181 Increased Abdominal Echogenicity in Utero as Marker for Intestinal Obstruction?
1
178 179 Volume 168 Number I, Pa rt 2 DIAGNOSIS OF FETAL ATRIAL ARRHYTHMIA BY MOTION OF SEPTUM PRIMUM E. Baker", B. Romero" M. Dept. OB/GYN and Ped. Cardiology, Tufts University, New England Medical Center, Boston, MA OBJECTIVE: This study sought to determine the accuracy of analysis of motion of septum primum (SP) in detecting atrial activity in fetuses with normal sinus rhythm (NSR) and dysrhythmia. STUDY DESIGN: Two fetuses with atrial flutter (AF), one with supraventricular tachycardia (SVT) and 15 consecutive fetuses with NSR had standard fetal echocardiography. The M-mode cursor was placed perpendicular to SP avoiding inferior and superior limbic bands and eustacian valve tissue. SP was recognized as a thin echogenic linear structure that moved with biphasic oscillations per atrial activation. The oscillation with greatest excursion had a thin jet of color flow Doppler (CFD) traversing through SP and was used to measure atrial rate. Ventricular rate was confirmed by aortic Doppler flow velocity. All rhythms were confirmed at birth. RESULTS: In NSR atrial rate was easily detected by this method and conesponded to ventricular rate. In the 3 cases of atrial tachycardia SP had a singular peak oscillation with a thin jet of CFD per atrial activation. In AF, atrial rate was 440 bpm and ventricular rate 220 bpm. In the case of SVT, atrial and ventricular rates were 220 bpm. CONCLUSION: Rate and type of motion of SP accurately determined atrial electrical activity in 15 fetuses with NSR and 3 with atrial tachycardia. In patients with AF this technique determined atrial rhythm more easily than measuring atrial waH motion. SONOGRAPIDC EVALUATION FOR ANOMALIES IN TWIN GESfA· TIONS. MS Edwards x • 1M Ellingsx. MK Menard. RB Newman. Department of Obstetrics 1ft. Gynecology. Medical University of South Carolina. Charleston. S.C. OBJECTIVE: The incidence of congenital anomalies in multiple gestations is higher than in singleton pregnancies. This is of particular concern since level II ultrasound exams in twin pregnancies are technically more difficult The purpose of this study was to evaluate the effectiveness of serial ultrasonography in the detection of fetal anomalies among multifetal gestations cared for in a specialized antepartum twin clinic. STUDY DESIGN: A retrospective cohort study of 146 consecutive multiple gestations followed in our twin clinic was performed. The sensitivily. specificily. and predictive value of ultrasound 10 detect anomalies in 293 infanls delivered from 198810 the present was detennined. RESULTS: A mean of3.7± 1.7 (Range 1-9) ultrasounds wen: performed per patient m...o.m. Ileoe<tioo of AoomaHa Y .. No Conlenjtal Anomalies Present 10 21) 7 286 The resultant sensitivity is 70%. specificity 100%. positive prediclive value 100%, and negative predictive value 99%. The incidence of congential anomalies in this population of multifetal gestations was 3.4%. The anomalies undetecled by ultrsonography were a single umbilical artery not associated with other anomalies; a moderate sized ventricular septal defect which at this time has not required surgical correction; and a hypoplastic len ventrical with a double ouUet oflhe right venlrical which was a fatal anomaly. CONCLUSION: Serial ultrasonography in our institution is highly specific in Ihe assessment of fetal anomalies in multipJe gestations. however. its sensitivity is limited. Fetal cardiac anomalies continue to be resistant to ultrasound detection in all cases. Despite a high negative predictive value. caution would be advised when counseling patients offetal well-being and the limitations of ultrasound in detecting congenital anomalies. 