Reduction of complications during first trimester ... - Wiley Online Library

Ultrasound Obstet Gynecol 2001; 18 (Suppl. 1): 32–61

Posters POSTER SESSION 1: OBSTETRICS – FIRST TRIMESTER, GYNECOLOGY P01 Early diagnosis in ovarian cancer: role of transvaginal ultrasound M. A. Pascual, F. Tresserra, P. J. Grases & S. Dexeus Purpose: To evaluate the efficiency of transvaginal ultrasound in the early diagnosis of ovarian cancer. Methods: Screening transvaginal ultrasound has been annually performed during the last 2 years in asymptomatic women without familial history of ovarian cancer. When abnormalities were detected, the procedure was repeated after 4–6 weeks. If the findings disappeared, the study was repeated after 1 year. If the abnormality persisted, study was complemented with tumor markers, computed tomography and laparoscopic surgery. The findings were compared with a control group of women in whom ovarian transvaginal ultrasonography was formally indicated. Results: A total of 26007 transvaginal ultrasound were performed: 8813 (33.8%) belonged to the screening group and 17194 (66.2%) to the control group. In 14 patients of the screening group, a malignant tumor was diagnosed and histologically confirmed. The mean age of these patients was 45 years old (SD 12). Eleven of these tumors were stage I (seven Ia, and four Ic), two stage IIIc and one was a metastatic melanoma in both ovaries. Six lesions were borderline tumors (five serous and one mucinous). In the control group, 27 ovarian cancers were diagnosed in patients with a mean age of 48 years (SD 17). In this group, 11 tumors were in stage I, and six were borderline. Conclusions: Although consensus about the benefits of using transvaginal ultrasound as a screening procedure is not conclusive, our data reveals that tumors detected in patients screened with transvaginal ultrasound are in earlier stages when compared with those diagnosed in the control group. No differences were found in age and number of borderline tumors between both groups. Additional studies are needed to support this preliminary findings.

P02 Endometrial sampling during sonohysterography (SHGes) E. Ferrazzi, C. Lanzani, N. Ciminera & V. Conserva Purpose: To assess the diagnostic accuracy of sonohysterography (SHG) and endometrial sampling during SHG (SHGes) compared to traditional hysteroscopy and biopsy. Methods: Seventy-two consecutive patients with irregular bleeding and/or intracavitary abnormalities underwent transvaginal sonography (TVS) and SHG. SHG was performed with a 4.7-mm intrauterine catheter. In all patients, an endometrial biopsy was performed by a syringe vacuum aspiration at the end of SHG. Procedure-related pain was assessed. Sonographic findings at SHG were defined as normal, focal lesions or diffuse endometrial abnormality. In patients with diffuse endometrial abnormality, hysteroscopy and hysteroscopic guided biopsy were performed. In patients with focal lesions, an operative hysteroscopy was performed. Pathologic report was the gold standard. Results: Mean age was 48 years (interquartile range 38–54). At SHG, no pain, mild, and severe discomfort was reported by 75, 18 and 7% of patients, respectively. Fifty patients underwent hysteroscopic guided biopsy, 22 operative hysteroscopy. Hysteroscopic findings were compared to SHG–SHGes finding. (A) Benign lesions: in 56 cases SHG and SHG sampling was concordant with pathologic report, in five cases SHG and SHG sampling over diagnosed the endometrial lesion. In five cases, simple hyperplasia was missed by SHG endoemetrial sampling. (B) (pre)Malignant lesions (six cases): in five cases SHG–SHGes was correct. One case of adenocarcinoma was intepreted as atypical hyperplasia at SHG–SHGes. Sensitivity, specificity, positive and

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negative values of SHG and SHGes for intracavitary abnormalities were 100, 64, 94 and 100%, respectively. Conclusions: SHG and SHGes should be considered a reliable office triage in the management of patients with intracavitary uterine abnormalities, as adequate as hysteroscopic endometrial biopsies.

P03 Factors associated with endometrial thickness and uterine size in a random sample of postmenopausal women B. E. Gull, B. Karlsson, I. Milsom & S. Granberg Objective: To investigate factors possibly associated with endometrial thickness and uterine size in a random sample of postmenopausal women. Study design: A random sample (n ¼ 1000) of the total population of women aged 45–80 years resident in the city of Go¨teborg was invited to attend for a transvaginal sonography examination. Eight hundred and twenty-seven women accepted the invitation and underwent a gynecological and a transvaginal sonographic examination with measurement of endometrial thickness and uterine size. The women’s height and weight were measured and a blood sample for analysis of serum estradiol and follicle stimulating hormone was taken. The women also provided information regarding previous medical and gynecological history, possible medication and smoking habits. Results: Five-hundred and fifty-nine women were postmenopausal and 183 of them were taking some form of hormonal substitution (33%). Factors associated with endometrial thickness and uterine size were analyzed using univariate and stepwise multiple regression analyses. The current use of hormone replacement treatment was the most important factor associated with both endometrial thickness and all the uterine size parameters studied. The presence of fibroids was also associated with endometrial thickness. Other factors shown to be associated with uterine size were age, parity, smoking, hypertension and diabetes mellitus. Conclusions: Several of the known risk factors for endometrial cancer were shown to be associated with endometrial thickness and uterine size parameters.

P04 Morphological and color Doppler velocimetry ultrasound evaluation of breast solid lumps – a malignancy S-score proposition E. F. Marussi, J. G. Cecatti, M. Alvarenga, M. R. M. Machado, C. M. M. O. Franzin & E. C. Martinez The purpose was to evaluate the sensitivity, specificity and predictives values for each morphological or CDV ultrasound criteria, alone or associated, for the prediction of breast’s solid lumps malignancy and to create a malignancy’s score. We studied 430 women with 502 breast lumps (359 benign and 143 malignant). They were cared at CAISMUNICAMP from May 1998 to November 1999 when a US examination of the breast were performed and the results compared with the pathological diagnosis, the gold standard. They had been evaluated through US morphological criteria such as borders, posterior wall, ecotexture, ecogenic halo, Cooper ligaments, diameters, volume, skin, compressibility, ratio between width and depth and CDV criteria such venous flow, color index, maximum systolic velocity, resistance index, pulsatility index and A/B ratio intra- and peritumoral. For data analysis, the groups of benign and malignant tumors were compared regarding control variables adjusted by age via logistic regression. The best individual performance among the morphologic criteria, were borders, ecogenic halo, Cooper ligaments, ecotexture, width/depth ratio and biggest diameter and among the CDV criteria, they were the color

23–28 October 2001, Melbourne, Australia index, maximum systolic velocity, pulsatility and resistance index inside tumor. In the logistic regression analysis, the criteria identified as statistically associated to the malignancy were the borders, ecogenic halo, the largest diameter and the woman’s age. They compound the equation of the malignancy’s score, whose performance was of 95.2%. No one CDV criteria improved the global performance of the score. Excluding subjective criteria, the logistic regression analysis selected, for compound another equation of malignancy’s score, the woman’s age, the lump’s largest diameter, the measure of the Cooper ligament and the VSmx inside the lump. This second score had a slightly lower performance than the first one (92% against 95.2%).

P05 Three-dimensional ultrasound and treatment of choice in cervical cancer A. Babinszki, A. Artner, J. Szalay, L. Palfalvi & L. Ungar Purpose: Tumor volume, parametrial involvement, lymph nodal status, urinary bladder and rectum involvement are essential parameters in the treatment planning of early stage cervical cancer. Fertility sparing trachelectomy criteria has become a new diagnostic challenge within the last years. We assumed that three-dimensional (3D) ultrasound may add useful information for the oncologists in planning the treatment of cervical cancer patients. Methods: Three-dimentional transvaginal sonography was performed in all cases to assess tumor volume, parametrial involvement, local and distant spread of the tumor. Tumor vascularization was also examined by 3D power Doppler. Results: In the last 5 months, 15 patients with early stage cervical cancer, considered for primary surgical treatment, have been examined with 3D sonography prior to surgery. Two out of 15 patients have undergone abdominal radical trachelectomy, 13 were surgically explored with the intention of Wertheim hysterectomy. In one patient, paraaortal tumor spread was suspected on our 3D examination, surgical finding at exploration has proven lymphatic spread extending above the renal blood vessels, that has made the surgeon to abandon first line surgery as a curative intent treatment. Conclusions: Tumor volume was difficult to measure since most of the early stage patients underwent cone biopsy prior to referral for radical surgery. Macroscopic pelvic lymph node involvement was assessed accurately in all of our patients. Our impression was, that parametrium involvement, especially the caudal third of the parametrium, and the urinary bladder wall could be visualized and assessed more accurately than it was possible with 2D method. Involvement of the upper part of the cervical canal could be examined accurately in candidates for radical trachelectomy. Early experience suggest, that 3D examination of the macroscopic lymph node involvement, parametrial, urinary bladder and rectal wall tumor spread can be helpful for treatment planning of early stage cervical cancer patients.

Poster Session 1: Obstetrics – First Trimester, Gynecology benign tumors. A wash-out time >170 s showed a 91% sensitivity and 75% specificity for the diagnosis of ovarian malignancy, and the accuracy was 78%. Conclusions: After microbubble contrast agent injection, malignant and benign adnexal lesions behave differently in degree, onset, and duration of Doppler ultrasound enhancement.

P07 Value of texture analysis in ultrasonographic examination of exised specimens of breast masses W. Bader, G. Westhof, J. Hackmann, S. Dieterle, W. Hatzmann & S. Boehmer Purpose: Specimen sonography is necessary for successful surgical excision of non-palpable breast masses, discovered only in breast ultrasound. But is there any difference in echogenicity and echostructure between native and in vitro sonography? Methods: The ultrasound images from 46 benign and malignant breast tumors were documented under standardized conditions preand postoperative, using a linear array machine (Shimadzu, US device SDU-490) and 7.5 MHz transducer with a water path interposed between the transducer and skin or the plastic bag, containing the fresh specimens after surgical excision. Two images of each tumor were documented on a 3/4 in. Sony high-band video device (U-matic BVU800-P), and the recordings were digitized with an 8-bit resolution in 384 288 pixels (frame grabber band, Ing. Bu¨ ro Fa. Fricke, Berlin). In each sonographic image, the maximum area of the region of interest of the tumor was marked and then subjected to consecutive texture analysis and correlation to the histological findings. For evaluation of tumor status eight parameters of first and second order texture statistics (grey level histogram, Fourier analysis, co-occurrence matrix) were applied. Results: In all cases, the mass was clearly identified on sonograms obtained in the operating room. Fibroadenomas (n ¼ 11), fibrocystic diseases (n ¼ 5) and ductal carcinomas (n ¼ 26) showed comparable results in texture analysis. On the other hand, lobular carcinomas (n ¼ 4) were clearly different in all parameters, in especially mean of grey level, homogeneity and contrast (P < 0.001 on the basis of Wilcoxon and Student’s t-test). Conclusions: In vitro examination is a rapid and efficient method of localizing impalpable breast masses in excised specimens, but differences in echostructure and echogenicity are possible.

P08 Which is the role of color Doppler sonography in the diagnoses of malignancy in postmenopause ovaries carcinomas? S. Speca, V. Summaria, A. M. Costantini & P. Marano

P06 Transit-time study of an ultrasound contrast agent in benign and malignant adnexal tumors M.-R. Orde´ n, J. S. Jurvelin & P. P. Kirkinen Purpose: To evaluate objectively the effects of a microbubble contrast agent on the power Doppler ultrasonographic examination of adnexal tumors specially focusing in timing of the transit of the microbubble bolus. Methods: Seventy patients with suspected ovarian tumors were examined pre-operatively using contrast-enhanced ultrasonography. A 5 min examination was stored digitally and the behavior of the contrast agent was evaluated objectively by measuring the time-dependent image intensity at the region of interest with a computer program. A time–intensity curve of each case was derived and analyzed. Results: Both the baseline and maximum power Doppler intensities as well as the absolute and relative (%) rise in intensity were significantly higher (P < 0.001) in malignant as compared to benign tumors. The arrival time was shorter (17.5 s vs. 22.5 s; P ¼ 0.005) and the washout time longer (219 s vs. 128 s; P ¼ 0.000) in malignant than in

Aim: To assess the reliability of B-mode sonography signs in association with color Doppler (CDS) flow analysis in diagnosing the ovaries cancer in postmenopause women. Material and methods: We studied by sovrapubic and transvaginal sonography 400 consecutive female patients (age 48–64) from January 1996 to September 2000. All the patients were asymptomatic and under estro-progestinic therapy (postmenopause). We evaluated the morphological, volumetric and sonography changes of the ovaries, in association with the angioarchitecture (absence or presence of a neovascularization; low impedence arterial flow with PI < 0.8 and RI < 0.4). Results: In the 710 ovaries studied, we diagnosed 37 benign lesions (25 cystis, eight cystic teratomas, and 14 unilateral hydrosalpinxes), all with no flow signal at CDS and four carcinomas (one bilateral ovaries adenocarcinoma, one endometrial adenocarcinomas, one hidrosalpinx with Walthard’s nidus); all these last lesions showed a neovascularization with a RI < 0.4 and a PI < 0.8. Conclusion: Our study confirmed the validity of the CDS in the diagnoses of ovaries malignant lesions, above all if associated to high flow speed and low impedence flow rate.

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11th World Congress on Ultrasound in Obstetrics and Gynecology

P09 Abnormal ductus venosus blood flow in fetuses with normal nuchal translucency (NT) A. A. Yamasaki & D. Pares Objective: To assess the incidence of reverse flow during atrial contraction at ductus venosus in fetuses with normal nuchal translucency and correlation with cardiac abnormalities. Methods: Ductus venosus Doppler ultrasound blood flow velocity waveform were obtained in 932 fetuses with 11–14 weeks’ gestation during measurement of nuchal translucency. Results: Among 932 fetuses, NT was increased in 43 (4.6%). The incidence of reverse flow was observed in 5.4% of fetuses with normal NT (2.5 mm) and 13.9% of fetuses with increased NT (>2.5 mm). Among fetuses with normal NT, there was no cardiac abnormalities observed. Conclusion: Reversed flow in fetuses with normal NT is not associated with cardiac abnormalities.

