulating pleural effusion, nonhydropic circumstances.

F110Human fetal gallbladder contractility exists in utero

Y. Tanaka, D. Senoh and T. HataKagawa Medical University, Kagawa, Japan

Objective: The purpose of this study was to evaluate whether humanfetal gallbladder contractility exists in the second half of pregnancy.Method: Ultrasound examinations were performed on 54 normalpregnant women from 20 to 40 weeks of gestation. Fetal gallbladdervolume was monitored every 30 min from 8 to 18 o'clock in each patient.Results: Maximum gallbladder volume (Max) had a linear relation-ship with gestational age between 20 and 32 and 35 weeks ofgestation, after which a plateau was observed. Minimum gallbladdervolume (Min) was not changed throughout gestation. Functionalcapacity (Max ± Min) of the fetal gallbladder increased linearly withadvancing gestation until 32±35 weeks' gestation, thenafter becameconstant. Contractility rate [(Max ± Min/Max) � 100] increasedcurvilinearly with advancing gestation. The change of fetal gallbladdervolume in a day showed a typical sinusoidal pattern, and thecontractility cycle of gallbladder volume was not changed duringpregnancy.Conclusion: We suggest that there is an gallbladder contractility inhuman fetuses in utero, and that maternal meals seem not to affect thevolume of fetal gallbladder.

F111Evaluation of routine prenatal ultrasound detection of fetalgastrointestinal malformations: European multicentric study

I. Barisic*, M. Clementi², M. Haeusler³, R. Gjergja Matejic*,C. Stoll§ and EUROSCAN STUDY GROUP*Children 0s University Hospital Zagreb, Croatia; ²University ofPadova, Italy; ³University of Graz, Austria; §University ofStrasbourg, France

We have evaluated the effectiveness of routine prenatal ultrasoundscreening in detection of selected groups of major gastrointestinalmalformations occurring among 690 123 pregnancies monitored fromJuly 1st 1996 to December 31st 1998 in 19 European CongenitalMalformation Registries. There were 243 cases of abdominal walldefects, 177 cases of diaphragmatic hernia and 386 cases ofgastrointestinal atresia/stenosis. Only 57% of cases with diaphrag-matic hernia and two thirds of cases of omphalocele compared to95% of the fetuses with gastroschisis are currently being identified inan unselected population offered routine mid trimester ultrasoundscreening in europe. Among various cases of atresia/stenosis, thehighest detection rate was recorded for duodenal (59%) and anorectal(32%) anomalies. Sensitivity of prenatal ultrasound clearly dependson the type of malformation and the presence of other structuralanomalies or chromosomal aberrations. There is also significantvariation in detection rates between different european regionsreflecting policies, equipment and operators experience. The highest

rates of elective top after prenatal ultrasound diagnosis were observedfor omphalocele (50 or 36%), and gastroschisis (32 or 30%), andlowest for esophageal atresia (8%).

F112Prenatal sonographic diagnosis and outcome of anteriorabdominal wall defects

T. C. See, P. A. K. Set, J. Brain² and N. Coleman*Departments of Obstetric Radiology, Pediatric Surgery² and PediatricPathology*, Addenbrooke's Hospital, Cambridge, UK

Objectives: (1) To evaluate the accuracy of routine second trimesterultrasound screening in the detection of anterior abdominal walldefects (AAWD); (2) To assess the outcome of these pregnancies.Methods: A retrospective study of low risk population between January1993 to December 1999. Cases with AAWD were obtained fromantenatal, neonatal surgical and pathology Departments. Correlationwas made with the second trimester ultrasound examinations to assessthe accuracy of detection. Pregnancy outcome was reviewed.Results: There were 25 fetuses with AAWD. 15 with omphalocoele, 9with gastroschisis and 1 with bladder exstrophy. All except thebladder extrophy case were detected antenatally. Pathology report ona case of omphalocoele was inconclusive. A case of gastroschisis didnot have histological confirmation following termination of preg-nancy. However, sonogram review of these 2 cases confirmed theoriginal diagnosis and hence are included as true positives. 7 of the 9cases of gastroschisis were live births and all did well followingsurgery. 7 of the 15 cases of omphalocoele were livebirths. One died at9 months but others did well post surgery.Conclusion: We demonstrate a sensitivity of 96% (24/25) and aspecificity of 100% for the detection of AAWD. 13 of the 14 livebirths (93%) did well following surgery. With the increasingawareness of evidence based medicine, this study hopes to set astandard for clinical practice.