180 181 SPO Abstracts 349 IMPROVED SONOGRAPHIC ASSESSMENT OF FETAL WEIGHT BY A NEW FORMULA INCORPORATING THE CHEEK-TO-CHEEK DIAMETER, BIPARIETAL DIAMETER, AND ABDOMINAL CIRCUMFERENCE Jacques S Abramqwjcz. David M. Sherer, Tamara A. AUen x , James R. Woods, Jr. University of Rochester. Strong Memorial Hospital, Rochester. New York. OBJECTIVE: To improve the accuracy of sonographic fetal weight estimation (EFW) by incorporating the cheek-to-cheek diameter (CCD), an indicator of subcutaneous tissue mass, to the biparietal diameter (BPD). and abdominal circumference (AC) in generating a new weight formula. STUDY DESIGN: Three hundred well-dated singleton pregnancies, > 32 weeks gestational age (GA) were analyzed. Sonographic fetal measurements obtained in every case were BPO, head circumference. AC. femur length. and CCO. Sonographic EFW was derived by using BPO and AC (Warsoff AJOG 1977, Shepard AJOG 1982). Actual birthweights (BW) of fetuses delivered within 7 days of the last sonographic exam with BW >10th, <90th percentile (n-88) were compared to EFW. A new formula was derived by correlating BPO, AC. and CCO with BW in these 88 fetuses. a group similar in number to that of the group included in the original BPO and AC formula. This new formula was then tested in 200 other singleton pregnancies for accuracy of prediction of fetal weight. Of these. 10 delivered at term within 7 days of last sonographic exam with BW >95th percen6ie (LGA) or <5th percentile (SGA) and were included in the final analysis. RESULTS: The new formula for improved EFW (IEFW) was: Log(IEFW)-1 .72+0.0607(BPO)+0.018(AC)+0.185(CCD)· 0.0133(CCO)2 (BPD, AC and CCO measurements in cm.). with a corrected coefficient of correlation of 0.82. Prediction of BW in the 10 fetuses with markedly abnormal growth yielded a mean absolute and percent error of 368 gm and 10.09% respectively. for the old formula and 218 gm and 5.98% respectively. for the new formula (p<0.05). CONCLUSION: Employing CCO measurements to modify the well- accepted BPO, AC generated method greatly improved prediction of fetal weight of LGA and SGA fetuses. groups in which most inaccuracies presently occur. INCREASED ABDOMINAL ECHOGENICITY IN UTERO: A MARKER FOR INTESTINAL OBSTRUCTION? G. GoIlin,x W. ShaIIer. x J. Copel. Dept. CM,yn, Yale University, New Haven, CT. OBJECTIVE: In recent studies, mid-trimester increased abdominal (IAE) has bean associated Trisomy 21, cystic fibrosis, and intrauterine growth retardation (IUGR). However, correlation the subsequent delection of intestinal obstruction has bean to case reports. The purpose of this sludy was to evaluate the hypothesis that IAE may be a marker of early inteslinal obstruction. STUDY DESIGN: Review of a computerized data base revealed 15 cases of IAE identified during the course of a targeted uhrasound examination over the last 4 years . IAE was noted when the lower abdomen appeared markedly more echogenic Ihan the Indicalions lor uhrasound evaluation included advanced maternal age (n.3), elevated (n.3) or low (n_l) MSAFP, drug exposure (n=I), twin gestation (n.l), previous anomaly (n. l) , abdominal mass (n. l), and referral for echogenic bowel (nz4). Amniocenleses were performed on 12115 patients. Follow up information was obtained from review of the medical record, pathology studies, and phone interviews. Outcome dala analyzed included birthweight, gestational age at bi1h, karyotype, and the presence of intestinal malformation. RESULTS: The 15 casas of increased abdominal were descrbed between 16 and 23 weeks of geslation. A normal outcome was documented in 8115 (53%) cases. 01 the remaining 7 cases, there were 4 gastrointestinal (GI) malformations: bowel obstruction normal karyotype, duodenal atresia with Trisomy 21, colovesical fistula, and meconium pseudocyst. In addition, there was one case each of abruptio placenta, fetal demise, and isolaled Trisomy 21. Bloody amniotic fluid was found in 5112 cases and was associated with malernal vaginal bleeding in all cases. There were no infants cystic fibrosis or IUGA. CONCLUSION: The linding 01 hyperechogenicity of the letal abdomen was associated bloody amniotic fluid (42"k), Trisomy 21 (13%), and gastrointestinal malformalions (29%). In cases associated bloody fluid, IAE likely resuhs from the presence of heme pigments in Ihe alimentary tract of the fetus. In intestinal obstruction, the abnormal echoes may be derived from inspissated meconium which could account for the recent associations of IAE cystic librosis. Although IAE in the second trimesler was associated a benign outcome in 50% of casas, Ihis finding should arouse suspicion of gastrointestinal malformations, particulariy intestinal obstruction, in karyolypically normal and abnormal fetuses.
Transcript of 181 Increased Abdominal Echogenicity in Utero as Marker for Intestinal Obstruction?
