P114Fetal echocardiography in chromosomally normal fetuses with increased nuchal translucency. A preliminary report

4±7 October 2000, Zagreb, Croatia Posters

Posters

E A R LY P R E G N A N C Y

P01First trimester normograms for a wide variety of ultrasound,hemodynamic and serum parameters

V. Serra-Serra, J. E. Serrano, M. J. Ballester, C. Lara, J. Bellver andF. Bonilla-MusolesHospital Clinico Universitario and IVI Departamento POG, Facultadde Medicina, Universidad de Valencia, Spain

Background: The aim of the study was to assess prospectively theevolution of multiple clinical parameters throughout the first trimesterof pregnancy.Method: A transvaginal ultrasound examination and a blood test wasweekly performed until the 13th gestational week in a group ofhealthy volunteers. A total of 25 spontaneously conceivedsingleton pregnant women with good pregnancy outcome finallycompleted the study. The evolution of 10 transvaginal ultrasoundparameters, 5 Doppler measurements and 6 serum parameters wasstudied.Results: An increasing trend with advancing gestation was evident forthe mean gestational sac (MSD) and amniotic sac (AS) diameters,trophoblastic rim, CRL and serum progesterone. The uterine,umbilical and fetal cerebral arteries PI decreased with advancinggestation. The FM yolk sac (YS) diameter and b-hCG levels showedan initial rise and a final decrease. A great interindividual variationwas evident for the b-hCG titer. The YS/CRL progressivelyapproached to 0, whereas the MSD/CRL and the AS/MSD progres-sively approached to 1. The corpus luteum diameter, corpus luteumarteries PI, subehorionic arteries PI, complement levels (C3 and C4),platelet count and activated partial thromboplastin time experiencedminimal changes.Conclusion: First trimester normograms for multiple clinical para-meters are provided.

P02The first results of the ultrasound transvaginal screening inearly pregnancies in Kazan city, Tatarstan, Russia

L. Teregoulova, L. Bajazitova, A. Latypov and L. ShajhutdinovaRepublican Clinical Hospital of Ministry of Health of TatarstanRepublic, Russia

In 1 January 2000 in order of Tatarstan Health Care Ministrytransvaginal first trimester screening was introduced in Kazan city. Allpregnant women have to be examined in one of 5 the medical centers.

We present the results of six month screening for all pregnantwomen between 10 and 14 weeks gestation.Method: Routine transvaginal ultrasound examination included themeasurement of fetal crown-rump length, nuchal translucency andestimation of fetal anatomy.Results: A total 1620 pregnant women of 10±14 weeks of gestationwere examined from January till June 2000. All abnormalities weredetected at the 12±13 weeks gestational ages. The increasing ofnuchal translucency thickness were found in 23 cases, 7 of themchromosomal defects had, in this group in 5 cases cystic hygroma withhydrops were identified.

In 12 cases structural anomalies were found: 1-body stalk anomaly,1 case-omphalocele with liver in it, 1-holoprosencephaly withproboshisis and microphtalmia, 1-encephalocele, 3-acrania, 5-anen-cephaly. In the cases of holoprosencephaly and encephalocele nuchaltranslucency measured at 10±11 week was normal.Conclusion: Even the first results of early pregnancy transvaginalscreening show its great significance in our city. The most adequateperiod for transvaginal screening is 12±13 weeks.

P03The value of ultrasound screening for fetal abnormalities inthe first trimester

A. TankoÂ*, G. Y. Steinmetz, AÂ . Varga, A. G. KovaÂcs, G. Y. GodoÂ ,T. Marton and Z. Papp Z.²*Department of Obstetrics and Gynaecology, County HospitalKecskemeÂt, ²University Department of Obstetrics and Gynaecology,Semmelweis University, Budapest, Hungary

Objective: Evaluation of routine screening in the early pregnancy bytransvaginal sonography (TVS) in an unselected population. Designand methods: A routine ultrasound examination was offered to everywoman in the 12th week of her pregnancy. Besides a detailed survey offetal anatomy, a measurement of nuchal translucency and karyotypingwas performed as appropriate.Results: In a five-year period (from 1. Jan. 1995 ± to 31. Dec. 1999)9556 women were examined. Fetal anomalies were diagnosed in 54cases at the 12th week of pregnancy: 63 morphological abnormalitiesand 16 chromosomal aberrations. The detection rate for structuraland chromosomal abnormalities in early pregnancy was 50.5% (54/107) of all anomalies, which were diagnosed antenatally.Conclusions: It is possible to detect fetal abnormalities very early inpregnancy. The ultrasound screening may increase the detection rateof chromosomal disorders. The interpretation of fetal anatomy in thefirst trimester requires comprehensive understanding of embryologicaldevelopment. The detection rate of fetal malformations is increasedsignificantly by introducing an early pregnancy scan in addition to themid-trimester scan. The fetopathological examination can add moreinformation to the clinicians and to genetic counselling.

P04Pre-abortion ultrasonography

A. BalicÂ, D. BalicÂ, B. BalicÂ, S. BerbicÂ and I. ZukicÂDepartment of Ob/Gyn, University of Tuzla, Health Centre, Bosniaand Herzegovina

Background: The aim of this study was to audit prospectively thevalue of pre-abortion ultrasonography.Methods: All women who came in our Centre because of doubt unplannedpregancy in first trimester from March 1994 to March 1996 were underwentan exam by vaginal ultrasound before abortion. We analysed these data andcompared them with complications after legal induced abortion.Results: During two years a total of 334 women were surveyed.Twenty-seven women (8.08%) were not being pregnant. In thirty-three cases (10.75%) the pregnancy was greater for two weeks thanwe expected on the basis of last menstrual period. Also we founded:21 (6.84%) myoma uteri, 5 (1.62%) ovarian cysts, 5 (1.62%) multiplepregnancy, 4 (1.3%) anomaly of the uterus, 1 (0.32%) blighted ovumand 1 (0.32%) nuchal translucency greater than 5 mm.Conclusion: Pre-abortion ultrasonography increases security of thisintervention by elimination some problems about induced abortion.Since the elimination is simple, fast and cheap we recommended it forroutine use. We hope that is one of the way for decreasing of latecomplications after abortion like as infertility.

P05Use of prognostic biophysical test in the prediction ofspontaneous abortion risk in early pregnancy

K. Bøaszczyk, M. Wojcieszyn, A. èukasik, M. Biemat and R. PorqbaIV Department of Obstetrics and Gynaecology, Silesian UniversitySchool of Medicine, Katowice, Poland

Ultrasound in Obstetrics and Gynecology 67

Background: The aim of the study was to introduce PrognosticBiophysical Test (PBT) in ultrasound diagnostic practice to evaluatespontaneous abortion risk in the first trimester of pregnancy. PBTconsists of 3 routine USG parameters estimated together: CrownRump Length and Yolk Sac (YS) measurement and visualization ofFetal Heart Rate (FHR).Method: USG examination with, 7.0 MHz transvaginal Bruel & Kjaertransducer was performed in 199 pregnant women between 5 and12 weeks of pregnancy. YS diameter and cram-rump length weremeasured and compared to nomograms. FHR presence or absence wasstated. PBT score was 1 point for correct value off each parameter, and0 for incorrect one. PBT score of 3±2 points were considered to begood prognostic value, 0±1 points as poor prognostic value. PBTresults were compared with pregnancy outcome.Results: PBT allowed prediction of spontaneous abortion with asensitivity of 97%, specificity of 67%, false positive of 33%, falsenegative of 3% and positive predictive value of 72%.Conclusion: The test called by the authors PBT seems to be a simpleand sensitive option in prediction of spontaneous abortion risk in thefirst trimester of pregnancy using ultrasound examination.

P06Isolated hyperechogenic foci in the fetal thalamus in earlypregnancy

M. Bronshtein*, E. Z. Zimmer*, R. O. N. Auslander² and S. Blazer³Departments of Obstetrics and Gynecology*, and Neonatology³Rambam Medical Centre, and Departments of Obstetrics andGynecology², Carmel Medical Centre, Faculty of Medicine,Technion±Israel Institute of Technology, Haifa, Israel

Background: The purpose of this study is to describe the monographicfeatures and outcome of fetuses with isolated hyperechogenic foci inthe thalamic region.Method: A detailed monographic survey was performed in 46244consecutive pregnancies. Both low and high-risk pregnancies wereincluded. Transvaginal examinations were performed at 14±16 weeks' gestation, while transabdominal examinations were per-formed after 18 weeks' gestation.Results: Isolated hyperechogenic foci in the thalamic region wereobserved in 7 fetuses. All cases were diagnosed at 14±16 weeks'gestation. Six fetuses had one hyperechogenic focus, and one fetus hadtwo foci. The size of these foci ranged from 2 to 4 mm. A serologicwork-up was negative in all these fetuses and their karyotype wasnormal. The hyperechogenic foci disappeared in mid-pregnancy in allcases, and fetuses were normal at delivery and on follow-up up to theage of 9 years.Conclusion: Isolated hyperechogenic foci in the thalamic region in theearly pregnancy have probably a benign nature.

P07Fetal gender determination in the first trimester using thetransverse view: the importance of the third point

D. A. L. Pedreira, A. Yamasaki and C. CzeresniaClinica de Assistencia a Mulher, Laboratorio Fleury, SaÄo Paulo, Brazile-mail: [email protected]

Aim: To determine the accuracy of fetal gender determination between11±13 weeks of pregnancy.Material and methods: Retrospective evaluation from October 1997to July 1999. Transabdominal sonography using 3.5±5.0 MHzcurvilinear probes. Fetal gender was evaluated at the transverse viewof genital region. Male gender was considered when three hiperecogenicpoints, triangular in shape (probably corresponding to the escrotum(`two points') and falus (`third point') were visible. Female gender wasconsidered when only two parallel white lines were observed (probablycorresponding to the falus pointing to the caudal fetal region.Results: 166 singleton pregnancies had fetal sex determined after birthand/or after cytogenetic results. Total accuracy in determining fetalsex was 82.1%. The most frequent error was evaluating as female themale fetuses.

Conclusions: Recent studies on fetal sex determination in the firsttrimester used mainly the longitudinal view of the fetus to thisevaluation. In this study, we describe the presence of the `third point'as an important sign in the characterization of fetal gender, in thetransverse view, during the first trimester.

P08Case report: transvaginal ultrasonographic aspiration in themanagement of an ovarian cyst detected at the seventhgestational week

B. Tekin, H. Hassa, T. SËener and I. SaracËOsmangazi University, Faculty of Medicine, Department of Obstetricsand Gynecology, Eski8ehir, Turkey

Objective: To discuss a different approach, other than cystectomy, toan ovarian cyst detected at early gestation due to the risk of torsion.Case report: During ultrasonographic control of a pregnant at sevenweeks of gestation, 30-year-old with two gravidity, one parity and oneliving child, a cyst with regular contour, measuring 150 � 130 mmwith a wall thickness smaller than two mm was detected. By Dopplerevaluation, vascular pattern could not be detected on the cyst wall. Ca125, AFP, CEA levels were measured as 41.4 U/ml, 2.4 IU/ml, 1.2 ng/ml, respectively. The cyst was aspirated by a 17 g needle throughposterior fornix with the assistance of tranvaginal ultrasonography. Incytological evaluation of the cyst fluid, no malignant cells were found.The case was called for control at 12th week of gestation which wasknown as the week of the completion of luteoplacental shift.Conclusion: Since ca125 levels could be increased by pregnancy andthere was no malignant feature except the dimensions of the cyst, thecyst was supposed to be benign and a conservative approach wasplanned. Corpus luteum is necessary for the continuation ofpregnancy at these weeks of gestation so the anxiety about cystectomywas the termination of pregnancy due to corpus luteum deficiency. Onthe other hand, however, expectant management could not also bechosen, because the risk of torsion was high due to the texture,dimensions and mobile characteristic of the cyst. For this case whowas at a younger age for ovarian malignancy the shrinkage of the cystby aspirating it with the assistance of transvaginal ultrasonographywithout dysfunctioning corpus luteum, was decided. The managementcould be changed according to the cytological evaluation.

In conclusion, at the early weeks of gestation, transvaginal cystaspiration could be a way of management by decreasing the torsionrisk without being a handicap for the continuation of pregnancy.

P09Flow velocity waveforms in the spiral artery versus AFP andBHCG maternal serum concentration in pregnancycomplicated by threatened abortion

A. Persona-SliwinÄ ska, J. Brazert and R. BiczyskoDepartment of Gynecology and Obstetrics, Karol MarcinkowskiUniversity of Medical Sciences, PoznanÄ , Poland

Objectives: The aim of the study was to determine the values ofresistance index (RI) and pulsatility index (PI) in the spiral arteries andto evaluate the maternal serum concentration of AFP and b-hCGtrying to find correlation between these parameters in the patients inearly pregnancy complicated by threatened abortion.

GA (weeks) CRL (mm) n

Correct

N %

11±11 1 6 43.8±55.3 46 35 76.112±12 1 6 55.4±67.9 74 60 81.113±13 1 6 68.0±81.7 46 43 93.5Total 166 134 80.7

10th World Congress on Ultrasound in Obstetrics and Gynecology Posters

68 Ultrasound in Obstetrics and Gynecology

Study methods: We have analysed 32 pregnant women between 5thand 12th weeks of pregnancy diagnosed as threatened abortion. In allpatients TV ultrasound with pulsed color doppler was performed. TheRI and PI were calculated for blood flow obtained from the spiralarteries. The concentration of AFP and b-hCG in maternal serum wasevaluated by immunoassays.Results: 32 velocity waveforms from spiral arteries were analysed andblood flow indices were calculated. We have found statisticallysignificant negative correlation between the values of both blood flowparameters (RI & PI) and successive weeks of pregnancy. In the testedgroup in 37.5% of patients the level of b-hCG was low. There wasstatistically significant correlation between serum b-hCG, AFPconcentrations and blood flow parameters.Conclusions: Only the combination of Doppler blood flow analysis inspiral arteries and evaluation of AFP and b-hCG in the maternalserum performed in first trimester may be useful for the intensive fetalmonitoring of high risk pregnancies.

P10Development of cardiac size in early pregnancy

P. Rosati and L. GuarigliaDepartment of Obstetrics and Gynecology, Catholic University of theSacred Heart, Rome, Italy

Background: The relationships between measurement of cardiaccircumference, obtained by transvaginal sonography in early preg-nancy, and other sonar fetal parameters ± crown rump length,biparietal diameter, head, toracic and abdominal circumference,femur, humerus and foot length ± were analysed in order to assessthe role of these variables for the identification of fetuses at risk ofabnormal cardiac development.Methods: Study population consists of 1435 euploid fetuses at 9±16 weeks of gestation. Ultrasound examinations were performedusing high-resolution apparatus (model SSA-270 A and SSA-340 A;Toshiba Medical Corporation, Tokyo, Japan) equipped with 5.0±7.0 MHz transvaginal probes with a maximal angle of vision of 868

and 1218, respectively. au scans were performed by the authors.Nomograms were established for cardiac circumference vs. eightsonographic parameters.Results: Cardiac circumference demonstrates to be highly correlatedwith abdominal circumference (r2of 0.65) with narrow confidenceinterval of cardiac circumference ranging from 6 to 19%.Conclusion: Our results showed also a good correlation betweencardiac circumference and the other variables suggesting that cardiacmeasurement in early pregnancy could be a screening tool foridentifying fetuses at risk of disorders affecting heart growth.

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

P11Fetal scanning between 18 and 22 weeks is passeÂ

M. BronshteinHaifa, Israel

Our study summarizes about 40000 early transvaginal examinations(14±16 weeks gestation). There were more than 1200 anomalousfetuses which demonstrated more than 1700 anomalies. We analysedthe anomalies according to (1) early onset anomalies, (2) transientanomalies which disappeared toward the second trimester (nuchalfindings, echogenic bowel, hypospadias., etc.), (3) anomalies whichare much more easily detected in early pregnancy (vascular ring, rt.aortic arch, coarction, finger anomalies, kidney anomalies and others),(4) abnormalities which appear or manifest only in late pregnancy(lissencephalos, achondroplasia, etc.).Conclusions: The percentage of late onset abnormalities is lower thanfor transient abnormalities. Therefore, performing only one examina-tion by an expert will detect 97% of the detectable abnormalities inearly pregnancy. Performing only one examination between 18 and22 weeks will reveal a lower rate of the detectable anomalies. Most ofthe late onset anomalies appear later than the 22rd week of gestation.Therefore, the 18±22 week scan is passeÂ and should give way to the14±16 week TVS scanning in the search for fetal anomalies.

P12High sensitivity of routine ultrasound scan at 20±24 weeksfor detection of fetal anomalies

S. C. Cha, O. T. Toma, G. Braia, M.B. Carvalho and D. L. PedreiraFetal Medicine unit, LaboratoÂ rio Fleury, SaÄo Paulo, Brazil

Aim: To emphasize importance of experienced sonographer fordetection of fetal anomalies.Materials and method: 2726 routine scans were performed at 20±24 weeks for the detection of fetal anomalies between February 1997and May 2000. All scans were performed by five sonographers withmore than 10 years' experience and the duration of scan examinationwas 30±60 min. The scan protocol included not only visualization offetal structures but also besides classical fetal biometry, we performedadditional measurement of fetal structures such as cerebellar distance,ocular, cysterna magna, nuchal fold, length of nose bone, atrium of

lateral ventricule, cardiac and toracic area, renal pelvis, iliac angle,relation feet/femur length, length of femur, tibia, fibula, humerus,radius and ulna.Results: Ultrasound scans were able to detect 67 anomalies in a totalof 74 malformations observed at delivery. The sensitivity of themethod when performed by a highly skilled sonographer is 90%. Atotal of 7 anomalies were not diagnosed by ultrasound at 20±24 weeks, including 2 esophageal atresia with distal fistula and 5perimembranous interventricular communication.Conclusions: Ultrasound scanning for fetal anomalies is highlysensitive when performed by highly skilled sonographers. However,minor cardiac malformations for a low risk population is still thechallenge for sonographers.

P13The impact of transvaginal obstetric ultrasound scan in highrisk pregnancy

G. R. G. Benute, V. Wojciechowski, T. V. Dias, P. Cianciarullo,J. Quayle, Burlachini, V. Bunduki, R. Yamamoto, S. Miyadahira,M. C. S De Lucia and ZugaibPsychology Division and Obstetric Department, Hospital dasClõÂnicas, SaÄo Paulo University Medical School, SaÄo Paulo, Brazil

Background: The acceptance of transvaginal ultrasound amongBrazilian pregnant women is not yet established.Objective: To evaluate the level of acceptance of transvaginalultrasound (US) among high risk pregnant women.Method: Psychological semi structured interview with 50 pregnantpatients scheduled to undergo ultrasound exam.Results: 94% of the patients arrive without knowing they are going toundergo a transvaginal US and 80% believe they are going to undergoa regular abdominal US. Asked about the utility of transvaginal US,46% didn't know; 70% didn't have any preferences about the sex ofthe ultrasonographist. After the exam, 76% of the patients referred noparticular discomfort, but 46% would prefer to have an abdominal USscan if they could choose, but all emphasized they would undergo theexam again if the doctor said it was necessary. As far as sexuality, 12%mentioned some difficulty with the partner and 40% referred that it ishard for women to discuss subjects related to sex.Conclusion: The discomfort eventually associated to transvaginal US



is not related to the sex of the examiner but to his attitude. Patients'fantasies play an important role in the emotional discomfort elicitedby the situation where cultural aspects are deeply imbricated.

P14Sonographic features of the cervix in the midtrimester as apredictor of preterm delivery

T. Fukami, T. Sekiya, K. Yoshimatsu, T. Otabe, K. Tsukada,K. Ishihara and T. ArakiDepartment of Obstetrics and Gynecology, Nippon Medical School,Tokyo, Japan

Background: The purpose of this study was to predict preterm deliveryby transvaginal ultrasound in the midtrimester.Method: This prospective study was conducted on 568 outpatientswith normal pregnancy up to 16 gestational weeks. After the patient'sconsent was obtained, serial transvaginal ultrasound scanning (TVS)was planned at 2±4 weekly intervals from 16 to 27 gestational weeks,and used to assess cervical length, cervical gland area and internal osdilatation.Results: (1) The preterm delivery (37 weeks gestation) rate of thepatients was 3.0% (17/568). (2) Of the three predictive factors ofpreterm delivery namely shortened cervical length (30 mm), absenceof cervical gland area, and internal os dilatation, the most usefulmonographic feature of the cervix was absence of cervical gland areaexamined at 16±19 weeks gestation. (3) The combination of thesefactors at 16±19 weeks gestation improved the predictive value(sensitivity 35%, specificity 99%, positive predictive value 88%,negative predictive value 96%).Conclusion: For the prediction of preterm delivery by TVS in themidtrimester, the most appropriate gestational period was at 16±19 weeks, and the best predictive factor was a combination of theabsence of cervical gland area with shortened cervix and internalosdilatation.

P15Cervical cerclage: comparison of two techniques bytransvaginal ultrasound

P. Rozenberg, A. Gillet and Y. VilleUniversity Paris-Ouest, Department of Obstetrics and GynecologyCHI Poissy-St Germain, France

Background: Cervical cerclage can be performed using either theMacDonald technique or following an anterior colpotomy (Shirodkartechnique). A randomized study comparing the two techniques wouldbe impossible to run since 1900 patients would have to be included ineach arm.Objective: To evaluate the benefit of performing a colpotomy prior toputting a cervical suture, by measuring the distance between the stitchand the external os.Design and methods: Retrospective case-control study (January 1997±January 1999). All patients having had cervical cerclage after anteriorcolpotomy and giving birth in our Institution were the study group.Each case was matched with the next patient giving birth in ourInstitution after having had a MacDonald cerclage. The indicationwas left to the surgeon's decision and each surgeon used only onetechnique. Obstetrical characteristics were recorded and ultrasoundmeasurement of the cervix was performed within 8 days following theprocedure.Results: During the study period, there were 15 cases in each group.There was no significant difference between the two groups in theobstetrical outcome. Cervical length was 36.6 mm and 35.4 mm,and the distance between the stitch and the external os was 16.1 mmand 13.5 mm in the Shirodkar and the MacDonald groups,respectively.Conclusion: Anterior colpotomy did increase the distance between thestitch and the external os by only 2.6 mm and does not seem to offerany clinical benefit.