F113The diagnosis and therapy in pregnancies complicated byacute hydramnios

K. Szaflik, D. Borowski, P. Oszukowski, D. Wyrwas, A. Kunert, P.Hincz and A. CiesielskiInstitute `Polish Mother's Memorial Hospital', èoÂdzÂ, Poland

Background: The aim of the study was an analysis of frequency ofhydramnios and its etiology, and assessment of therapeutic modalities.Method: The study group consisted of 77 pregnant women withdetected hydramnios. The entry criteria were amniotic fluid index (byPhellan) . 28 cm.Results: The mean gestational age was 29 ^ 4.5 weeks. The meanAFI was 35 ^ 7.9 cm. In 30 cases of hydramnios the congenitalmalformation was diagnosed. The most frequent were anomalies ofgastrointestinal tract, lesions of central nervous system and teratomas.In 23 cases viral infections were diagnosed. Another group ofpregnancies with the acute hydramnios constitute 13 twin gestationswith TTS. In 16 cases, no etiologic factor was found. In all cases, thetherapy of acute hydramnios was based on serial amnioreductions. Intwo cases maternal treatment with indomethacin was introducedbeside amniocentesis. In 13 cases there were performed additionalintrauterine drainage procedures. The mean gestational age duringdelivery was 33.6 ^ 4.6 weeks. The mean interval between thediagnosis and delivery was 4.6 weeks. The mean birth weight was2055 ^ 1060g. 5th min Apgar score was 4pt. In 13 cases intrauterinedemise of fetus occurred.Conclusion: The most frequent causes of acute hydramnios includefetal anomalies, the TTS in twin pregnancies and congenitalinfections. Amnioreductions are the therapeutic approach with asignificant effect on the prolongation of pregnancy.



F114Ultrasonographic detection of undescended testes in the thirdtrimester of pregnancy

I. Wolman, I. Gull, J. Hartoov, G. Fait, R. Amaster, J. B. Lessing andA. J. JaffaUS Unit Ob/Gyn, T.A.M.C, Israel

Objective: The aim of the present study was to assess, the sonographicrate of detection of undescended testes among a low-risk populationduring the third trimester.Study methods: 332 women between 34 and 40 weeks of pregnancyunderwent prospectively an ultrasonographic evaluation includingbiometrical studies and detailed study of the fetal genitals. Thepresence of the testes within the scrotum was examined by a qualifiedneonatologist within 3 days after birth.Results: Of the 332 fetuses that were examined, the scrotum was visiblein 294 of them (89%). Nine cases of undescended testes were detected(3%). Of these, the diagnosis of one case, examined at 34 weeks ofgestation, was a false positive one as revealed after birth. There was nofalse negative result. The present series has delineated the best timing forthe detection during the late 3rd trimester as being between 34 and36 weeks of pregnancy. When undescended testes is diagnosed, a secondevaluation is recommended at around 37 weeks of pregnancy.Discussion: Ultrasound examination during the late third trimester ofpregnancy appears to allow an accurate diagnosis of undescendedtestes prenatally. This early identification will alert the neonatologistof the possibility of cryptorchidism and permit early postnatalidentification and treatment.

F115Prenatal diagnosis and clinical management of fetalhydro(metro)colpos: report of 3 cases

A. Geipel, C. Berg, U. Germer, K. Gloeckner-Hofmann*, J. MoÈ ller²and U. GembruchDepartment of Obstetrics and Gynecology, Department of Pediatricsand Institute of Pathology, Medical University of LuÈbeck, Germany

Background: Hydrometrocolpos represents the dilatation of thevagina and uterus due to obstruction of the genital tract, leading toaccumulation of secretions.

We report on 3 female fetuses with prenatally diagnosed hydro(-metro)colpos. Gestational age ranged from 28 to 35 week's. In thefirst case, hydrometrocolpos was associated with postaxial hexadac-tyly of both upper extremities, strongly indicating McKusick Kaufmansyndrome. In the second case, malformation of the urogenital sinusincluded anorectal and vaginal atresia with rectovaginal andurethrovaginal fistula. Furthermore, vertebral segmentation anoma-lies, horseshoe kidney and ventricular septal defect were detected,creating an overlap between VACTERL and MURCS association. Inthe third case, hydrometrocoplos secondary to cloacal anomaly withanal atresia and bilateral hydronephrosis were observed. All 3newborns underwent surgical correction, 2 of them survived.Conclusion: The presence of hydro(metro)colpos warrants a system-atically evaluation of fetal and neonatal anatomy to rule out a largevariety of possibly associated malformations or syndromes.