P10 Color Doppler in the assessment of cervical cancer M. Ciampelli, C. Mastromarino, R. Lopez, D. Basso, M. Distefano, A. Poerio & G. Scambia The treatment and prognosis of cervical cancer depends on the clinical stage based on the FIGO classification and the presence of lymph node metastases. Clinical staging of cervical cancer does not attain a good diagnostic performance, since it is incorrect in approximately one-third of patients who undergo surgical staging. Magnetic resonance (MR) imaging resulted to be superior to clinical evaluation and computed tomography (CT) in parametrial evaluation and in the staging of uterine cervical carcinoma. Endoluminal ultrasound was introduced to analyse the cervix but no improvement in the diagnostic accuracy with respect to clinical staging was obtained. Color Doppler velocimetry was proposed as a non-invasive tool in the examination of cervical cancer. Cervical cancers with detectable intratumoral blood flow were associated with larger size, invasion of parametrium, pelvic lymph node metastases and greater microvessel density. A ‘vascularity index’ resulted to be correlated with staging and lymph node metastases. The aims of our study were to assess color Doppler characteristics of 48 cervical cancers at different stages and to analyse the correlation between Doppler parameters and clinical–pathological features of the tumors. Three-dimensional color power Doppler technique was used to investigate the vascular architecture of the neoplastic tissue. Threedimensional vascular images were compared to magnetic resonance results. The actual clinical application of the three-dimensional vascular analysis in the evaluation of cervical cancers remains still to be defined.

P11 Doppler evaluation in gynecological tumor recurrences M. Ciampelli, C. Mastromarino, R. Lopez, D. Lorusso, C. F. Filidi & G. Scambia Diagnosis of recurrent malignant disease in the abdomen and in the pelvis is a challenging problem. Because the survival of patients with disease recurrence is improved only in patients with small recurrent lesions, the detection of recurrences at a very early stage is of great importance. Clinical examination and tumor markers are used for the follow up of oncological patients; however, their diagnostic value is not very reliable. Computed tomography (CT) and magnetic resonance (MR) have been studied extensively and their diagnostic accuracy varies from 50 to 84%. Transrectal ultrasound has been used in monitoring recurrent female cancer with a diagnostic accuracy of 90.5% for pelvic lesions. However the ultrasound approach cannot be used to differentiate between radiation fibrosis and recurrent malignancy on the basis of tissue appearance. Color Doppler examination was proposed in the management of patients treated for rectal tumor. The aim of our study was to evaluate the ultrasound diagnostic accuracy in the detection of recurrent gynecological disease in a group of 350 patients, followed up every 3–6 months at our Department after surgical treatment of a pelvic gynecological malignancy. The

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Poster Session 1: Obstetrics – First Trimester, Gynecology ultrasound data have been compared to clinical examination, tumor markers and instrumental tools such as CT and MR. The usefulness of color Doppler velocimetry in the examination of recurrent malignant lesions has been analyzed. In a selected group of patients with small-sized pelvic masses located in the central region of the pelvis, color Doppler analysis was able to differentiate recurrent vs. benign lesions.

P12 Ductus venosus blood flow assessment at 10–16 weeks’ gestation and chromosomal abnormalities E. Antolıń, C. Comas, M. Echevarrıá, M. Torrents, A. Mun˜ oz, F. Figueras, M. Cararach & J. M. Carrera Background: Enlarged fetal nuchal translucency (NT) is a well established ultrasonographic marker for aneuploidy screening, especially during the first trimester of gestation. Nuchal translucency screening combined with maternal age at early mid-trimester can identify about 75–80% of chromosomal abnormalities with a false–positive rate of 5%. Recently, Doppler parameters have been included in fetal aneuploidy screening, in order to improve the test performance. Changes in the ductus venosus (DV) blood flow velocity waveforms have been reported in a significant proportion of chromosomally abnormal fetuses at first and early mid-trimester of pregnancy. Objective: The aim of our study was to evaluate the role of the DV blood flow assessment at 10–16 weeks’ gestation in the screening for chromosomal abnormalities. Methods: From December 1998 to June 2001, DV blood flow was prospectively evaluated in 5067 consecutive pregnancies between 10 and 16 weeks of gestation. Pulsatility index for the DV (DVPI) was calculated. All cases were screened for chromosomal defects combining maternal age and fetal NT thickness. Results: The average maternal age was 32 years (range 22–47). Seventy-four percent of the women were younger than 35. The incidence of chromosomal abnormalities was 1.06% (n ¼ 54), including trisomy 21 (n ¼ 25), trisomy 18 (n ¼ 6), trisomy 13 (n ¼ 2) and others (n ¼ 21). The incidence of chromosomal abnormalities was 13.8% in those cases where DVPI was greater than the 95th centile, compared with an incidence of 0.3% in the remaining cases with a DVPI below this cut-off. This fact gives and odds ratio (OR) of 48 (95% IC: 26–87). The overall detection rate (DR), specificity (S), positive predictive value (PPV) and negative predictive value (NPV) for chromosomal abnormalities were 70.4, 95.3, 13.8, and 99.7%, respectively, when using the 95th centile DVPI as a cut-off. According to gestational age, all the statistical parameters were increased in early gestational age (10–13 weeks) when comparing with late gestational age (14– 16 weeks), the corresponding DR and OR being 76.3% and 64 (95% CI: 30–138) compared with 56.3% and 26 (95% CI: 9–72), respectively. Moreover, when only autosomal trisomies were considered, a DR of 87.9% was reached with an S, PPV, NPV and OR of 95.3, 10.9, and 99.9% and 146 (95% CI: 51–418). Conclusions: Our results suggest that the evaluation of DVPI at 10–16 weeks’ gestation is a useful tool in the screening for chromosomal defects, especially in detecting autosomal trisomies and when it is assessed in early gestational age.

P13 Abnormal umbilical vein blood flow in trisomy 9 fetus during early pregnancy C. C. V. Murta, A. F. Moron, M. A. P. A´ vila & F. A. P. Vasques We describe a case of reversed flow in the umbilical vein and in the ductus venosus during atrial contraction of one fetus at 12 weeks’ gestation with increased nuchal translucency (9.1 mm). In addition, Doppler velocimetry detected high retrograde flow in the inferior vena cava. Cytogenetic analysis of chorionic villi revealed trisomy 9. We suggest that these findings can be an early sign of chromosomal abnormalities and cardiac defects in the first trimester. To the best of our knowledge, this is the second report of reverse umbilical venous blood flow described in the literature and the earliest case reported in pregnancy.

23–28 October 2001, Melbourne, Australia

P14 Correlation between ductus venosus, gestational age and nuchal translucency at 11–14 weeks scan: preliminary study H. Munoz, M. Parra, D. Pedraza, P. Jimenez, S. Villa & M. Puga Background/objective: Fetal ductus venosus assessment at 11– 14 weeks’ gestation is one of the best tests to identify fetuses with cardiac malformation. Negative blood flow during atrial contraction has been used as qualitative sign in this cases. The aim of this study is to describe normal ranges for Doppler velocimetry of ductus venosus at 11–14 weeks’ gestation and correlate it with nuchal translucency thickness. Material and methods: We performed a prospective study, 88 patients were examined at 11–14 weeks of pregnancy. Crown rump length, nuchal translucency, fetal anatomy and uterine artery Doppler velocimetry were evaluated transabdominally. Ductus venosus was identified using longitudinal plane and Doppler velocimetry index was measured using Doppler duplex ultrasound. An average of three waveforms were analyzed and pulsatility index venousus was measured. For statistical analysis mean values and 95% CI for pulsatility index of ductus venosus was established for each crown rump length, Spearman regression and normal centile distribution was performed. Results: The 77 out of 88 patients with nuchal translucency below 95th centile were used for calculating normal ranges for each gestational age. Mean maternal age was 29 6.5 years old (range ¼ 15–42), and 20% was over 35 years old. Mean pulsatility index was 1.02, 0.99, 0.95 and 0.92 at 11, 12, 13 and 14 weeks, respectively. Although ductus venosus pulsatility index was not modified according to gestational age, there was a significant positive correlation with nuchal translucency thickness (r ¼ 0.59, P 0.001). Conclusion: Ductus venousus pulsatility index is correlated positively with nuchal translucency at 11–14 weeks’ gestation.

P15 Abstract withdrawn

Poster Session 1: Obstetrics – First Trimester, Gynecology

P16 Diagnosis and management of low segment Cesarean section scar pregnancies B. Woelfer, R. Salim, J. Elson, A. C. Lawrence & D. Jurkovic Background: Rising Cesarean section rates have led to an increasing number of pregnancies implanted into postoperative uterine scars. We report a large series of Cesarean scar pregnancies treated in a single tertiary referral center. Methods: The diagnosis of Cesarean scar pregnancy was made on ultrasound scan when trophoblast was seen covering the lower segment uterine scar. Pregnancies 14 weeks required total abdominal hysterectomy. Results: In a 4-year period, 14 Cesarean section scar pregnancies were diagnosed. Out of 13 women who were 2.5 mm NT), the pregnant woman was counseled and the invasive test was optional. All the newborns were physically examined thoroughly by pediatricians to detect the markers for major chromosomal anomalies such as DS, trisomy 18 and 13. For the suspected DS or other chromosomal abnormalities, the newborn’s blood was sent for the chromosome study. Results: The mean maternal age was 28.71 þ 0.13 years and 2037 pregnant women (86.57%) were 2.5 mm decided to have the invasive tests. Sixty had normal karyo-types while five had abnormal chromosome abnormalities (one trisomy 13, two trisomy 18 and two trisomy 21). All of them were >35 years old. Sixty pregnant women with normal chromosome fetuses had detailed ultrasound scanning at 18–20 weeks’ gestation and screening for maternal toxoplasmosis, cytomegalovirus, rubella virus, and herpes virus. The infection screen was negative in all cases. There were 20 congenital heart diseases, four fetal deaths in utero at 28–30 weeks, one Bart’s hydrops fetalis and 10 abortion. The rest had normal pregnancy outcomes and NT resolved by 20 weeks. There were 316 (13.43%) cases with maternal age >35 years. Twenty-three had >2.5 mm. NT and all of them had the invasive tests which revealed five abnormal chromosomes (as mentioned above). However, no DS fetuses were detected in 2.5 mm NT was used to increase sensitivity. We can detect all the cases of DS with this cutoff value but one case of DS will be missed if we use the cut-off of >3.0 mm. Conclusions: This study revealed the feasibility in NT measurement for DS screening in the first trimester of pregnancy in Thai population. This test can increase detection rate of DS in the high-risk pregnant women, who did not accept the invasive prenatal diagnosis procedures, as well as in the low risk pregnancy.

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P20 First trimester determination of fetal gender by ultrasound M. Podobnik & M. Podgajski Objective: To determine the feasibility of correctly identifying fetal gender from 11 to 13 weeks of gestation. Methods: Fetal gender assessment by ultrasound was prospectively carried out in 425 singleton pregnancies at 11–13 weeks of gestation (confirmed by crown-rump length or biparietal diameter) immediately before chorionic villus sampling for karyo-typing. A total of 425 women underwent a detailed assessment of fetal anatomy at 11– 13 weeks of gestation by means of transabdominal and transvaginal sonography. Fetal gender was identified in transverse and sagital planes, and was confirmed by chorionic villus sampling. Results: The accuracy of sex determination increased with gestation from 91.7% at 11 weeks, to 97.2% at 12 weeks and 100% at 13 weeks. Male fetus were wrongly assigned as female in 5.5% of cases in 11 weeks, 2.4% at 12 weeks and 0% at 13 weeks. The accuracy of correctly identifying fetal gender increased with gestational age. Conclusion: Whilst the accuracy of sonographic determination of fetal gender at 11–13 weeks is good, our decision on invasive testing for sex-linked conditions should be undertaken only after 12 weeks of gestation.

P21 Heart activity visualization in embryos with crown-rump length shorter than 5 mm A. A. Yamasaki & D. Pares Introduction: In the past, heart activity was only visualized by ultrasound in embryos with a crown-rump length (CRL) of 5 mm or more. When CRL was shorter than 5 mm, non-visualization of heart activity was considered normal. However, improvement in ultrasound equipment resolution has made it possible to diagnose viability in embryos with CRL as small as 2 mm. Objective: The aims of this study were to determine: (a) how often heart activity is visualized in embryos with CRL between 2 and 5 mm; (b) outcome when CRL is shorter than 5 mm and heart activity is not visualized. Methods: Presence or absence of heart activity was examined in embryos with CRL between 2 and 5 mm by vaginal ultrasound (Medison Model Voluson 530 and Aloka Model 1700), 4–7 MHz; B- and M-mode). Follow up scans were carried out one-week later when the initial scan did not demonstrate heart activity. Results: Two hundred and forty-four embryos were examined and heart activity was demonstrated in 210 (86%) cases. Follow up scans demonstrated heart activity in six (17.5%) of the 34 embryos in which heart activity was not initially visualized. Conclusion: This study has demonstrated that visualization of heart activity is possible in most embryos with CRL between 2 and 5 mm nowadays. Non-visualization at this stage is associated with embryonic demise in about 80% of cases.

P22 How to discriminate between normal and abnormal early pregnancy S. A. Jun & M. O. Ahn Early fetal growth delay and early oligohydramnios have been suspected as signs of embryonal jeopardy. Sonographic examinations of 100 early pregnancies between the sixth and ninth gestational week were performed to investigate predictable sonographic findings of early abortion. Sonographic measurements of the gestational sac (G-SAC), Crown-rump length (CRL) and fetal heart rate (FHR) were performed using a transvaginal transducer with Doppler. All measurement of 11 early abortions were compared to those of 89 normal pregnancies to investigate the objective rules for the screening of early abortion. Most of the early aborted pregnancies were classified correctly by discriminant analysis with G-SAC and CRL (G-SAC ¼ 0.5222 CRL þ 14.6673 ¼ 0.5 CRL þ 15). In conclusion, early fetal growth

23–28 October 2001, Melbourne, Australia retardation and oligohydramnios could discriminate the poor prognosis of early pregnancies.