P16Office ultrasonography in obstetrics: an eight year experience

E. A. Assimakopoulos1st Department of Ob/Gyn. Aristotle University of Thessalonki,Greece

Background: We present an eighth year experience (1991±98) ofultrasonography in a private office, using a portable ultrasound unit,Aloca SSD-500.Method: Each pregnant woman underwent transvaginal ultrasoundexamination 7±8w in order to date pregnancy, to confirm fetalviability and the number of fetuses. At 17 weeks, a second trimesterscreening for Down syndrome was ordered by using BPD, maternalage and maternal serum AFP and free b-HCG. Later, at 20±22w adetailed scan was performed to all pregnant women in order toexclude fetal anomalies.Results: In 1019 consecutive pregnant women, 22 could not recall thedate of their LMP and 59 had irregular cycles. By measuring the CRL,the expected date of delivery was accurately calculated. One hundredand seventy-six women underwent amniocentesis with no complica-tions, and from these, there was only 1 case with trisomy 18. Allpregnant women had level II scan. There were 5 cases withabnormalities (1 cystic hygroma, 1 diaphragmatic hernia, 1 withtalipes, 1 anencephalic and two with hydrops). We couldn't diagnoseprenataly 1 case with coarctation of the aorta, 1 anorectal atresia, 1microcephaly and 3 with Down Syndrome. All the other womendelivered babies with normal anatomy. As far as the cost is concerned,there was no extra charge for ultrasound examinations.Conclusion: Office ultrasonography is feasible after long-term trainingand experience.Acknowledgements: W. R. Lees and J. C. Hobbins.

P17At what gestational age can the corpus callosum and cavumsepti pellucidi be regularly seen at routine obstetricalultrasound examination?

A. ToiUniversity Health Network, Toronto General Hospital, Toronto,Canada

Background: Agenesis of the corpus callosum (ACC) is reported to bedifficult to detect before 22 weeks gestation. However, the cavumsepti pellucidi (CSP) develops with the CC and is seen by 15±16 weeks. Thus, ACC should be detectable by 16 weeks.Purpose: To determine at what gestational age the cavum septipellucidi and corpus callosum become regularly visible and henceACC can be suspected if they are not visible.Methods: Fifty consecutive women referred for US for all indicationsbetween 25 June and 9 July 1999 were scanned trans-abdominallywith specific attempt to see the cavum septi pellucidi (CSP) and thecorpus callosum.Results: BPD ranged from 32 (15.6 week) to 81 mm (33.1 week). TheCSP was visible in every fetus starting at BPD 34 mm (16.2 week). Onmid sagittal views the CC was also visible starting at BPD 34 mm(16.2 week) in all but 3 fetuses due to fetal position. The CC was seenwell enough to confidently measure its length in 27/49 (55%).Conclusions: At routine examination, the CSP was detectable by16.2 week (BPD 34 mm) gestation and in every pregnancy after thisage. Using only trans-abdominal scans, the CC was visible on sagittalviews by exploiting access provided by sutures and fontanelles.Detection of complete agenesis of the corpus callosum should bepossible by 16 weeks gestation.

P18Fetal cerebral ventriculomegaly. An observational study

R. Pinzano, J. Meir, R. Natale, G. C. Conoscenti, L. Fischer-Tamaro,G. P. Maso, P. Bogatti, M. A. Rustico and G. D'OttavioIstituto per l'Infanzia `Burlo Garofolo', IRCCS, Trieste, Italy

Background: The aim of this study is to review all the cases of FCV



diagnosed in the Obstetric and Gynecology Unit of our Institutionfrom 1990 to 1999 and to evaluate the neonatal outcome.Method: This is a retrospective study. The diagnosis of ventriculome-galy is according to Cardoza criteria and to atrial width $ 10 mmbetween 15 and 40 weeks gestational. For all cases we consider:progression and/or resolution; association with other fetal ultrasoundsigns of malformations and with chromosomal abnormalities; fetalinfections (TORCH); pregnancy termination and follow-up bypediatric report. In cases of interruption of pregnancy we evaluatepostmortem examination.Results: Among 165 cases of FCV, n 84 (50.9%) are associated withmalformation of SNC, n 59 (35.76%) are isolated, n 22 (13.33%) areassociated with other fetal malformations. In the group of isolated: 32case are borderline (# 15 mm), chromosomal abnormalities are 4among 40 evaluated (10%), favourable neonatal outcome is present in22 cases of 29 born (75.86%).Conclusions: In this study the percentage of chromosomal abnorm-alities in the FCV isolated is higher than other series in the literature.The reproducibility of measurement of atria rather permits compar-isons than other qualitative and quantitative signs.

P19Evaluation of fetal lung maturity by the gray level histogramwidth

M. Serizawa and K. MaedaDepartment of OG/GY. Hamamatsu Medical Center, and Departmentof OB/GY. Seirei Hamamatsu Hospital, Shizuoka, Japan

Maeda has normalized gray level histogram width (GLHW) of fetallung and liver. The fetal lung GLHW was less than 30% and smallerthan the liver in 24±29 weeks. However the fetal lung GLHW wassimilar to the liver and over 30% after 30 weeks. We suggest thischange of GLHW have relation to fetal lung maturity.Method: The histogram was described with Aloka SSD-1200, the1250pixels were set at fetal lung and liver. GLHW is obtained by thehistogram base length is divided by the full gray scale length. The 10fetuses lung and liver were recorded in 24±31 weeks, and amnioticfluid samplings by transvaginal or amniocentesis were examinedmicrobubble test. They were delivered during 1±3 days later, wediagnosed RDS or nonRDS by clinically.Result: The GLHW of fetal lung/liver was 32.45/34.03 in 5 fetuses lessthan 10 microbubble rate and nonRDS (Group 1), no significantdifference. The GLHW of fetal lung/liver was 30.23/34.44 in 5fetuses over 10 microbubble rate and RDS (Group 2), significantdifference (PAÊ AÊ 0.016). The fetal lung GLHW was no significantdifference in group 1 and 2 (32.45/30.23) (P � 0.064), however, inthe over 30 fetal lung GLHW, 5 were nonRDS and 2 were RDS, inless than 30 fetal lung GLHW, all are RDS, significant difference(P � 0.04).Conclusion: The fetus of fetal lung GLHW is smaller than liver andless than 30 is almost RDS, the case of fetal lung GLHW is larger thanliver and over 30 is almost nonRDS.

P20Early membrane funnelling may occur from 16 weeksonwards and carries a worse prognosis

J. Bellver, G. Lberico, C. Lara, J. Ferro, J. RemohõÂ, A. Pellicer andV. Serra-SerraInstituto Valenciano de Infertilidad & Departamento POG, Facultadde Medicina, Universidad de Valencia, Spain

Background: Sonographic screening for cervical incompetence duringpregnancy is currently a routine procedure. However, no consensusexists on the optimal gestational age to perform such screening.Method: Serial transvaginal ultrasound examinations of the uterinecervix were routinely performed from 12 weeks onwards. Thescreening was considered positive when membrane funnelling waspresent or the cervical length was , 2 cm. Therapeutic measuresincluded bed rest, antibiotics, tocolytic treatment and a modifiedMcDonald's cervical suture (up to 25 weeks).

Results: Membrane funnelling was detected between 16 and 22 weeks(group A) in 9 women (31%); between 23 and 28 weeks (group B) in11 women (38%) and between 29 and 36 weeks (group C) in 9women (31%). Two women presented with hourglass membranes at20 and 23 weeks, respectively. Comparison between groups A and Bshowed similar women characteristics and risk factors (P � NS).Delivery rate at # 28 weeks was higher in group A (62.5%) than ingroup B (9.1%) (P , 0.03). Only one woman in group A and three ingroup B delivered at term.Conclusion: This small series provides evidence to recommend serialmonographic examinations of the uterine cervix, starting at 16 weeks.A greater risk of very premature delivery was evident when membranefunnelling was diagnosed before 23 weeks.

P21Fetal liver volume in normal and reduced fetal growth

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

Background: To establish reproducibility and normal values for fetalliver volume and its significance in identifying fetal growth restrictionrelative to head (HC) and abdominal circumference (AC) according toa cross-sectional study design.Method: The measurements were obtained using a Voluson 530-D forvolume scanning. The coefficient of variation (CV) for liver volumescans (t0, t20 min) and liver area tracings (t0: 2x; t20: 2x) wasdetermined (n: 20; 23±36 weeks). Normal charts for liver volume,HC, AC were constructed (n: 60; 22±37 weeks) and related to datafrom growth-restricted fetuses (birthweight , P5) (n: 13; 23±36 weeks).Results: CV is 2.9% for volume scans and 1.6% for area tracings.Mean liver volume (P50) ranges between 16.5 mL (^ 5.9 (SD)) at22 weeks and 101.8 mL (^ 8.2 (SD)) at 37 weeks. In fetal growthrestriction, liver volume, HC and AC expressed as percentage of thenormal P50 is 45%, 91% and 83%, respectively. Mean difference inliver size between fetal growth restriction (FGR) and normal fetaldevelopment (Z score � Liver volumeFGR ± P50normal/SDnormal) is24.5 ^ 1.6 (SD), which is significantly different (P , 0.05) from HC:2 3.2 ^ 1.5 (SD), but not from AC: 2 4.3 ^ 1.3 (SD).Conclusion: Acceptable reproducibility exists for liver volumedeterminations. Normal liver volume increases 6-fold at 22±37 weeks. Fetal growth restriction: reduction is more pronouncedfor liver volume than HC and AC; liver volume is a betterdiscriminator than HC, but not AC.

P22The efficacy of IUGR treatment with argininÐthe ultrasoundassessment: preliminary report

P. Sieroszewski, J. Suzin, G. Surkont and A. Karowicz-BilinÂ iskaMadurowicz Hospital, Institute of Obstetrics and Gynecology,Medical Academy, University of èoÂdzÂ, Poland

Objective: To study the efficacy of IUGR treatment with arginin withthe use of ultrasound biometry measurements.Design and methods: A pilot study was performed on 45 pregnantwomen with IUGR fetuses (EFW , 10%ile). 30 patients were treatedwith arginin 2 g daily po during 20 days (I group). 15 patients werenot treated (control-II group). After 3 weeks ultrasound measure-ments were repeated.Results: The increase in EFW was greater in I group (587 g vs. 321 g,P , 0.005). After delivery we noticed differences in weight betweenboth groups, but they were not statistically significant (2753 g vs.2495 g, NS). Percentage of IUGR newborns was higher in 11 group(29% vs. 73%, P , 0.005).Conclusions: 1. EFW (ultrasound assessment) is useful to superviseIUGR fetuses treated with arginin. 2. Arginin treatment of IUGRfetuses is often skuteczne. The project is ongoing. (KBN 4 P05E01616).



P23Ultrasonographic weight estimation of the macrosomic fetus:the benefit of two examiners

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

Background: Using two examiners to obtain more accurate estimationof fetal weight (EFW) in suspected macrosomy is commonly accepted.However, the real benefit of such routine has not been validated.Aim: To validate and calculate the benefit of using two examiners forincreasing the accuracy and decreasing errors of more than 10% inEFW of macrosomic fetuses.Methods: Fifty term fetuses suspected for macrosomy were examinedby two examiners. The accuracy and the number of errors of EFW ofmore than 10% were calculated for each examiner, and compared toan average estimation of both examiners.Results: The average birth weight was 4140gr. The estimationaccuracy of the examiners was 5.83% and 6.18% (N.S.). Using anaverage estimation of both examiners the accuracy increased to 5.75%(N.S.). However, using two examiners decrease the number of errorsof more than 10%. Twelve fetuses were estimated erroneously by atleast one examiner. Only 6 fetuses were estimated erroneously whenthe EFW was based upon the average of the two examiners.Conclusion: Although the use of two examiners for EFW inmacrosomic fetus doesn't increase the accuracy, it decreases errorsof more than 10%.

P24Fetal porencephaly as a rare complication of epignathusoccluding blood flow in the internal carotid artery

B. Lex*, C. Berg*, E. Reusche², D. Masson³ and U. Gembruch*Division of Prenatal Medicine* & Department of Pathology²,University of LuÈbeck, Hamburg³, Germany

Background: Epignathus is a rare benign congenital teratoma of thehard palate. Some of these tumors protrude bidirectionally involvingpharyngeal as well as intracranial structures. The poor prognosis ofthe affected fetuses is due to consecutive airway obstruction anddestruction of brain tissue. We report an unusual case of epignathusleading to compression of the internal carotid artery with subsequentporencephaly.

In a 27-year-old gravida 1 at 25 weeks gestational age withpolyhydramnios, ultrasound examination demonstrated extensiveepignathus with displacement of adjacent structures, hydrocephalyand porencephaly. Neither brainstem nor cerebellum could be clearlyidentified. A steal effect was excluded as low tumor vascularisationand high resistance indices of the supplying vessels was demonstrated,therefore porencephaly was suspected to be caused by vascularcompromise. Amniocentesis revealed a normal karyotype. The parentselected to terminate the pregnancy. Autopsy results were confirma-tory. An immature teratoma of the hard palate measuring95 � 42 � 32 mm compressing the left internal carotid artery wasdemonstrated, leading to colliquation necrosis of the left hemisphere.Additionally displacement of brainstem and infiltration of cerebellumled to cerebrospinal fluid block and consecutive hydrocephalus.Conclusion: Only few reports exist on the prenatal diagnosis ofepignathus. We report the first case of epignathus causing extensivebrain damage by vascular compromise.

P25An alobar holoprosencephaly; a case report

A. GuÈ lDept of Ob/Gyn, Turkey

Alobar holoprosencephaly characterised by median malformations ofthe face and brain due to incomplete cleavage and morphogenesis ofthe fore brain. The alobar holoprosencephaly occur in about 0.6±1.9of 10.000 deliveries. Median facial abnormalities consist of orbitalhypotelorizm, cyclopia in combination with a flat nose or proboscis

and oral deformities can be diagnosed with ultrasonographicaly at theearly antenatal period. In this case report we introduced a fetus withan alobar holoprosencephaly diagnosed at 24 weeks of gestationaccording to BPD and FL measures. In obstetric ultrasonography,spinal cord, vertebras and spinal canal were normal in structure, butinterhemispheric fissure, falx cerebri and corpus callosum were notvisualised. There was single-chamber ventricle in semihiron shape thatcontinued with a dorsal cyst filing the calvarium. Decision forpregnancy termination was made after the consultation with thepediatricians. In neonatal examination, there was no gross deformity ofthe trunk and extremities. As a facial deformity, cyclopia and 3 � 2 cmsized proboscis attacked above the insignificant nasal structure wasdetected and only one eye was present at the middle of the face.

P26Congenital Rubella syndrome and fetal exencephaly ± casereport

J. Q. Andrade, S. Miyadahira, S. P. Curtis, C. A. Figueiredo,R. M. Yamamoto and ZugaibDepartments of Obstetrics and Gynecology, SaÄo Paulo UniversitySchool of Medicine, SaÄo Paulo, Brazil (FMUSP)

Exencephaly is characterized by a complete or partial absence of theskull'cap, follwed by abnormal development of the cerebral tissue.

We report a case of a 31-year-old, white patient, on the 9th. week ofher second gestation who presented with fever, coryza and myalgia. Thegestational period was calculated based on the first ultrasonography, andthe maternal sorology for rubella was positive (IgG and IgM).

The patient was send to the department of Fetal Medicine-HCFMUSPfor evaluation. Morphologic ultrasonography and another sorology forrubella were performed. On the 12th gestation week, ultrasonographyrevealed absence of the skullcap and the presence of cerebral tissuefloating in the amniotic fluid. Maternal sorology still showed positive(IgG and IgM). The patient suffered a miscarriage and the maternal (fetusand placenta) was analyzed at the Virology Department of Adolfo LutzInstitute. The virus of rubella was isolated in all the examined organs,and the presence of congenital rubella was confirmed.

Considering that the etiology of this malformation is still umknownand is associated with a severe congenital infection we speculate that iscoul be a consequence of the massive fetal compromise caused by therubella virus.

P27Unusual fetal infection leading to early IUGR andhydrocephaly: case report

D. A. L. Pedreira, D. Jasinowodolinsk, A. J. Rocha, R. Schultz,M. C. N. Zerbini and S. C. ChaLaboratoÂ rio Fleury, SaÄo Paulo, Brazil. [email protected]

LRK, 34 years-old, primigravida, had first scan done at 10 weeks1 day with CRL compatible with 9 weeks 1 5 days. At 12 weeks2 days, nucal translucency measured 1.0 mm, Doppler velocimetry ofductus venosus (positive A wave) showed posite A wave and CRLmeasured 46 mm (11 weeks 4 days). At 21 weeks 1 6 days theanomaly scan revealed dilatation of cerebral ventricles, asymmetricIUGR (measurement compatible for 17w 1 6d), oligohydramnios andsevere placentomegaly. Amniocentesis showed normal karyotipe(46XX). MRI was performed at 22 weeks, using T2 sequence andsingle shot fast spin echo (SSFSE) without maternal or fetal sedation.Global dilatation of cerebral ventricles, without signs of obstructionor other CNS malformations. Delivery was induced after spontaneousfetal death at 23 weeks, a female stillborn weighting 240g showed noother malformation then those described in CNS. Anatomo pathologicevaluation of the brain revealed encephalitis and periventriculitis andplacenta showed severe vilositis. Immuno-histochemistry of the brain/placenta was negative for herpesvirus and CMV, but adenovirus waspositive in both tissues. Maternal serology from the begining ofpregnancy showed no antibodies against toxoplasmosis, HIV orsyphilis and acquired antibodies to rubella, CMV, Hepatitis B. Atdelivery all this serologies were repeated and results remained the



same. Maternal serology for adenovirus in a stored sample collected at18 weeks showed a 1/8 titre.Discussion: Besides the usual torch infection, other infections canseverely affect otherwise normal pregnancies. The identification ofother possible infection agents may help to elucidate the so-called`idiophatic' causes of spontaneous fetal death. We suggest theinclusion of adenovirus in the infection screening of such cases.

P28Prenatal diagnosis of schizencephaly: case report

N. Lagos, C. GarcõÂa, R. Walton, I. Hoffmann and H. MunÄozHospital de Carabineros, Universidad de Santiago, Santiago, Chile

Background: Schizencephaly is a rare congenital malformation of thecentral nervous system. It consists in the finding of unilateral orbilateral clefts in the cerebral hemispheres.Case report: 36-year-old patient, at week 22, an ultrasound showedhydrocephaly with a 19-mm atrium. At week 27, a 6-mm diameterdefect was shown in the cerebral parenchyma of the right hemisphere,that was comunicated with the lateral ventricle, with normal atrium.The conclusion was Schizencephaly. Magnetic resonance imaging(MRI) also showed the parenchymal defect, with comunication to thelateral ventricle, and no hydrocephalus. Cesarian section wasperformed at week 38, with a 2780 g.Newborn: Postnatal echography and computed tomography showedno changes.Discussion: Two types of schizencephaly have been described: Type I,in which the defect is closed-lip, because the lips of the clefts are fusedwithin a pia-ependymal seam that is continous with the ependyma ofthe lateral ventricle, and type II, in which the lips remain open, and theclefts are more extensive. Pathogenesis is unclear but anomalies ofneuronal migration during the third to fifth gestational months areinvoked. Clinically, patients have seizures, developmental delay andhemiparesias. In this case, diagnosis was suspected by ultrasound andconfirmed by MRI, which is the best method. Ultrasound permited usto follow the defect and best decide when to interrupt pregnancy.

P29The effectiveness of antenatal ultrasound in the detection offacial clefts

C. Cash, P. Set and N. Coleman*Department of Radiology and Histopathology*, Addenbrooke'sHospital, Cambridge, UK

Objective: The aim of this study was to assess the sensitivity andspecificity of antenatal ultrasound in the detection of facial clefts in alow risk screening population.Design: This retrospective study covered a five year period fromJanuary 1993 to December 1997. From the study of antenatal,postnatal surgical and pathological records, a complete number ofsecond trimestre fetuses with a cleft defect was identified. Correlationwas made with the routine 18±20 week anomaly ultrasoundexamination in order to assess accuracy of diagnosis.Results: After necessary exclusions there were 26 fetuses with cleftdefects out of 23 577 live and stillbirths. The defect was detected in 17of these 26 cases (65%). In 12 of these 17 (70.5%) the antenataldiagnosis was completely accurate, in the remaining 5 cases part of thedefect was not detected.Conclusion: In a low risk population it is possible to detectapproximately two thirds of all fetuses with a cleft lip or palate.With the increasing emphasis on clinical governance, this study helpsto set an achievable standard.

P30Early prenatal diagnosis of fetal seizures

S. Haddad, J. Younis, D. Peleg and Ben-AmiUltrasound Unit, Department of OB/GYN, Poriya GovernmentHospital, Tiberias, Israel

Background: Prenatal diagnosis of fetal seizures is rarely reported. We

present the earliest prenatal case of fetal seizures diagnosed byultrasound during the 15th week of gestation.Method: A 34-year-old woman gravida 10, para 3, with 6miscarriages and 2 healthy living children, was referred for targetedsonographic examination at 15 weeks' gestation because of her badobstetric history. Normal fetal structures and biometry were revealed.Repetitive episodes of jerking movements of fetal body and limbs weredetected. Limited flexion of the limbs was also observed.Results: Triple marker screening performed at 17 weeks' gestationwas abnormal with a 1:13 risk for Trisomy 21, but the woman refusedamniocentesis. The couple received extensive counselling, but refusedfurther investigation and were lost to follow-up until delivery. At36 weeks' gestation, the woman was admitted with prom and breechpresentation. A female newborn weighing 2000 g with apgars of 8 and9 and cord ph 7.32 was delivered by cesarean section. Several hoursafter delivery, the newborn developed apnea and seizures requiringanticonvulsive treatment. The neonatal investigation revealed mito-chondrial disease.Conclusion: Fetal seizures can be diagnosed in early gestation. In thispresentation, we will present the case and review the literature anddifferential diagnosis of fetal and neonatal seizures.

P31Structural reorganization of the brain after perinatal damage± US/MRI review

T. Gojmerac, V. MejasÏki-BosÏnjak, J. Polak-BabicÂ and M. RadosÏChildren's Hospital Zagreb and Croatian Institute for Brain Research,Zagreb, Croatia

Background: The aim of this study was to estimate structuralreorganization of the brain after perinatal brain damage, diagnosedby ultrasonography (US) in the neonatal period, using magneticresonance imaging (MRI).Methods: A follow up study was carried out on a cohort of 28perinatal risk children who were ultrasonographicaly followed duringthe first 2 years of life. 22 children, who had intraventricularhaemorrhage (IVH I and II), were in the investigation group and theother 6, who had continuous normal us findings, were in the controlgroup. Follow up included high resolution 2T magnetic resonanceimaging of the brain at 13±16 years.