F116Wharton's jelly quantification during gestation and itscorrelation with fetal biometry

F. Ghezzi, L. Raio, E. Di Naro, M. Franchi, R. Ferronato, H.BruÈhwiler, P. Triacca, D. Bolla and H. SchneiderUniversity of Insubria, Varese, Italy, University of Bern and RegionalHospital of MuÈnsterlingen, Switzerland and University of Bari, Italy

Background: Abnormalities of the umbilical cord size have beenassociated with the growth of the fetus (Raio et al. Ultrasound ObstetGynecol 1999; 13: 176). Therefore, this study was undertaken togenerate a nomogram for the amount of Wharton's jelly (WJA) duringgestation and to investigate whether it is related to fetal biometricparameters.

Method: The sonographic cross-sectional area of the umbilical cordand of its vessels was measured in 627 healthy fetuses between 15 and42 weeks of gestation. The WJA was calculated subtracting thevascular area from the umbilical cord area. The conventionalbiometric parameters were measured.Results: The WJA increases as a function of gestational age (r � 0.63,P , 0.001). A stron correlation was present between the WJA and theumbilical cord area (r � 0.97, P , 0.001). A significant correlationwas found between the WJA and fetal biometric parameters (withBPD, r � 0.66, P , 0.001; with AC, r � 0.65, P , 0.001; with FLr � 0.64, P , 0.001) and between WJA and estimated fetal weight(r � 0.63, P , 0.001).Conclusion: A nomogram for the WJ amount has been generated. TheWJA increases as a function of gestational age and it is related eitherwith fetal size and with umbilical cord diameter.

F117Hystero-embryoscopic findings in early nonviable pregnancies

J. Ferro, C. Lara, M. C. MartõÂnez, J. Crespo, C. Vidal, J. RemohõÂ,A. Pellicer and V. Serra-SerraInstituto Valenciano de Infertilidad & Departamento P.O.G. Facultadde Medicina, Universidad de Valencia, Spain

Background: A high proportion of early pregnancy losses areassociated to abnormal embryo development. However, chromosomalanalysis of routine curettage samples are of limited value; andhistopathological examinations of the embryos are rarely performedin clinical practice.Method: A transcervical hystero-embryoscopy was performed prior tothe curettage in 31 nonviable first-trimester pregnancies and a controlgroup of 5 early terminations of pregnancy. In the study group, theestimated gestational age according to the ultrasound findings was 6.7(4±9) menstrual weeks. Direct biopsies of different gestationalstructures were taken during the endoscopic procedure.Results: In nonviable pregnancies, focal haemorrhagic/necroticchanges were present in the decidua capsularis. The collapse of thegestational sac was variable. Most chorionic villi had an oedematousappearance. Degenerative changes of the embryo and yolk sac werenot uniform. The following gestational anomalies were identified:partial moles (n � 2), structural abnormal embryos (n � 4), umbilicalcord cysts (n � 3) and abnormal yolk sacs (n � 2). Chromosomalanalysis of selective chorionic and embryo biopsies identified amisdiagnosis of the curettage sample result in 8 cases.Conclusion: Hystero-embryoscopy offers great potential for evaluat-ing early nonviable pregnancies. Accurate karyotypes can be obtainedfrom direct chorionic and embryo biopsies.

F118Placental size and growth in early pregnancy: does it affectbirthweight?

G. D. Michailidis, P. Papageorgiou and D. L. EconomidesFetal Medicine Unit, Department of Obstetrics and Gynaecology,Royal Free Hospital, London, UK