P23 Nuchal translucency screening and antenatal maternal serum screening for Down syndrome: results of a project C. E. Benavides, C. C. Garcia, N. C. Lagos, X. C. Melgarejo & M. I. C. Ferres Objectives: To asses the implementation of antenatal screening for Down syndrome using individual risk estimates based on maternal age, nuchal translucency and three serum markers; alpha fetoprotein, unconjugated estriol and human chorionic gonadotrophin (hCG) in maternal blood. Women with an estimated risk of 1 in 250 or greater were classified as screen positive and offered diagnostic amniocentesis. Subjects: A total of 1956 women of all ages with singleton pregnancies seen between June 1999 and March 2001. Results: The screening result of combination of first trimester ultrasonographic and serum screening was 85% Down syndrome detection and the false positive rate was 3%. The median gestational age of nuchal translucency was 11 weeks and the time of serum screening was 16 weeks. Conclusion: The combination of nuchal translucency and serum screening increases the Down syndrome detection and decreases the false positive rate. Is very important because the amniocentesis is associated with a risk of pregnancy loss from 0.5 to 1%. Besides, it is costeffective and performs better than the selection for amniocentesis on the basis of maternal age only, nuchal translucency only or serum screening.

P24 Reduction of complications during first trimester abortion with the use of sonography A. Malvasi, A. Losito, D. Baldini, A. Mudoni & V. Traina Background: In our reproductive medicine service, more than 3000 abortions have been practised every year, since 1978. The standard operation for legal abortion is executed, according to law 194/78 within 90 days. The technique in voluntary or spontaneous abortion provides D&C as well as hysterosuction with the patients in general anesthesia. In order to reduce the possible complications for this operation and the increasing legal cases, routine perioperative sonography has been used to evaluate sudden abortion complications. Methods: Besides ordinary preoperative sonography assessing gestational age, evolution of pregnancy, pelvic disease, etc. the use of intraoperative sonography has been shown to be necessary. A permanent team of four operators performs the operation under sonographic guide by using an R–T 36600 General Electric apparatus owned by our medicine service. In a lapse of time of five years, 16804 abortions under sonographic guide were practised and in a retrospective way there was a statistically significant reduction of complications according to literature. The 16118 cases in the previous 5 years and within the two homogeneous groups. Results: We registered 11 complete and 13 incomplete uterine perforations vs. 4 and 7 (P < 0.01), 18 cases of retention of ovule remainders vs. 6 (P < 0.05), which required hospital readmission for a further examination of uterine cavity. In addition, the group under sonographic guide has shown a lower rate of failures in operations, antibiotics administrations (P < 0.001), endovaginal prostaglandin use (P < 0.005), anesthetics use (P < 0.05) and hospital stay (P < 0.01). If for the 24 previous uterine perforations in 19 cases the operation was delayed (11 days later) 13, when intraoperative sonography was used, it occurred only in three cases, for the other patients under sonographic guide, the uterine cavity was completely cleared with no complications at all (P < 0.001). Conclusions: In our service, as well as according to literature, intraoperative sonography during abortions, led to a great reduction of complications with a better compliance for the patient and a significant reduction of costs. In particular, thanks to the use of sonography, complete and incomplete uterine perforations descreased, in 91% cases

Poster Session 1: Obstetrics – First Trimester, Gynecology under sonographic guide the uterine cavity was emptied with no complications for the patients. Because of the favorable relationship between costs and benefits, the intervention can be performed under sonographic guide.

P25 The combination of uterine artery Doppler and placental volume measurement in the first trimester for the prediction of high risk pregnancies K. Schuchter, M. Metzenbauer, E. Hafner & K. Philipp Purpose: To evaluate the combination of placental volume measurement and uterine artery Doppler in the first trimester for the prediction of pregnancies complicated by preeclampsia, pregnancy induced hypertension, preterm placental abruption or fetal growth retardation. Methods: At the booking scan in the first trimester one single operator was performing Doppler examinations of both uterine arteries on 380 women with singleton pregnancies. Both the pulsatility index (PI) and the criteria of notching or not notching were recorded. Another operator was recording and afterwards calculating the placental volume at the same visit. In order to correct the placental volume measurement for the gestational age a placenta quotient was calculated (placental volume/crown-rump length). Results: Uterine artery PI above the 90th centile could be recorded in 38 pregnant women. Three of these pregnancies were complicated with placental abruption, two of these were preterm placental abruptions with additional PIH. Six of the 38 pregnancies ended with SGA babies. On 39 women, the calculated placental quotient was below the 10th centile. Two of these women developed PIH in addition to the occurance of placental abruption. Six babies had a birth weight below the 10th centile and one of these had PIH. Only eight pregnancies met the criteria of uterine artery PI above the 90th centile and placenta quotient below the 10th centile. Two of these ended with placental abruption and PIH before 37 weeks of gestation, four of these babies had a birth weight below the 10th centile and none of these had a birth weight above the 50th centile. Conclusion: Regarding our results we think that the combination of placental volume measurement and uterine artery Doppler might be a possible way for the evaluation of high risk pregnancies.

P26 Transvaginal ultrasound and induced abortion A. N. Balic, D. B. Balic, B. Balic & I. Zukic Background: The aim of this study was to audit prospectively the value of preabortion ultrasonography. Methods: All women who came to our center because of doubt unplanned pregnancy in first trimester from March 1994 to July 2001 underwent an exam by vaginal ultrasound before abortion. We analyzed these data and compared them with complications after legal induced abortion. Results: During 2 years a total of 334 women were surveyed. Fiftythree women (8.04%) were not pregnant. In 65 cases (9.86%), the pregnancy was greater by 2 weeks than we expected on the basis of last menstrual period. Also we found: 41 (6.22%) myoma uteri, 10 (1.51%) ovarian cysts, 15 (2.27%) multiple pregnancy, 8 (1.21%) anomaly of the uterus, 4 (0.61%) missed abortions and 5 (0.76%) embrionic abnormality (anencephalus, abdominal cyst, nuchal translucency). Conclusion: Preabortion ultrasonography increases security of this intervention by eliminating some problems linked induced abortion. Since the examination is simple, fast and cheap, we recommended it for routine use. We hope that it is one way for decreasing late complications after abortion, like infertility.

P27 Twin cervical ectopic pregnancy M. P. Bethune & A. Sampson A 40-year-old woman presented for IVF treatment due to 8 years of secondary infertility. Two embryos were transferred without

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ultrasound guidance. The patient presented at 6.5 weeks gestation with heavy vaginal bleeding. A transvaginal ultrasound revealed twin cervical ectopic pregnancies, lying side by side in the cervical canal and within 6 mm of the external os. One contained a 9-mm embryo with a normal fetal heart rate. The other sac was anembryonic. The bHCG level was 129 000 IU/L. The patient was treated with the same regimen of methotrexate as used for persistent trophoblast disease: second daily methotrexate with folinic acid rescue after each dose. Complete resolution of the twin pregnancy occurred, bleeding was however, recurrently heavy over the next 6 weeks. Discussion: Cervical ectopic pregnancy is a rare event, accounting for less than 1% of ectopic pregnancies. The incidence is increasing due to the increased use of in vitro fertilization. Prior to the advent of conservative treatments most patients required hysterectomy due to severe, uncontrollable bleeding. Conservative measures include dilatation and curettage (usually combined with uterine artery embolization, ligation or cervical balloon tamponade); local injection of methotrexate or potassium chloride (ultrasound guided); or systemic methotrexate. Twin cervical pregnancy is an extremely rare event with only two previous case reports in the literature [1]. Due to the large size of this twin pregnancy mass, the high bHCG level and the large volume of vascular trophoblast; we decided to treat this patient in a similar manner to a patient with gestational trophoblast disease. This mode of treatment should be considered with cervical ectopic pregnancies where the bHCG level is abnormally elevated. Reference 1 Pascual MA, Ruiz J, Tresserra F, Sanuy C, Grases PJ, Tur R, Barri PN. Cervical ectopic twin pregnancy diagnosis and conservative treatment. Human Reproduction 2001; 16, 584–6

the values were 0.106 for the F-test and 0.956 for the P-value and for week 38 the values were 0.102 (F-test) and 0.904 (P-value). We conclude that the measurement of the UCCSA as proposed by Raio et al. 1999 is reproductible and can be adopted as a new obstetric ultrasound parameter.

P28 Ultrasonographically measured umbilical cord cross-sectional area – reproducibility of the method F. A. P. Vasques, A. F. Moron, C. G. V. Murta, F. H. C. Carvalho, H. Cattini, T. R. Gonçalves, M. M. Barbosa & W. J. Hishaba A prospective cross-sectional study was developed in order to determine the reproducibility of the measurement of the umbilical cord cross-sectional area (UCCSA) during normal pregnancies (patients with known dates of LMP and an ultrasound examination before the 20th week, without any pathologic condition), measured by different and trained examiners. The measurements of the umbilical cord cross-sectional area were obtained in a plane adjacent to the insertion of the cord abdomen, as proposed by Raio et al. 1999, after the different examiners were trained by the author. The inclusion criteria were: (1) singleton pregnancy; (2) gestation age >20 weeks; (3) intact membranes (4) normal umbilical Doppler flow velocimetry. The exclusion criteria, in the presence of any of those were: (1) congenital and/or chromosomal abnormalities; (2) pregnancy complications (any type); (3) inadequate size for gestational age with when the examination was performed, i.e. the weight below the 10th percentile or above the 90th; (4) abnormal AFI for the gestational age. The patients were examined and included only once. During the period of the study (February 2000–May 2001), 545 patients were examined, after meeting the inclusion criteria determined for the present study. The age of the patients ranged from 15 to 42 years (mean ¼ 26.7 4.8), 242 patients (44.4%) had two gestations, 135 patients (28.1%) were at their first gestation, 129 patients (23.7%) were at their third gestation and 39 patients had four or more gestations (3.8%). The ultrasound machine used was the Synergy Multi Sync M 500. The statistical program used was the statistical package for social sciences (SPSS). The first examiner collected 22% of the data, the second examiner collected 45% of the data, the third examiner collected 24% of the data and the fourth one collected 9% of the data. According to the analysis of variance (ANOVA), we performed, comparing the data obtained by the different examiners, no significance was found and this fact was also showed by the comparison of the data among them and verifying that the data had a dispersion inside tolerable limits. The ANOVA showed the following data (example for 3 weeks): At 25 weeks, the F-test showed a value of 0.930 and a P-value of 0.454; at 32 weeks

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P29 A comparison of the uterine and intraovarian arterial flows in women having a history of recurrent spontaneous miscarriage associated with antiphospholipid syndrome J. Jirous, M. E. Diejomaoh, F. Al-Abdulhadi & M. H. Boland Purpose: To study the relationship between values of Doppler indices characterizing the uterine and intraovarian arterial flows in the presence of antiphospholipid syndrome in women with history of recurrent spontaneous miscarriage (RSM). We are not aware of any previous study undertaken on this specific topic. Methods: Sixty-two women attending our recurrent spontaneous miscarriage clinic were recruited for this prospective study and subsequently divided to group A (n ¼ 35) involving RSM women with normal anticardiolipin antibodies values (ACL IgM, ACL IgG) and group B (n ¼ 27) for those with antiphospholipid syndrome (abnormal ACL IgM, ACL IgG values). ACL IgM and ACL IgG antibodies were measured in the blood using the standardized enzyme linked immunosorbent assay (ELISA). Color and power Doppler transvaginal ultrasonography was used to estimate the uterine artery pulsatility index (UTAPI), spiral artery resistance index (SARI) and intraovarian resistance index (IOARI) in the 21st day of a regular 28-day unstimulated menstrual cycle. The data were analyzed using the statistical software SPSS 9.0 Windows. Statistical significance was defined as P < 0.05. Results: There was no statistically significant difference in the mean age in group A (33.67 5.52 years) and group B (32.70 5.85 years), the mean UTAPI values (3.14 1.16 for group A and 3.44 0.88 for group B), the mean SARI values (0.73 0.13 for group A and 0.73 0.07 for group B). The incidence of the first trimester miscarriages in women over 30 years was significantly higher in group B compared with group A (P < 0.01). Conclusions: Our preliminary study has revealed that there was no significant difference in UTAPI, SARI and IOARI values of RSM women with normal and abnormal ACL IgM and ACL IgG values. This fact could be explained by the predominantly mild form of antiphospholipid syndrome in Kuwait confirmed in our previous studies. We could hypothesise that such mild disease will have minimal/mild vascular effects in the non-pregnant uterus and subsequently in the placental bed.

P30 Vascularity index of the testis: a guiding technique for testicular sperm extraction (TESE) J. Har-Toov, O. Eitan, R. Hauser, A. Butchan, I. Gull, I. Wolman, H. Yavez & A. J. Jaffa Aim: To develop a non-invasive computerized technique that predicts the presence of spermatogenic sites within the testes of non-obstructive azoospermic (NOA) patients. Material and methods: Power Doppler ultrasound images of the testes of seven NOA patients and six fertile men were acquired. Three sagittal, three transverse and one coronal cross-sections of the testis were scanned by a linear 7.5 MHz transducer. Three-dimensional (3D) matrix of 32 elements was generated from all images of each testis. Each element carried information (a vascularity index, VI) about the blood vessels that crossed its volume. The matrix (4 4 2) was divided into regions of 16 elements which were classified as ‘positive’, ‘negative’ and ‘undetermined’ according to the VI values in the anterior and posterior layers of a region. The NOA patients underwent testicular biopsies at three locations along the midline of the testis. The results of the biopsies were correlated to the appropriate regions in the 3D matrix.

23–28 October 2001, Melbourne, Australia Results: Of the seven NOA patients, 12 testes were scanned, however, only 27 biopsies were performed. Accordingly, only 27 regions were considered. Thirteen regions were ‘positive’, 12 regions were ‘negative’, and two were ‘undetermined’. Motile spermatozoa were found in nine out of 12 ‘positive’ regions (69.2%). No sperm was found in 10 of the 12 ‘negative’ region (83.3%). In the control group of six patients, there were 12 testes, which divided into 36 regions. Twenty-four regions were ‘negative’ (66.7%), one was ‘positive’ (2.7%) and 11 were ‘undetermined’ (30.6%). Conclusion: The results yielded that positive/negative region predict the presence or absence of spermatozoa, and thus, this method appears to be a promising non-invasive guiding tool for TESE in NOA patients. TESE will be more effective, less biopsies will be needed, and testicular damage will significantly be lowered. However, this method is not suitable to identify spermatozoa in fertile men.