Conclusion: Abnormal MRI scans are more frequently in the caseswith IVH II, than in the cases with IVH I. We can conclude thatstructural reorganization of the brain can repair majority of mildperinatal intraventricular haemorrhage.

P32Early prenatal diagnosis of axillary cystic limphangioma

G. Sancho-Leza, P. Morales Utrillas, I. Guerra, J. M. MarõÂn Mesa andR. FernaÂndez SepuÂ lvedaTxagorritxu Hospital, Vitoria, Spain

We present the rare occurrence of a progressive fetal axillary cysticlimphangioma. A 37-year-old woman was referred at 13 weeks'gestation for fetal karyotyping because of the maternal age. At thismoment the sonographic examination revealed a single live fetus with

Results

MRI

normal PV1 CA2 ML3

cases (n � 22) US IVH I (n � 12) 9 0 2 1IVH II (n � 10) 4 3 1 2

controls (n � 6) 4 2 0 0

1PV � periventricular tracks of haemorrhage; 2CA � cortical atrophy;3ML � multiple lesions



a 30 � 23 � 27 mm right axillary multilobulated mass withoutcolour-flow imaging. At 15 weeks' gestation the amniocentesis wascarried out. At this moment the size of the mass was45 � 33 � 40 mm. Cytogenetic analysis revealed a normal 46, XYkaryotype, At 18 weeks' gestation the ultrasound examinationindicated progressive enlargement of the mass and its size was78 � 80 � 80 mm. The patient was counselled regarding thediagnosis of limphangioma. Although the prognosis appears to begood the couple opt to terminate the pregnancy. Pathologicalexamination confirmed the diagnosis of cystic limphangioma. Thedifferent types, the prognosis and management of the fetal limphan-gioma are discussed.

P33Fetal diaphragmatic hernia: our experience of 43 cases

A. Galindo, Carrera, J. Arbues, J. M. Puente, Benedicto, I. Cano andP. De La FuenteDepartment of obstetrics and Gynecology, Hospital Universitario `12de Octubre' de Madrid, Madrid, Spain

Aim: To review our experience with diaphragmatic hernia (DH).Methods: We review retrospectively 43 cases prenatally diagnosed and7 postnatally between January 1990 and November 1999.Results: The incidence was 1/1496 deliveries. Sensitivity was 86%.Mean gestational age at diagnosis was 29 weeks. In 15 cases (38%),diagnosis was # 22 weeks; perinatal mortality rate (PMR) in thesedid not differ significantly from that in cases of later diagnosis (80%vs. 50%). In 36 cases (83.7%) there was left-sided DH and in 7 cases(16.3%) was right-sided without differences in PMR (58.3% vs.71.4%). In 17 cases (39.5%) associated anomalies were observed;PMR was significantly higher than in isolated cases (94.1% vs.38.5%). In 14 cases (32.5%) liver herniation was noted; PMR wasalso significantly higher than in cases without herniation (78.6%vs. 51.7%). The incidence of polyhydramnios was 30% (13/43);differences in PMR between subgroups were statistically significant(76.9% vs. 16.7%). A pseudohypoplasia of the left heart was observedin 9 cases (20.1%); PMR was significantly higher than the observed incases without it (77.8% vs. 55.9%). Mean weight of the newbornswas 2435 g. The PMR in cases , 2500 g was significantly higher thanin newborns . 2500 g (75% vs. 26.3%). Overall PMR in casesprenatally diagnosed was 60.5% and in those postnatally diagnosedwas 43% (not statistically significant). Considering only prenatallydiagnosed isolated cases, the survival rate rose to 65.3% andexcluding terminations of pregnancy to 85%.Conclusion: The prognosis of DH largely depends on the existence ofassociated defects but there are several prognostic factors associatedwith a worse outcome. However isolated cases may have a favourableoutcome with `classical' management.

P34Mechanical ileus diagnosed with transvaginalultrasonography

P. KlaricÂ, G. Grubisic, M. Zovak and N. TueÁkarUniversity Hospital `Sestre Milosrdnice', Zagreb, Croatia

Background: The aim of this work is to present a rare case ofmechanical ileus diagnosed with ultrasound and confirmed onradiology.

Thirty-six years old women underwent an operation because of anendometric cyst and left adnexectomy was done. Mechanical ileusoccurred on the fifth postoperative day. A level of liquid in bowel wasseen at radiology. At ultrasound we saw on left hemiabdomendistended bowel and a thin, wire-like hyperechogenic structure withno vascularization, thick about 5 mm. This structure was surroundedby the bowel. Laparotomy detected the bowel surrounded by a wire-like thin fibrinoid structure which was extended from uterus corn tothe left pelvic wall and caused mechanical ileus. After release of thistissue the bowel was in normal condition and peristaltics was restorednext day.

Conclusion: It is possible to observe a localization of mechanical ileuswith vaginal sonography.

P35Duodenal atresia: prenatal diagnosis and perinatal outcome of27 fetuses

R. Has, C. E. M. Batukan, H. ErmisË, S. BasËaran, A. YuÈksel andIbrahimogluIstanbul University, Faculty of Medicine, Department of Obstetricsand Gynecology

Objective: To discuss the prenatal diagnosis, obstetrical management,and perinatal outcome of duodenal atresia, and investigate theincidence of associated malformations and chromosomal anomalies.Materials and methods: The data about 27 fetuses with duodenalatresia which were diagnosed on prenatal sonographic evaluation, andconfirmed postnatally, among 20401 high risk pregnancies who werereferred to Prenatal Diagnosis Unit of Obstetrics and GynecologyDepartment of Istanbul Medical Faculty between 1988 and 1999, areanalyzed. Presence of polihydramnios, gestational week at diagnosis,associated malformations and chromosomal abnormalities, andperinatal outcomes were evaluated. Fisher's exact test is used forstatistical analysis.Results: Duodenal atresia was diagnosed in 43 fetuses, but postnataloutcomes of 38 fetuses could be obtained. Ten of the fetuses hadadditional abnormalities in 27 cases whom diagnosis was confirmed.Nine chromosomal abnormalities (33.3%) including seven trisomy 21(29.6%), one deletion, one translocation anomaly detected. Theperinatal mortality of duodenal atresia is found 44.4% with 12 preand postnatal deaths. Fifteen infants discharged in a healthy conditionafter operations.Conclusion: Duodenal atresia, especially in the presence of associatedabnormalities has a high perinatal mortality. Establishment ofdiagnosis in prenatal period, even in the late stages of gestation,may contribute the obstetrical and neonatal management.

P36Prenatally diagnosed duodenal obstruction: a report of 16cases

A. Galindo, J. Arbues, J. M. Puente, O. Villar, I. Cano, A. GranÄ erasand P. De La FuenteDepartment of obstetrics and Gynecology, Hospital Universitario `12de Octubre' de Madrid, Madrid, Spain

Aim: To evaluate main ultrasound findings, associated anomalies andperinatal outcome of fetuses with duodenal obstruction (DO).Methods: Retrospective review from January 1990 to October 1998of 16 fetuses with DO.Results: The incidence was 1 in 2771 deliveries. DO accounted for53% (16/30) of all the small bowel obstructions. Sensitivity was 76%.Mean gestational age at diagnosis was 32.6 weeks. Associatedanomalies were diagnosed prenatally in 5 cases (31.3%) andpostnatally in 3 more cases, so associated anomalies were present in50%. DO was an isolated finding in 11 cases (68.7%) and nochromosomal anomalies were observed in this group. These werediagnosed in 4 out of the 5 cases with associated anomalies.Polyhydramnios was quite common (93.7%). Taking into accountalso cases postnatally diagnosed, chromosomal defects rate was33.3% (trisomy 21 represents 86% of all). Mean gestational age atdelivery was 35.1 weeks. Mean weight at birth was 2315 g. Perinatalmortality rate for prenatally diagnosed DO cases was 31.2%, but thisrate rose up to 62.5% in those cases with associated anomalies. Nodeaths were seen in isolated cases. DO resulted from atresia in 6 cases(37.5%), from web in 5 (31.2%) and from annular pancreas in 5(31.2%).Conclusion: DO is most prevalent type of small bowel obstruction.Associated anomalies and chromosomal defects (Tr.21) are commonand should always be ruled out. While isolated cases have goodprognosis, outcome is worse with associated anomalies, the latterbeing the major prognostic factor.



P37Ileal atresia and thrombo-embolic liver calcifications, apossible complication after treatment with intrauterine lasercoagulation therapy for twin to twin transfusion syndrome

R. M. Van Zalen-Sprock, A. H. P. Schaap, W. J. Van Wijngaarden,J. M. Schnater, D. C. Aronson and O. P. BlekerAcademic Medical Center, Amsterdam, The Netherlands

Background: Two fetuses with complications after laser coagulationtherapy for twin to twin transfusion syndrome (TTTS) are described.Case 1: In this patient laser coagulation of the connecting placentalvessels was performed at 21 weeks of gestation. Two weeks after thistreatment the donor twin had died. Sonography of the survivorshowed progressive intestinal distension from 24 weeks onwards.After birth a laparotomy was performed and an ileal atresia wasfound.Case 2: In this patient laser coagulation was performed at 19 weeks ofgestation. Premature rupture of membranes occurred at 21 weeks andboth fetuses died. At autopsy thrombo-embolic calcifications werefound in the liver of the smallest, donor twin.Discussion: Whereas duodenum atresia is considered a `true'congenital anomaly, jejuno/ileal atresia is thought to be caused by amesenteric vascular accident during fetal life, which leads to necrosis.Intra-uterine laser coagulation therapy seems promising in thetreatment of TTTS. Although it cannot be proven, this therapy mustbe regarded as one of the possible causes for the thrombo-embolicprocesses described in the two cases.

P38Prenatal diagnosis of severe hypotonia and polihydramnius ina fetus with mitochondrial disorder

J. A. De LeoÂn, R. PeÂrez FernaÂndez, M. Granados, M. GonzaÂ lez,J. LoÂpez and J. Clavero`Gregorio MaranÄoÂn' General Hospital, Madrid, Spain

Introduction: The diagnosis of polihydramnius is ultrasound and canbe measure with a various test but finally the result is the increment ofthe amnioticus liquid. It is secundary from a differents pathologicalsituations but severe hypotonia is a rare cause. The hypotonia is theresult of a heterogeneous group of conditions including severehypoxia, neuromuscular disorder, deposit disease, chromosomal, andmitochondrial pathology.Case report: A 30-year-old woman in the 40th week of gestation cameto us referring a decrease in foetal movements during the last 24 h.The pregnancy curse had been normal. The foetal heart rate variabilitywas pathological and the ultrasound study showed a decrease inrespiratory movements, foetal movements and foetal tone with aabnormal amniotic liquid volume. The foetus was delivered byurgency caesarean section. A 3160-g male was born, Apgar 6/8,pH 7.32. The newborn was taken to nciu and the neonatal outcomewas unfavourable. The newborn had a severe hypotonia, hyporeflexia,the eec was pathological. Finally the newborn died.

P39Recurrent non inmune hydrops fetalis in parents with sharedHLA DR and DQ

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

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

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

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

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

P40Fetal treatment for hydrops fetalis assisted by interventionalultrasound

M. Tanemura and K. SuzumoriOB/GYN, Nagoya City University Medical School, Nagoya, Japan

Background: Fetal hydrops has many causes including hydrothoraxand cardiac abnormality. Our fetal treatment experience with suchdisorders associated with hydrops fetalis is reviewed and the efficacyof new interventional ultrasound is presented.Methods: Case 1. A case of fetal lung tumor. Color Doppler analysisand MRI were introduced for differential diagnosis. Case 2. A case ofsevere pleural effusion. Detailed examination of intrathoracic fluid ledto a diagnosis of congenital fetal chylothorax. Fetal treatment byintrapleural injection of OK-432 was introduced. Case 3. A case offetal tachyarrhythmia. We introduced transmaternal-abdominal fetalECG and administered transplacental medication.Results: Case 1. Color Doppler analysis revealed an anomalousarterial supply from the aorta to tumor, leading to a diagnosis ofpulmonary sequestration. Only reduction amniocentesis was repeated,with the circulatory failure spontaneously improving. Case 2. Thepleural effusion was reduced by adhesion of the intrathoracic space,with pulmonary hypoplasia successfully prevented by OK-432. Case 3.Transmaternal-abdominal fetal ECG led to a diagnosis of fetal PSVT.Transplacental propranolol stopped fetal PSVT quickly, while digoxinslightly improved fetal cardiac function.Conclusions: OK-432 may be considered as an alternate intrauterinetherapeutic option to shunt insertion for severe fetal hydrothorax.Fetal ECG was also useful for the diagnosis of fetal tachyarrhythmia.Since some untreated cases show spontaneous improvement, theindications for fetal treatment should be reconsidered.

P41Prenatal diagnosis of chorioangioma of the placentae: casereport

Nurwansyah*, K. Murti² and E. Taufik³*Department of Feto-Maternal. Harapan Kita Children and MaternityHospital, ²Department of Obstetrics and Gynecology, ASIHMaternity Hospital, ³Department of Patology, University ofIndonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Background: Chorioangioma of the placentae are the most commonprimary tumors of the placentae, occurring in 1% of all pregnancies.In the past, the majority of patients' diagnosis is made after thedelivery of the placenta. But, with the increasing use of ultrasound,prenatal diagnosis of these tumors is should become more common.Clinical implications of placental chorioangioma have been asso-ciated with adverse perinatal and maternal outcomes such as



polyhydramnios, premature labor, fetal hydrops, fetal disseminatedintravascular coagulopathy, fetal anemia, fetal cardiomegaly, fetalgrowth retardation, abruptio placentae, gestosis and maternal hemolysis.Case: A 25-year-old primigravid was admitted to the hospital in 35thweek of gestation with premature rupture of the membrane (PROM).Ultrasound examinations were performed on two occasions. First, at28 weeks gestation, ultrasound revealed placental tumor and no fetalabnormality. The second one, at admission, ultrasound revealedolygohydramnios caused by PROM, intrauterine growth retardationand large placental echogenic mass with anechoic parts. Diagnosiswas made as placental chorioangioma.Conclusion: Demonstrating well-circumscribed placental mass with orwithout anechoic area and its clinical implications makes prenataldiagnosis of placental chorioangioma.

P42Hydrops fetalis and hepatosplenomegaly in the second half ofpregnancy as a sign of myeloproliferative disorder in fetuseswith trisomy 21

J. Smrcek, U. Germer, A. Baschat and U. GembruchDivision of Prenatal Medicine, Department of Obstetrics andGynecology, Medical University of LuÈbeck, Germany

Background: Fetal hydrops and/or hepatosplenomegaly in the secondhalf of pregnancy may be a sign of myeloproliferative disorder infetuses with trisomy 21.Methods: In order to search for fetuses with myeloproliferativedisorder a retrospective study was performed in fetuses with trisomy21 and hydrops diagnosed in our prenatal unit. Three of these fetusespresented hepatosplenomegaly and myeloproliferative disorder. Inaddition, one fetus with sonographic signs of trisomy 21, wherekaryotyping was unfortunately unsuccessful, presented with hepatos-plenomegaly, hydrops and myeloproliferative disorder.Results: The four fetuses reported presented with fetal hepatospleno-megaly and hydrops in the second and third trimester. Infectiousserology was negative. The characteristics of blast cells in theperipheral blood smear revealed a myeloproliferative disorder. Thediagnosis was confirmed by postmortem examination, since all fourcases ended up in fetal demise.Conclusion: Fetal hydrops and/or hepatosplenomegaly in the secondhalf of pregnancy, although suggestive of infectious aetiology, may bea sign of myeloproliferative disorder in fetuses with trisomy 21 ormosaic trisomy 21. It seems to be possible, that a myeloproliferativedisorder is the most common cause of hydrops in cases of trisomy 21,at least during late second and third trimester. Furthermore, theincidence of myeloproliferative disorder in utero may be morefrequent than realized.

P43Endocardial fibroelastosis associated with nonimmunehydrops fetalis ± case report

P. Dimcev, J. Stojkovski, M. Kapusevski, A. Sopova and V. JanevskaSpecial Hospital for Gynecology and Obstetrics, Skopje, UniversityInstitute for Pathology, Skopje, Republic of Macedonia

Over 30% of cases with nonimmune hidrops fetalis remain withidiopathic etiology. In cases with known origin, cardiovascular failureis on the first place with over 20%. We report case of 29-year-oldprimigravida, no previous risk factors, 32 second week of gestation.At her first admit to our Hospital, ultrasound examination (performedon SIEMENS Sonoline Versa Pro, 3.5 MHz abdominal probe)revealed obvious signs of severe nonimmune hidrops fetalis: ascites,hepatosplenomegaly, cardiomegaly, pleural and pericard effusion.Prenatal evaluation excludes immune, chromosomal, diabetic, urin-ary, gastrointestinal, metabolic origin and infection. As there wasobvious sign of extreme fetal tahicardia, over 230 hbpm, we concludethat cardiovascular etiology is the main in patogenesis. Because wecan not find any big cardiac anomaly, we tried to menage thiscondition with intravenous administration of digoxin to the mother.Unfortunately, after 3 days there was no proper answer of the therapy

and baby died in utero after extreme tahiarithmia, 250 hbpm. Autopsyreport maintain our prenatal diagnosis ± endocardial fibroelastosis.The conclusion is that early diagnosis and proper investigations incorresponding institution are very important for menagement ofnonimmune hydrops fetalis.

P44Fetal kidney biometry from 10 to 14 weeks of gestation

Y. Spathopoulos, I. Chatzipapas, B. Whitlow and D. EconomidesRoyal Free Hospital, Fetal Medicine Unit, London, UK

Background: To determine fetal biometrical reference ranges for thefetal kidney from 1018 to 1416 weeks' gestation.Methods: A prospective cross-sectional study in a University Depart-ment of Obstetrics and Gynaecology, London. Four hundred andthirty-eight women from an unselected population underwent adetailed assessment of fetal anatomy at 10±14 weeks' of gestation(confirmed by crown-rump length) using transabdominal sonography,and transvaginal sonography (37.4%: 164/438) when necessary.Anterior-posterior (AP), transverse (T) and longitudinal (L) para-meters for the kidney and renal pelvis were measured and charts forcentiles derived using regression analysis and a model of best fitconstructed.Results: Centiles were derived for each biometrical parameter. Newcharts for each biometrical parameter are presented and comparedwith previously published data. The 95th centile for the renal pelvisanterior-posterior diameter varied from 1.4 to 3.1 mm from 1018 to1416 weeks, respectively.Conclusion: We have constructed new reference ranges for kidneydimensions including new data on the renal pelvis dimensions.

P45Amnioinfusion and CFM in prenatal diagnosis of bilateralrenal agenesis

V. Ferianec*, M. HolaÂ² and K. Pohlodek**2nd Department of OB/GYN, Comenius University, Bratislava,Slovakia, ²Children Faculty Hospital, Bratislava, Slovakia

Background: Absence of ureteral bud formation during embryogenesiscauses bilateral renal agenesis and occurs approximately 1:4000±5000 births. Severe oligohydramnios causes difficulties in apparentvisualization. To improve the sonographic conditions the amnioinfu-sion and CFM of the renal arteries permits the accurate diagnosis.Methods: We present the case report of 18 weeks' gestation fetus.Sonography was extremely difficult because of anhydramnion, butfetal cardiac arrhythmia was confirmed and congenital renal agenesiswas suspected. In order to facilitate visualization transabdominalamnioinfusion ± instillation of cca 350 ml saline solution wassuccessfully performed.Results: After amnioinfusion fetal cardiac arrhythmia disappeared,fetal movements appeared. Amnioinfusion enhanced sonograficresolution of renal fossae, which confirmed bilateral renal agenesisand bilateral adrenal hyperplasia. CFM did not confirm renal arteriaein abdominal part of aorta.Conclusion: Technique of transabdominal amnioinfusioin enable todefine the specific cause of severe oligohydramnios or anhydramnios.Improvement in vizualisation after this procedure is very importantfor exact final diagnosis which can be enhanced by CFM.

P46Differential diagnosis in fetal obstructive uropathy

D. M. Paternoster and A. StellaDepartment of Obstetric Gynecology, via Giustiniani 3, PadovaUniversity, Italy

Case report: A healthy 24-year-old secundigravida presented for aroutine ultrasound examination at the 11th week of gestation. Thescan showed a singleton pregnancy and the crown-rump length(43.8 mm) was compatible with the gestation calculated from the lastmenstrual period. The foetal abdomen was distended by the presence



of one only cyst (12 � 7.4 mm), compatible with distension of thebladder. There was no other evident abnormality. Amniotic fluidvolume was normal for the first trimester despite total urethralobstruction. At 14 weeks still birth was found and the patientdelivered three days later. Diagnosis was confirmed at autopsy. Postmortem examination confirmed a phenotypically normal male foetusconsistent with 14 weeks gestation and weighing 70 gr. The abdomenwas distended and the abdominal wall was thin. Internal examinationconfirmed the presence of an enlarged bladder. There was urethralatresia, with associated dilatation of the bladder but the ureter andkidneys were normal. Internal genitals were male with normal testiclesand penis. Chromosome analysis was performed on foetal skin andkaryotype was 46, XY.Discussion: Cloacal dysgenesis sequence (CDS) is a rare cause of fetalobstructive uropathy (FOU). The prenatal differentition of CDS fromother FOU is important because CDS is not amenable to in uterosurgical intervention in the form of vescicoamniotic shounts.Differential diagnosis must be made with pathologies capable ofdetermining cystic lesions localised in the inferior foetal abdomen,such as ovarian cysts, intestinal duplications, Hirschsprung disease, colicdilatation, imperforate hymen with hydrometracolps and megacystes±microcolon syndrome. Accurate prenatal diagnosis can be difficult andrequires prolonged serial observations. The above-mentioned pathologieshave characteristics of relative `fixity', while typical imaging of cloacaundegoes variations due to sequential filling in, or repletion, of the liquidcontained in the urinary, genital and digestive components of themalformation. Moreover, intestinal obstruction is generally associatedwith polyhydramnios. In the first trimester diagnosis of cloaca anomaliesare very difficult because there are no great changes in amniotic fluidvolume and ascites rarely is present; serial examinations are required forenable definition of diagnosis.

P47The functionality of renal kidneys. Can amniotic markers beused to diagnose renal pathologies?