Objectives: To study the influence of placental size and growth fromfirst to mid-second trimesters on birthweight.Subjects/methods: Eighty one pregnant women with a singletonpregnancy were recruited at 11±14 weeks' gestation. For each case weperformed three scans of the placenta the first at recruitment and thefollowing two in three weeks intervals. The volume of the placentawas measured at each visit using a three dimensional ultrasoundscanner. The information for the birth weight was obtained from thehospital notes. Customised centiles were used to correct birth weightfor gestational age at delivery, parity, BMI and ethnic origin.Results: The placental growth rate from the first to the early secondtrimester was associated with birthweight (r � 0.33, P , 0.01) whilethe growth later in the second trimester was not. The placentalvolume, corrected for gestational age, at the first trimester (11±14 weeks: r � 0.3, P , 0.01), early second (14 to 17 weeks:



r � 0.42, P , 0.01) trimester but not at the mid-second (17±20 weeks) trimester was correlated with birthweight. The placentalgrowth rate was not related to maternal BMI, or parity.Discussion: This study demonstrates the influence of early placental

development on pregnancy outcome and supports the hypothesis thatearly pregnancy events can affect the final pregnancy outcome. Ourdata suggests that placental growth in early pregnancy could be auseful independent predictor of birthweight.

F E TA L E C H O C A R D I O G R A P H Y

F119Fetal cardiac flow velocity waveforms between 14 and16 weeks' gestation in normal pregnancies

M. Ben-Ami, Y. Perlitz and D. PelegDepartment of Obstetrics/Gynecology, Poriya Government Hospital,Tiberias, and the Rappaport Faculty of Medicine, Technion Israel ofTechnology, Haifa, Israel

Background: The purpose of this study was to establish normal valuesfor flow velocity waveforms in fetuses at 14±16 weeks' gestation.Method: Doppler waveforms were recorded in 89 normal fetuses at14±16 weeks' gestation. All scans were performed transvaginally.Peak velocities at E (passive atrial filling) and A (atrial contraction)waves were obtained from tricuspid and mitral flow velocitywaveforms. Peak systolic velocities for the ascending aorta andpulmonary artery were also calculated. Linear regression analysiswas performed.Results:

There was no significant correlation between any of the velocities andgestational age.

Conclusion: Fetal cardiac function by Doppler waveform analysisremains unchanged between 14 and 16 weeks' gestation in normalpregnancies.

F120Effectiveness of screening for major cardiac defects in aroutine obstetric population

E. Mavrides*, F. Cobian*, G. Moscoso*, S. Campbell*,B. Thilaganathan* and J.S. Carvalho*²*Fetal Medicine Unit, St George's Hospital and ²Brompton FetalCardiology, Royal Brompton Hospital, London, UK

Background: The aim of this study is to evaluate the effectiveness ofroutine antenatal screening for CHD in a routine obstetric population.Method: A three-year prospective, observational study. All womenwere routinely offered first trimester nuchal translucency screeningand an 18±23 week anomaly scan, where the four chamber view andoutflow tracts were visualised. The main outcome measure wasidentification of major CHD in all pregnancies, either in the antenatalor postnatal period.Results: Major defects of the heart and the great arteries wereidentified in 51 out of 9277 pregnancies. Major CHD were diagnosedantenatally in 42 fetuses and postnatally in nine (including 15aneuploidies). The overall antenatal detection rate was 82.4% in allpregnancies and 80.6% in chromosomally normal pregnancies. In 10cases, the first trimester NT measurement was increased.Conclusion: The overall prevalence of major CHD (5.4/1000) suggeststhat ascertainment in the study population was thorough. The

combination of first trimester NT screening and visualisation of thefour-chamber/outflow tracts is effective in the detection of themajority of major CHD.

F121The routine use of the three vessels and trachea (`3VT') viewin fetal echocardiography

S. YagelDepartment of Obstetrics and Gynecology, Hadassah UniversityHospital, Mt. Scopus, Jerusalem, Israel

Detailed fetal echocardiography potentially detects most congenital heartdefects. In the last decade, screening programs have been established innumerous institutions in an attempt to rule out fetal heart anomalies in allpregnancies. However, fetal heart examination is time-consuming andrequires special skills. The `four chamber view' and identification ofventricular outflow tracks became standard tests in screening programs.Examination of the aortic arch and superior vena cava, the location of thetrachea in the mediastinum, the size of the aortic arch, main pulmonaryartery, and the ductus arteriousus, and the direction of flow in thesevessels, demands special attention and increases significantly the timerequired for routine fetal heart examinations.