P31 Lower abdomen cystic masses diagnosed in female infants in fetoneonatal period: diagnosis and management M. Hrehorcak, D. Smetanova, K. Pycha, A. Zuntova, J. Horejsi & M. Holemarova Cystic masses in female fetuses and neonates are in waste majority of cases identified in screening ultrasound during pregnancy. Often they are detected as early as in second trimester screening sonography (18– 22 weeks). When they are identified, problems with differential diagnosis and management modalities arise. In majority of cases, the cystic formation is simple ovarian cyst. It might be misinterpreted with other conditions such as: hydronephrosis, bowel obstruction, mesenterial cysts, etc. We attempt to identify US criteria for reliable prenatal diagnosis of simple not complicated ovarian cysts. Define treatment possibilities and recommendations. Forty-three cases of such formation in lower abdomen were reported in our hospital either in pediatric gynecology or pediatric surgery departments. Thirty-three were diagnosed prenataly, nine diagnosed postnataly. Cysts were unilateral in all cases. Twenty-two cases were treated surgically by ovarectomy. Nine of the treated cases were cysts larger than 60 mm, in four cases the diameter was less than 40 mm, Nine cases were cyst between 40 and 60 mm. Histological examination proved 18 cases with hemorrhagic necrosis of the ovarian cyst, four cases were diagnosed as follicular cysts and one case of malignant retroperitoneal sarcoma. Twenty cases of cystic formation were observed and expectation management was applied. All of them were smaller than 40 mm in largest diameter and they resolved spontaneously within 1 year of age. We conclude that basic criteria for accurate diagnosis include mandatory visualization of the kidneys and stomach in the time of diagnosis. Simple ovarian cyst has following features on ultrasound: one chamber cystic formation in lower abdomen, smooth walls, anechogenic. Expectation management with serial follow up is recommended for cysts smaller than 40 mm in diameter, Surgical treatment should be instituted only in case of ovarian torsion (cyst diameter seems to be of good predictive value) or rupture with bleeding. Simple cysts with diameter larger than 40 mm remains controversial. Should we treat them to prevent torsion? We conclude that conservative approach is adequate in certain cases, when risk of acute abdomen is low and spontaneous disappearance is presumable in respect to preservation of future reproductive function of female infant.

P32 A large pedunculated leiomyoma with unusual features – a case report S.-L. Lee & S.-K. Tay Introduction: Leiomyoma, a benign tumour arising from smooth muscle, is a common finding on gynecological ultrasound examination. It usually presents as a heterogeneous, hypoechoic mass with ill-defined borders. According to its location, it may be described as submucous, subserosal, and intraligamentous. With the new generation ultrasound units, its perfusion may be mapped with accuracy.

Poster Session 1: Obstetrics – First Trimester, Gynecology Case report: The patient is a 39-year-old lady who was first seen in our department in October 1998. She just had a delivery by cesarean section in August 1998. Her pregnancy was looked after by a different hospital, where she was told to have a fibroid. No follow up was arranged for her after her delivery. When she came to our department, she was complaining of occasional lower abdominal pain. An ultrasound scan that was performed revealed some small intramural and subserous leiomyomata of 1–2.6 cm. A predominantly cystic, loculated mass with an irregular contour was seen in the POD. It had some echogenic components and its measurements were 10.7 cm 7.5 cm 11 cm. Power Doppler detected some intratumoral venous flow. Impression was that it was not of ovarian origin. The patient was scheduled for a myomectomy/frozen section for fibroid on 9 November 1998. Histopathology report: Leiomyomas with edema, hyalinization and infarction. Discussion: The ultrasonic features in this case are not typical of a leiomyoma. Although cystic degeneration are sometimes seen in myomata, it is usually not so predominant. Although the state-of-the-art ultrasound units, with color and power Doppler facilities, are supposed to be capable of producing very accurate assessment of pelvic masses, it was found to be inadequate in this instance. Firstly, the classification according to its location was not possible as the stalk was not seen, probably as a result of tumor size. Secondly, the blood flow results were not helpful as this is a predominantly cystic mass. Hence, not much useful information could be derived for the planning of the surgery.

P33 Asymptomatic endometrial polyps in postmenopausal women: are they an indication for surgical removal? E. Ferrazzi, C. Lanzani, V. Conserva & A. Padoan Purpose: To compare demographic, sonographic, and outcome data of postmenopausal patients with asymptomatic endometrial polyp, surgically treated or not treated. Methods: Ninety postmenopausal women with sonographic/sonohysterographic diagnosis of asymptomatic endometrial polyp were prospectively enrolled in this study. All patients underwent transvaginal sonography with color Doppler evaluation (Voluson 5300, KRETZ), and sonohysterography in selected cases. Patients were counseled on the risk of malignancy (estimated risk < 1/200). Sonographic follow up at 3, 6 and 12 months was proposed as an option to standard hysteroscopic polipectomy. Surgery was considered in case of bleeding, polyp enlargement, or Doppler PI < 0.6. Demographic and sonographic data of both groups were recorded. Surgical complications in group B patients were considered as abnormal outcome. Results: Sonographic follow up was chosen by 42 women (group A) and surgical removal by 47 patients (group B). Forty-three patients underwent operative hysteroscopy, and four patients hysterectomy (group B). One major (uterine perforation not requiring surgery) and three minor complications (two cervical lacerations requiring hemostatic suturing, one false entry) (9%). Demographic (age, years of menopause, blood hypertension/diabetes, BMI, nulligravidity, hormonal replacement therapy assumption, tamoxifen assumption) and sonographic data) Endometrial thickness mean (interquartile range) ¼ 8 (5–10) vs. 11 mm (7–13); volume (cc): 3 (1–4) vs. 4 (1–5); PI: 0.48 (0.44–0.51) vs. 0.49 (0.45–0.53) were not significantly different between group A and B. Pathologic findings were glandulocystic and hyperplastic polyp in 45 and in two patients, respectively. All group A patients remained asymptomatic in the follow up period (mean 10 months, interquartile range 5–16). Conclusions: Demographic and sonographic data were not significantly different in the two groups. No untreated patient became symptomatic during follow up period. Benign lesions only were found in treated patients, at the cost of one uterine perforation. A large multicentre study is needed to understand the exact prevalence of endometrial cancer in asymptomatic endometrial polyp, and verify the safety of conservative management.

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P34 Sonographic based triage – transvaginal sonography (TVS) and sonohysterography (SHG) – for benign uterine lesions and surgical management F. P. G. Leone, A. Tonta, C. Lanzani, M. Di Grandi & C. Mastromatteo Purpose: To assess the reduction of clinical indications to hysterectomy as a consequence of sonographic based triage – transvaginal sonography (TVS) and sonohysterography (SHG) – in the surgical management of benign uterine lesions. Methods: All women undergoing surgery for symptomatic (methrorragia) benign uterine lesions were included. Women with prolapse, cervical lesions and malignant lesions were excluded. Data from 180 and 154 patients treated during 1998–99 (group A) and the year 2000 (group B), respectively, were analyzed. Diagnostic triage: All patients had complete history collected and pelvic examination performed. Group A. Patients were evaluated by TVS – not mandatory – VABRA curettage and/or D&C and/or diagnostic histeroscopy with biopsy. Group B. All patients were evaluated by TVS and in case of endometrial thickness >4 mm, a SHG was performed to distinguish focal lesions (polyps, myomas, focal hyperplasia) and diffuse lesions (hyperplasia). Theraputic protocol (in group A) was decided in each single case by the medical-equipe; in group B: patients with focal endocavitary lesions underwent operative hysteroscopy. Patients with diffuse lesions underwent hysteroscopy and endometrial guided biopsy. Indications to abdominal miomectomy were: submucous myomas (G0–G1) > 5 cm, G2 or subserous myomas in women asking to preserve the uterus. Indications to hysterectomy (vaginal/ abdominal) were large miometrial lesions non-responding to medical therapy. Results: Median age of group A and B patients was not significantly different (46 years, interquartile range 40–56). The frequency of abdominal/vaginal hysterectomy was significantly lower in group B (28%) than in group A (54%) (P < 0.01). Laparotomic myomectomy were not significantly different in the two series (24% vs. 22%). The frequency of operative hysteroscopy was significantly higher group B 63%) than in group A (9%) (P < 0.01). Conclusions: The introduction of sonographic based triage and therapeutic protocols for benign uterine lesions determined a dramatic reduction of demolitive uterine surgery, even in the same medical equipe. This involves a significant reduction of economic cost and an improvement in health care for the same abnormal conditions.


P35 Sonohysterographic staging of submucous myomas E. Ferrazzi, C. Lanzani, M. Digrandi, A. Padoan & C. Mastromatteo Purpose: To assess the diagnostic accuracy of sonohysterography in preoperative assessment of submucous myomas. Methods: Twenty premenopausal patients with submucous myomas and irregular uterine bleeding and/or infertility were consecutively collected in 12 months. Before surgery, all patients underwent transvaginal sonography (TVS) (Voluson, KRETZ, 5300), with color Doppler evaluation, and sonohysterography (SHG). Number and site of myomas and the myoma–perimetrium distance were considered at TVS. SHG was performed with a 4.7-mm (14F) intrauterine catheter. Patient compliance to SHG was evaluated by a subjective pain scale. Duration from TVS to completion of the procedure, and volume of saline solution instilled for SHG, were evaluated. Sonographic findings at TVS and SHG were classified as submucous myoma G0, G1 and G2 and compared to hysteroscopic finding. Depending on myoma grading and volume, selected patients underwent preoperative medical treatment with triptorelin (decapeptyl-ipsen). Hysteroscopic myomectomy was the standard surgical approach. Diagnostic accuracy of TVS and SHG was evaluated. Results: Mean age was 41 years (interquartile range 34–47). Mean BMI was 24 kg/m2 (interquartile range 21–28). Twelve patients reported irregular bleeding, eight infertility. Eleven patients had additional intramural and or subserous myomas. Mean duration time of SHG was 12 min (interquartile range 9–16). Mean volume of sterile solution instilled for SHG was 16 mL (interquartile range 8–24). In all cases, a successful SHG was performed, with no and mild discomfort in 16 (80%) and 3 (11%) patients, respectively. Hysteroscopic findings were compared to TVS and SHG considering the submucous myoma grading. SHG correctly classified all miomas (five cases of G0, 11 cases of G1, five cases of G2). TVS correctly classified all G0 cases, over classified two G1 cases as G2, correctly classified five cases of G2. Conclusions: Sonohysterography was a simple and well tolerated imaging technique, with a diagnostic accuracy comparable to hysteroscopy. We speculate that endometrial sampling performed during SHG could help to exclude coexisting endometrial abnormalities which are likely to occur in larger series.

POSTER SESSION 2: OBSTETRICS – DOPPLER AND MISCELLANEOUS P36 Weekly and 2-week Doppler investigations to avoid misunderstanding compromised fetal conditions? SGA fetuses management in our experience L. Solerte, A. Ragusa & S. Garsia Fetal surveillance in adequate for gestational age (AGA) and small for gestational age (SGA) allows to predict distress conditions and improve neonatal outcome. Doppler velocimetry (DV), fetal heart rate monitoring (CTG), biophysical profile with amniotic fluid index, are the common tools used to have fetal direct–indirect signs of well-being. Several clinical studies stressed DV and CTG-like reliable evidences of fetal conditions, despite their known limitations, connected with gestational age and compensatory mechanisms. In order to establish the best follow up time for fetal health, we analyzed two different groups of 20 non-selected pregnant women with SGA 10–30 percentile. Intrauterine growth retardation were excluded for different role of DV in prediction and screening in placental disorders. From January to July 2001 we observed our two groups divided by maternal history; women were homogeneous for age and weight, with SGA. Diagnosis: Made at 20–24 weeks scan, according to most common used biometry diagrams. DV was performed on the main arterial

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districts by pulsatility index, in umbilical and middle cerebral artery, and peak velocity in intracardiac aorta, to estimate changes in blood flow velocity and cardiac out-put, to compare with Apgar index in neonatal outcome, including cesarean section rate. We closed our assessment with a precise definition of utility and applicability of weekly and 2-week follow up, in order to improve fetal conditions at delivery time, avoid misunderstanding fetal distress organize better work-time.

P37 Cardiac function in fetuses of poorly controlled pregestational (pre-existing) diabetic pregnancies S.-F. Wong, F.-Y. Chan, R. Cincotta & C. Ward Background: Cardiac impairment is frequently found in fetuses of diabetic mothers. Poor diabetic control has been implicated as one of the cause for cardiac dysfunction, but it is still controversial. Aim: To assess the cardiac function in fetuses of well-controlled and poorly controlled pregestational (pre-existing) diabetic pregnancy in the third trimester. Methods: Women with pregestational diabetes (Type 1 and 2) were enrolled at 30–36 weeks. Right-, left-ventricular septal wall and interventricular septal wall thickness were measured by M-mode at

23–28 October 2001, Melbourne, Australia end-diastolic phase. At the mitral and tricuspid valves inflow, the ratio between early ventricular filling and active atrial filling (E/A) at both atrioventricular valves were measured by Doppler echocardiography. Peak velocities of ascending aorta and pulmonary artery were assessed. Angle of isolation was kept at less than 208. Results from women with poorly controlled diabetes (HbA1c > 6.5%) were compared with those whose diabetes were satisfactorily controlled (HbA1c 6.5%). Results: A total of 15 women were included in this study. Six had wellcontrolled diabetes and the other seven had poorly controlled diabetes. HbA1c in the poorly controlled group was 7.3% and in the well-controlled group was 5.4% (P < 0.001). There was no difference between the groups in cardiac size, interventricular septal wall thickness, ejection fraction, aorta and pulmonary artery peak flow velocities. The right atrioventricular E/A ratio was significantly lower among the poorly controlled DM pregnancies (0.71 vs. 0.54; P < 0.05). This reflected an impaired right ventricular compliance in fetuses of poorly controlled diabetic mothers. Conclusion: Fetuses of poorly controlled diabetic mothers had lower atrioventricular E/A ratio. This may be due to impaired right ventricular compliance.