J. M. Troyano, M. T. Clavijo, C. M. Feo, Y. Marco and E. LaynezUltrasound Division and Fetal Medicine, University Hospital ofCanary Islands, Tenerife, Spain

Background and method: Fetal urine was analysed for differences inrenal functionality between physiological cases and pathological casesfeaturing dilatation of the excretory channels (hydronephrosis).Kidney samples were taken by means of aspirative nephrostomyunder echographic monitoring, and 4 parameters were assessed inboth amniotic fluid and urine, namely osmolarity, [Na1], [Cl2], [NAG]and [b2 microglobuline].Results: A total of 51 cases (healthy group) presented hypotonic urine,medium osmolarity (200 mosm), low levels of Na1(, 100 mEq/ml),Cl2 (, 90 mEq/ml), NAG (, 2 U/l) and b microglobuline (, 5 ml/l),and a healthy postnatal evolution. In contrast, the remaining 19 cases(pathological group) had hypertonic urine, NAG and b2 microglobulinelevels over 18 U/l and 26 ml/l, respectively, and evolved towards heavyrenal disfunctionality after delivery. In the pathological group theconcentration of NAG and b2 microglobuline in the amniotic fluid wassignificantly larger than in the physiological group, but no differencesin amniotic Na1, Cl2 and osmolarity were observed between bothgroups.Conclusion: The concentration of liposomial proteins (NAG and b2

microglobuline) from the amniotic fluid is a sound indicator of heavyproximal tubulopathy. Invasive techniques such as puncturing canthus be avoided to diagnose fetal disfunctionality.

P48Parameters of renal function by the obtention of fetal urine byintrauterine aspiration

J. M. Troyano Luque, M. T. Clavijo, C. M. Feo, E. Laynez andM. GoÂmezUltrasond Division and Fetal Medicine, University Hospital of CanaryIslands, Tenerife, Spain

Background: We have studied the fetal renal function by urinarybiochimical analysis obtained by aspirative nephrostomy.Method: Since 1993 we have practiced in our ultrsound unite 51aspirative nephrostomies in cases of over 15 mm hydronephrosis sincethe 20th week of pregnancy. We have determined the tubular dynamicof Na1, Cl2, K1, P1, the excretory response after overcharge of theNaCl, the tubular response to the aqueous diuresis, Calcium tubulardynamic, uric acid, glucose. Acid-base equilibrium.Results: Limited excretory capacity of Na1and Cl2. Excretorydiminishing with Na1Cl2 overcharge. The diuresis aqueous decreasesthe reabsortion of Na1, Cl2, Ca1, P1, glucose and uric acid. Inpremature fetuses there is hypocalciuria with hyperphosphaturia. Theexcretion of uric acid is higher in premature fetuses (7.7 ^ 2.7 mg/dl)than in mature fetuses (5.2 ^ 1.6 mg/dl). The excretion of glucose ishigher in premature fetuses. In all the cases a perinatal renal functionwas verifyed. In a 78.4% of the cases, reparatory surgery was needed.Dyalisis wasn't needed in any new-born. In two of the cases unilateralnephrectomy was needed.Conclusion: The theoretical renal obstructive prenatal problems arenot always associated to renal disfunction. The neprhourologicalmatureness presents important changes in tubular dynamic of Ca1,P1, glucose and uric acid, nevertheless it keeps the same tubulardynamic with Na1, Cl2 and potassium.

P49Prenatal diagnosis of myelocystocele-cloacal exstrophy in amale neonate with a abnormal penis and urethra

J. A De LeoÂn, P. Pintado, M. VinÄuela, E. Herrero, F. GarcõÂa,A. AguaroÂn and R. PeÂrez FernaÂndez`Gregorio MaranÄoÂn' General Hospital, Madrid, Spain

Introduction: Cloacal exstrophy results from a migration failure of thelateral mesodermal folds of the infraumbilical anterior abdominalwall, and rupture of the resulting enlarged, persistent cloacalmembrane before the eighth week of gestation. Myelocystocele is adefect of the medular channel characterizased by a cystic that containdural and arachnoid layer and the ependymal lining layer, respectively.The association of persistent cloaca and caudal spinal anomalies isthought to be related to cell loss in the caudal cell mass, which affectscaudal spinal column formation and cleavage of the cloaca by theurorectal septum. Cloacal malformation occurs in approximately 1 in65 000 live male births. Prenatal ultrasound may lead to the diagnosisin selected cases.Case report: We report an unusual case of prenatally detected with amyelocystocele and cloacal malformation. Additional anomaliesincluded an omphalocele and malformations of the upper urogenitaltract, skeleton, and vertebral column. Labor was induced at 34 weeks'estimated gestational age. It finish by eutocical delivery. A 2154-gmale was born, Apgar 6/8, pH 7.32. The newborn was taken to NCIUand the neonatal outcome was favourable.

P50Ultrasonographic research of gonadas at a truehermaphroditismis

A. S. Latypov, L. E. Teregoulova and I. G. BubisDivision of Medical Genetics of Republican Hospital of Tatarstan,Kazan, Russia

Background: The differential diagnosis between the various forms ofviolation of a structure of gonadas at the patients with a femalephenotype represents a problem, especially at a primary inspection.Method: We represent a case of ultrasonographic diagnostics anovotestis at a true hermaphroditismis in our practice. There was usedlinear transabdominal and convex transrectal transducers on ultra-mark-9 device.Results: The young woman (17yo) who has addressed to thegynecologist concerning a primary amenorrhoea, was examined byultrasound in the Hospital. There were detected a male's structureinternal sexual ductuses and presence of gonadas located below usualposition of ovaries with structure, estimated as a testicula. The Morris



syndrome was diagnosed. At the consequent inspection in center,specializing in genetic ultrasound, specific echostructure of thegonadas was detected, appropriated to their mixed structure(ovotestis), thus a true hermaphroditismis with a female phenotypewas diagnosed. The consequent karyotyping (46XX/46XY (16:4)) hasconfirmed the preliminary ultrasonographic diagnosis.Conclusion: The sufficient qualification of the sonographist conduct-ing a ultrasonic research, knowledge of a ultrasonographic picture ofthe this pathology, allows correct diagnostics already before lab stageof an inspection, using even the routine equipment and review.

P51Prenatal detection of Fraser syndrome withoutcryptophthalmos

C. Berg, A. Geipel, U. Germer and U. GembruchDivision of Prenatal Medicine, Department of obstetrics andGynecology, Medical University, LuÈbeck, Germany

Background: Fraser syndrome (cryptophthalmos±syndactyly syn-drome) is an autosomal recessive multiple malformation syndromewhose major manifestations are cryptophthalmos, syndactyly, laryn-geal atresia and urogenital defects. Enlarged hyperechogenic lungscontrasted by oligohydramnios, nonvisualization of the kidneys andmicrophthalmia were sonographic markers leading to the prenataldetection of this rare autosomal recessive disorder in earlier reports.Case report: Fraser syndrome was diagnosed at 16.0 weeks gesta-tional age in a women whose previous pregnancy was terminatedbecause of multiple malformations. Abnormal sonographic findingsincluded agenesis of kidneys and bladder, dilated trachea and mainbronchi suggestive for high airway obstruction, hyperechogenic lungs,syndactyly of the fingers, hepatomegaly, oligohydramnios andhydrops placentae. Strikingly, face and cerebral structures appearednormal. However these findings together with the previously affectedchild led to the diagnosis of Fraser syndrome. The parents elected toterminate the pregnancy. Autopsy results were confirmatory. Nodefects of the face could be demonstrated.Conclusion: Prenatal diagnosis of Fraser syndrome is possible in thehands of an expert, but due to the great variety of possiblemalformations the diagnosis will remain at doubt in most cases inwhich no previous child is affected.

P52Ultrasonographic diagnosis of an approach to a case withintrauterine clitoromegaly

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

Introduction: Adrenal androgens are one of the important determi-nants of sexual differentiation in fetal period. Increased circulatinglevels of adrenal androgens as seen in congenital adrenal hyperplasia,interact with genital skin androgen receptors and induce clitoralenlargement, fusion of labial folds and cause migration of theurethral-vaginal perineal orifice resulting in ambiguous genitalia. Weare reporting a female newborn with clitoromegaly from a nulliparousmother at term pregnancy.Case report: The mother was followed up from 22 weeks of gestationwith no signs of hyperandrogenism. Because of late application forantenatal follow up and since clitoromegaly was observed at 29 weeksof pregnancy, amniocentesis could not be done. During ultrasono-graphic evaluation at 29 weeks of gestation, clitoris with a size of13 � 18 mm was detected and dexamethasone 1 � 0.5 mg orally wasstarted to use. In reevaluation at 33 weeks of gestation clitoral sizewas measured as 4.8 � 6.8 mm and treatment was stopped. At40 weeks of gestation a female neonate with 10±10 apgar scores,weighing 4040 g was delivered with caesarian section due tocephalopelvic disproportion. After delivery physical examination ofthe neonate revealed clitoral measurements consistent with clitor-omegaly. Hyperandrogenic state of the case persists and evaluation ofthe newborn is going on in Pediatrics Clinic.

Discussion: Although adrenal androgen secretion starts at 6±8 weeksof gestation and dexamethasone therapy was shown to beeffective in regression of virilization if it was used as early as6±8 weeks of gestation, our case was diagnosed later in thecourse of pregnancy. But when similar regimen was appliedsimilar result was obtained. So we propose that patients withintrauterine virilization signs like clitoromegaly and ones with riskof congenital adrenal hyperplasia should take glucocorticoid therapywhenever it is determined in order to ameliorate genital ambiguity infemale fetuses.

P53Repetition of osteochondro-dysplasia ± a rare hereditarydisorder of bones

S. Sipos, T. Marton, A. UjhaÂzy and J. RigoÂ JrDept. OB/GYN Semmelweis University Medical School, Budapest,Hungary

Background: Osteochondrodysplasia with defective bone mineraliza-tion is a rare hereditary disorder. It is characterized by bone structuredefects and a deficiency of bone/liver/kidney alkaline phosphataseactivity in serum and tissues.Case report: Type 2a osteochondrodysplasia was detected in the firstand second pregnancies of a 28-year-old woman. Fetal age was 20and 17 gestational weeks, respectively. Ultrasonographical findingsshowed a soft, dilatated spine, narrow chest and short ribs as well asdeformed bones and skull. An additional fetopathological finding wshypomineralization of the skelet (diagnosed by hystopathology and X-Ray examination). The disorder proved to be Infantile Hypopho-sphatasia (congenital lethal type).Outcome: Both pregnancies were terminated after the diagnosis of thedisorder.Conclusion: In order to detect this disorder, careful, repeatedultrasound exam should be performed in the first and secondtrimester. A Serum alkaline phosphatase level and elevated urinarephosphoethanolamine level of the family members may help to predictthe disorder.

P54A case of Gollop Wolfgang complex: prenatal diagnosis andpregnancy termination

B. Tekin, H. Hassa, T. SËener and T. SËensesOsmangazi University, School of Medicine, Department of obstetricsand Gynecology, EskisËehir, Turkey

Objective: To report a prenatal diagnosis of Gollop Wolfgangcomplex.Case history: This is a pregnant women of 29 years of age, G:2 P:1Ab:0 with 23 weeks of gestation, has not any history of drug use norinfection during pregnancy. Her husband 29 years of age, has not anyfamily history of anomaly nor medical illness of skeletal deformity ashis wife. Ultrasound examination of this pregnancy at 16 weeksgestation showed pes equinovarus deformity and an absence of distalbone of right extremity. The family was informed about the problem.At the meantime ethical permission was obtained for termination ofthis pregnancy. At 23th weeks, after having family's consent fortermination of pregnancy, careful ultrasound examination of the fetuswas carried out; double distal femoral epiphysis with ipsilateraldeficiency of distal bone (tibia or fibula) and pes equinovarus of theright lower extremity were diagnosed. After cervical priming andinduction of labor, female fetus with 1-1-1 Apgar scoring at 1st, 5thand 10th minute was born. There was also hypoplastic right knee jointwith bony prominence and flexion contracture at the right leg. X-raysof whole body were taken. There was also some other deformities andabsence of some small bones.Conclusion: This is the first case of prenatal diagnosis of WolfgangComplex. We showed the importance of a careful ultrasoundexamination of fetus in the first and second trimesters for thediagnosis of fetal malformation.



P55Large yolk sac preceding increased nuchal translucency inskeletal malformations: report of two cases

M. Odeh, M. Kais, M. Wolfson, E. Ophir and M. OettingerDepartment of Obstetrics and Gynecology. Regional Hospital ofWestern Galilee Nahariya, Israel

Case 1: A 20-year-old secondegravida was screened at 20 weeks dueto consanguinity. The fetus had extreme shortening of the limbs, cystichygronia, hydrocephalus and tetralogy of fallout. The pregnancy wasterminated. Missed abortion was diagnosed in her third pregnancy at18 weeks. The fetus had extreme shortening of the limbs, spina bifidaand cystic hygroma. In her fourth and fifth pregnancies she was firstscanned at 7±8 weeks. A large yolk sac was detected (10 mm) andlater the fetuses developed increased nuchal translucency short limbsand ascites. Both pregnancies were terminated. Twins were diagnosedin her sixth pregnancy. At 8 weeks one fetus had large yolk sac andthis fetus developed the same features, including spina bifida andascites and at 17 weeks heart activity was not detected. She delivered ahealthy term female.Case 2: A primigravida was scanned due to consanguinity at22 weeks. The fetus had fixed extension of four limbs and bilateralclub feet the parents refused termination and a newborn withcongenital arthrogriposis died a few days after delivery. In her secondpregnancy she was first seen at 9 weeks and a large yolk sac was foundand 2 weeks later increased nuchal translucency developed. Defor-mities of the limbs were first detected at 16 weeks and this pregnancywas terminated. The third and fourth pregnancies were normal. In herfifth pregnancy the same features developed. The parents refusedtermination and the baby died a few days after delivery.

P56Antenatal diagnosis and separation of conjoined twins: casereport

E. CË elik, C. Sen, K. Kepkep, A. Vural and D. YekerUniversity of Istanbul, Cerrahpasa Medical School, Department ofObstetrics and Gynecology, Pediatric Surgery

The incidence of conjoined twins is extremely small and rangesbetween 1:30 000 and 1:100 000 live births. Recent years, theprenatal diagnosis is possible in very early pregnancy and alsodetailed USG gives us an opportunity for making differential diagnosisin the case of well or poor prognosis. We present two cases withthoracophagus which were diagnosed at 19th and 25th week ofgestation. First case was terminated because of severely conjoined(Shared hearth with single ventricule, two atrium, single aorta underthe diaphragm. Second one was diagnosed at 25th week of gestationwhom had just conjoined liver, attached pericardium on theventricular walls and no other anomaly. After given counseling, thefamily opted to continue the pregnancy and the follow up of thepregnancy was uneventful and delivered at 38th week by cesareansection. They well tolerated in the neonatal period. The babies havegone operation at 10th months of age. They recovered after separationprocedure and the outcome was uneventful. In recent years, definingthe anatomical relationship of conjoined twins is greatly simplified bynew technologies like 2D and/or 3D ultrasonography. Differentialdiagnosis of the cases with good or bad outcome in terms of sharedorgan and anomalies is important in clinical making decision for thetermination or continuation of pregnancy.

P57Twin pregnancy with a hemiacardiac fetus

V. KosÏec and B. HodekDepartment of Obstetrics and Gynecology CH `Sestre milosrdnice'Zagreb, Croatia

Background: Fetal acardia is a rare anomaly occuring exclusively inmonozygotic multiple pregnancies with an incidence of 1:35000deliveries or in 1% of monozygotic twins. Since 1920, rudimentarydeveloped heart of an acardiac twin, mostly called `hemiacardius' or

`pseudoacardius', has been recognized in eigth cases. Four of themhave been discovered during autopsy.

We are showing a twin pregnancy of a 25-year-old woman with ahemiacardiac and a normal fetus, which was conducted in ourMaternity Hospital. In the 22nd week of amenorea a suspicion ofacardia of a deceased fetus with multiple malformations wasexpressed for the first time by ultrasound. With help of amniocenth-esis we defined a normal male kariotype of a live twin and byultrasound we carefully observed its morphology and growth.Furthermore, in the course of the pregnancy, mother's coagulationparameters were controlled weekly. In the 33rd week of gestation anextreme polyhydramnios developed, so amniodrainage was performedtwice. The pregnancy was finished in the 36th week of gestation witha caesarian section: a live male child ± 2330/46 and a hemiacardiacfetus ± 2800 g with multiple malformations were born. The live twinwas discharged from hospital three weeks later as a healthy baby.

P58Fetal anemia, thrombocytopenia, dilatated umbilical vein andcardiomegally due to voluminous placental chorioangioma: acase report

P. Calda, M. MaÂra, V. EretovaÂ , Z. ZÏ izÏka, T. Binder, D. PavlisÏta andV. SebronDepartment of Obstetrics and Gynecology, First Medical Faculty,Charles University, Prague, Czech Republic

We present a rare case of voluminous placental chorioangiomadiagnosed by ultrasound and color Doppler imaging at 20 weeks ofgestation. The tumor size enlarged progressively up to 10 cm at32 weeks. Further pathological findings, showing fetal intrauterinevolume overload and blood cells consumption were observed(cardiomegally, umbilical vein dilatation, polyhydramnion, anemiaand thrombocytopenia of the fetus). At 32 weeks of gestation the signsof uteroplacental insufficiency and fetal hypoxia appeared. Pregnancywas terminated by sectio Caesarea. The newborn, a girl, withbirthweight 1870 g was dismissed in good condition after 48 days.Histopatological examination of placental tumor showed benign,vascular-type chorioangioma.

P59Prenatal diagnosis of fetal rubella infection by ultrasound-guided cordocentesis

J. S. Park, J. W. Roh, J. B. Moon, J. K. Jun, B. H. Yoon, S. Y. Moon,H. C. Syn and H. P. LeeDepartment of Obstetrics and Gynecology, Seoul National UniversityCollege of Medicine, Seoul, Korea

Objective: Our purpose was to compare the accuracy between rubella-specific IgM and polymerase chain reaction (PCR) for the diagnosis offetal rubella infection by ultrasound-guided cordocentesis.Method: 30 pregnant women with the evidences of rubella infectionwere enrolled. Fetal rubella infection was diagnosed by rubella-specific IgM using microparticle enzyme immunoassay (MEIA) andrubella virus PCR with the blood obtained by ultrasound-guidedcordocentesis after 21 weeks of gestation. Neonatal outcomes wereevaluated by physical examination at birth and rubella-specific IgM ifpossible.Results: 20 cases were evaluated by IgM and PCR, and 10 cases onlyIgM. No fetus showed positive IgM antibody, and 8 of 20 casesshowed positive PCR in cord blood, and 6 in amniotic fluid. Oneinfant with negative rubella-specific IgM by cordocentesis beforecompleted 22 weeks resulted in positive IgM at birth, low birthweight, strabismus and developmental delay. These findings werecompatible with congenital rubella syndrome. No case showedcongenital rubella syndrome in the fetuses with positive rubella PCR.Conclusion: (1) The incidence of fetal rubella infection may be verylow in mothers with rubella infection. It is suggested that prenataldiagnosis should be performed even if maternal infection occurs inearly pregnancy; (2) Cord blood rubella-specific IgM is more accuratethan PCR for the prenatal diagnosis of congenital rubella syndrome;



(3) Cordocentesis for rubella-specific IgM detection should be doneafter 22 weeks of gestation for accurate diagnosis.

P60Effectiveness of treatment the fetal hemolytic disease byintravascular transfusions

P. Puacz*, E. BrzezinÂ ska*, E. Sobczak², K. Drews* and Z. Søomko**Department of Perinatology and Gynecology, ²Department ofNeonatology, University of Medical Science, PoznanÂ , Poland

Background: The aim of our study was to estimate the efficacy oftreatment the fetal hemolytic disease by intravascular transfusions(IVT).Method: In the group of 71 immunized patients, after 21 weeks'gestation we performed amniocentesis. Results of the optical densityat 450 nm in 2nd or 3rd zone in Liley's scale were an indication forcordocentesis, fetal blood sampling and in cases with low values ofblood parameters ± intravascular transfusion with drugs administra-tion. In some cases we chose elective preterm cesarean delivery. Themanagement depended on the gestational age, fetal maturity, bloodparameters, ultrasound examination and FHR patterns.Results: The number of 24/71 patients required IVT. We transfused 20±90 ml of blood in 3±10 days intervals. The total amount of IVTwas 78:65/78 into a free loop of umbilical cord and 13/78 into its placentalinsertion. In 22/24 cases there were born healthy neonates, five of themrequired exchange transfusion because of hyperbilirubinemia. Weobserved one intrauterine death 10 h after IVT, probably due to cordhematoma and one death of hydropic neonate 48 h after delivery.Conclusion: The treatment of fetal hemolytic disease by IVT isassociated with high perinatal survival rate and low perinatalmortality rate.

P61The possible impact of storing fetal samples collected duringprenatal invasive procedures: case report

D. A. L. Pedreira, A. Yamasaki, M. L. Chauffaille, R. Muller andS. C. ChaLaboratoÂ rio Fleury, SaÄo Paulo, Brazil

MGB, 34 years-old, primigravida, conceived after IVF (still has 08frozen embryos). At 21 weeks 1 2 days the anomaly scan showedmild dilatation of fetal cerebral ventricles and a multicystic rightkidney with mild nasal bone hypoplasia. Fetal growth was considerednormal (20 weeks 1 3 days based on biometry). Karyotipe obtainedat 23 weeks showed a normal male (46, XY). By that time ventriculardilatation had increased but head circumference was normal forgestational age. Delivery occurred at 24 weeks. Postnatal examinationshowed smooth brain, ventricular dilatation, agenesis of corpuscalosus and cystic dysplasia of right kidney. Lisencephaly wassuspected and fish test targeting microdeletion of chromosome 17was performed in the frozen cells obtained at amniocentesis, whichshowed negative results. Parents were counselled with the maximumrisk of recurrence of an autosomal recessive disease for the nextpregnancy.Discussion: The recent advances in the genetics field will soon offer usthe possibility of diagnosing an increasing number of diseases that canhave an impact in counselling. If we could diagnose de Mieller±Diekersyndrome in this fetus we could have changed the empirical risk of25% recurrence in counselling for a future pregnancy. This is because,if none of the parents was found to be a carrier of the microdeletion,we could postulate that this was a `de novo' mutation (happens in80% of the cases) and the risk for the next pregnancy should benegligible.