We introduced the identification of the main pulmonary artery,ductus arteriosus, aortic arch, transverse section of the superior venacava, and transverse section of the trachea into our routine fetal heartstudy. This `three vessel view' is obtained by sliding the transducerupward from the four-chamber plane toward the fetal uppermediastimun. In more than 2500 cases this maneuver significantlyreduced the time required to examine these structures. Moreover, thisapproach facilitated detection of pathologies such as abnormal vesselsize, abnormal vessel alignment or arrangement, and was shown to besuperior in detecting anomalies such as persistent left superior venacava, right aortic arch, vascular ring, and others.

We believe that this view should be introduced into the routineexamination of the fetal heart.

F122Fetal cardiology considering fetal intervention, and animalmodel of fetal pacing and fetal cariopulmonary bypass

Y. Chiba, K. Kawamata, K. Bando* and Y. Kawahira*Department of Perinatology, and Department of CardiovascularSurgery, National Cardiovascular Center, Osaka, Japan

Background: Two hundred two cases of structural heart diseases werediagnosed prenatally, and 23 cases of complete AV block weredelivered. However, their mortality has not been decreased. We haveto discuss the possibility of fetal interventions for heart diseases.Methods: The mortality of fetal heart diseases diagnosed prenatallywere discussed. Resent new findings of fetal cardiology consideringfetal mortality and the possibility of fetal interventions were discussed.Animal experiments for fetal cardiac interventions were performed.Results: The total mortality of fetal structural heart diseases was60.2%. The mortality of hydropic heart diseases was 92%. Themortality of hypoplastic left heart syndrome was 100%, that ofEbstein's anomaly was 88%, and that of pulmonary valve atresia orstenosis was 64%. The total mortality of complete AV block was30.4%. That of hydropic complete AV block was 50%. Fifteen casesof complete AV block were performed implantation of pacemakerafter birth. The youngest case was 32 weeks delivered, the birth

Velocity(cm/sec) r P

Tricuspid valve peak E-wave velocity 25.3 ^ 4.3 0.04 0.74Tricuspid valve peak A-wave velocity 42.7 ^ 5.7 0.08 0.48Mitral valve peak E-wave velocity 23.0 ^ 4.1 20.02 0.84Mitral valve peak A-wave velocity 39.9 ^ 5.1 0.01 0.94Aortic peak systolic velocity 38.5 ^ 4.8 0.01 0.96Pulmonary peak systolic velocity 38.6 ^ 4.9 20.14 0.21



weight of which was 1906g. The procedure of fetal interventionshould be simple. They will be aortic valvotomy, pulmonaryvalvotomy, enlargement of foramen ovale, and fetal pacing. Con-sidering fetal or neonatal interventions for pulmonary atresia orcritical stenosis, the findings of sinusoidal communication is essential.According to the good resolution of ultrasonic equipment, details ofsinusoidal communication can be diagnosed. We have started groupstudy to select cases to be considered cardiac interventions for fetusesand to develop surgical technique by support of japanese ministry ofhealth and Welfare. We performed the implantation of pacemaker tofetal ram and experiments of fetal cardiopulmonary bypass.

F123Intracardiac echogenic focus: no apparent association withstructural cardiac abnormality

I. Wolman, S. Diamant, I. Gull, J. Hartoov, G. Fait, R. Amster,J.B. Lessing and A.J. JaffaUS Unit Ob/Gyn, T.A.M.C, Israel

Objective: The purpose of this prospective study was to evaluatewhether intracardiac echogenic foci (ICEF) are related to impairmentof ventricular performance.Study methods: 3744 low risk patients were prospectively evaluatedby the same ultrasonographer. ICEFs were defined as an hyperecho-genicity located on the chordae tendinae. Fetuses with ICEFsunderwent further echocardiographic evaluation. After birth, theneonates were referred for an additional echocardiographic evaluationonly if a clinical suspicion of cardiac impairment arose. Fetuses withICEFs were compared to a control group consisting of low-riskfetuses, with no detectable ICEF, who underwent a similar echocar-diographic evaluation.Results: Of the 3744 patients in the study group, 138 fetuses (3.7%)presented with icefs. The majority of the ICEFs (78%) were located inthe left ventricle. Eighteen percent were located in the right ventricleand 4% were bilateral. Of the 138 fetuses in this group, there was onecase (0.7%) of pulmonic stenosis in a twin gestation. There was noother cardiac malformation or dysfunction in the other fetuses. Of the167 fetuses in the control group, there was one case of fetal bicuspidaortic valve there was no statistical significance between the 2 groups.Conclusions: We conclude that the finding of icefs is not correlatedwith cardiac dysfunction. However, these lesions should be carefullydifferentiated from rhabdomyoma or teratoma.