P38 Changes in fetal blood flow in hypoxemia during labor M. Ropacka, M. Dubiel, K. Marsal, S. Gudmundsson & G. H. Breborowicz Objective: The aim of this study was evaluation of intrapartum Doppler velocimetry changes in fetuses with signs of fetal hypoxemia in fetal pulse oximetry (arterial hemoglobin saturation 1. This is the fact concluded worse prognosis of the fetuses with cortical sparing effect in utero, but also worse postnatal adaptation. Main outcome – corticocerebral index is simple parameter for detection of different saturation of the brain of the fetus under hypoxemia. Fetal prosperity in utero has coming worse during cortical preservation. There is significantly higher occurrence of perinatal complications.

specific and positive predictive values, but equal negative predictive value to comprise adverse pregnancy outcomes. Conclusion: For routine clinical practice, it seems justified to use singleton nomograms to assess uterine circulation in twin gestation. However, as the negative predictive value of uterine Doppler studies is slightly lower when compared to singletons, maternal and fetal complications might occur despite normal uterine waveforms.

P42 Does cigarette smoking causes periodic decreases in blood flow to the fetus of mothers with hypertensive disorders and/or impaired fetal growth? T. A. Lawrie, F. Rosier-van Du¨ nne, K. Norman & H. J. Odendaal Aim: To evaluate the acute effect of maternal cigarette smoking on umbilical and middle cerebral artery blood flow in the fetus of women with and without pre-eclampsia and/or intrauterine growth restriction. Methods: Pregnant women and 24 weeks gestation were recruited from the antenatal ward at Tygerberg Hospital, South Africa. Doppler studies of the umbilical and middle cerebral arteries were performed before and at 10, 20 and 30 min after the mother had smoked a cigarette. The same studies were performed in the non-smoking controls. Results: There were 13 smoking mothers with hypertension and/or a fetus with growth restriction (group A), 15 non-smoking mothers with hypertension and/or a growth restricted fetus (group C) and 24 normotensive smoking mothers and an appropriately grown fetus (group B). There was a significant difference in the mean umbilical artery RI and PI values in group A vs. group C (P ¼ 0.03 and 0.004, respectively). There was a significant difference in the mean middle cerebral artery PI between group B and group C (P ¼ 0.004). Conclusions: Smoking significantly reduces the feto-placental perfusion in pregnancies compromised by hypertension and/or intrauterine growth restriction and should be actively discouraged in these patients.

P43 Doppler assessment of the uterine circulation in the second trimester in twin pregnancies: prediction of hypertensive disorders, small-for-gestational age and weight discordance A. Geipel, C. Berg, U. Germer, S. Gro¨ ger, M. Krapp, A. Katalinic & U. Gembruch Objective: To compare singleton nomograms of the uterine circulation with previously established twin nomograms in the prediction of hypertensive disorders, small-for-gestational age (SGA) and birth weight discordance >20%. Methods: This was an analysis of maternal and perinatal data obtained from 256 diamniotic–dichorionic twin pregnancies. The uterine artery resistance and pulsatility index were calculated as a mean from both sides and the presence and absence of notching was recorded. Cut-off levels for abnormal flow parameters were the 95th centile of reference ranges using singleton and twin nomograms. Results: As mean uterine artery indices are lower in twin gestation, a higher number of patients (n ¼ 73; 28.5%) was screen positive according to twin reference values when compared to those of singletons (n ¼ 51; 19.9%). However, singleton reference ranges or recording of notches only proved to be more efficient than twin reference ranges to correctly predict SGA (17.6, 19, 13.7%), birth weight discordance >20% (30.6, 37.5, 23.9%), and hypertensive disorders (23.5, 21.4, 16.4%), respectively. Compared to singleton nomograms of uterine artery Doppler, twin nomograms had higher sensitivities, lower

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P44 Doppler velocimetry of uterine arteries between 12 and 16 weeks of gestation A. A. Yamasaki, G. Braia & O. Toma Introduction: The aim of prenatal care is to identify high risk pregnant in order to adopt preventive and/or therapeutic treatments. The presence of an end diastolic ‘notch’ at uterine Doppler velocimetry has been considered a predictor to pre-eclampsia and intrauterine reduced growth. It reflects an answer expressed by a wave of high amplitude representing vascular bed with high resistance (uteroplacental circulation). Objective: To identify high risk patients by analysis of uterine Doppler velocimetry between 12 and 16 weeks of gestation when occurs the second wave of trophoblastic invasion. Patients and methods: Between June 1999 and June 2001, we did a longitudinal study with 127 pregnant from 12 to 16 weeks. This study analyzed uterine Doppler velocimetry using two types of equipment: Aloka Model 1700 and Medison Model Voluson 530. We determined the incidence of end diastolic ‘notch’ between 12 and 16 weeks and its evaluation during pregnancy. Results: The incidence of end diastolic ‘notch’ was 26% (33 patients). Among these patients only nine (7%) still had notch at 16–24 weeks. Among patients with normal uterine Doppler velocimetry at 12– 16 weeks, none developed pre-eclampsia or intrauterine reduced growth. Conclusion: It is possible to identify low risk patients (74%) to preeclampsia and intrauterine reduced growth at the end of first trimester of pregnancy by uterine Doppler velocimetry. At the end of first trimester, 26% of patients can be identified as high risk for pre-eclampsia or intrauterine reduced growth. The advantage of this early screening method is the possibility to give aspirin (100 mg/day) at time of second wave of trophoblastic invasion as prophylactic treatment.

P45 Evaluation of placental Doppler velocimetry in pregnancies complicated with oligohydramnios K. Blaszczyk, A. Lukasik, K. Swadzba, M. Stokowacka & R. Poreba Objective: The objective of the study was to evaluate intraplacental Doppler indices in pregnancies complicated with oligohydramnios. Methods: Thirty-six singleton pregnancies between 32 and 39 weeks complicated with oligohydramnios (cases of premature rupture of the membranes and fetal malformations were excluded from the study) and 40 normal pregnancies were examined by real time ultrasonography, color and pulse Doppler. Placental Doppler velocity waveforms were estimated in the placental cord insertion (umbilical artery velocimetry) and in three different pulsatile intraplacental vessels (the mean value). Placental Doppler velocity waveforms analysis was performed on the base of Haberman and Friedman method. The ratios between intraplacental and umbilical artery pulsatility index values were calculated. Fetal well-being was evaluated by means of non-stress test analyzed according to Fischer method. Results: In normal pregnancies group all Doppler velocity waveforms values were between 10 and 90th percentile of the normal for gestational age values based on Doppler indices nomograms, as well as all patients had the normal (1) intraplacental to umbilical pulsatility index ratio were observed (P < 0.05, sensitivity 42%, specificity 100%, positive predictive value 100%, negative predictive value 65%). In that group the results of non-stress test analysis according to Fisher method were pathological (Fisher 10/day] and 20 non-smokers) using an ATL HDI 5000 scanner for fetal anatomic survey and measurement of uterine and umbilical artery flow velocities. Maternal BMI change and weight gain during pregnancy, uterine and umbilical cord flow velocities, and fetal weight at delivery were measured in all patients. Results: There were no differences between the smoking and nonsmoking groups in gestational age at scanning (23.7 1.5 vs. 26.5 1.3 week), gravid (2.3 0.3 vs. 2.1 0.3) and parity (0.9 0.2 vs. 0.6 0.2). The median maternal BMI was less in smokers than non-smokers both pre-pregnancy (19 vs. 24) and at delivery (27.5 1.3 vs. 32.3 1.3). Maternal weight gain was less in smokers than non-smokers (10.2 1.6 vs. 14.7 1.5 kg, P < 0.05). In the uterine artery, there was no significant difference in the systolic/diastolic ratio between smokers and non-smokers (1.9 0.1 vs. 1.8 0.1). The umbilical artery systolic/diastolic ratio was greater in smokers than non-smokers (3.25 0.2 vs. 2.31 0.07, P < 0.05) and fetal weight at delivery was lower in smokers (2.7 0.2 vs. 3.3 0.2 kg, P < 0.05). Conclusions: Decreased BMI and lower weight gain of women who smoke suggest that their nutritional intake may be lower than in non-smokers. Decreased maternal weight gain in smokers and increased umbilico–placental resistance may both contribute to fetal growth restriction. Smoking appears not to affect utero-placental resistance.

P47 Intrapartum umbilical artery, fetal aorta and middle cerebral artery Doppler velocimetry as a predictor of poor perinatal outcome in growth retarded fetuses N. Klep, H. Concin & A. Kurjak Background: The aim of the study was to evaluate the diagnostic prediction of the Doppler waveform analysis during active labor for adverse perinatal outcome in a group at significant risk of intrapartum hypoxia. Materials and methods: The study population consisted of 33 pregnant women at high-risk and ultrasonographic diagnosis of IUGR between 28 and 35 weeks of gestation. On the basis of the flow velocity changes in the fetal vessels during pregnancy, patients were divided into two study groups A, with physiological Doppler waveforms (12 women) and B, with pathological Doppler waveforms (21 women). The percentage of the changes of the index values during active labor were correlated with pH values of the blood from the umbilical artery. Results: In group A, no statistically significant correlation was found. In group B, following was established: high negative correlation between the changes of the index values and pH values of the blood from the umbilical artery: dPAU 24%, r ¼ 0.531, t ¼ 2.179, P < 0.05. dPIAFD 26%, r ¼ 0.655, t ¼ 3.0, P < 0.05; dPIACM 10%, r ¼ 0. 699, t ¼ 3.1, P < 0.01. Conclusions: The study revealed a significant correlation between the changes of index values of the Doppler waveform analysis during active labor and pH values of the blood from the umbilical artery in the process of intrapartum aggravation of already antepartum from chronic hypoxemia suffering fetuses.

Poster Session 2: Obstetrics – Doppler and Miscellaneous

P48 The association between the Doppler hypoxia index and arterial umbilical cord pH in multiple gestation pregnancies complicated by intrauterine growth restriction U. Musser, E. P. Gaziano & P. H. Arbeille Purpose: To study the relationship between the Doppler hypoxia index and umbilical cord pH in multiple gestation pregnancies complicated by fetal growth restriction. Methods: Seventeen fetuses were studied from 12 multiple gestation pregnancies (11 twins and 1 triplet). Each pregnancy had at least one growth-restricted fetus from which middle cerebral artery and umbilical artery Doppler values were collected, the last value of which was within 3 weeks of delivery. For each fetus, we calculated the cerebral umbilical ratio and the hypoxia index, which reflects the duration and degree of Doppler determined fetal blood flow redistribution. Umbilical arterial cord blood was obtained for blood gas analysis immediately after the births. Excluded were fetuses with major congenital anomalies and those with reverse end diastolic flow in the umbilical artery. Results: There is a significant correlation at the 0.05 level, one-tailed, between the hypoxia index and arterial umbilical cord pH. A linear regression model suggests that gestational age and birth weights are not cofounders in the relationship between the hypoxia index and arterial pH. While the hypoxia index has the same sensitivity (75%) as the cerebral umbilical ratio for identifying fetuses who will have an arterial cord pH of less than 7.20, the hypoxia index has a better specificity (85 vs. 69%), positive predictive value (50 vs. 38%) and negative predictive value (92 vs. 90%). Conclusions: There is a significant correlation between the non-invasive hypoxia index and arterial umbilical cord pH in the growthrestricted fetus from multiple gestation pregnancies.

P49 The evaluation of Doppler indices in renal vessels in normal fetuses and in fetuses with obstructive uropathy D. Wyrwas, K. Szaflik, D. Borowski & M. Kozarzewski Purpose: The aim of the study was an evaluation of Doppler indices in renal vessels in normal fetuses and in fetuses with diagnosed obstructive uropathy. Methods: In the study, there were included 106 normal fetuses and 21 fetuses with signs of the obstructive uropathy. In pregnancies complicated by the uropathy, the measurements of Doppler flow in renal arteries were performed twice: in the ahydramnion settings and after the diagnostic amnioinfusion. The analyzed indices included the pulsatility index and the resistance index. Results: The diagnosis of uropathy was set-up at the mean gestational age of 20.3 2.0 weeks. The control group consisted of 106 healthy fetuses from normal pregnancies at the mean gestational age (28 weeks). The physiological absence of an end-diastolic flow in renal arteries was found in normal pregnancies and that parameter was excluded from further analysis. The PI values in normal pregnancies decreased with the gestational age from the mean value of 3.16 at 15 weeks to 2.19 at 40 weeks of gestation. In pregnancies at gestational age below 26 weeks complicated by the uropathy, the PI was significantly lower with the mean value of 1.57. However, there were no statistical difference in PI values for pregnancies above 30 weeks of gestation, the mean values of PI were 2.39 and 2.33 for normal and pathological pregnancies, respectively. There were also no differences for PI values among pregnancies with the uropathy before and after amnioinfusion. Conclusions: There is a physiological linear decrease in the PI values in fetal renal arteries with the gestational age. The RI cannot be used for the evaluation of renal function due to the physiological absence of an end-diastolic flow in renal arteries. The PI was significantly lower in pregnancies complicated by obstructive uropathy at the gestational age below 26 weeks.

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P50 The role of thromboelastography in conjunction with second trimester uterine artery Doppler velocimetry in the prediction of adverse pregnancy outcome C. Karidas, P. Anastassopoulos, D. Perry & D. L. Economides

Poster Session 2: Obstetrics – Doppler and Miscellaneous the sensitivity dropped down. It is not advisable to wait for both to happen before taking a decision for induction of labor.