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

P62First trimester ultrasound measurement of nuchaltranslucency thickness in predicting chromosomalabnormalities. I. Normal ranges of nuchal translucencythickness

P. Sieroszewski, J. Suzin, G. Surkont and A. Karowicz-BilinÄ skaMadurowicz Hospital, Institute of Obstetrics and GynecologyMedical Academy-University of èoÂdzÂ, Poland

Objective: 1. To establish the usefulness of nuchal thickness to predictchromosomal abnormality.I. Normal ranges of nuchal translucency thickness.:

Design and methods: After evaluating detailed length of pregnancyNT was measured. We included pregnancies which resulted in healthyborned babies.Results: 715 ultrasouns exams were performed between 9 and15 weeks of normal pregnancy. Mean NT value in 9th week was1.37 mm, in 15th week ± 3.09 mm (P , 0.005).Conclusions: 1. There is an increase in NT measurement with theprogress of pregnancy.

The project is ongoing (KBN nr 4 P05E 01817 i 4 P05E 05116).

P63The effect of fetal neck position on nuchal translucencymeasurement

I. Chatzipapas, Y. Spathopoulos, B. Whitlow and D. EconomidesRoyal Free Hospital, Fetal Medicine Unit, London, UK

Background: The aim of this study was to determine whether theposition of the fetal neck has a significant effect on nuchaltranslucency measurement (NT).Method: A prospective cross-sectional study was carried out. Onehundred and ninety-six women from an unselected population

underwent transabdominal sonography. The nuchal translucencywas measured in the mid-sagittal plane, with the fetal neck in theflexed, neutral and extended positions. Measurement was taken to thenearest 0.1 mm. Statistical analysis using a paired t-test for thedifferences in the extended and neutral position nuchal translucency[delta extended NT] and in the flexed and neutral position nuchaltranslucency [delta flexed NT] was performed.Results: On average the extended NT was 0.62 mm greater than theneutral NT value [95% confidence interval 0.53±0.70, T � 14.33,P � , 0.00001]. The flexed NT was on average 0.40 mm less thanthe neutral NT value [95% confidence interval 0.34±0.47, T � 11.99,P � , 0.00001]. The repeatability coefficient was lower in the case ofneutral NT measurement [0.48] and was higher in the other groups[extended � 1.04, flexed � 0.70].Conclusion: The effect of fetal neck position can make a significantdifference on nuchal translucency measurement. Repeatability ofmeasurements are more accurate with the fetal neck in the neutralposition. These findings have important implications for cliniciansusing nuchal translucency to screen the general obstetric population.

P64The newly calculated equations of nuchal skinfold thicknessmeasurement in mid-trimester

H. S. Won, M. K. Kim, P. R. Lee, I. S. Lee, A. Kim and J. H. NamDepartment of Obstetrics and Gynecology, College of Medicine,University of Ulsan, Asan Medical Center, Seoul, Korea

Background: Use of nuchal skinfold thickness (NT) measurement asan ultrasound marker for Down syndrome has been limited due to ahigh false positive rate. We suggested that some variables, whichinfluence on NT have been presented. The purpose of our study was toidentify the variables that have effects on measured values of NT, andto make a regression equation based on those variables.



Method: The data on gestational age (GA), cephalic index (CI),presentation (Pr; vertex or breech) and the presence or absence ofnuchal cord (NC) were collected prospectively on 548 normalsingleton fetuses between 16 and 24 weeks' gestation. We calculatedindependent correlation of those variables with NT by multipleregression analysis and made a regression equation based on GA, CI,Pr, and NC.Results: GA has positive correlation and CI has negative correlationwith NT significantly. The nuchal skinfold was thicker among fetuseswith breech presentation rather than those of vertex presentation andincreased in the presence of nuchal cord. The all four variables(GA, CI, Pr, and NC) were independent factors to NT by multipleregression analysis.

We calculated the expected NT through these observations; forfetuses presenting vertex, NT � 5.608 1 0.243GA 2 0.066-CI 1 NC* and for breech, NT � 2.803 1 0.392GA 2 0.066-CI 1 NC* (*if no NC, NC* equals 20.785 and zero for the other).Conclusion: This is the first report, which takes GA, CI, Pr and NC forcorrelation factors with NT as a whole. These equations may beconsidered as a screening method for the detection of aneuploidies.

P65Feasibility and accuracy of NT measurement in twinpregnancies

E. Dreazen, R. Maymon, Z. Weinraub and A. HermanDepartment of Obstetrics and Gynecology, Assaf Harofe MedicalCentre, Zerifin, Israel

Background: The aim of our study was to evaluate the feasibilityand accuracy of nuchal translucency measurement (NT) in twinpregnancies.Method: We reviewed nt images of 66 pairs of twins (10.3±14 weeksgestation), matched with nt images of 66 pairs of consequent singletonpregnancies with similar gestational ages. Each of the inspectedimages was assigned a score, which classified it into one of fourquality zones.Results: In the twins, as well as in the singleton control group, the vastmajority of the nt images were in the excellent-reasonable zones(288%), and 10% in each of the groups had their nt images in theintermediate zone (11% vs. 12%). Less than 1.5% of the images wereof unsatisfactory quality (1.5% vs. 0.8%), according to the strictcriteria, required for reliable, comparable and reproducible results.(Hennan et al. Ultrasound Obstet Gynecol 1998; 12: 398±403).Conclusion: NT measurement in twin pregnancies is as feasible,accurate and reproducible as in singleton pregnancies. However, itprovides a better DS risk assessment when compared with the secondtrimester triple test in twin pregnancies, as it evaluates DS riskindividually for each of the fetuses.

P66Early screening for chromosomal abnormalities: biochemical,ultrasonographic and Doppler assessment

C. Comas, E. AntolõÂn, F. Figueras, K. EchevarrõÂa A MunÄoz andM. TorrentsCarrera Jm. Institut Universitari Dexeus, Barcelona, Spain

Objective: To evaluate the role of prenatal markers in screening forchromosomal abnormalities (CA) at 10±16 weeks' gestation.Methods: Biochemical serum assessment, nuchal translucency mea-surement (NT), fetal heart rate (FHR), umbilical artery pulsatilityindex (UAPI) and ductus venosus pulsatility index for veins (DVPIV)were prospectively evaluated.Results: A total of 7718 cases were evaluated, including 76 CA. Thetable summarises the effectiveness of each single parameter as amarker of CA. Detection rate (DR), specificity (S), positive predictivevalue (PPV) and negative predictive value (NPV) are shown.Conclusions: 1. Early screening programmes for CA are, at least, aseffective as later strategies. 2. NT is the most sensitive and specificmarker for autosomal trisomies. 3. DVPIV is the most sensitive andspecific marker for overall CA. 4. UAPT and FHR are not effective

single markers for CA. 5. Biochemical serum strategies should bereconsidered when we early scan unselected population.

P67Analysis of fetal karyotypes after abnormal ultrasoundfindings

J. Auren, E. Ekholm and P. PaloDepartment of Obstetrics and Gynecology, University of Turku,Turku, Finland

Background: The aim of this study was to evaluate fetal karyotypes inpregnancies with abnormal ultrasound findings. The cases wereobtained from the catchment area of the Turku University centralHospital between March 1993 and September 1999. In 48% of casesmaternal age was below 30 years.Methods: 287 pregnancies with abnormal ultrasound findings wereevaluated. Ultrasound examination was performed on average at21 weeks of gestation (range 10±40 weeks). In 247 cases fetalstructural abnormality was detected. In the remaining 40 casesultrasound abnormality was fetal intrauterine death, small fetal size,and or oligohydramnion or polyhydramnion and partial hydatiformmola (two cases). Amniocentesis was done in 90% and villus biopsy in10% of cases.Results: Fetal karyotype was found abnormal in 15% of pregnancies.Trisomy 21 was found in 10 cases. Six of these pregnancies were sentfor evaluation because of increased nuchal translucency, the remainingbecause of fetal hydrops, ascites or pleural effusion. Nine fetuses hadmonosomy XO and ultrasonography revealed a cystic hygroma. Fourfetuses with trisomy 18 and four with trisomy 13 were found due tostructural abnormalities. Fifty pregnancies were terminated, 19 ofthese because of fetal chromosomal abnormality. Six pregnanciesended in spontaneus abortion. Three of these carried a chromosomallyabnormal fetus. Moreover, eight fetuses died in utero later inpregnancy. Karyotyping was not possible in one case.Conclusion: Fetal karyotyping should be done also in young mothersin the first and second trimester when fetal ultrasound examination isabnormal.

P68Chorionic villus sampling for prenatal diagnosis in Zagreb:experience with 3000 cases

M. Podgajski, M. Podobnik, Z. Duic, S. Cigiar and B. GebauerDept. Ob/Gyn, University Hospital Merkur, Zagreb, Croatia

Objectives: This study comprises data from 3000 women allocated totranscervical CVS (TC-CVS), transabdominal CVS (TA-CVS) andtransvaginal CVS (TV-CVS). We have assessed the efficacy oftransabdominal CVS compared with transcervical CVS andtransvaginal CVS, and examined factors that have been implicatedin causing spontaneous abortion.Method: Over a 10-year period, 3000 women underwent chorionicvillus sampling at 9±12 weeks of gestation, by transcervical (500

Single markers DR (%) S (%) PPV (%) NPV (%)

Chromosomal abnormalitiesNT . 95th c 75.0 95.6 14.5 99.7FHR , 2.5th or . 97.5th c 15.3 96.2 4.1 99.1UAPI . 95th c 19.1 96.0 4.5 99.2DVPIV . 95th c 81.5 95.6 15.3 99.8

Autosomal trisomies1

NT . 95th c 89.9 95.6 11.5 99.9FHR , 2.5th or . 97.5th c 15.2 96.2 2.6 99.4UAPI . 95th c 16.3 96.0 2.5 99.5DVPIV . 95th c 85.0 95.6 12.2 99.9Biochemical risk . 1/2702 64.3 92.2 2.4 99.9

1Referred to main autosomal trisomies (21, 18 and 13). 2Referred totrisomies 21.



patients), transabdominal (2400 patients) and transvaginal technique(100 patients). Transvaginal color Doppler was used to investigate theuteroplacental and fetal vessels in 500 pregnancies between 11 and12 weeks of gestation (400 TA-CVS and 100 TC-CVS) before andafter CVS procedures.Results: Five hundred (16.7%) patients underwent transcervical CVS(TC-CVS) and spontaneous abortion after TC-CVS occurred in fivecases (1.0%). Some 2400 (80.0%) patients underwent transabdominalCVS (TA-CVS) using a 20 gauge spinal needle and abortion after TA-CVS occurred in 10 cases (0.4%). One hundred (3.7%) patientsunderwent transvaginal CVS (TV-CVS) using a 20-gauge needle andabortion after TV-CVS occurred in three cases (3.0%). Thespontaneous abortion rate after CVS procedures was 0.6%. Some120 (4.0%) cases showed chromosomal aberration. The spontaneousabortion rate was lower among cases allocated to TA-CVS after11 weeks of gestation. There were no significant differences in meanpulsatility indices (PI) between maternal, fetal and intraplacentalcirculation, before and after CVS procedures.Conclusions: Transabdominal CVS has lower fetal loss rate thantranscervical and transvaginal CVS.

P69Abstract withdrawn

P70Abstract withdrawn

P71Isolated choroid plexus cysts: a controversial morphologicsonographic marker for chromosomal abnormalities. Ourexperience in seven years (1993±1999)

P. Totaro, A. Malvasi, G. Caringella, D. Baldini, V. Traina andM. ChiellaCenter of ultrasonography and Prenatal Diagnosis, Human GeneticsUnitCasa di Cura `Santa Maria', Bari, Italy

First reported by Chudleigh and colleagues in 1984 and considered`benign transient findings with no harmful sequelae', an associationbetween choroid plexus cysts and trisomy 18 was described by severalfollowing publications. Later on further studies have also suggested asignificant risk for other chromosomal abnormalities, trisomy 21 inparticular, so that literature data report an association betweenchoroid plexus cysts and chromosomal abnormalities in about 8% ofcases, more specifically in 1% if isolated and in 46% if associated withother malformations. As a consequence there are now differentopinions on clinical significance and management, with some authorsadvocating karyotyping and others not. The aim of this study was todefine the incidence of choroid plexus cysts in an unselectedpopulation and describe their association with aneuploidy. In theyears 1993±99 a total of 10743 women from an unselectedpopulation attending a routine second-trimester scanning werestudied. Everyone underwent a detailed assessment of fetal anatomyby transabdominal sonography. In this period there were 27 fetuses inwhich choroid plexus cysts were the only sonographic abnormality,giving an incidence of 0.25% (in literature between 0.2 and 3.6%).Karyotyping was performed in only 12 cases, 11 normal and onetrisomy 18. At birth the other 15 fetuses were normal. The incidenceof aneuploidy was 3.70% (in according with literature review). Wedid not found association with other chromosomal abnormalities,trisomy 21 in particular. In the majority of cases the final riskremains small, but the presence of choroid plexus cysts increasesthe risk for aneuploidy, mainly trisomy 18. A need for further andwide studies about soft morphologic sonographic markers it'snecessary to better define their association with chromosomalabnormalities and as a consequence to better select the patientswho need karyotyping, not underestimating that they appear in alarge percentage of normal fetuses.

To combine all the well-known parameters (maternal and gesta-tional age, serum biochemical screening, soft markers and nuchal

translucency) seems to be the better way to adjust the risk of trisomy21 and that of other chromosomal abnormalities, taking theirdifferent natural history into consideration.

P72Prenatal assessment of the thymus in detecting fetuses withdel.22q

R. Chaoui, H. KoÈ rner and C. BommerClinic Obstetrics, University Hospital Zurich, Switzerland; Instituteof Human Genetics, Charite Hospital, Berlin, Germany

Background: Some congenital heart defects (CHD) were found to beassociated with a deletion 22q11 and grouped as catch-22 an acronymfor Cardiac anomaly, Abnormal facies, Thymus hypo- or aplasia, Cleftpalate and Hypothyreoidism with del.22q.11. It is still discussedwhether all fetal CHD or only conotruncal anomalies (CTA) shouldget the targeted del.22q11 evaluation. Aim of the study was to findout the importance of thymus visualization in the prenatal detection ofthese affected fetuses.Method: During a period of 3 years only fetuses with CHD under-going invasive procedure for determination of the karyotype and fishfor del.22q11 were included in the study. Fetal thymus was visualizedas the structure in front of the great vessels as seen in the three-vessels-trachea view.Results: 95 fetuses with different CHD were evaluated including 31with conotruncal anomalies. Seven fetuses were found to have adel.22q11 (7.3% of all CHD, 22.5% of CTA). Six of these 7 (85.7%)had no or a hypoplastic thymus. A false positive result was found intwo further cases.Conclusions: Fetal thymus can be assessed on prenatal ultrasound. Infetuses with CHD especially in CTA the absence or hypoplasia of thethymus can be a hint in the targeted examination for del.22q11.

P73The value of sequential screening in avoiding invasiveprocedures when maternal age is considered advanced

D. A. L. Pedreira, S. C. Cha and C. CzeresniaClõÂnica de assisteÃncia aÁ Mulher, LaboratoÂ rio Fleury, SaÄo Paulo, Brazil

Aim: To evaluate the importance of sequential screening in thediagnosis of aneuploidies when maternal age is advanced, but invasiveprocedure is wanted only if screening tests are altered.Material and methods: We retrospectively analysed all pregnantpatients aged 35 years or more at estimated data of delivery, from July1996 to June 2000. For those in doubt about having an invasiveprocedure, we offered an alternative strategy of screening. Startingwith nucal translucency (NT) (11±14 weeks), if altered we offer CVS,if normal, we offer an anomaly scan at 16±18 weeks targeted to softmarkers of chromosomal abnormalities and major malformations. Ifaltered, we then offer amniocentesis, if normal we repeat the anomalyscan at 22±24 weeks, targeting for other malformations (especially inthe heart), uterine artery screening and cervical screening.Results: We evaluated 296 fetuses (280 pregnancies) patients meanmaternal age 37.4 years-old (range 35±45). 39.9% patients (118) hadinvasive procedures (IP) with 3 abnormal karyotipe result (1 case T21,2 cases 47XXY). One missed abortion detected at NT revealed T21.122 fetuses (114 patients) had NT performed with Likelyhood Ratioincreased in 11 cases (9.1%): 2 fetal malformation (skeletal dysplasiaand acrania), 5 normal karyotipe after IP and 4 normal live-bornbabies. Among this 114 patients, 52 had one or two reassuringanomaly scans after NT and did not had an IP done. 17 pregnanciesare still ongoing and all live-born babies so far were normal (94.8%follow-up).Conclusion: New studies about the psychological impact of latergestational age termination vs. early ones, showed no significantdifference. We believe that sequential screening is a valid alternativefor older pregnant patients, especially after IVF. The choice of havinga later termination vs. the possible loss of a normal pregnancy after anIP must be given to patients.



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

P75Uterine artery Doppler velocimetry in low risk nulliparouswomen

G. Daskalakis, D. Paouleskou, S. Kitmirides, N. Papantoniou,S. Mesogitis and A. Antsaklis1st Department of Obstetrics and Gynaecology, University of Athens,Athens, Greece

Background: The aim of this study was to assess how placentalposition and gestational age can influence the value of a diastolicnotch of the uterine arteries as a screening test for pre-eclampsia, in alow risk population of healthy nulliparous women.Methods: Color Doppler ultrasound was used to examine both uterinearteries in 654 healthy nulliparas at four-weekly intervals between 20and 32 weeks (wks). The only criterion for an abnormal result was thepresence of an early diastolic notch. In each subject the placentalposition was also recorded.Results: Twenty-one out of 654 women developed pre-eclampsia(3.2%). The sensitivity of the test becomes lower as gestational ageadvances and ranged from 81% at 20 wks, to 71.4% at 32 wks. Incontrast the specificity and positive predictive value increasesignificantly. Eleven out of 12 women who delivered before 34 wkshad abnormal waveforms at 24 wks. In women with a full lateralplacenta the predictive value of the test was extremely low.Conclusion: Pre-eclampsia can be more accurately predicted if alongwith the presence of a notch, both gestational age and placentalposition are taken into account.

P76Early diastolic notch of uterine artery Doppler velocimetry inrelation to placental location

C. H. Lee, Y. W. Park, J. S. Cho and S. S. HanDepartment of Obstetrics and Gynecology, College of Medicine,Yonsei University, Seoul, Korea

Background: The aim of this study was to investigate the relationbetween types of early diastolic notch and placental location and toevaluate the difference in perinatal outcome.Method: We evaluated the Doppler waveform of the uterine artery in149 pregnant women having an early diastolic notch after 26 weeksgestation, however, we were unable to follow the obstetric outcomesin 20 women. Placental location was determined by transverse view ofultrasonography and classified as central and lateral placenta. Theunilateral diastolic notches were divided into 3 groups dependingon the placental location (ipsilateral: same side of the placenta,contralateral: opposite side of the placenta, and median: centralplacenta).Results: In the bilateral notch group, the S/D ratio of the contralateraluterine artery was higher than the ipsilateral one (n � 60, mean �3.22 VS 2.80, P � 0.0067). Of the 89 unilateral notches observed, theS/D ratio of the uterine artery in patients having early diastolic notchwas higher compared to those without early diastolic notch. (t-test,mean � 2.74, 1.92, P � 0.0001) Patients with bilateral notches wereassociated with poor perinatal outcomes significantly more than thepatients with unilateral notches (P � 0.003). Among the unilateralgroups (ipsilateral: n � 10, median: n � 21, contralateral: n � 58),there was no significant difference in perinatal outcomes.Conclusion: The early diastolic notch can be observed on both oreither sides of the uterine artery independent on placental location.More bilateral notches were associated with poor pregnancy outcomesthan unilateral notches. The pregnancy outcomes tended to be similarin unilateral notch irrespective of placental side is necessary because ofthe frequent appearance of early diastolic notch and higher vascularresistance.

P77The usefulness of uterine artery Doppler velocimetry in theprediction of high risk pregnancy. I. Normal ranges

P. Sieroszewski, J. Suzin, G. Surkont, and A. Karowicz-BilinÂ skaMadurowicz Hospital, Institute of Obstetrics and GynecologyMedical Academy-University of èoÂdzÂ, Poland

Objective: 1. To establish the value of Doppler ultrasound of theuterine artery in identyfying high risk pregnancies. 2. To assess theefficacy of prophylactic aspirin treatment in high risk pregnancies(abnormal uterine artery Doppler velocimetry). 3. To show theefficacy of arginin treatment of IUGR fetuses in high risk pregnancies(abnormal uterine artery Doppler velocimetry).I. Normal ranges of uterine artery Doppler velocimetry:

Design and methods: We studied 428 single normal pregnanciesbetween 19 and 39 weeks. There were assessed S/D, RI & PI in bothuterine arteries. We included results of singleton pregnancies wherehealthy babies were born.Results: We assessed decreasing of S/D, RI & PI values with theprogression of pregnancy. We did not find statistically significantdifferences between right & left uterine arteries.Conclusions: 1. The uterine artery velocimetry depends on gestationalage ± the values of S/D, RI, PI values decrease with the progression ofgestation. 2. There are not significant differences between right andleft uterine artery Doppler velocimetry.

We continue our studies. (KBN nr 4 P05E 01616 i 4 P05E 01717).

P78Second trimester uterine artery Doppler velocimetry in theprediction of poor perinatal outcome

H. MunÄoz, D. Veloso, S. Leible, J. Jankelevich, R. Vonmullenbrock,M. Puga and S. VillaFetal Medicine Unit, Clinical Hospital, Universidad de Chile,Santiago, Chile

Background: The patients with an increase of resistance of uterinearteries in second trimester has between 5 and 8 times increased therisk of presenting adverse perinatal outcome. The objective is toevaluate the utility of uterine artery Doppler velocimetry in theprediction of poor perinatal outcome.Method: We performed a prospective study, in 512 consecutivespregnant women between 22 and 24 16 weeks of pregnancy. Uterineartery Doppler velocimetry was done in all patients using colorDoppler duplex technique. The presence of notch or resistance indexover 95 centile was defined as abnormal. Adverse perinatal outcomewas defined as presence of preeclampsia, intrauterine growthretardation, and preterm delivery before 34 weeks of pregnancy. Forstatistical analysis non parametrics test and meta analisis model wasused.Results: Uterine artery Doppler velocimetry was carried out in 512patients, 198 was delivered. Resistance index was significantly higherin poor perinatal outcome group than in normal perinatal outcomegroup (Pulsatility index 1.38 vs. 0.9; P , 0.001). The relative risk ofpresenting adverse perinatal outcome was 3.8 times higher in patientswith abnormal uterine artery Doppler velocimetry compared withthose that has normal uterine artery Doppler velocimetry (ic 95%;1.8±7.7; P , 0.0006).Conclusion.: Uterine artery Doppler velocimetry evaluated in thesecond trimester of pregnancy is able to identify high risk patients ofpoor perinatal outcome.