F124Prenatal diagnosis of congenital heart disease and postnataloutcome in a tertiary care center

B. Toth*, U. RoÈmer², A. Schulze³ and A. Strauss**Department of Obstetrics and Gynecology, Groûhadern,²Department of Pediatric Cardiology, Groûhadern, ³Department ofNeonatology, Groûhadern, Ludwig-Maximilian University, Munich,Germany

Background: Prenatal sonographic diagnosis of congenital heartdisease (CHD) is important for proper perinatal and neonatalmanagement as CHD occurs in approximately eight of 1000 live birth.Method: All fetal echocardiograms obtained in the department ofobstetrics and gynecology between January 1994 and June 2000 andpostnatal echocardiograms obtained in the department of pediatriccardiology were reviewed.Results: A CHD was found in 63 fetuses prenatally and in 116newborns postnatally. The prenatal diagnosis was confirmed in 82%.Most of the false-negative diagnosis were septal defects.

Thirty-three of the 116 neonates with a CHD died in the first yearof life (28.4%). Eight (7%) needed a surgical intervention. Regardingonly the neonates with a septal defect 64 (92%) showed normaldeveloping, without surgical or medical intervention.Conclusion: Echocardiographic diagnosis of CHD can be achieved withaccuracy in fetal life. Septal defects are the most unrecognized CHDprenatally but did not influence the postnatal hemodynamic circulationin most neonates. Nearly one third of the children with a CHD died and

around 10% needed a surgical intervention in the first year of life. 59%were in good clinical condition and showed normal developing.

F125Fetal pulmonary venous Doppler flow velocity waveforms incongenital heart defects

R. Chaoui and F. Lenz*Clinic of Obstetrics, University Hospital ZuÈ rich, Switzerland*Supported by BMBF grant Nr.Lung ZZ9511

Aim of the study: is to analyze blood flow velocity waveforms (FVW)in the pulmonary veins using pulsed Doppler ultrasound in fetuseswith a prenatally detected congenital heart defect (CHD).Methods: In 96 fetuses with various CHD Doppler FVW from thepulmonary veins were assessed. Gestational age varied between 18and 38 weeks. Following Doppler parameters were analyzed andcompared to reference ranges: systolic (S), diastolic (D) peak velocity,end-diastolic velocity during atrial contraction (A), peak velocityindex for veins (PVIV) and Pulsatility Index for veins (PIV).Results: We could distinguish 5 different patterns of FVW reflectingdifferent stages of pulsatility and preload within the left atrium.Abnormal patterns were mainly observed in fetuses with left atrialobstruction and a restrictive foramen ovale having a reversed A-waveas well as in mitral regurgitation.Conclusions: Abnormal FVW in fetal cardiac defects depend from theleft atrial pressure rather than on the cardiac defect itself. Patterns ofFVW can help in quick differentiation of increased interatrial pressure,which can impair early neonatal outcome.

F126Congenital complete atrio-ventricular (AV) block. Prenataldiagnosis and perinatal outcome

H. MunÄoz, F. Guerra, I. HernaÂndez, C. DõÂaz, G. Palominos,M. Nazaretian, M. Puga and S. VillaFetal Medicine, Clinical Hospital, Universidad de Chile, Valdivia,Roberto del RõÂo, San Borja ArriaraÂn and Carabineros, Santiago, Chile

Background: There are two types of complete heart AV block; associatedand non associated with congenital heart malformations. The purpose ofthis work is to describe the ultrasound features and perinatal outcome ofcases with prenatal diagnosis of complete AV block.Methods: A descriptive retrospective trial was performed. The AVblock criteria were the presence of ventricular cardiac frequencies lessthan 80 bpm, and atria ventricular dissociation. In normal fetal heartgroup presence of Ro, Ssa and/or Ssb maternal antibodies were tested.Results: Thirteen cases of complete AV block were identified, 8 withstructural malformations and five with normal cardiac structure butwith presence of maternal antibodies. The patients average age was23 years (range: 18±37), the gestational age at diagnosis was25 weeks (range: 20±30). The ventricular frequency was 52 bpm(range: 42±73) and the atrial frequency was 112 bpm (range: 70±152). The cardiac malformations were present in 8 fetuses and themost frequent were the AV channel and single atria. Mortality inmalformations cases was 100% and in those with immunologicalorigin was about 40% (2/5). There were three survivors; two of themneeded definitive heart peacemaker.Conclusion: The prognosis in the cases associated to structuralmalformations was always lethal, nevertheless in immunologicalorigin cases prenatal diagnosis and perinatal management allowedthe survival of them.