P52 Abstract withdrawn

Purpose: A pilot, prospective study to evaluate the use of thromboelastography in conjunction with uterine artery Doppler in the second trimester as predictors of pre-eclampsia and IUGR (intrauterine growth restriction defined as birth weight below the 5th centile for gestational age). Methods: Two-hundred and forty-nine (249) unselected pregnant women were recruited at their booking appointment in the Royal Free Hospital. They underwent thromboelastography assessment and color flow/pulsed Doppler imaging of both uterine arteries at 20–24 weeks gestation. Standard parameters were measured from each thromboelastography tracing (R, reaction time; K, clot formation time; A, angle; MA, maximum amplitude). The presence or absence of notches in the flow velocity waveform was noted and the resistance index measured. The main outcome measures were pre-eclampsia and IUGR. Results: Twenty-three pregnancies (9.2%) were complicated by IUGR and 10 (4%) by pre-eclampsia. Assessment using abnormal Doppler velocimetry, defined as bilateral notches/mean RI 0.55 (27 cases) or unilateral notch/mean RI 0.65 (5 cases), demonstrated 52% (95% CI 33–71%) sensitivity for IUGR and 40% (CI 17–69%) for pre-eclampsia with positive predictive values 37.5% (23–55%) and 12.5% (5–28%), respectively. Furthermore, in the pregnancies complicated by an adverse outcome, the groups with normal (14 cases) and abnormal (15 cases) Doppler velocimetry did not differ significantly in any of the thromboelastography parameters (Mann–Whitney test for comparisons). Conclusion: Pulsed Doppler velocimetry of the uterine arteries in the second trimester is an established predictor of adverse pregnancy outcome. The additional use of thromboelastography assessment does not appear to contribute significantly in providing further information. As this is a pilot study, larger trials are required to delineate its role.

P51 The sensitivity of Doppler studies vs. biochemical indices in predicting fetal outcome in cases of pregnancy induced hypertension M. R. Ghoneim, K. Nicolaides, M. A. Abd-El Moneim, H. E. Megahid & M. S. Hafez Location: The Outpatient Clinic of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt and the High Risk Pregnancy Unit of King’s College University Hospital, London, UK. Aim of the work: To compare the sensitivity and specificity of the Doppler studies vs. the biochemical indices in predicting fetal outcome in cases of pregnancy induced hypertension. Material and methods: A total of 252 cases were the subject of this study 192 cases from King’s College Hospital and 60 from Suez Canal University Hospital. All cases were selected as having pregnancyinduced hypertension, 226 cases with proteinuric hypertension and 26 cases with non-proteinuric pregnancy induced hypertension. All cases were monitored weekly from 28th gestational week till delivery whereby all Doppler studies were carried out on a free loop of umbilical artery. Serum uric acid, liver enzyme aspartate-aminotransferase, and platelet count were estimated weekly. Results: Out of 252 patients with PIH, 136 patients (54%) had abnormal Doppler flow velocimetry associated with abnormal higher mean AST proteinuria, serum urate >350 mm/L, lower platelet count and higher perinatal mortality. The sensitivity and specificity of abnormal Doppler velocimetry in the prediction of intrauterine growth retardation (IUGR) were 80 and 52.6%. These were raised to 94 and 88%, respectively, with higher mean serum urate and lower platelet counts. However, the specificity of the abnormal Doppler with abnormal all biochemical indices for the prediction of adverse neonatal outcome and IUGR was 100%, but this was a late event in cases of PIH as

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P53 The use of umbilical artery Doppler velocimetry in the monitoring of pregestational diabetic pregnancy S.-F. Wong, F.-Y. Chan, R. Cincotta, J. Oats & D. McIntyre Purpose: To assess whether umbilical artery Doppler velocity waveform analysis can predict adverse perinatal outcomes for pregnancies complicated with pre-existing diabetes mellitus (types 1 and 2 diabetes mellitus). Methods: All diabetic pregnancies (types 1 and 2) delivered at Mater Mothers’ Hospital, Australia, between 1st January 1995 and 31st December 1999, were included. All pregnant diabetic women were monitored with umbilical artery Doppler velocimetry at 28, 32, 36, and 38 weeks gestation. Umbilical artery Doppler study was repeated on weekly basis for pregnancies complicated by macrosomia, polyhydramnios, or fetal growth restriction. Adverse perinatal outcome was defined as pregnancies with one or more of the following: small-forgestational age (birth weight 4 ms after 10 min; group II (n ¼ 40) represented by pregnant with no TA and STV < 4 ms after 10 min. In all cases traces were continued until presence of TA, and the longest trace was 60 min of duration. Results: In group I, all cases showed TA while in group II in 60% cases initial STV < 4 ms have become more than 4 ms and with presence of TA, showing fetal in good conditions. In the other hand, in 40% cases even after keeping trace until complete 60 min there were not changes in STV or presence of TA. Conclusion: Fetuses with STV > 4 ms are related to active fetuses (presence of TA) and the ones with STV < 4 ms does ever not mean altered result as when prolonging trace until 60 min, 60% of these fetuses become active.


P63 Computerized cardiotocography: correlation between STV > 4 ms and response of fetal cardiac frequency to vibroacoustic stimulation test A. A. Yamasaki, G. Braia & O. Toma Introduction: In classic cardiotocography, a fetus is considered active when there are two transitory accelerations (TA) or elevation of 20 bpm in cardiac frequency after vibroacoustic stimulation test. In computerized cardiotocography there must an instant variability, also named short-term variation (STV), higher than 4 ms. Objective: Comparison between STV > 4 ms and fetal response to acoustic stimulus. Patients and methods: Twenty-four normal pregnant were analyzed between 30 and 36 weeks by computerized cardiotocography (SYS 8002). If STV > 4 ms, but TA is absent after 10 min, a vibroacoustic stimulation test was done for 3 s. The fetus was considered reactive when heart rate increased by 20 bpm for 3 min. The fetus was considered hyper-reactive when heart rate increased less than 20 bpm or duration of response less than 3 min. Results: Among 24 fetuses, 20 (87%) were considered reactive after vibroacoustic stimulation test (elevation of 20 bpm for 3 min or more). Only four fetuses (13%) were hyperactive. Conclusion: When STV > 4 ms fetuses are reactive in 87% cases and hyperactive in 13%. The STV can be used as isolated parameter for assessment of fetal well-being.

P64 Correlation between the umbilical cord cross-sectional area and fetal anthropometric parameters F. A. P. Vasques, A. F. Moron, C. G. V. Murta, H. Cattini, M. M. Barbosa, T. R. Gonçalves, W. J. Hisaba & F. H. C. Carvalho A prospective cross-sectional study was developed to determine the correlation between the umbilical cord cross-sectional (UCCSA) and fetal anthropometric parameters during normal pregnancies (patients with known dates of LMP and an ultrasound examination before the 20th week, without any pathologic condition). The measurements of the umbilical cord cross-sectional area were obtained in a plane adjacent to the insertion of the cord in the abdomen, as proposed by Raio et al., 1999, and compared to the biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL) by the non-parametric correlation of Spearman. The inclusion criteria were: (1) singleton pregnancy; (2) gestational week >20 weeks; (3) intact membranes; (4) normal umbilical Doppler flow velocimetry. The exclusion criteria, in the presence of any of those were: (1) congenital and/or chromosomal abnormalities; (2) pregnancy complications (any type); (3) inadequate size for gestational agent the time the ultrasound examination was performed, i.e. the weight below the 10th or above the 90th percentile; (4) abnormal AFI. The patients were examined and included only once. The statistical analysis was performed by the program called Statistical Package for Social Sciences (SPSS) and we used a Toshiba 140 with a transabdominal transducer of 3.5 MHz. Our results showed a strong correlation (Spearman rank ¼ 0.610, significant at the level of P < 0.01) between the UCCSA and the estimated fetal weight by ultrasound examination and also with the fetal anthropometric parameters (UCCSA BPD ¼ 0.622; UCCSA HC ¼ 0.617; UCCSA AC ¼ 0.625; UCCSA FL ¼ 0.604, all of them significant at the level of P < 0.01). We concluded that the UCCSA is a parameter that can be included at the routine of obstetrical ultrasound examinations.

P65 Does amniocentesis (AC) influence fetal growth? T. huu Nguyen & T. Larsen Purpose: To examine the relationship between AC and birth weight. Methods: A cohort of singleton pregnancies with AC carried out in Denmark (n ¼ 96893) was compared to the total population of singleton pregnancies without AC or CVS (chorionic villus sampling) (n ¼ 873254) for infants born in years between 1980 and 1996.

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Exclusion criteria were multiple pregnancies, infants with malformations, chromosomal abnormalities, stillbirths, and death within the first living year. The pregnancies with AC were grouped according to gestational age (14–19th week of gestation) at the time of AC, and mean birth weight was calculated for each group. Maternal age, parity and previous abortions were taken into account when comparing mean birth weights. To exclude social status as a confounder, the overall mean birth weight (pregnancies without CVS or AC) was also compared to the mean birth weight of a subgroup of infants (also without CVS or AC) born to women who undergo AC in some other pregnancy. Results: The mean birth weight of the AC cohort was found to be significantly higher than that of the total population and inversely related to the gestational age at AC. Conclusion: The invasive procedure seems to stimulate growth. No known potential cofounders can explain the higher birth weight after pregnancies with AC.

development requires further study. Breathing movements may provide important information on fetal health and outcome.

P66 Effect of income on fetal biometry by ultrasound M. A. Taher Objective: To compare gestational age corrected fetal biometry among rich and poor women. Methods: An ultrasound database from August 2000 to January 2001 was used for the purpose of this study. One hundred and seventy-five patients with certain menstrual history were included. Patient’s income was assigned based on their report during the initial evaluation. There were 137 rich and 38 poor women. All data were enter into Statistix 7.0 statistical package, and analyzed using appropriate statistical tests. Probability values less than 5% were considered significant. Results: Multiple regression analysis using a second-order model for gestational age a S function of fetal biometry, income, and fetal biometry–income interaction did not show income to alter the relationship between gestational age and fetal biometry except for femur lengths. Ninety-five percent prediction intervals for gestational age did not show clinically significant difference between rich and poor. Conclusion: There does not appear to be a significant difference in ultrasound measured fetal biometry among different income groups.

P67 Fetal breathing: a clinically useful paradox P. G. Hepper, A. Shannon & J. C. Dornan Purpose: To examine fetal breathing movements in fetuses with congenital diaphragmatic hernia and compare this to unaffected fetuses and with their outcome after birth. Methods: Twenty women with normal singleton pregnancies and four cases of congenital diaphragmatic hernia were studied. All fetuses were observed for 60 min at 36 weeks of gestation. Fetal breathing movements were observed by scan taking a cross-sectional view across the abdomen. The scan was recorded and breathing movements analyzed off-line. All sessions occurred at the same time of the day and two hours after a light meal. No patients were cigarette smokers. Bouts of fetal breathing activity were defined as the length in seconds of each series of successive individual breathing movements bracketed by periods of apnea. The absence of fetal breathing movements for more than 3 s was called the apnea period. Total duration of breathing was the sum of all bouts. Results: The normal fetuses exhibited a breath to breath interval of 1.3 s and displayed breathing movements for around 30–35% of the observation period. Of the four fetuses with congenital diaphragmatic hernia, three died during the neonatal period due to lung hypoplasia, one survived following surgical repair. All four fetuses exhibited a similar breath to breath interval as unaffected fetuses but the three fetuses who died spent 80% (range 70–90%) of the time breathing whereas the fetus that survived spent 32% of its time breathing. Increased yawning was also observed in the fetuses who died. Conclusions: It has been speculated that the inhibition of fetal breathing movements may result in pulmonary hypoplasia, yet fetuses with lung hypoplasia spend more time breathing than those without lung hypoplasia. The relationship between breathing movements and lung

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P68 Fetal responses to invasive procedures B. M. Petrikovsky, E. Schneider & N. Holsten Objective: To study fetal responses to invasive procedures. Study design: Seven fetuses underwent invasive procedures between 23 and 38 weeks of pregnancy for accepted clinical indications. Two ultrasound machines were used simultaneously; one to provide guidance, and one to register FHR and respiratory rate (RR). A pairedtest was used for statistical analysis. Results: Three patients had bladder centesis, two placements of the bladder shunts and two placements of pleuro-amniotic shunts. FHR changed from 128 6 bpm prior to the procedure to 168 8 after it (P < 0.05). RR also increased from 26 12 to 32 8 (P < 0.1). Conclusion: Invasive fetal procedures are accompanied by an increased FHR and RR which are likely to represent pain response.

P69 Predicting neonatal outcome after prolonged preterm membrane rupture by ultrasound measurement of fetal lung length P. R. Stone, L. Sadler, M. Battin, S. Grant, J. Mitchell & A. Roberts Purpose of study: To assess the ability of ultrasound measurements of fetal lung length to predict neonatal respiratory outcome after prolonged membrane rupture and oligohydramnios. Methods: From the database of all cases of spontaneous membrane rupture 21 days the findings were the same. Serial lung growth data also did not predict outcomes (figures are presented to illustrate the results). Conclusions: Fetal lung length determined by antenatal ultrasound does not predict adverse neonatal respiratory outcome and the prediction of pulmonary hypoplasia remains an elusive goal.

P70 Pregnancy in women with Marfan syndrome C. G. Garcıá, N. P. Lagos, C. E. Benavides, I. F. Hoffmann, G. A. Castillo, M. A. Astorga, X. Melgarejo & I. Ferres Background: The Marfan syndrome is inherited as an autosomal dominant trait, and the fetus has a 50% risk of inheriting the mutant gene. It is caused by an abnormal fibrin gene located on chromosome 15q. The prevalence of the syndrome is 717/100 000. The symptoms and complications usually affect ocular, skeletal and cardiovascular systems. Pregnancy in the Marfan syndrome is associated with

23–28 October 2001, Melbourne, Australia major problems: the first are maternal catastrophic cardiovascular complications which include aortic dissection, aortic rupture, or cardiac failure, due to mitral and aortic valve regurgitation. These conditions are responsible for 90% of the maternal deaths. The second problem is the risk of having a child with the syndrome (50%). Case report: An 18-year-old patient with a Marfan syndrome and with mental retardation. She had long limbs, slenderness of hands and feet, marked hyperextensible joints, kyphoscoliosis, narrow chest with pectum excavatum, an high arched palate with malocclusion. On first evaluation by US, she was 18 weeks pregnant. A maternal echocardiography was done, showing that all four chambers, and the valvular structures were normal, and the aortic root measured 26 mm, which was normal. The echocardiography was repeated at weeks 29 and 36, and showed no change in the aortic root or in the rest of the parameters. Study of the fetus showed normal anatomy, without morphotype of Marfan in utero. Fetal echocardiography was normal. There was moderate IUGR. At 39th week, there was a vaginal delivery, without complications, of a male newborn, 2910 g, 49 cm, Apgar 9–9, on a normal physical examination. Conclusions: Maternal and fetal outcomes were monitored with systematic echocardiography, which is the best and safest method available for the follow up of the severe cardiovascular complications. Patients with Marfan syndrome with aortic root of 38.5 8C). In Misgav Ladach method, only seven women had adhesion of light-medium importance so that uterine exteriorization was not necessary, and not significant (NS) in comparison with the reference of nine women. Conclusion: Peritoneum closure in repeat c.s. lengthens operative time and in some cases favors bladder-flap hematomas which increase postoperative morbidity (P < 0.05), antibiotics use 2.6 and 4.8% (P < 0.01), length of hospital 3 1 vs. 7 2 days staying (P < 0.01) and costs (P < 0.05). In conclusion, follow up has shown no intraperitoneal compare to repeat c.s. with closed and open peritoneum.