P79Maternal ophthalmic artery Doppler velocimetry in type 1diabetes during pregnancy

K. Kanenishi, C. Yamashiro, H. Tanaka, A. Kuno, T. Yanagihara andT. Hata



Department of Perinatology, Kagawa Medical University, 1750±1Ikenobe, Miki, Kagawa 761±0793, Japan

Background: Our purpose was to evaluate whether maternalophthalmic artery pulsatility index (PI) in normotensive pregnancieswith type 1 diabetes is different from that in normal normotensivepregnancies.Method: The ophthalmic artery in 15 normal normotensive pregnantwomen, and 13 normotensive pregnant women with type 1 diabeteswas studied once with colour Doppler flow imaging and pulsedDoppler ultrasonography after 16 weeks gestation. The heart rate,mean arterial blood pressure, and ophthalmic artery PI werecalculated in each group.Results: The PI (1.94 ^ 0.45) in normotensive pregnant women withtype 1 diabetes was significantly lower than that (2.73 ^ 0.32) innormal normotensive pregnant women (P , 0.0001). There was nosignificant difference in maternal heart rate or mean arterial bloodpressure between the two groups.Conclusion: These results suggest that vascular resistance in the maternalorbital circulation is reduced in pregnancies with type 1 diabetesthat are normotensive. The lower PI in pregnant women withtype 1 diabetes should be interpreted as orbital vascularvasodilatation, indicating orbital hyperperfusion or hyperaemia.

P80Combined assessment of the fetal distress in diabeticpregnancy class R/F using uterine, middle cerebral, umbilicalartery blood flow and fetal heart rate monitoring

M. Pietryga, E. Wender-Ozegowska, E. BieganÂ ska, J. Brzert andR. BiczyskoDivision of Obstetrics and Maternal Diseases, Department ofGynecology and Obstetrics, Karol Marcinkowski University School ofMedical Sciences, PoznanÂ , Poland

Background: Pregnacies complicated by diabetes mellitus cl.R/Fare in higher risk of placentae insufficiency and poor perinataloutcome.Methods: We have investigated 15 diabetic pregnant women of classR/F after 26 weeks of pregnancy. We observed waveform `notch' inascending uterine artery. Fetal distress was diagnosed when, in the nstsilent oscilation or late decelarations appeared. Pathological bloodflow in term pregnancy was diagnosed when RI and PI was abnormaland cerebro-placental ratio was above 1. AEDF and REDF wereassessed as fetal distress. Newborns were estimated by Apgar scoreand pH value of umbilical artery. The mean diurnal glycemia ranged110 mg/dl, and the HbA1c 6.2%, 8.0%.Results: Pathological condition acc. to the AS and pH A.umb.manifested 75% newborns, but acc. only to pH A.umb.values15% of them. Positive predictive value of NST in fetal distressdetection was 66%, of the DV 53%, uterine artery `notch' 66%when neonates condition was analysed by using AS and pH. Thehighest (80%) PPV was achieved all methods. False positive resultsin NST analysis were found in 19.8% of cases. False negativeresults was for methods together in 6.6%. When the neonatescondition was analysed only by using pH A.umb.value, the PPVfor NST was 66%, for DV 73%, for `notch' 73% and for allmethods together 86%. False positive results for all methods NST,DV, `notch': and for all methods tohether, achieved the followingvalues: 26%, 19.8%, 19.8% and 26%. False negative result in allmethods was 6.6%.Conclusins: Blood flow measurements in fetal and maternal circula-tory circles combined with FHR monitoring reaches very highprognostic values in detection of the fetal distress.

P81Predicting delivery before 30 weeks in pregnancies withabsent or reversed end-diastolic velocity (ARED) flow in theumbilical artery

R. P. V. Francisco, R. M. Yamamoto, C. C. Chuba, S. Miyadahira andM. Zugaib

Hospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: A study of the relation between methods for assessmentof fetal well-being and the occurrence of delivery before 30 weeks ofgestational age in fetuses with ARED.Methods: A prospective study was conducted to assess the fetal well-being in 30 singleton pregnancies with ARED. The results of thesemethods were compared with the occurrence of delivery before30 weeks of gestational age (GA). All data were analyzed andcompared using logistic regression.Conclusion: The probability of delivery before 30 weeks in AREDVfetuses was predicted by the ti between AREDV diagnosis and deliveryand by the gravity of placental lesion estimated by the PI in theumbilical artery.

P82Fetal death in pregnancies with absent or reversed end-diastolic velocity waveforms in the umbilical artery

R. M. Yamamoto, R. P. V. Francisco, K. Sakamoto, S. Miyadahira andZugaibHospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: Description of pregnancies with fetal death followingabsent or reversed end-diastolic velocity (AREDV).Method: Between 1992 and 2000, 249 singleton high risk pregnancieswith AREDV were followed. Twenty-nine cases of intrauterine fetaldeath (IUFD) were reviewed. All the patients were hospitalized afterthe AREDV diagnosis, and followed with intensive surveillance offetal vitality.Results: The results are shown in the table:

Conclusion: Pregnancies with severe placental insufficiency thatpresented fetal death showed a high incidence of reverse flow in theumbilical artery. The cases that presented early fetal death showed ahigher time interval between the AREDV diagnosis and IUFD

P83Fetal hemodynamic profile in pregnancies with absent orreversed end-diastolic velocity waveforms in the umbilicalartery that presented fetal death

R. M. Yamamoto, R. P. V. Francisco, D. S. Steinman, S. Miyadahiraand M. ZugaibHospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: A description of the fetal hemodynamic profile inpregnancies with absent or reversed end-diastolic velocity (AREDV)that presented fetal death.Material and methods: Between 1997 and 2000, 107 high riskpregnant women with AREDV were followed by the Fetal Surveil-lance Unit. Seventeen cases that presented fetal death (FD) weresubmitted to Dopplervelocimetry of the umbilical artery (UA),descending thoracic aorta (DTA), middle cerebral artery (MCA) andductus venosus (DV).

AREDV diagnosis19±24 week(n � 14)

25±28 week(n � 15)

Total(n � 29)

Fetal weight 454 1 180 694 1 194 578 ^ 221GA at AREDV diagnosis 22.8 1 1.5 26.5 1 1.1 24.8 1 2.3Interval AREDV-IUFD

(days)12.4 1 12.2 6.3 1 6.4 9.2 1 9.9

Reversed flow 7 (50%) 9 (60%) 16 (55%)Interval reversed flow-IUFD

(days)5.0 ^ 4.1 4.8 ^ 5.5 4.9 ^ 4.8



Results: The results are shown in the table:

Conclusions: The results show severe fetal hemodynamic profileabnormalities, revealed by Doppler studies conducted in AREDVcases that presented fetal death.

P84Early neonatal death according to metabolic acidosis at birthin pregnancies with absent or reversed end-diastolic velocityflow in the umbilical artery

R. M. Yamamoto, R. P. V. Francisco, D. Okatani, S. Miyadahira andM. ZugaibHospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: An analysis, in pregnancies with absent or reversed end-diastolic velocity (AREDV) flow in the umbilical artery, of the relationbetween blood gas values at birth and the occurrence of early neonataldeath (until 7 days after delivery).Method: Between 1992 and 2000, 146 high risk pregnancies withAREDV where it was possible to obtain blood gas analysis results atbirth were studied. The criteria used for delivery included: fetaldistress, fetal maturity, worsening of maternal condition and severeoligohydramnios. The umbilical arterial blood gas values at birth werecompared to early neonatal death.Results: The results are shown in the table (*P , 0.05):Conclusion: Buffer base depletion (negative base excess-BE), and

when this variable is associated with low pH values (pH , 7.15 andBE , 210) showed a significant statistical correlation with earlyneonatal death.

P85Pulsatility index in the umbilical artery Doppler studies forpredicting birth weight in pregnancies with absent or reversedend-diastolic velocity flow (ARED) in the umbilical arteries

R. P. V. Francisco, R. M. Yamamoto, S. Miyadahira and M. ZugaibHospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: A study of the relation between methods for assessmentof fetal well-being and birth weight.Methods: A prospective study was conducted to assess the fetal well-being in 30 singleton pregnancies with ARED. The results of thesemethods were compared with the occurrence of birth weight above1000 g. All data were analyzed and compared using logisticregression.

Conclusion: Higher values for the pulsatility index in the umbilicalarteries reflect the gravity of placental lesions and the probability ofoccurrence of a very low birth weight.

P86Assessment of fetal well-being in patients with poor obstetrichistory: comparison between cases of absent or reversed end-diastolic velocity in the umbilical artery

R. P. V. Francisco, R. M. Yamamoto, C. C. Leite, S. Miyadahira andM. ZugaibHospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: A study of the assessment of fetal well-being andperinatal results in patients with poor obstetric history and absent orreversed end-diastolic velocity flow (AREDV).Methods: Between 1997 and 2000, 36 high risk pregnant women withpoor obstetric history and AREDV were followed by the FetalSurveillance Unit. Ten cases presented reversed end-diastolic velocitywaveforms.Results: The results are shown in the table:

Conclusions: The results show a higher incidence of abnormal BPSand AFI in red cases, with a high rate of perinatal death.

P87Cardiotocography in pregnancies with absent or reversed end-diastolic velocity in the umbilical artery: a mathematicalmodel for estimating the probability for fetal acidosis at birth

R. M. Yamamoto, R. P. V. Francisco, C. C. Chuba, S. Miyadahira andM. ZugaibHospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: A study of cardiotocographic (CTG) variables andacidosis at birth (umbilical arterial pH , 7.20) in AREDV.Methods: The last CTGs of 127 AREDV cases were studied. Thevariables analyzed by the Logistic Regression model were: baseline,accelerations, variability (variab.), sinusoidal pattern, bradycardia,late and variable (var.) decelerations (mild, moderate and severe).Results: The maximum likelihood estimates are shown below:

Conclusion: The results made it possible to develop a mathematicalmodel for estimating the probability of acidosis at birth, through theanalysis of cardiotocographic variables.

AREDV diagnosis19±24 week(n � 10)

25±28 week(n � 7)

Total(n � 17)

GA at fetal death 24.7 1 1.6 26.3 1 1.0 25.4 1 1.6Reversed flow 6 (60%) 7 (100%) 13 (76%)UA Doppler PI 5.0 ^ 3.1 6.3 ^ 1.8 5.5 ^ 2.7Abnormal DV 10 (100%) 6 (86%) 16/17 (94%)DV Doppler ± PIV 2.3 ^ 1.5 2.3 ^ 1.3 2.3 ^ 1.4Abnormal DTA 9/10 (90%) 3/6 (50%) 12/16 (75%)MCA PI , 5th p 6 (60%) 6 (86%) 12 (71%)loss of redistribution 4 (40%) 1 (14%) 5 (29%)

pH , 7.15 pH , 7.20 BE , 210pH , 7.15and BE , 210

ND (# 7d) 10/43 (23%) 11/75 (15%) 13/56 (23%)* 9/30 (30%)*n � 21ND (total)n � 36

14/43 (32%) 19/75 (25%) 31/56 (55%) 20/30 (67%)

AEDVn � 26

REDVn � 10 P

fhr with deceleration 13/19(68.4%) 5/7(71.4%) NSBPS below 6 1/26(3.8%) 5/7(71.4%) 0.004Amniotic fluid index # 5 6/26(23.1%) 7/10(70.0%) 0.025MCA PI , 5th p 23/24(95.8%) 8/10(80.0%) NSPerinatal death 6/26(23.1%) 6/10(60.0%) 0.04Birth weight , 1000g 10/26(36.5%) 6/10(60.0%) NS

VariableParameterestimate

Standarderror P

Oddsratio

Intercept 22.1210 2.0741 0.3065 ±GA (weeks) 0.0329 0.0654 0.6150 1.033variab. 5±9 bpm 0.5987 0.5118 0.2421 1.820Variab. , 5 bpm 1.9443 0.7576 0.0103 6.989Late decel. 1.4429 0.4823 0.0028 4.233Mild var. decel. 20.4138 0.5239 0.4296 0.661Mod. var. decel. 20.2440 0.6991 0.7271 0.783Sev. var. decel. 1.2156 0.6260 0.0522 3.372



P88Cardiotocography predicting buffer base deficit (. 10 mM)at birth in pregnancies with absent or reversed end-diastolicvelocity in the umbilical artery Doppler studies

R. M. Yamamoto, R. P. V. Francisco, D. Okatani, S. Miyadahira andM. ZugaibHospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: A study of cardiotocographic (CTG) variables and bufferbase deficit at birth in fetuses with AREDV.Methods: The last CTGs of 127 AREDV cases were correlated tobuffer base deficits above 10 mM. The variables selected by theLogistic Regression model were: baseline, accelerations, variability(variab.), sinusoidal pattern, bradycardia, late and variable (var.)decelerations (mild, moderate and severe).Results: The maximum likelihood estimates are shown with thevariables:

Conclusion: The analysis of cardiotocographic variables makes itpossible to estimate the probability of a base deficit above 10 mM atbirth, i.e. buffer base depletion. Low placental permeability tobicarbonate and buffer base is an advantage for studying theseresults, which are less influenced by acute events.

P89A longitudinal study of computerized cardiotocography inpregnancies with absent or reversed end-diastolic velocity(AREDV) in the umbilical artery Doppler studies: preliminaryresults

D. S. Steinman, R. M. Yamamoto, R. P. V. Francisco, S. Miyadahiraand M. ZugaibHospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: A study of computerized cardiotocography (CTG)results in pregnancies with AREDV.Methods: Forty-eight computerized CTGs of 13 AREDV cases werestudied. All the patients were hospitalized after the AREDV diagnosisand submitted to intensive fetal vitality evaluation.Results: From the 48 exams performed, 25 (52%) met Dawes/Redman's criteria, and the mean time of analysis was31.7 ^ 15.3 min. fhr decelerations were found in 1 (4%) of the 25cases where the criteria were met and in 9 (39.1%) of the 23 caseswhere the criteria were unmet. Fetal death occurred in 2 cases. Theresults of the last CTG are shown in the table:

Conclusion: The preliminary results show that, in AREDV cases,Dawes/Redman's criteria were not met in 47.9% of the examsperformed. A high incidence of abnormalities (80%) was found in thecomputerized CTG in cases that presented acidosis at birth or fetaldeath.

P90Growth hormone and insulin- like growth factor 1, in small-for-gestational-age pregnancies with increased pulsatilityindex in the umbilical artery

T. Larsen, K. Main, A. M. Andersson, A. Juul, G. Greisen andN. E. SkakkebaekHerlev Hospital, University of Copenhagen, Denmark

Background: The aim of the study was to examine some endokrino-logical aspects of intrauterine growth retardation and, in particular,test whether low levels of GH and IGF-1 in maternal serum areassociated with direct evidence of placental dysfunction.Method: Prospectively 48 singleton pregnancies with a SGA fetus and28 with an AGA fetus were examined with maternal serum GH, IGF-1, IGFBP-1 and 3, and fetal weight and umbilical artery pulsatilityindex at 33 weeks of gestation.Results: Serum IGF-1 was lower in the SGA group, which wasaccounted for in the subgroup of SGA with increased pulsatility index.Conclusion: A decreased maternal level of IGF-1 seems to bespecifically related to placental dysfunction as diagnosed by increasedDoppler flow pulsatility

P91The influence of maternal exercise on placental blood flowmeasured by simultaneous multigate spectral Doppler imaging(SM-SDI)

S. Degani, B. Feiner, Z. Leibovich, I. Shapiro and G. OhelBnai Zion Medical Center, Haifa, Israel

Objective: To evaluate the effect of maternal isometric exercise on theplacental blood flow as reflected by the velocimetric indices PI and RIderived from placental arteries.Subjects: Thirty-four healthy women with normal singleton pregnan-cies between 22 and 35 weeks of gestation.Methods: All subjects underwent an isometric handgrip exercise test.Maternal blood pressure and heart rate together with placental PI andRI were measured at rest, during the exercise and in the postexerciserecovery phase. All Doppler measurements were obtained using theSimultaneous Multigate Spectral Doppler Imaging (SM-SDI) techni-que, a new ultrasound modality that enables a Doppler study ofmultiple locations to take place within a very short time.Results: There was a significant increase in the mean values of thematernal blood pressure and heart rate during the exercise, and asignificant decline in the recovery phase. There was no significantchange in the mean value of the Doppler indices throughout theexamination.Conclusion: Maternal isometric exercise of a similar degree of effortdoes not affect the impedance of the placental circulation.

P92Early second trimester low umbilical coiling index predictssmall for gestational age fetuses

S. Degani, Z. Leibovich, I. Shapiro, R. Gonen and G. OhelBnai Zion Medical Center, Haifa, Israel

Objective: To evaluate the role of early second trimester Dopplervelocimetric studies, umbilical coiling index and umbilical cord cross-sectional area as a test for the prediction of small for gestational age(SGA) infants.Study design: Doppler blood flow studies in 147 singleton pregnanciesat risk for delivery of a SGA newborn were performed at15 ^ 1 weeks of gestation from umbilical artery, middle cerebralartery, inferior vena cava and ductus venosus. Pulsatility index (PI)values were calculated for the arteries and preload index (PLI) and S/Avalues for the veins. The sonographic cross-sectional area of theumbilical cord was measured in a plane adjacent to the insertion intothe fetal abdomen. The umbilical coiling index was calculated usingsonographic longitudinal views of cord vessels from several segmentsantenatally. SGA newborn was identified when the birth weight wasbelow the 10th percentile for gestational age.

VariableParameterestimate

Standarderror P

Oddsratio

Intercept 20.4976 1.8374 0.7865GA (weeks) 20.0195 0.0590 0.7407 0.981variab. 5±9 bpm 0.5330 0.4431 0.2290 1.704Variab. , 5 bpm 2.5275 0.5804 0.0001 12.522

pH , 7.20or fetal death (n � 5)

pH . 7.20(n � 6)

STV , 4.0 2 (40%) 1 (16.7%)Criteria unmet 4 (80%) 3 (50%)



Results: Among 147 pregnancies studied, 124 fulfilled the studycriteria. 39 of the fetuses were SGA at birth (31.5%). The meangestational age at delivery (^ SD) of the normally grown fetuses was39.7 ^ 1.28 weeks and of the SGA newborns was 34.6 ^ 2.9 weeks(range 28±40 weeks). The best single predictor of a SGA infant wasthe coiling index with a sensitivity of 79% specificity of 86%, positivepredictive value of 72% and negative predictive value of 90%.Conclusion: Umbilical coiling index measured in the early 2ndtrimester is useful in predicting birth of a SGA infant and may be amarker of subsequent growth restriction.

P93Comparison of renal artery blood flow velocity waveform andrenal volume in normal and growth-retarded fetuses

K. S. Lee, M. Y. Park and B. H. WooDepartment of Obstetrics and Gynecology, College of medicine,Ewha Woman's University, Seoul, Korea

Objective: The purposes of this study are to evaluate renal arteryblood flow velocity waveform and renal volume in growth-retardedfetuses compared with normal fetuses.Method: Doppler flow velocity waveform of renal artery and renalvolume measured by three-dimensional ultrasonography wereobtained in 78 normal fetuses at gestational age from 25 to39 weeks and 18 cases of IUGR fetuses weighted below the tenthpercentile at birth.Results;: Fetal renal artery pulsatility index (PI) decreased throughoutthe gestational period (r � 0.703, p 0.0001). In growth-retardedfetuses, although all of them had abnormal Doppler velocity wave-form of middle cerebral artery, renal pi was not increased significantly.Fetal renal volume increased throughout the gestational period(r � 0.834, p 0.0001). and in growth-retarded fetuses, renal volumeof all was below the fifth percentile of normal fetuses.Conclusion: Fetal renal volume measured by three-dimensionalultrasonography may be the helpful parameter in the evaluation ofgrowth-retarded fetus.

P94Fetal cerebrovascular response to chronic hypoxia

D. Jugovic, R. Laurini, M. JudasÏ, Ph. Arbeille, A. Kurjak andA. SalihagicÂ

Objective: To study the cerebral and umbilical hemodynamics changesin hypoxic and growth-retarded fetuses. To determine if at long-term,fetal brain hyperperfusion with loss of cerebral vascular flow velocityvariability is associated with brain damage and poor fetal outcome.Methods: The fetal blood flow redistribution was assessed by usingDoppler cerebral-umbilical ratio in 8 growth-retarded fetuses, mainlyevery day. The evolution of the fetal hemodynamics was interpretedaccording to the clinical, anatomical and histological data.Results: All 8 fetuses had poor fetal outcome including fetal death(n � 5). Fetal blood flow redistribution with brain hyperperfusionwas detected in all fetuses during the whole period of observation. Theearly phase of fetal deterioration was characterized by the develop-ment of oligohydramnios and the disappearance of the cerebral flowvelocity variability. During the later phase of deterioration, fetal heartrate decelerations and the increase of cerebral vascular resistance withreduction of brain perfusion were detected. Histological study of thebrains showed hypoxic lesions.Conclusion: The loss of variability of the cerebral resistance index, inthe cases of absent umbilical end diastolic flow, and the loss ofvariability of the cerebral-umbilical ratio in the other cases, identifiesthe beginning of the period of very high risk for the fetus. Such apattern may be considered as a predictor of brain lesion and poor fetaloutcome. These results also indicate the existence of two phases in thefetal cerebrovascular response to chronic hypoxia.

P95Doppler velocimetry in M1 and M2 segments of middlecerebral artery (MCA) in prediction of fetal hypoxia in normaland growth-restricted fetuses

M. Bednarek, M. Dubiel and G. H. BreÃborowiczDepartment of Obstetrics and Gynecology, University of MedicalSciences, PoznanÄ , Poland

Background: The aim of the study was to evaluate the prognosticvalue of the examination of PI of two segments of MCA in theprediction of hypoxia in normal and growth-restricted fetuses.Method: Doppler examination was performed in 98 normal and 64growth-restricted fetuses. A combined color coded pulsed Dopplerand two-dimensional real time ultrasound equipment with transab-dominal 3.5 MHz transducer was used (Acuson 128XP). A fetal/neonatal hypoxia was defined as: late decelerations during thedelivery, Apgar score in 5 0 , 7, pH of umbilical artery below 7.15,neonatal respiratory disorders leading to artificial ventilation.Results: The prognostic values (sensitivity, specificity, positive andnegative predictive values) of PI estimated during 7 days beforedelivery were as follow: for M1 ± 31%, 83%, 67%, 52% and for M234%, 88%, 75%, 55%, respectively. Using stronger criteria for therecognition of fetal/neonatal hypoxia (pH and BE of umbilical artery, 7,10 and , 2 12 mmol/l, respectively) the prognostic values of PIwere as follow: for M1 ± 40%, 89%, 70% and 70%; for M2 ± 48%,87%, 69% and 72%, respectively.Conclusion: PI of M1 and M2 segments of the MCA seems to be agood predictor of fetal hypoxia during the second half of pregnancycomplicated by growth restriction.