F127Prenatal diagnosis of fetal cardiac tumors: 18 cases reported

A. Galindo, F. GutieÂrrez-Larraya, A. GranÄ eras, C. Alvarez andP. De La FuenteHospital Universitario `12 de Octubre' de Madrid, Department ofObstetrics and Gynecology, Spain

Aim: To evaluate our experience with fetal cardiac tumors.



Methods: Retrospective study of 18 cases from Jan.1991±Apr.2000,analyzing US features, histology and perinatal outcome.Results: The incidence was one in 3224 deliveries (18/58037). Meangestational age at diagnosis was 32 weeks (22±38). In 17 cases (94%)were isolated while in one the fetus had another defects. In 7 cases (39%)there was one tumor, in 6 two (33%) and in 5 three or more (28%); totalnumber of masses was 42. Size ranged from 2 to 46 mm. In 3 cases(17%) a significant growth of the mass was observed prenatally. Mostmasses (26) were sited at ventricles (18 left and 8 right). Pericardialeffusion was observed in 8 cases (44.4%). In 4 cases there were asignificant arrythmia. Histology was available in 7; 5 rhabdomyomas,one cavernous hemangioma and one pericardial teratoma. In the othercases the sonographic appearance was compatible with rhabdomyoma.A postnatal conservative management has been performed in mostcases. Overall survival rate was 67% and if top are excluded (2 cases)survival rate rose to 75%. At one year follow-up, extracardiacmanifestations of tuberous sclerosis were diagnosed in 5 cases (28%).In all the 5 cases, there were 2 or more cardiac masses. In 5 of the 11 cases(45%) with more than one tumor, extracardiac manifestations oftuberous sclerosis were observed.Conclusions: Fetal cardiac tumors are unfrequent and the diagnosis isusually made in the III trimester. They appear commonly isolated andits size is widely variable; in up to 61% of the cases more than onetumor is observed. Main localization is ventricular and the mostcommon type is rhabdomyoma. A conservative approach is recom-mended as can behave in a benign fashion. Caution is advocated whencounselling families about tuberous sclerosis, mainly if several cardiacmasses are detected.

F128The sonographic detection of fetal cardiac rhabdomyomas

V. Pinto, S. Selvaggio, P. Volpe and V. D'Addario4th Unit of Obstetrics and Gynecology, University Medical School,Bari, Italy

Objective: To compare the sonographic appearance of suspectedcardiac tumors with the postnatal results and to assess the influence ofantenatal ultrasound on the management of these lesions.Study design: The study group consisted of 6 patients at 28±37 weeksof gestation referred to our Ultrasonic Unit, between March 1992 andDecember 1998, for suspected fetal cardiac masses.Results: All the 6 cases of suspected rhabdomyomas have beenconfirmed in the neonatal period. The tumors were single in threecases and multiple in the other cases. The size ranged from 11 to47 mm. In two cases the tumors arose from the right ventricle, in onecase from the interventricular septum and in three cases from the leftventricle. Five infants are alive and in a satisfactory hemodynamiccompensation. In two patients a regression in the maximum diameterof the tumor masses has been observed. One case underwent a surgicaltreatment at the age of six months and the baby died after surgery. In 3out of 6 cases an association with tuberous sclerosis has been detected.Conclusions: Two-dimensional and Doppler echocardiography areaccurate non invasive methods to evaluate fetal cardiac masses. Theyallow an immediate diagnosis and a reliable follow-up of fetal andneonatal cardiac tumors. In our cases prenatal diagnosis did notappear to influence the outcome.

F129Prenatal diagnosis of conotruncal anomalies: associateddefects and chromosomal abnormalities

A. Galindo, A. GranÄ eras, F. GutieÂrrez-Larraya, F. Regojo, M. Carreraand P. De La FuenteHospital Universitario `12 de Octubre' de Madrid, Department ofObstetrics and Gynecology, Spain

Aim: To evaluate the incidence, type, associated defects andchromosomal abnormalities of fetuses with conotruncal anomalies(CTA).Methods: Retrospective study of CTA prenatally diagnosed betweenJan.1998±May 2000.