P72 Third trimester abdominal pregnancy A. Salim, P. Handaya, G. H. Wiknjosastro & B. Karsono Introduction: Surviving of the fetus of the third trimester abdominal pregnancy is possible although very rare. The high fetal and maternal

Poster Session 2: Obstetrics – Doppler and Miscellaneous mortality rates is associated with it. We report four cases which succeed in having two living healthy babies. The subsequent problem is about the placenta which is left in the abdomen. Methods: Four women suspected of late abdominal pregnancy were referred to our center for further management. All of them underwent abdominal ultrasound and vaginal if necessary. Blood flow of the umbilical artery also studied. They were treated until the fetus is viable according to our pediatrician prior to be delivered abdominally. Results: From April 1994 until October 2000, we have four cases of third trimester abdominal pregnancy. Two cases of 30 and 32 weeks gestational age with fetal death intra-abdominally. Another two cases of 33 and 31 weeks with living fetus intra-abdominally and placenta implanted at the superior and posterior side of the uterus. Umbilical artery RIs were 0.67 and 0.71. The interval between time of admission till the delivery were 19 and 33 days. Female babies 2400 g Apgar score 9/10 and 1680 g Apgar score 6/8 for 1 and 5 min. They are growing and developing well except the first one has a slight club-feet. Conclusion: We report four cases of third trimester abdominal pregnancies, two of which succeed in delivering healthy babies.

P73 Thromboelastography in the second trimester of pregnancy in the prediction of adverse pregnancy outcome C. Karidas, P. Anastassopoulos, D. Perry & D. L. Economides Thromboelastography (TEG) is a method of monitoring global homeostatic function as a dynamic process, involving the interaction between the protein coagulation cascade and platelets, as opposed to the isolated end points measured by conventional coagulation screens. The purpose of this study is to determine whether TEG variables can be used in the second trimester to predict the development of adverse pregnancy outcomes such as pre-eclampsia and intrauterine growth restriction (IUGR defined as birth weight below the 5th centile for gestational age). Methods: A prospective study of a cohort of 273 pregnant women who underwent TEG assessment at 18–24 weeks gestation. Standard parameters were measured from each TEG tracing (R is the reaction time, K the clot formation time, A the angle, and MA the maximum amplitude). Pregnancy outcomes were obtained from the case notes of 251 participants. Twenty-two patients were lost at follow up. The Mann–Whitney test was employed for analysis, as the above parameters did not follow normal distribution. Results: Twenty-three pregnancies (9.2%) were complicated by IUGR and 10 (4%) by pre-eclampsia. In the IUGR group, no significant difference was observed in any of the TEG parameters in comparison to the normal pregnancies (for R time: Mann–Whitney U ¼ 2296, for K time: U ¼ 2556, for MA: U ¼ 2514.5, for A-angle: U ¼ 2433, 95% CI (1972, 3273)). Similarly, TEG parameters did not differ significantly in the pregnancies complicated by pre-eclampsia (for R time: Mann– Whitney U ¼ 971.5, for K time: U ¼ 1063.5, for MA: U ¼ 1199.5 and for A-angle: U ¼ 1183, 95% CI (765, 1646)). Comparisons after logarithmic transformation, did not reveal any significant differences between the two groups. Conclusion: Thromboelastography parameters in the second trimester of pregnancy did not differ in normally developed and complicated pregnancies. Therefore, they cannot be used as a single predictor of adverse pregnancy outcome. This is a pilot study, therefore, further studies are required to evaluate their use in conjunction with established predictive tests.

P74 Ultrasound during breast-feeding in normal term infants L. A. Jacobs The primary objective of this pilot study of infant feeding mechanisms on ultrasound was to develop local ultrasound techniques to assess the infant oral cavity during breast-feeding. Study methods: A convenience sample of 32 volunteers with term babies were invited for ultrasound during a breast-feed in week 1

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and 4 of life. Useable data was obtained in 22 participants but not all attended for both scans yielding 36/44. The whole breast-feeding scan was videotaped for analysis later. Conventionally, accepted positioning and attachment criteria were used. The infant was weighed before and after feeding to satisfaction from one breast. A submental approach was used to obtain a median sagittal view of the nipple position, hard and soft palate, tongue movements and the relationship between these intraoral structures. Various designs and frequency of transducers were tested. The optimal transducer is an EC-7 endocavity transducer with a 1358 end-firing 7 MHz small radius curved array on a long, thin handle that does not interfere with feeding positioning.

Conclusions: The relationship of nipple to hard palate/soft palate junction is shown to be variable with distances from 3 to 11 mm. The participants had previous and present history of breast-feeding success. They were not specifically directed to attach in a particular way since their current infants were recruited as thriving, contented examples of the appearances of ‘normal breast-feeding’. It is unknown, whether the participants in the landmark study by Woolridge et al. (1986), were instructed in feeding attachment prior to ultrasound imaging thus influencing the nipple position. Further data analysis will detect any infant maturation or learning differences between weeks 1 and 4. This simple ultrasound technique can be applied to the assessment of infant feeding problems and preterm infant feeding behavior.

POSTER SESSION 3: OBSTETRICS – 3D, FETAL ANOMALIES, FETAL THERAPY AND CERVIX P75 Fetal magnetic resonance imaging S. J. Sinnott, D. Traves, T. Ryan, K. Frawley, T. Wood & R. B. Cincotta Fetal magnetic resonance imaging (MRI) is rapidly establishing a key role in the diagnostic evaluation of fetal central nervous system (CNS) anomalies. We present, a pictorial essay of the effectiveness of fetal MRI in the assessment of cerebral anomalies and ventriculomegaly. High resolution neurosonography remains the cornerstone in antenatal CNS screening. When cerebral anomalies are diagnosed or suspected by ultrasound examination, MRI clearly has a role and often adds useful information or can increase the level of diagnostic confidence and may alter patient counseling and management. MRI examinations also can be used to obtain further opinions from different subspecialists, such as neuroradiologists, neurosurgeons, neurologists and intervention radiologists. Subtleties that may not be distinguishable on ultrasound can be seen on MRI. The MRI should not be seen as a competitor to ultrasound, rather a complementary study from which the imaging specialists can improve their working knowledge in CNS anatomy and pathology.

P76 Prenatal diagnosis of congenital cardiac tumors: two cases reports G. Rodrigues & E. Castela Introduction: Congenital cardiac tumors are rare. Among the pediatric population, more than 90% of cardiac neoplasms are histologically benign. However, they have the potential for serious consequences, if not detected in a timely manner, usually because of their conspicuous location. Rhabdomyomas are the most common tumors of both infancy and childhood, occurring in 62% of cases. Case report: Cardiac rhabdomyomas were diagnosed in two patients at 33 and 34 weeks with support of pediatric cardiology through telemedicine. The first patient had multiple tumors, in right atrium, atrial septum, ventricular septum and mitral valve, with variable size and without cardiac arrythmia or stigmata of the tuberous sclerosis. This patient had unilateral ventriculomegaly due to cerebral ischemy probably linked to tumor embolization. The second patient had a single tumor, localized in ventricular septum without other ultrasounds findings. The two patients had not obstructed valvular inflow or outflow. Conclusion: Prenatal diagnosis of congenital cardiac tumors is possible in the hands of an expert, although it is impossible to make a histological diagnosis in utero, several ultrasonographic criteria, including tumor number, size, location and echogenicity, may help narrow the differential diagnosis. Thrombosis of cerebral venous circulation can occur antenatally. Accurate diagnosis can be made using fetal real time and color Doppler ultrasound. At the date of preparation of this abstract, the pregnancies are in course and delivery is expected in short-term in a center of pediatric cardiology.

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P77 Prenatal sonographic appearance of Beare–Stevenson cutis gyrata syndrome C.-C. Tsai, T.-Y. Hsu, S.-Y. Chang, T.-J. Wang, C.-Y. Ou, Z.-H. Chen & P.-U. Hsu Background: Beare first described a 2-year-old boy who had abnormal physical feature including hypertelorism, cutis gyratum, acanthosis nigrican, cleft palate, functional pyloric obstruction and abnormal genitalia. Ten cases of Beare–Stevenson cutis gyrata syndrome have been reported. Here, we present, the first case of antenatal ultrasound image of this rare syndrome. A 31-year-old Taiwanese, gravida 2, para 1, was referred for fetal evaluation at 32 weeks gestation because of polyhydramnios and fetal head anomaly. Conventional sonography revealed a single fetus with amniotic index of 27.3 cm, cover leaf skull, and a skin fold-like umbilical cord. Three-dimensional sonography of the face of the fetus showed, high wide forehead, ocular proptosis, and depressed nasal bridge. The patient delivered a male infant weighing 2980 g at 39 weeks gestation. Physical examination of the infant showed furrows of corrugated appearance of the skin, craniofacial anomalies, particularly craniosynosis, displaced ears, prominent umbilical stump and hypospadia. Computer tomography and magnetic resonance image were performed and revealed fronto-ethmoid-nasal, cephalocele, pansynostosis and frontal base defect. Conclusion: A total of 10 cases of Beare–Stevenson cutis gyrata syndrome have been previously reported. All of the previously reported cases of the syndrome were diagnosed postnatally. Our patient presented with ocular hypertelorism, low-set and creased ears, ocular proptosis, choanal atresia, cloverleaf skull, craniosynosis, cutis gyrata, acanthosis nirican, prominent umbilical stump and bifida scrotum. Here we present the first case of antenatal ultrasound image of this rare syndrome.

P78 The post-exercise cervix M. Gun & D. Gluis Measurement of the cervix via transvaginal ultrasound is now recognized as reproducible and accurate. The length of the cervix as determined by transvaginal ultrasound has an inverse relationship to the risk of preterm delivery. Studies utilizing transfundal pressure to elicit changes in the cervix have been reported [1,2]. This poster will illustrate the use of ‘post-exercise’ transvaginal scanning in an attempt to identify those patients at risk for preterm delivery both pre- and postcerclage placement. References 1 Iams JK, Goldenberg RL, Meis PJ, Mercer BM, Moawad A, Da A et al. The length of the cervix and the risk of spontaneous premature delivery. N Engl J Med1996; 334: 567–72.

23–28 October 2001, Melbourne, Australia

Poster Session 3: Obstetrics – 3D, Fetal Anomalies, Fetal Therapy and Cervix

2 Guzman ER, Vintzileos AM, McLean DA, Martins ME, Genito CW, Hanley ML. The natural history of a positive response to transfundal pressure in women at risk for cervical incompetence. Am J Obstet Gynaecol 1997; 176: 634–8.

P79 Warfarin embryonopathy S. J. Sinnott, C. McDonald, D. Traves & G. Pritchard Warfarin sodium readily crosses the placenta due to its low molecular weight and intrauterine exposure to this oral anticoagulant has multiple recognized complications. Complication outcomes seem to be dependent on the timing of exposure. Exposure during the first trimester between the 6 and 12 weeks of gestation is associated with warfarin embryonopathy: characterized by nasal hypoplasia, stippled epiphyses or vertebrae and digital hypoplasia. Warfarin embryonapathy has been identified in up to 25 fetuses with known exposure to warfarin sodium during the first trimester. Exposure during the second and third trimesters is thought to lead to a number of central nervous system abnormalities. The authors report a rare case with images of the prenatal ultrasound and postnatal X-rays and clinical photos. A discussion of the pathogenesis and literature review is included.

P80 2D/3D sonographic imaging of thanatophoric dysplasia type I at 19 weeks of gestation R. K. Pooh, S. Nishida & Y. Ohno Thanatophoric dysplasia is a sporadic, lethal congenital skeletal dysplasia. There are two major subtypes: (1) a short, curved femur characterizes type I; and (2) a straighter femur with cloverleaf skull characterizes type II. We, here, present a case of type I disease. A 30-year-old pregnant woman was referred to the ultrasound unit due to fetal short extremities at 19 weeks and 4 days of gestation. Ultrasound revealed short limbs and a severely small thorax. Every limb bone was markedly short, and the femur, tibia, fibula and humerus were remarkably curved. 3D ultrasound demonstrated the abnormal appearance of extremities. Cranial and intracranial structures were normal. One week later, no growth of limb bones was seen. Thanatophoric dysplasia type I was strongly suspected and counseling of the couple was done. Pregnancy was terminated at 21 weeks of gestation and a female fetus was aborted. Short and curved limb bones were confirmed by postnatal X-ray. Genomic DNA obtained by cord blood showed a point mutation in the fibroblast growth factor receptor 3 (FGFR3) gene; a C to T substitution at position 742 in the FGFR3 gene, resulting in a Arg248Cys substitution, known to be associated with type I disease. By ultrasound in the second trimester, prenatal diagnosis of skeletal dysplasia can be feasible. However, differentiating this lethal disease from non-lethal skeletal disorders should be done prudently.

P81 A critical evaluation of three-dimensional and two-dimensional sonographic studies, and color Doppler ultrasound in detecting nuchal cord in utero U. Hanaoka, T. Yanagihara, A. Kuno, H. Tanaka & T. Hata Objective: To evaluate whether three-dimensional sonography is more valid than two-dimensional sonography, and color Doppler ultrasound in diagnosing nuchal cord in utero. Methods: Eighty-five singleton pregnancies without nuchal cord and 35 with nuchal cord (30 single nuchal cord, four double nuchal cords, and one triple nuchal cords) were studied within 1 week before delivery using a transabdominal three-dimensional sonography. Two-dimensional sonography and color Doppler ultrasound were also conducted. Results: Three-dimensional sonography identified in utero 22 (73.3%) single and 3 (60%) multiple nuchal cords found at birth. There were no significant differences in overall diagnostic indices of each diagnostic

modality for detecting nuchal cord. However, the ability to view nuchal cord was better with three-dimensional sonography than with two-dimensional sonography or color Doppler ultrasound. Conclusions: Three-dimensional surface imaging does not provide more useful diagnostic information than two-dimensional sonography and color Doppler ultrasound for detecting nuchal cord in utero.