P96Abnormal trajectory of the anterior cerebral artery. A keyfinding to the diagnosis of the fetal lobar holoprosencephaly

P. Zaarour, J. P. Bernard, M. V. Senat, B D. E. Keersmaecker,M. Molho and Y. VilleHoÃpital Poissy St Germain en Laye, France

Background: The prenatal diagnosis of alobar and semi lobarholoprosencephaly is accesible in routine ultrasound. In contrast thediagnosis of lobar holoprosencephaly is still difficult. Prenatalydifferential diagnosis of lobar holoprosencephaly with septal defectsis important for counseling.Case report: We describe the shape and trajectory by color Doppler ofthe anterior cerebral artery in a case of lobar holoprosencephaly.Results: The anterior cerebral artery runs under the frontal bones andis a key to the diagnosis of fusion of the two frontal gyri. This hasalready been described on angiography in children with holoprosen-cephalyConclusion: This aspect in color Doppler of the anterior cerebralartery is particularly useful in the difficult diagnosis of lobarholoprosencephaly

P97Elevated maternal midtrimester chorionic gonadotropin isassociated with fetal cerebral blood flow redistribution

R. Hershkovitz, O. Erez, D. Mankuta and M. MazorDepartment of Obstetrics and Gynecology, Soroka UniversityMedical Center, Ben-Gurion University of the Negev, Beer-Sheva,Israel

Background: Elevated midtrimester human chorionic gonadotropin(hCG) is associated with adverse maternal and perinatal outcome. Theaims of the study were to evaluate the association between elevatedhCG and fetal arterial circulation and to determine the relationshipbetween maternal and perinatal complications and elevated hCG.Methods: Pulsatility indices (PI) of middle cerebral artery (MCA) andumbilical artery (UA) were determined prospectively in 72 consecutivepatients with abnormal maternal serum hCG (. 2.5 MoM). Eachpatient had between two to four US scans during pregnancy. Patients



with known structural or chromosomal anomalies were excludedfrom the study.Results: Out of 72 women with hCG . 2.5 MoM, 48% (35/72) hadhCG . 3.5 and 24% (17/72) had. hCG levels . 4.5 MoM. MCA PIwas lower in women with hCG . 4.5 MoM between 28 and 36 wks'gestation, but not between 18 and 27 wks' gestation (fig). Nodifferences of MCA PI were found when the cutoff point of hCG was3.5. PI of the UA was not different between the groups.

Women with hCG levels . 4.5 MoM had a higher prevalence ofPIH and preeclampsia, preterm deliveries and cesarean sections incomparison to women with hCG , 4.5 MoM. Birthweight was lowerand the rate of Apgar score , 7 was higher. No differences were notfound with cutoff 3.5MoM.Conclusions: Maternal midtrimester hCG . 4.5 mom is associatedwith cerebral blood flow redistribution and with higher rates ofmaternal and perinatal complications in comparison to maternal hCGof 2.5±4.5 MoM.

P98Effects of maternal betamethasone administration on fetalDoppler flow velocity waveforms

C. Kaehler, E. Schleuûner, A. MoÈ ller, U. MoÈ ller and H. -J. SeewaldDepartment of Obstetrics and Gynaecology, Friedrich-Schiller-University, Jena, Germany

Background: To investigate the effect of maternal betamethasoneadministration on fetal arterial, venous and cardiac Doppler flowvelocity waveforms.Method: Patients: 13 women with singleton pregnancies considered atrisk of preterm labour received an intravenous dosis of 2 � 8 mgbetamethasone. Study design: Prospective study. Main outcomemeasures: Doppler studies were performed from the umbilical artery,middle cerebral artery, both uterine arteries, from the ductus venosus,inferior vena cava, right hepatic vein, form the av-valves, right and leftventricular outflow tract and the ductus arteriosus before and after(30 min, 24, 48 and 72 h) betamethasone administration. Peaksystolic velocities and maximum end-diastolic velocities wererecorded. Calculation of the resistance index (RI) for the arterialsystem, the peak velocity index for veins (PVIV) for the venous systemand the E/A ratio for the av-valves.Results: No significant variation was noted in the Doppler measure-ments before and after betamethasone administration. A slight andreversible increase of the peak systolic velocity of the ductus arteriosusand the right ventricular outflow tract was observed at 30 min afterbetamethasone administration.Conclusion: Betamethasone administration does not cause a signifi-cant change of the arterial, venous and intracardiac Doppler flowvelocity waveforms in healthy fetuses.

P99Effect of the vitamin E on the vasoconstrictor reflex

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

Background: The vitamin E is an antioxidant agent used in theregulation of the vascular reactivity. We describe the use of the vitaminE on the regulation of the vasoconstrictor effect (VE) of the proximalsegment of the middle cerebral artery (pMCA).Method: In 11 fetuses we performed a pressure test. First the VE wasdemonstrated using pulsed Doppler and then we administrate orallyvitamin E to the pregnant (15±50 mg per day). Later, we repeat the ptto observe the response on the VE.Results: After the vitamin E the VE was decreased or abolished (seetable at top of page).Conclusion: With vitamin E we can regulate the VE of the pMCA.This response could avoid some perinatal motor injury of intrauterineorigin and best the neonatal vascular adaptation.

P100IUGR fetuses with abnormal umbilical artery Doppler andelevated S100B protein levels

M. Bruschettini, C. Grondona, E. Marinoni, R. Di Iorio, M. Lituania,P. L. Bruschettini, F. Michetti and D. Gazzolo

Maternal and umbilical blood samples were collected in IUGRpregnancies with abnormal umbilical artery Doppler findings and incontrols. S100B protein levels were measured by means of a specificradioimmunoassay and flow velocimetry waveforms were recordedfrom uterine, umbilical and fetal middle cerebral arteries. We studiedthe correlation between S100B protein, an acidic calcium bindingprotein previously demonstrated as a reliable indicator of brain lesion,and the degree of fetoplacental blood flow impairment to examinewhether S100B could be helpful in the detection of brain sufference inintrauterine growth retarded (IUGR) fetuses. Mean S100B protein inumbilical plasma were higher (P , 0.05) in IUGR patients(113.5 ^ 65.9 fmol/mL) than in controls (52.7 ^ 34.8 fmol/mL),and particularly in those cases in which brain sparing was present(169.6 ^ 67.8 fmol/mL). Fetal S100B concentrations were correlatedwith middle cerebral artery PI (r � 20.50, P , 0.05) and withumbilical artery PI/middle cerebral artery PI ratio (r � 0.51,P , 0.05). This study provides evidence that fetal S100B protein isincreased in IUGR and suggests that it may play.

P101Doppler flow velocimetry in fetal and maternal circulation inrelation to blood serum and amniotic fluid erythropoietinlevels

J. WeËgrzynowski and E. Ronin-WalknowskaDepartment for Pathology of Pregnancy and Labour, PomeranianAcademy of Medicine, Szczecin, Poland

Objective: To correlate arterial Doppler flow velocimetry withamniotic fluid and umbilical cord erythropoietin levels and umbilicalcord gasometry.Material and methods: The study compromised 80 pregnant womanwho delivered in cesarean section without prior uterine contractions.The AB, PI and RI indexes of fetal umbilical, cerebral arteries as wellas uterine arcuate arteries was assessed max. 24 h before delivery.Amniotic fluid was collected during the cesarean section before theuterine incision and umbilical cord blood was retrieved after thedelivery, 1 min after the cord was clamped.Results: The correlation was found between umbilical arteries ABratio and amniotic erythropoietin levels, fetal serum erythropoietinlevels as well as umbilical artery pO2 and apgar score 5 min afterdelivery. The correlation was also found between fetal blood andamniotic fluid erythropoietin levels.Conclusions: Doppler flow velocimetry of umbilical artery reflects thefetal and newborn well being. Umbilical cord and amniotic fluiderythropoietin levels reflect fetal oxygenation. Erthropoietin levels

Numberof case

W/VE/E(mg)

W/VE/E(mg)

W/VE/E(mg)

W/VE/E(mg)

1 305/11/start 15 306/1/15 34/0/15 36/0/152 305/1/start 15 334/1I/15 34/0/15 37/0/153 332/11I/start 15 342/0/15 352/0/15 36/0/154 306/11/start 15 316/0/15 35/0/155 292/11I/start 50 312/0/506 313/11I/start 50 33/0/50 355/0/507 256/11/start 50 263/0/508 293/11I/start 50 296/0/509 293/11/start 50 296/11I/100 302/1/0/50 311/0/5010 265/11I/start 50 272/0/5011 282/11I/start 50 29/0/50

W � weeks. E � vitamin E. 1� ve; 0 � no ve. i � inverse flow in thepMCA.



may be checked in amniotic fluid beceause amniocentesis is related tolower incidence of complications in comparisone with cordocentesis.

P102Preterm newborns with normal flow velocimetry and elevatedS100B blood cord levels

C. Grondona, Bruschettini, D. Gazzolo, M. Lituania, P. Vinesi,E. Marinoni, R. Di Iorio, M. Marras, P. L. Bruschettini and F. Michetti

S100B blood cord levels were significantly higher in the pretem group(1.31 ^ 0.64 vs. 0.47 ^ 0.35 g/L; P , 0.001), peaking in earliest weeksof gestation, and progressively decreased near term, being undetactableor at the limit of sensitivity in the term group. A significant correlationbetween S100B blood cord levels and gestational age was observed in allconsidered fetuses (r � 20.69; P , 0.01). We investigated 58 preg-nancies (30 at term and 28 preterm), with normal flow velocimetrywaveforms, whose delivery was between 27 and 42 weeks' gestation.Exclusion criteria were: multiple pregnancies, IUGR, gestationalhypertension, diabetes and infections, fetal malformations, chromoso-mal abnormalities, perinatal asphyxia, and distocia. At birth, allnewborn infants showed normal clinical conditions and no neurologicalinjury was observed at the discharge from the Hospital. As expected,gestational age at birth (32.2 ^ 3.1 vs. 39.4 ^ 1.4 weeks) and birth-weight (1859 ^ 723 vs. 3250 ^ 210 g) were higher in the term group(P , 0.01 for both), while no significant differences were observedregarding delivery mode, Apgar score at 1st (8 ^ 2 vs. 9 ^ 1) and 5thmin (9 ^ 1 vs. 8 ^ 1) and gender (preterm female/male: 13/15; termfemale/male: 16/14). S100B levels significantly higher in female pretermand term fetuses (preterm 1.65 ^ 0.48 vs. 0.99 ^ 0.61; term1.14 ^ 0.69 vs. 0.75 ^ 0.51, respectively; P , 0.05 for both).

P103Effect of uterine contraction on preload index1 in recipientfetus of feto±fetal transfusion syndrome: case report

Y. Takahashi and I. KawabataDepartment of ObGyn., Gifu University School of Medicine, Japan

A case of monochorionic-diamnionic twin was diagnosed as feto-fetaltransfusion at 19 weeks gestation. We performed amniocentesis toreduce the fluid and amnioseptostomy. The discodancy of amnioticfluid was remarkably dissolved for long period. At 25 weeksgestation, we started tocolysis by ritodrine and magnesium sulfatedrip infusion. During the uterine contraction, we detected increasedpreload index on recipient fetus by evaluation of the flow of inferiorcaval vein and reverse end-diastolic flow of umbilical artery on donorfetus and these unfavorable findings disappeared a few minutes afterthe uterine contraction improved. These findings suggest that uterinecontraction is absolute risk factor for feto±fetal transfusion syndromebecause they worsen blood flow on both fetuses.

(1) Kanzaki T, Chiba Y. Evaluation of the preload condition of thefetus by inferior vena caval blood flow pattern. Fetal Diagn Ther1990; 5(3±4):168±74.

P104Ultrasonic fetal and placental tissue characterization and therole of Doppler ultrasound in lung maturity

M. Podobnik, M. Podgajski, B. Breyer and B. GebauerDepartment of Obstetrics and Gynecology, University HospitalMerkur, Zagreb, Croatia

Objectives: The aim of this study is to known the relationship betweenthe gestational age and quantitative assessment of ultrasonic signs ofplacental tissue, fetal lungs and liver tissue and to correlate Dopplerparameters from main stems of the pulmonary arteries for determiningfetal lung maturity in normal pregnancy and pregnancy withpreeclampsia and diabetes.Method: The placenta, fetal lungs and fetal liver in 300 normalpregnancies, 100 preeclamptic pregnancies and 100 diabetic pregnancywereexaminedbyultrasoundat30±41 weeksofgestation.Thecoefficientsof variation (the standarddeviationdividedby themeanvalue)wereused to

characterise the tissue in different groups during pregnancy. Dopplervelocimetry was performed in the main stems of pulmonary arteries innormal pregnancies and pregnancies with preeclampsia and diabetes.Results: The coefficients ofvariation inmature foetusesweregreater than29% for placentas in-vivo, greater than 34% for placentas in-vitro,greater than 28% for liver tissue and greater than 30% for lung tissue.Placental, lung and liver tissue of diabetic pregnancy tended to have lowercoefficients of variation throughout their pregnancies. We found inmature foetuses mean peaksystolic velocityhigher than40 cm/sec. and PIlower than 3,00. In mature foetuses with preeclampsia we found highermean peak systolic velocity in comparing with normotensive patients.Conclusion: The coefficient of variation values for placentas in-vivoand in-vitro, and fetal lungs and liver increase during pregnancy innormal and preeclamptic patients with increasing gestational age anddecrease in diabetic patients.

P105Umbilical vein blood flow changes in normal and growthretarded fetuses

E. Di Naro, F. Ghezzi, L. Raio, M. Franchi, F. Romano, L. ClericoÁ , G.Lanzilotti, D. Bolla and D. BalestreriUniversity of Bari, University of Insubria, Varese, Italy and Universityof Bern, Switzerland

Background: The aim of this study was to assess whether changes ofUV flow volume over time in late (third trimester) growth retardedfetuses (IUGR) are different than those in normal fetuses.Method: Umbilical morphometric characteristics and UV blood flowparameters of 15 women whose fetus was diagnosed to be IUGR withoutumbilical artery Doppler abnormality were compared to those of 30women whose fetus was healthy. Gestational age and parity were used asmatching criteria. Digital color Doppler velocity profile integration wasused. For each patient, two scans were performed in a period of 3 weeks.Results: The umbilical cord area was significantly smaller in IUGRthan in healthy fetuses at each examination (P , 0.05). The umbilicalartery areas were not different between groups. The UV blood flownormalized for estimated fetal weight was lower in IUGR than inhealthy fetuses 115 ^ 41 vs. 145 ^ 39, P , 0.05). The UV flowincrease between two consecutive exams was significantly lower inIUGR than in healthy fetuses (P , 0.05).Conclusion: The umbilical cord area and the uv blood flow of IUGRwere reduced in comparison to healthy fetuses. The normalized UVblood flow difference between IUGR and healthy fetuses increaseswith advancing gestation.

P106Persistent right umbilical vein: incidence and significance in alow risk population

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

Objectives: Our purpose was to conduct the first prospectiveevaluation of the incidence and neonatal outcome of fetuses withpersistent right umbilical vein (PRUV). This condition had tradition-ally been considered to be extremely rare and to forebode graveconsequences for the babies, but later evidence raised some doubtupon the veracity of these contentions.Methods: Between August 1995 and November 1998, 8950 low-riskpatients were prospectively evaluated at two medical centers. Theultrasonographic diagnosis of a persistent right umbilical vein wasmade in a transverse section of the fetal abdomen when the portal veinwas curved toward the stomach and the fetal gallbladder was locatedmedially to the umbilical vein.Results: Seventeen cases of fetuses with PRUV were detected duringthe study period among the 8950 study participants. Four of them hadadditional malformations of which three had been detected antenatally.Conclusions: We established that the incidence of PRUV in a low riskpopulation is 1:526. We believe that the sonographic finding of thisanomaly is an indication for conducting targeted fetal sonography and



fetal echocardiography. When the PRUV is connected to the portalsystem and after other anomalies are ruled out, the prognosis cangenerally be expected to be favorable.

P107The study of the ductus venosus for predicting umbilicalartery pH at birth below 7.10 in pregnancies with absent orreversed end-diastolic velocity flow (ARED) in the umbilicalarteries Doppler studies

R. P. V. Francisco, R. M. Yamamoto, C. C. Leite, S. Miyadahira andM. ZugaibHospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: A study of the relation between methods for assessmentof fetal well-being and umbilical artery pH at birth below 7.10.Methods: A prospective study was conducted to assess the fetal well-beingin 61 singleton pregnancies with ARED. The results of these methods werecompared with the occurrence of umbilical artery pH at birth , 7.10. Alldata were analyzed and compared using logistic regression.Conclusion: The probability of umbilical artery pH below 7.10 inARED fetuses could be predicted by means of the ductus venosusDoppler studies and the BPS. Knowledge of this probability can helpto choose the best moment for delivery in these cases.

P108The importance of studying the ductus venosus for predictingacidosis at birth in pregnancies with absent or reversed end-diastolic (ARED) velocity flow in the umbilical arteries

R. P. V. Francisco, R. M. Yamamoto, K. Sakamoto, S. Miyadahira andM. ZugaibHospital das ClõÂnicas, SaÄo Paulo University School of Medicine, SaÄoPaulo, Brazil

Background: A study of the relation between methods for assessmentof fetal well-being and birth weight.Methods: A prospective study was conducted to assess the fetal well-being in 61 singleton pregnancies with ARED. The results of thesemethods were compared with the occurrence of umbilical artery pH atbirth , 7.20 and , 7.15. All data were analyzed and compared usinglogistic regression.Conclusion: The pulsatility index for veins in the ductus venosus is themost important predictor for acidosis at birth. Once the ductusvenosus pi is known, it is possible to estimate the probability of fetalacidosis in pregnancies with AREDV.

109Transcranial-duplex-Doppler US findings andneurodevelopmental outcome of infants with perinatalcerebral infarction

V. �uranovicÂ, V. MejasÏki-BosÏnjak, B. MarusÏicÂ-Della Marina,R. DuplancÂicÂ, L. LujicÂ, J. Babic-Polak and R. HuzjanChildren's Hospital Zagreb, Klaiceva 16, Zagreb, Croatia

Objectives: We recorded cerebral flow velocities by TCDD in 10infants diagnosed with cerebral infarction (CI) of the irrigational area

of the middle cerebral artery (MCA), with special reference to theetiology and pathogenesis of CI. We correlated the hemispherallocalization and the distribution of the lesion with neurodevelop-mental outcome of the children affected.Patients and methods: Two children were preterms and other eight werefull terms. The diagnosis was obtained in all children by using cranial US,CT and MRI. Because of vascular etiology of lesion cerebral circulationwas investigated by TCDD. Perinatal risk factors were assessed andpatients underwent neurodevelopmental follow-up for 1±14 years.Results: Cerebral infarction involved the irrigational area of MCA.Asymmetric flow between the left and right MCA was the main findingon the TCDD. Lower velocities were found in the MCA on the affectedside. These side-to-side differences were present at subsequent Dopplermeasurements. The lesion was more often found on left size. Thedistribution of the infarction was classified as the area of the lesiondetermines the neurological sequels. All infants had delayed psycho-motoric development: contralateral hemiparesis, persistent seizures andlanguage delay. The level of cognitive functioning was variable.Conclusions: Based on clinical and diagnostical follow-up the resultsshowed no simple and clear connection between lesion parameters andneurodevelopmental outcome. We suppose that the time when lesionoccurred is crucial for the possible neurodevelopmental outcome. The dataindicates that beside brain US, CT and MR, TCDD can be useful methodfor identifying and following infants with suspected cerebral infarction.

P110Neurodevelopmental outcome of children with intrauterinegrowth retardation and pathological antenatal color Doppler:a 1-year follow-up

R. Huzjan*, V. MejasÏki-BosÏnjak*, T. Gojmerac*, D. JugovicÂ²,B. Grguric-KoprcÏina², J. Tumbri², J. Polak-BabicÂ³ and D. KalafaticÂ³*Children's Hospital Zagreb, ²Sveti Duh General HospitalDepartment of Obstetrics and Gynecology, ³University School ofMedicine Zagreb, Croatia

Objective: The aim of the study is to determine the neuro-developmental outcome of children with IUGR due to placentalinsufficiency diagnosed by Color Doppler during pregnancy.Patients and methods: 25 children who were diagnosed with IUGRwere included. The intrauterine growth was evaluated by repeated USand Doppler examinations and the resistance indexes in umbilical andcerebral fetal blood vessels were registered. The C/U ratio lower thanone was considered pathological, implying the phenomena of fetalcirculation centralization and brain sparing effect. All childrenunderwent protocol that included the evaluation of other perinatalrisk factors and extensive neurological follow-up with repeated brainUS, electrophysiological tests, visual and hearing acuity testing, as wellas developmental assessment.Results: The gestational age ranged from 30 1 6 to 41 gestationalweeks. The follow-up period ranged from 2 to 16 months. None of thechildren has severe disorder. Some children have signs of dystonicsyndrome (6 cases) or global neuroedevelopmental delay (2 cases). Thenonoptimal outcome was always connected to neonatal complicationsand pathological brain US finding (PV-IVH or cortical brain atrophy).Further neurodevelopmental evaluation for assessment of highercognitive functioning at later (even school age) age will be necessary.

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

P111Bradyarrythmia in the first trimester, a predictor of pregnancyloss

T. VinczeDepartment of Obstetrics and Gynecology, Markusovszky HospitalSzombathely, Hungary

Background: To determine the prognostic of cardiac bradyarrythmiadetected in the first trimester.Method: Cases in which bradyarrythmia was detected by ultrasoundbetween 8±11 weeks were retrospectively reviewed.Results: Bradyarrythmia was founded in five cases of 1292 examina-tions. One week later was not detected cardiac activity in three, and2 weeks later in two cases.