Results: 46 CTA was diagnosed and the number of congenital heartdefects (CHD) diagnosed in the period reviewed was 154; therefore,CTA accounts for 30% of CHD. In this period there were 13 236deliveries; thus, incidence of CTA was 3.5% and of CHD was 1.2%.The chromosomal defects (CRD) rate in CTA was 28% (13 cases): 5CATCH 22, 3 Tr.13 (23%), 2 Tr. 18 (15%), 1 Tr.7 (8%), 1 45XO(8%), 1 triploidy (8%). Associated defects were diagnosed in 17 cases(37%), and 10 of these had a CRD (59%). CTA pernatally diagnoseddistribution was as follows: 12 tetraology of fallot (26%), with 4 CRD(33%): 1 Catch 22, 1 Tr.13, 1 Tr.7 and 1 triploidõÂa; 9 double-outletright ventricle (20%), with 2 CRD (22%): 2 Tr.18; 8 transposition ofgreat arteries (17%) without CRD; 6 coarctation of aorta (13%), with1 CRD (17%): 45XO; 6 truncus arteriosus (13%) with 5 CRD (83%):4 Catch 22 and 1 Tr.13; 4 pulmonary atresia (9%), with 1 Cr (25%):Tr.13 and finally 1 interrupted aortic arch (2%), without CRD. In 4out of the 5 cases of catch-22 additional anatomic defects wereprenatally observed (80%).Conclusions: CTA accounts for a high number of CHD prenatallydiagnosed. Therefore, extended fetal echocardiographic examination isof paramount importance to detect prenatally CTA. Associated defectsand chromosomal abnormalities are common. Thus, analysis of fetalkaryotype must be performed mainly in cases of tetralogy of Fallot,truncus, arteriousus, double-outlet right ventricle and pulmonary atresia.

F130The importance of the fetal echocardiography innonimmunological hydrops fetalis (analysis of the 156 cases)

P. Kaczmarek, A. KrasonÂ , K. Janiak and M. Respondek-LiberskaDepartment of the Diagnosis of Fetal Malformations, Institute `PolishMother's Memorial Hospital', èoÂdzÂ, Poland, http://www.fetalecho.z.pl

Background: The aim of the research was to assess the usefulness offetal echocardiography in nonimmunological hydrops (NIHF).Method: 156 fetuses with NIHF had echocardiography in 1994±99.Results: The most common cause of NIHF were structural abnorm-alities 99/156 (63%), especially congenital heart defects (CHD) 30/156 (19%). The fetal congestive heart failure was present in approx.50% cases.Conclusion: Fetal echocardiography in NIHF allows not only theprecise diagnose but also helps to establish a prognosis andqualification for ongoing procedures. Fetal echocardiography shouldbecome the recommended procedure in diagnostic/therapeutic algo-rithm in cases with NIHF.

F131The role of fetal echocardiography during maternalpharmacological treatment

A. KrasonÂ , P. Kaczmarek, K. Janiak and M. Respondek-LiberskaDepartment of the Diagnosis of Fetal Malformations, Polish Mather'sMemorial Hospital, èoÂdzÂ, Poland. http://www.fetalecho.z.pl

Background: The aim of this study was retrospective analysis of fetaltricuspid valve regurgitation (TR) during echo in the second half ofpregnancy in 100/5079 (1.98%) fetuses with normal heart anatomy(NHA) and without extracardiac malformations (ECM), beetwen01.01.1994±31.12.1999.Method: In this group, 43 (53.75%) cases with TR had treatment: 36fetuses betamimetics, 4 fetuses indomethacin and 3 fetuses aspirin. In34 (79.06%) cases trivial TR and in 9 (20.94%) cases holosystolic TRwere diagnosed. The mean fetal gestational age was 30.9 ^ 4.1 hbd.Twenty neonates (80%) were delivered vaginally and 5 by cesareansection, at mean gestational age of delivery was 37 ^ 3.7 hbd. Themean Apgar score was 9 pts.Conclusions: 1. Fetal TR with NHA was diagnosed in 53.7% fetuseswith maternal treatment. 2. The most common finding of TR withNHA was exposure on betamimetic. 3. Fetal echocardiography washelpful to confirm the safety and fetal well-being during maternalpharmacological treatment due to premature labour.



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