P82 Fetal renal blood flow assessment by three-dimensional power Doppler ultrasound: preliminary results of a three-dimensional histogram study F.-M. Chang, C.-H. Chang, C.-H. Yu, T.-P. Liao & H.-C. J. Ko Purpose: To assess the fetal renal blood flow in normal gestation using three-dimensional (3D) power Doppler ultrasound. Methods: The study was under a prospective, consecutive and crosssectional design. Normal pregnancies that attended the prenatal clinic were included. We used a three-dimensional power ultrasound scanner, Voluson 530D MT (Kretz, Zipf, Austria) to assess the total blood flow of fetal kidney. First, we used the 3D transabdominal probe to scan the whole fetal kidney under the 3D power Doppler mode at a fixed condition. Second, we used the VOCAL software (Kretz, Zipf, Austria) to calculate the histogram indices of fetal renal blood flow obtained from the 3D power Doppler scanning. The histogram indices included vascularization index (VI), flow index (FI) and vascularization-flow index (VFI). Results: In total, 81 fetuses ranging from 20 to 39 weeks of gestation were included for final analysis. Our results showed that VI had a high correlation with gestational age (r ¼ 0.90, n ¼ 81, P < 0.001). In addition, FI was positively correlated with gestational age (r ¼ 0.35, n ¼ 81, P < 0.05), and VFI also presented a high correlation with gestational age (r ¼ 0.88, n ¼ 81, P < 0.001). Furthermore, the VI, FI, and VFI of fetal kidney in the third trimester were all higher than those indices of fetal kidney in the second trimester (all P < 0.01). Conclusion: The 3D power Doppler ultrasound can assess the total blood flow of fetal kidney, which is superior to the previous methods of blood flow assessment. Our study indicates that fetal renal flow increases with the advancement of gestational age, and our data may be a useful reference for further studies of fetal renal flow in abnormal conditions.

P83 Prenatal neuroimaging of progressive ventriculomegaly at 20–21 weeks of gestation – a case report R. K. Pooh, M. Tanemura, M. Yamasaki & K. Pooh Intrauterine course of genetic hydrocephalus has not been revealed. We had a case with progressive ventriculomegaly between 20 and 21 weeks of gestation. A pregnant woman was referred to the ultrasound unit at 20 weeks of gestation. Her 8-year-old son had congenital hydrocephalus, gait disturbance, mental retardation and adducted thumbs, but genetic examination was not done. The male fetus had grown normally with normal BPD. However, 2D/3D sonography and fetal magnetic resonance imaging (MRI) demonstrated partial agenesis of the corpus callosum, moderate ventriculomegaly and a small inter-hemispheric cyst. Ventricular volume by 3D volumetry was estimated as 4.89 mL, which was more than twice as large as normal ventricle size. Subarachnoid space appeared normally. At 21 weeks of gestation, ventricular volume markedly increased to 8.29 mL within 7 days. Furthermore, 2D/3D ultrasound revealed the bilateral adducted thumbs. Genetic hydrocephalus, such as corpus callosum agenesis, retardation, adducted thumbs, spastic paraparesis, and hydrocephalus (CRASH) syndrome was strongly suspected from those sonographic findings. Pregnancy was terminated at the end of 21 weeks of gestation. Genetic examination by direct sequenced PCR resulted in a point mutation at Intron 6 of L1CAM located at Xp28. In our case, prodromic sign of progressive hydrocephalus was suspected by USG and MRI at the middle of gestation. Especially, 3D volumetry was useful for the assessment of the objective evaluation of the progressive ventriculomegaly.

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P84 The assessment of placental blood flow by three-dimensional color power Doppler ultrasound: preliminary result of a three-dimensional histogram study

three-dimensional transducer. The fetal nutrition score values were determined from a qualitative assessment of the amount of subcutaneous tissue present at three locations (face, ribs, and buttocks) on the antenatal three-dimensional ultrasonograms. Fetal nutritional status, using fetal nutrition score, was compared with those by modified neonatal nutrition score and ponderal index, respectively. Results: There was a significant linear correlation between fetal nutrition score and modified neonatal nutrition score. Fetal or neonatal nutrition score correlated well with birth weight and neonatal crown-heel length, respectively. However, no significant correlation between ponderal index and fetal nutrition score or modified neonatal nutrition score was evident. Ponderal index also did not correlate with birth weight and neonatal crown-heel length, respectively. Conclusion: We do cast doubt on the usefulness of the ponderal index for measurement of neonatal soft tissue and muscle mass. Fetal nutrition score using three-dimensional ultrasonography provides a novel means of evaluating the nutritional status of the fetus in utero, and should be useful for predicting the extreme in fetal growth earlier.

C.-H. Yu, C.-H. Chang, F.-M. Chang, T.-P. Liao & H.-C. Ko Objective: To assess the placenta blood flow in normal gestation by three-dimensional color power Doppler ultrasound. Methods: We collected normal pregnant women with gestational age between 20 and 40 weeks prospectively, consecutively and crosssectionally. Three-dimensional ultrasound scanner, Voluson, 530D MT (Kretz, Zipf, Austria) was used to assess the placental blood flow in each case. First, we used the 3D transabdominal probe to scan the placenta under the 3D power Doppler mode at a fixed condition. Second, we used the VOCAL software (Kretz, Zipf, Austria) to calculate the histogram indices of fetal placental blood flow obtained from the 3D power Doppler scanning. The histogram indices included vascularization index (VI), flow index (FI), and vascularization-flow index (VFI). Results: One-hundred singleton pregnant women were enrolled into the program. The best-fit equations for VI, FI, and VFI are 0.27107 G 4.02743, 0.56115 G þ 34.28945, and 0.15663 GA 2.53810, respectively. All the P-values are less than 0.05. All the indices were positively correlated with the fetal gestational age. Besides, The VI, FI, VFI of fetal placenta in third trimester were all higher than those indices of fetal placenta in the second trimester. Conclusion: The fetal placental blood flow increases with the advancement of gestational age. Our data may be a useful reference for further studies of fetal placental flow in abnormal gestations.

P85 Three-dimensional color power angiography of an aneurysm of the vein of Galen R. Ximenes, D. S. Ximenes, A. Ximenes, J. Szejnfeld, S. Ajzen, G. D’Hippolitto, S. M. Goldman & R. Sandoval Description of the case: A 26-year-old, gravida 1, para 0, female. The first scan was at 16 weeks, with normal fetal biometry and development. At 25 weeks’ gestation, a cystic area at the level of the biparietal-diameter, measuring 25 mm of diameter, ventricles has normal sizes, the cystic area was interrogated with color Doppler and showed a typical ‘turbulent flow’. The transvaginal probe was performed for evaluation of the fetal brain. Color Doppler energy was used to evaluate the cystic area and their communications – ‘angiography’, followed by tri-dimensional reconstruction of the brain vessels, especially the venous drainage and the arterial communications. This pathology is referred as a complex arterio-venous malformation (AVM). Antenatal MRI was performed to evaluate the central nervous system. The parents were counseled about the prognosis. At 34 weeks’ gestation, the shunts of the arteriovenous malformation were more prominent, ventriculomegaly, tricuspid regurgitation and polyhydramnios. Proof of diagnosis: At 35–36 weeks’ gestation, she delivered a female baby, weighing 2900 g, with Apgar score 4 and 8. The baby was transferred for the neonatal intensive care, but after 24 h died because of renal failure. Relevance: This report demonstrated that 3D color Doppler energy mode is useful in prenatal diagnosis and a more detailed angio-architecture of the aneurysm of the vein of Galen, with a excellent correlation with MRI. We hope, in the near future this technique could guide the identification of the fetus at increased risk for intrauterine and neonatal cardiac failure and therefore poor prognosis.

P86 Three-dimensional sonographic evaluation of fetal soft tissue deposition T. Yanagihara, M. Matsumoto, U. Hanaoka, A. Kuno & T. Hata Objectives: To evaluate fetal nutritional status in utero and to detect intrauterine growth restriction and macrosomia by use of threedimensional ultrasonography. Methods: Fifty-two fetuses from 28 to 41 weeks gestation were studied within 1 week before delivery using a transabdominal

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P87 Three-dimensional volumetry in fetal weight estimation, cerebral ventricle measurements, and cardiac function S. Yagel Objectives: To examine the applicability and efficacy of 3-D volumetry in three discrete areas: fetal weight estimation, cerebral ventricle measurements, and 3-D echocardiographic studies of fetal cardiac function. Materials and methods: Group 1: fetal weight estimation: 250 gravidae with uncomplicated singleton gestations and first-trimester confirmation of gestational age were examined up to 48 h before delivery using both standard 2-D fetal weight estimation and 3-D volumetry. Group 2: fetal cerebral ventricle measurements: 40 gravidae with first-trimester confirmation of dates were examined at 15–25 weeks gestation. Fetal lateral ventricles were measured by 3-D volumetry. Group 3: 3-D echocardiography: 40 gravidae with 1st-trimester confirmation of dates were examined at 15–25 weeks gestation. End-systolic and -diastolic ventricular volumes were studied to evaluate fetal cardiac function. Results: In these preliminary groups 3-D volumetry for fetal weight estimation was shown to have a considerable advantage over standard 2-D methods. Three-dimensional volumetry of the fetal cerebral lateral ventricles is a simple method of measuring the fetal brain, and may prove to be a more intelligent method of evaluating cerebral ventricular volume. Three-dimensional echocardiographic volumetry of the endsystolic and -diastolic ventricular volumes is a new method for evaluating fetal cardiac function, and has considerable potential in heart scanning in cases of suspected fetal heart failure. Conclusions: Three-dimensional ultrasonography shows great potential in the evaluation and volumetric measurement of many fetal organ systems.

P88 Cervical cerclage after hysteroscopic metroplasty G. Ragusa, C. Lanzani, M. Digrandi & E. Ferrazzi Purpose: The objective of the study is to evaluate the role of cervical cerclage after hysteroscopic metroplasty. Methods: Forty-six women, previously treated by hysteroscopic metroplasty for subseptate uteri, were prospectively recruited for this observational study. A total of 34 patients conceived 46 pregnancies. Miscarriages, ectopic pregnancies, and live births rate were 34, 7, 59%, respectively. Elective or ultrasound indicated cervical cerclage was proposed to these latter 27 patients. After discussing an informed consent form patients were asked to choose the elective cerclage or the ultrasound indicated cerclage. Cervical length was checked every 3 weeks, from 12 weeks of gestation. Indications for cervical cerclage were: cervical funneling or shortening 0.05). Conclusions: In order to define the risk of the preterm delivery, it is more meaningful if the cervical length is less than 30 mm and measured at the 28th and 32nd week of the delivery. On the other hand, funneling could not been determined during the earlier period of the delivery; therefore it is not used as a criteria to predefine the preterm delivery.

P90 Enhancing cervical sonography with methyl-cellulose gel

P92 Prevention of preterm labor by AIWA’s score

J. M. O’Brien, B. A. Houseman, A. A. Allen & J. R. Barton

H. Yoshitake, Y. Koyama, J. Fukuda, K. Uehira, S. Amiya & S. Yano

O. Okitsu, H. Niki & T. Mimura

Purpose: Our purpose was to evaluate the performance of two different contrast agents for cervical sonography in obstetrical patients. In addition, we sought to evaluate this technique in a setting other than with transvaginal sonography, such as utilizing a transperineal or transabdominal approach. Methods: Women with an indication for cervical sonography without premature rupture of the membranes underwent placement of 10 mL of normal saline or water-soluble methyl-cellulose gel. Assessment of cervical dimensions and contour was performed via transperineal sonography prior to and after contrast placement. Two authors independently evaluated, the adequacy of visualization of the cervical canal, external os, and vaginal fornices. When an improvement in visualization after contrast placement was noted by both observers, the attribute was counted. Results: Twenty-five patients were enrolled into two groups. The mean gestational age at examination was 26.6 6.2 weeks in the saline group, and 27.5 5.2 weeks in the methyl-cellulose gel group, P ¼ 0.58. Administration of contrast improved visualization in 18 women in the gel group vs. six in the saline group, P ¼ 0.002. Seventeen patients in the gel group had easier identification of the external os and enhanced visualization of the fornices was noted in 13 patients (12 patients had both). The mean cervical length was similar prior to and after administration of contrast (gel 2.8 0.9 vs. 2.9 1.0 cm,

Purpose: To elucidate the availability of ‘AIWA’s scoring’ in prevention of preterm labor. Patients: We retrospectively studied the 6434 deliveries after 22 weeks of gestation, managed at AIWA-Maternity Hospital from 1986 to 1990, and from 1995 to 2000. C-stage: deliveries from 1986 to 1990: 1786 (control stage without AIWA’s scoring); P-stage: deliveries from 1995 to 1997: 2190 (prototype stage without AIWA’s scoring); A-stage: deliveries from 1998 to 2000: 2458 (applied stage with AIWA’s scoring). Nine twins and seven cases of pregnant mother transportation (MT) in (C) 1786, 25 twins and 3 MT in (P) 2190, and 17 twins, 2 triplets, 6 MT in (A) 2458, were involved, respectively. Methods: The ‘AIWA’s score’ of risk assessment for premature delivery consists of cervical consistency, insertion resistance to external os of uterus by internal examination, and cervical length and funneling of internal os of uterus measured by transvaginal ultrasonography. The full AIWA’s score is 12 point, which means extremely high risk of premature labor. On the other hand, 0 point means no risk of it. Then, P-score (0–3) consists of the history of early delivery, abortion after 18 weeks of gestation, present multiplicity and so forth. AIWA’s score

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þ P-score ¼ AP-score. (A) From 1998 to 2000, in case with AP-score >8, before 26 weeks of gestation, patients had cervical cerclage if they wanted after severely informed consent. We compared some parameters between C- and A-stage. Results: The rate of premature delivery declined (from 4.5 to 3.2%