178
179
Volume 168 Number I, Part 2
DIAGNOSIS OF FETAL ATRIAL ARRHYTHMIA BY MOTION OF SEPTUM PRIMUM E. Baker", B. Romero" M. D'Alton,~. Dept. OB/GYN and Ped. Cardiology, Tufts University, New England Medical Center, Boston, MA OBJECTIVE: This study sought to determine the accuracy of analysis of motion of septum primum (SP) in detecting atrial activity in fetuses with normal sinus rhythm (NSR) and dysrhythmia. STUDY DESIGN: Two fetuses with atrial flutter (AF), one with supraventricular tachycardia (SVT) and 15 consecutive fetuses with NSR had standard fetal echocardiography. The M-mode cursor was placed perpendicular to SP avoiding inferior and superior limbic bands and eustacian valve tissue. SP was recognized as a thin echogenic linear structure that moved with biphasic oscillations per atrial activation. The oscillation with greatest excursion had a thin jet of color flow Doppler (CFD) traversing through SP and was used to measure atrial rate. Ventricular rate was confirmed by aortic Doppler flow velocity. All rhythms were confirmed at birth. RESULTS: In NSR atrial rate was easily detected by this method and conesponded to ventricular rate. In the 3 cases of atrial tachycardia SP had a singular peak oscillation with a thin jet of CFD per atrial activation. In AF, atrial rate was 440 bpm and ventricular rate 220 bpm. In the case of SVT, atrial and ventricular rates were 220 bpm. CONCLUSION: Rate and type of motion of SP accurately determined atrial electrical activity in 15 fetuses with NSR and 3 with atrial tachycardia. In patients with AF this technique determined atrial rhythm more easily than measuring atrial waH motion.
SONOGRAPIDC EVALUATION FOR ANOMALIES IN TWIN GESfA· TIONS. MS Edwardsx• 1M Ellingsx. MK Menard. RB Newman. Department of Obstetrics 1ft. Gynecology. Medical University of South Carolina. Charleston. S.C. OBJECTIVE: The incidence of congenital anomalies in multiple gestations is higher than in singleton pregnancies. This is of particular concern since level II ultrasound exams in twin pregnancies are technically more difficult The purpose of this study was to evaluate the effectiveness of serial ultrasonography in the detection of fetal anomalies among multifetal gestations cared for in a specialized antepartum twin clinic. STUDY DESIGN: A retrospective cohort study of 146 consecutive multiple gestations followed in our twin clinic was performed. The sensitivily. specificily. and predictive value of ultrasound 10 detect anomalies in 293 infanls delivered from 198810 the present was detennined. RESULTS: A mean of3.7± 1.7 (Range 1-9) ultrasounds wen: performed per patient
m...o.m. Ileoe<tioo of AoomaHa
Y .. No
Conlenjtal Anomalies Present
10 21)
7 286
The resultant sensitivity is 70%. specificity 100%. positive prediclive value 100%, and negative predictive value 99%. The incidence of congential anomalies in this population of multifetal gestations was 3.4%. The anomalies undetecled by ultrsonography were a single umbilical artery not associated with other anomalies; a moderate sized ventricular septal defect which at this time has not required surgical correction; and a hypoplastic len ventrical with a double ouUet oflhe right venlrical which was a fatal anomaly. CONCLUSION: Serial ultrasonography in our institution is highly specific in Ihe assessment of fetal anomalies in multipJe gestations. however. its sensitivity is limited. Fetal cardiac anomalies continue to be resistant to ultrasound detection in all cases. Despite a high negative predictive value. caution would be advised when counseling patients offetal well-being and the limitations of ultrasound in detecting congenital anomalies.
180
181
SPO Abstracts 349
IMPROVED SONOGRAPHIC ASSESSMENT OF FETAL WEIGHT BY A NEW FORMULA INCORPORATING THE CHEEK-TO-CHEEK DIAMETER, BIPARIETAL DIAMETER, AND ABDOMINAL CIRCUMFERENCE Jacques S Abramqwjcz. David M. Sherer, Tamara A. AUenx, James R. Woods, Jr. University of Rochester. Strong Memorial Hospital, Rochester. New York. OBJECTIVE: To improve the accuracy of sonographic fetal weight estimation (EFW) by incorporating the cheek-to-cheek diameter (CCD), an indicator of subcutaneous tissue mass, to the biparietal diameter (BPD). and abdominal circumference (AC) in generating a new weight formula. STUDY DESIGN: Three hundred well-dated singleton pregnancies, > 32 weeks gestational age (GA) were analyzed. Sonographic fetal measurements obtained in every case were BPO, head circumference. AC. femur length. and CCO. Sonographic EFW was derived by using BPO and AC (Warsoff AJOG 1977, Shepard AJOG 1982). Actual birthweights (BW) of fetuses delivered within 7 days of the last sonographic exam with BW >10th, <90th percentile (n-88) were compared to EFW. A new formula was derived by correlating BPO, AC. and CCO with BW in these 88 fetuses. a group similar in number to that of the group included in the original BPO and AC formula. This new formula was then tested in 200 other singleton pregnancies for accuracy of prediction of fetal weight. Of these. 10 delivered at term within 7 days of last sonographic exam with BW >95th percen6ie (LGA) or <5th percentile (SGA) and were included in the final analysis. RESULTS: The new formula for improved EFW (IEFW) was: Log(IEFW)-1 .72+0.0607(BPO)+0.018(AC)+0.185(CCD)·0.0133(CCO)2 (BPD, AC and CCO measurements in cm.). with a corrected coefficient of correlation of 0.82. Prediction of BW in the 10 fetuses with markedly abnormal growth yielded a mean absolute and percent error of 368 gm and 10.09% respectively. for the old formula and 218 gm and 5.98% respectively. for the new formula (p<0.05). CONCLUSION: Employing CCO measurements to modify the wellaccepted BPO, AC generated method greatly improved prediction of fetal weight of LGA and SGA fetuses. groups in which most inaccuracies presently occur.
INCREASED ABDOMINAL ECHOGENICITY IN UTERO: A MARKER FOR INTESTINAL OBSTRUCTION? ~.x G. GoIlin,x W. ShaIIer.x J. Copel. Dept. CM,yn, Yale University, New Haven, CT. OBJECTIVE: In recent studies, mid-trimester increased abdominal echogenic~y (IAE) has bean associated w~h Trisomy 21, cystic fibrosis, and intrauterine growth retardation (IUGR). However, correlation w~h the subsequent delection of intestinal obstruction has bean lim~ed to case reports. The purpose of this sludy was to evaluate the hypothesis that IAE may be a marker of early inteslinal obstruction. STUDY DESIGN: Review of a computerized data base revealed 15 cases of IAE identified during the course of a targeted uhrasound examination over the last 4 years . IAE was noted when the lower abdomen appeared markedly more echogenic Ihan the ~ver. Indicalions lor uhrasound evaluation included advanced maternal age (n.3), elevated (n.3) or low (n_l) MSAFP, drug exposure (n=I), twin gestation (n.l), previous anomaly (n. l), abdominal mass (n. l), and referral for echogenic bowel (nz4). Amniocenleses were performed on 12115 patients. Follow up information was obtained from review of the medical record, pathology studies, and phone interviews. Outcome dala analyzed included birthweight, gestational age at bi1h, karyotype, and the presence of intestinal malformation. RESULTS: The 15 casas of increased abdominal echogenic~y were descrbed between 16 and 23 weeks of geslation. A normal outcome was documented in 8115 (53%) cases. 01 the remaining 7 cases, there were 4 gastrointestinal (GI) malformations: bowel obstruction w~h normal karyotype, duodenal atresia with Trisomy 21, colovesical fistula, and meconium pseudocyst. In addition, there was one case each of abruptio placenta, fetal demise, and isolaled Trisomy 21. Bloody amniotic fluid was found in 5112 cases and was associated with malernal vaginal bleeding in all cases. There were no infants w~h cystic fibrosis or IUGA. CONCLUSION: The linding 01 hyperechogenicity of the letal abdomen was associated w~h bloody amniotic fluid (42"k), Trisomy 21 (13%), and gastrointestinal malformalions (29%). In cases associated w~h bloody fluid, IAE likely resuhs from the presence of heme pigments in Ihe alimentary tract of the fetus. In intestinal obstruction, the abnormal echoes may be derived from inspissated meconium which could account for the recent associations of IAE w~h cystic librosis. Although IAE in the second trimesler was associated w~h a benign outcome in ~oximately 50% of casas, Ihis finding should arouse suspicion of gastrointestinal malformations, particulariy intestinal obstruction, in karyolypically normal and abnormal fetuses.