Conclusion: The report suggest that bradyarrythmia is a poorprognosis in early pregnancy and associated with pregnancy loss

P112Early fetal echocardiography at 13±16 weeks of gestation

J.M. Martinez, B. Puerto, A. Borrell, V. Cararach and A. FortunyObstetrics and Gynaecology, Hospital Clinic, Barcelona, Spain

Objective: Our aim was to determine the potential value of fetalechocardiography at 13±16 weeks of gestation for early reassuranceof normality or a prenatal diagnosis of congenital heart disease inhigh-risk pregnant women.Methodology: 92 pregnant women from 13 to 16 weeks withsingleton pregnancies underwent fetal echocardiography because of ahigh risk of congenital heart disease. The main indications were:nuchal translucency . 95th centile, pregestational diabetes, familyhistory, suspected cardiac anomaly at screening ultrasound, womanat risk of chromosomal abnormality declining invasive testing andfetus affected by a chromosomal abnormality. All the examinationswere performed combining either the transvaginal or the transab-dominal route, and were considered as complete when the fourchamber view, and the origin and double crossing of the greatarteries were correctly identified. Colour and pulsed Dopplerexamination were used to detect regurgitation or very high velocitiessuggesting valve stenosis. A further conventional transabdominalechocardiography at 20±22 weeks of gestation was performed in allaparently normal cases.Results: We were able to reassure normality in 84 of the cases andeight congenital heart anomalies were diagnosed.Conclusion: Fetal echocardiography at 13±16 weeks' is feasible andcan be offered to high risk pregnants. It should be supplemented withthe conventional 20±22 weeks' examination whenever normality isdiagnosed in the early scan. Postmortem examination is essential toconfirm its accuracy.

P113Prenatal diagnosis of congenital heart defects: report of 263cases

A. Galindo, M. Carrera, M. Salvador, F. GutieÂrrez-Larraya, E. GoÂmezand P. De La FuenteDepartment of Obstetrics and Gynecology, Hospital Universitario `12de Octubre' de Madrid, Madrid, Spain

Aim: To evaluate the main characteristics of prenatally diagnosedcongenital heart defects (CHD).Methods: Retrospective study of 263 fetuses with CHD diagnosedbetween January 1993±September 1999. In this period 133 morecases were born with a CHD not identified prenatally.Results: The incidence in the period reviewed was 1/148 deliveries(7½). 161 patients (61%) were referred from other Hospitals. Meangestational age at diagnosis was 27.1 weeks (range: 13±41). 103 werediagnosed before 22 weeks (39%). Most common CHD werecomplete atrioventricular canal (CAVC) (49 cases, 18%), hypoplasticleft heart syndrome (HLHS) (37,14%) and conotruncal anomalies(CTA) (31, 12%). Postnatally, most common CHD were ventricularseptal defects (VSD) (70, 29%). Overall sensitivity was 66%,improving from 1993 (60%) to 1999 (80%). Sensitivity was higherfor CAVC (86%), HLHS (90%), tricuspid atresia (93%). Sensitivitywas poor in VSD (26%). Associated anomalies were seen in 105 cases(40%) more common in CAVC (37/49, 75%), VSD (16/22, 73%) andCTA (14/31, 45.2%). In 85 cases (32%) termination of pregnancy(top) was performed. This represents 82.5% of 103 cases diagnosed, 22 weeks' gestation. tops were more common in CAVC (39%) andHLHS (46%).Conclusion: Fetal echocardiography enables the diagnosis of a highnumber of CHD in the first half of pregnancy. Changes in themonographic visualization of the CHD over the pregnancy withpotential progression of the lesion in utero, the small size of the defectand difficulties in monographic work-up are explanations for latediagnosis and false negative cases. The distribution of the different

CHD differs from that observed postnatally. Associated anomaliesshould be ruled out because of their high frequency, mainly in somespecific heart defects.

P114Fetal echocardiography in chromosomally normal fetuses withincreased nuchal translucency. A preliminary report

B. Puerto, J. M. Martinez, A. Borrell, V. Cararach and A. FortunyObstetrics and Gynaecology, Hospital Clinic, Barcelona, Spain

Objective: To determine the value of first trimester screening forcongenital heart disease by measurement of nuchal translucency at10±14 weeks of gestation.Methodology: A transabdominal echocardiography at 20±22 weeksof gestation was performed in 104 singleton pregnancies withchromosomally normal fetuses and an increased nuchal translu-cency (. 95th centile) at 10±14 weeks. In the last 55 cases anearly examination combining either the transvaginal or thetransabdominal route at 13±16 weeks was also carried out. Theheart evaluation was considered as complete when the fourchamber view, with both atria, ventricles and atrioventricularvalves, as well as the origin and double crossing of the greatarteries were correctly identified. Colour and pulsed Dopplerexamination were used to assess blood flow through the aortic,pulmonic and atrioventricular valves, in order to detect regurgita-tion or very high velocities suggesting valve stenosis. The systemicand pulmonary venous return was also identified, and assessed byDoppler when possible.Results: Only one structural cardiac defect was detected in thispopulation. It was a tricuspid atresia with ventricular septal defectdetected at 14 weeks of gestation.Conclusion: Although the number of cases is too small to draw strongconclusions, the utility of nuchal translucency as a screening methodfor congenital heart disease in chromosomally normal fetuses is worthto be confirmed by further investigation.

P115First trimester diagnosis of the Pentalogy of Cantrell

A. Yamasaki, D. A. L. Pedreira, R. Muller, M. V. Machado, R. Schultzand S. C. ChaLaboratoÂ rio Fleury, SaÄo Paulo, Brazil

Case report: CATO, 31-year-old, 2G 0P 1 missed abortion (6 weeks).Ultrasound at 13 weeks gestation showed an opened fetal thoraco-abdominal wall, with ectopia cordis and a large omphalocele, severescoliosis was noticed, suggesting the diagnosis of Pentalogy ofCantrell. Nucal translucency measured 1.5 mm and Doppler veloci-metry of the venous ductus showed a reverse A wave. At 15 weeks, atransabdominal echocardiography showed a complete ectopia cordisand a ventricular septal defect with mild dilatation of right atrial andventricular cavities. Kariotype obtained by cvs at 14 weeks showed anormal male (46,XY). Spontaneous fetal death occurred at 18 weeksand after 4 days induced labor resulted in an uneventful vaginaldelivery. The anatomopathologic study confirmed the diagnosis ofPentalogy of Cantrel: ectopia cordis, cardiac anomalies (IAC, IVC,truncus arteriosus), sternal agenesis, diaphragmatic defect andgastrosquisis.Discussion: Ectopia cordis is present in the Pentalogy of Cantrell,which is one of the thoraco-abdominal malformation syndromes. It isa rare disease with a relatively good prognosis in neonatal series.Nevertheless, during pregnancy, few cases have been reported makingfetal counselling difficult. This anomaly seems to be a X-linkeddominant inheritance, suggesting that male fetus can have worseprognosis.



P116The role of fetal echocardiography and detailed sonography inthe prenatal diagnosis of the Edward's syndrome (analysis ofthe 30 cases)

P. Kaczmarek, K. Janiak, A. KrasonÂ , G. Nowicki, E. Czichos andM. Respondek-LiberskaDepartment of the Diagnosis of Fetal Malformations, Institute `PolishMother's Memorial Hospital', èoÂdzÂ, Polandhttp://www.fetalecho.z.pl

Background: The aim of this study a retrospective analysis from thevideo tapes fetuses with trisomy 18 (Edward's syndrome) who haddetailed sonography and echocardiography.Method: Between 1994 and 2000 at our Department 30 cases oftrisomy 18 were diagnosed.Results: Every fetus presented with congenital anomalies. The mostcommon were: intrauterine growth retardation (96%) and fetalcongenital heart defects (92%).Conclusion: The `genetic sonography' including fetal echocardiogra-phy allows a strong `suspicion' of trisomy 18, which later can beconfirmed by cytogenetic analysis.

P117Echocardiographic findings in fetuses with trisomy 18

M. Holan, V. Ferianec, K. Pohlodek, M. Kaldararova andM. BenedekovaChildren's Cardiology Centre, Children's University Hospital,Bratislava; IInd Obstetrics and Gynecology Clinic, Medical FacultyUK, Bratislava; Ist Paediatric Clinic, Children's University Hospital,Bratislava, Slovak Republic

The aim of this study was to present our 4 cases of trisomy 18, with acongenital heart defect detected during the last 6 months.Results: Two complex congenital heart defects (CHD) with a verysimilar anatomy were found during a prenatal ultrasonographicexamination ± Double outlet right ventricle (DORV) with completeatrioventricular septal defect (AVSDC) ± in the 20th and 38th week ofgestation and in other two cases ± in the 19th and 21st week ofgestation ± an isolated muscular ventricular septal defect (VSD) wasproved. In All fetuses also noncardiac (central nervous, gastro-intestinal and uropoetical) congenital malformations were present.Conclusion: Trisomy 18 (Edwards sy) occurs approximately in 1:7000live births. 95±100% of these newborns have some form of CHD.Because of a very poor prognosis a surgical correction is usually notconsidered. Left to their natural course, death occurs at the age of onehour to 18 months, the median life expectance is 5±48 days,according to the presence of severe CHD and associated anomalies.

P118The role of fetal echocardiography and detailed sonography inthe prenatal diagnosis of trisomy 13 ± analysis of 11 cases

K. Janiak, P. Kaczmarek, A. KrasonÂ and M. Respondek-LiberskaPolish Mother Memorial Insitute, èoÂdzÂ, Polandhttp://www.fetalecho.z.pl

The aim of the study was to show the importance of sonography andechocardiography at 2nd trimester of pregnancy on the ground of theretrospective analysis of cases with Patau syndrome.Materials and methods: From the database of 6430 fetuses examinedthroughout 1992 until 1999, aneuploidy in the form of patausyndrome was suspected in 11 fetuses (0,64%). Maternal, fetal andneonatal data were retrospectively evaluated.Results: The majority of cases come from low risk pregnancies. Thefull genetic antenatal diagnostic was performed in 7 cases. The meanapgar score was 1 and the mortality in analyzed group was 100%.During fetal echocardiography the congenital heart defect werediagnosed in 5 cases: 3xVSD, 1xVSD 1 aorta dextraposition,1xVSD 1 bright spot 1 cardiomegaly 1 pericardial effusion. Trisomy13 in analyzed group manifested by malformations of various organsand systems: congenital heart defects was the most common anomaly

diagnosed prenatally (7/11), the second one were central nervoussystem and genitourinary system anomalies (6/11) and others. In theanalyzed group the mean number of anomaly per fetus was 3. Prenataldiagnoses were confirmed at autopsy, additionally cleft palate wasidentified at 2 cases.Conclusion: Fetal detailed sonography and echocardiography in eachcase of trisomy 13 allows the visualisations of malformations atfetuses (min 1, max 5) and therefore this examination may be consideras `genetic sonogram'.

P119Usefulness fetal echocardiography in the prenatal diagnosis ofDown Syndrome (analysis of the 40 cases)

A. KrasonÂ , P. Kaczmarek, K. Janiak, M. Piotrowicz, G. Nowicki andM. Respondek-LiberskaDepartment of the Diagnosis of Fetal Malformations, Institute `PolishMother's Memorial Hospital' èoÂdzÂ, Polandhttp://www.fetalecho.z.pl

Background: The aim of our study was retrospective analysis of 40cases fetuses with down syndrome (T21) who had detailed sono-graphy and echocardiography.Method: Video tape analysis of 40 fetuses with T21 who hadcompleted ultrasound and echocardiography examinations andcompleted neonatal follow-up in the same center.Results: In our study the majority of cases 26 (65%) were low riskpregnancies. High risk pregnancies were in 14 (35%) cases.Congenital heart defect (72%) (AV-canal in 13/18 cases) was themost common anomaly diagnosed prenataly in fetuses with T21.Functional cardiac anomalies with normal heart anatomy wererecorded also such as: dyspoportion and hypertrophy in 4/12 cases,tricuspid valve regurgitation, bright spot and pericardial effusion in3/12 cases. Extracardiac malformations (25%) were diagnosed infetuses with T21 such as: dudenal atresia, femur length shortening,pyelectasis bilateralis, face anomalies, sceletal malformations,hydrops fetalis.Conclusions: 1. Congenital heart defect (72%) (AV-canal in 13/18cases) was the most common anomaly diagnosed in fetuses with T21.2. The most common extracardiac malformation was duodenal atresia13/40 � 32.5% cases. 3. Fetal echocardiography can be usefull toidentify in the group of low risk pregnancies, the potential patients forcytogenetic examinations of trisomy 21.

P120Prenatal demonstration of polyvalvular disease in a fetus withtrisomy 18

U. Gembruch, U. Germer, S. Denzel and K. Gloeckner-HofmannDivision of Prenatal Medicine, Medical University, LuÈbeck, Germany

A polyvalvular disease of cardiac valves is a common finding in earlytrimester fetuses with trisomy 18 at autopsy (Hyett et al. Am J MedGenet 1997; 69: 207). Prenatal diagnosis of this disease, however, isvery rare.Case report: Nuchal translucency screening was performed in a 26-year-old gravida 1 at 13 1 5 weeks. IUGR (CRL 65 mm) with nuchaltranslucency thickness of 3.0 mm, retrogenia and cardiomegaly(CTR . 0.5) was shown. Umbilical artery Doppler indices werenormal (PI 1.44), but in the ductus venosus a reversed blood flowduring atrial systole was demonstrated (PIV 4.18, PVIV 2.9).Echocardiography showed `doming' of the pulmonary and aorticvalves with poststenotic dilatation. Doppler echocardiographydemonstrated severe stenoses of the pulmonary and aortic valves(maximal velocities: 1.8 m/s and 2.13 m/s, respectively) andholosystolic insufficiencies of tricuspid and mitral valves (maximalvelocities: 2.12 m/s and 2.04 m/s, respectively). The CVS revealedtrisomy 18 (47,XY, 1 18). 6 days later, fetal demise was diagnosed.Abortion was induced by an intra-amnial injection of Rivanol.Autopsy confirmed the severe stenoses of both great arteries withoutadditional cardiac malformation.Conclusions: The case reports the option of Doppler echocardiogra-



phy in early pregnancy to diagnosed severe stenosis of the greatarteries and confirmed the data of autopsy studies, that fetuses withtrisomy 18 in early pregnancy have polyvalvular diseases, presumablybeing a lethal factor.

P121Pulmonary valve atresia. Fetal echocardiography findings inone case with intact ventricular septum

C. GarcõÂa, N. Lagos, C. Diaz, N. Meneses, G. Castillo, R. Pazols,C. Benavides, I. Hoffmann, Astorga, P. Ortega and I. FerresHospital de Carabineros, Universidad de Santiago, Santiago, Chile

Background: Right ventricular outflow obstruction with an intactventricular septum leads to severe hemodynamic problems in thenewborn, with hypoxemia and congestive heart failure due to tricuspregurgitation. Atresia of the pulmonary valve occurs in less than 3%of all congenital heart lesions, with a frequency of 1:25 000 of livebirths. Use of fetal echocardiography permits prenatal diagnosis ofthis and other congenital defects, for a better knowledge and therapy.Case report: 35-year-old pacient, with a previous newborn with aninterventricular comunication. On her 30 week of pregnancy, a fetalechocardiography showed atresia of the pulmonary valve with anintact interventricular septum, severe tricuspid regurgitation, a rightatrial dilatation, restriction of flow in the oval foramen of 8 m/seg andductus arterioso with retrograde or bidirectional flow, from the aortato the pulmonary circulation. Vaginal delivery occurred at 38 weeks,obtaining a female newborn, 2630 g, in good conditions. However shedeveloped severe cardiac failure and died at day 4, in spite ofpharmacologic with prostaglandins and surgical therapy.Conclusions: Echocardiography is the basis of prenatal diagnosis ofcongenital heart disease, like pulmonary valve atresia, and is of greathelp to understand and decide the best perinatal therapy.

P122Fetus with partial hyperechoic cardiac walls

J. A. DuyosClõÂnica EcograÂfica, Santander, Spain

Objective: To present a rare case of a fetus with very echogenic cardiacatrial walls, but with normal density in the rest of the heart, perhapsdue to a viral infection.Case report: The first ultrasound examination at 17 weeks wasnormal, but in the next exam at 24 weeks we detected that the fetalcardiac atrial walls were very echogenic. However, the density of theatrioventricular valves and the ventricular cardiac walls werenormal. The morphology of the heart was also normal. There wasalso an important amount of ascites. Doppler study of theatrioventricular valves was normal. Later examinations were similarbut the quantity of ascites gradually decreased. At 34 weeks, thepatient had a premature rupture of the membranes and a healthyinfant was born. The ascites had disappeared and the baby'soutcome was normal.Discussion: To prevent misdiagnosis of the density of the cardiacwalls, we made exams of different fetal positions, but hyperechoicatrial walls were always seen. After consulting a neonatal cardiologist,we concluded that the cause of this alteration may have been a viralinfection, which could have produced partial density alteration of thecardiac walls. The hyperechoic atrium may cause poor contractabilityand produce ascites.Conclusions: Despite the impressive aspect of the hyperechoic atrialcardiac walls and an important ascites, the infant's outcome wasnormal.

P123Congenital complete heart block. Prenatal diagnosis andsuccessful fetal therapy

C. GarcõÂa, N. Lagos, R. Pazols, M. Carrasco, I. Hoffmann and P. ToledoHospital de Carabineros, Universidad de Santiago, Santiago, Chile

Objective: Congenital complete heart block (CCHB) affects 1:20.000

live births. This condition reappears in 18±24% of future pregnancys.50% of the fetuses have a structural cardiac anomalies. It may presentisolated or in mothers with autoinmune disease, or positive anti-Ro(SSA) and anti-La (SSB) antibodies. Our purpose is to show theimprovement in perinatal outcome using 2D echocardiografy andfoetal Doppler to diagnose CCHB in the prenatal period.Case report: We present a 36-year-old female patient with 2 previousstillborns due to CCHB. She was positive for anti SSA and anti SSBantibodies and was evaluated for the first time at 22 weeks of herthird pregnancy. An Echography showed foetal hydrops, andechocardiography showed an anatomically normal heart, with acomplete heart block. The atrial rate was 120/min. and theventricular rate was 60/min. Treatment was started with dexameta-sone 4 mg/day, salbutamol 12 mg/day and Sandoglubulin (Novartis)400 mg/kg.

Following sonographys showed resolution of fetal hydrops,improvement in cardiac function and cardiac rates. Cesarian sectionat 34 weeks, newborn 2420 g. At day 7 a permanent pacemaker wasimplanted.Conclusions: Fetal echocardiography is the best method todiagnose and treat CCHB in the prenatal period. The use ofglucocorticoids, betamimetics and immunoglobulins has shown tobe of benefit.

P124S-shaped kinking and constriction of the fetal ductusarteriosus with pericardial effusion

M. Y. Park, Y. J. Kim, B. H. Woo and H. S. Kim*Department of Obstetrics and Gynecology, Department ofPediatrics*, College of Medicine, Ewha Woman's University, Seoul,Korea

Usually fetal ductus arteriosus (DA) closure or constriction is causedby maternal medication of prostaglandin synthase inhibitor orcorticosteroid. Although it is a rare condition, idiopathic DAconstriction in the human fetus has been also reported. In our case,the patient was reffered at 26 weeks gestation due to pericardialeffusion. The mother had not been received any medication ofnonsteroidal anti-inflammatory agents. The fetus had abnormally S-shaped kinking and constriction of the DA, right arterial enlargement,right ventricular hypertrophy, tricuspid valve regurgitation andconstrictive foramen ovale. An amniocentesis had been performeddue to abnormal triple test and the fetal karyotype was 46XY. Therewas no evidence of fetal infection and other congenital malformation.Cesarean section was performed at 313 weeks gestation due to fetalhypoxia diagnosed by Doppler sonography and biophysical profile,and the baby was born in poor condition. On follow-up, although thebaby has right ventricular dysfunction for 2 month after birth,expected a good prognosis.

P125Prenatal diagnosis of cardiac rhabdomyoma

L. HernaÂdi, M. ToÍ rocsik, D. AÂ . Player and Z. VasasCounty Hospital Eger, Hungary

Background: Our aim was to present a case of cardiac rhabdomyomadiagnosed at 24 weeks of pregnancy.

A 20-year-old woman, G2P0, was referred for sonographicexamination because of the history of cystic hygroma in her firstpregnancy. Karyotyping revealed trisomy 21 and termination wasperformed. There were no cardiac and neurologic diseases in herfamily history. For the present pregnancy routine ultrasound scans at12 and 18 weeks showed normal fetal anatomy. Fetal echocardio-graphy at 24 weeks revealed a large cardiac tumour protruding fromthe intraventricular septum into the right ventricle (12 mm). ColourDoppler showed blood flow around the tumour and the flow patternwas not suggestive for obstruction of the right ventricular outflowtract. No other fetal anomalies were noted. The patient was informedabout the diagnosis of rhabdomyoma and the possibility of associatedtuberous sclerosis. Termination of pregnancy was performed upon



patient's request. Pathologic examination confirmed the diagnosis butfound no sign for tuberous sclerosis. Karyotyping was normal. Hernext pregnancy was uneventful resulting a healthy newborn.Conclusion: The natural history of intracardiac rhabdomyoma is not

known and usually detected in the second half of gestation. Theprognosis depends on its influence on cardiac functions and theassociated anomalies.

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

P126The three-dimensional ultrasound analysis of embryonal andearly fetal development ± an improvement of prenataldiagnosis

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

Backround: There are two important trends in prenatal diagnosis± to avoid invasive diagnostic procedures as much as possibleand to find anomaly as soon as possible. Ultrasound evaluationis playing an essential role. The first trimester of pregnancyseems to be the suitable period for diagnosis for abovementioned purposes.Method: More than 450 first trimester pregnancies was evaluatedwith 3D sonography using its all computed features. The imageswhich were obtained can be used also for educative goal.Results: We provided 3D ultrasound diagnosis of fetal anomaliesfrom the moment of their development, up the 9th week of gestation(from LMP). The image quality allowed so precise analysis, thatpictures are comparable with embryological reality and will bepresent.Conclusion: With 3D ultrasound the first trimester seems to be themost important period of prenatal diagnostics. 3D can display thesame pictures in vivo, as invasive fetoscopy or embryologicalspeciments in vitro. The technical limits disapear and the knowledgeof embryology and of possible pathological fetal development remainsthe last limiting factor.

P127Assessment of fetal anatomy in the first trimester using twoand three dimensional ultrasound

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

Objectives: To study if a complete anatomical survey of the fetus at12±13 weeks gestation can be achieved using stored volumes acquiredby a 3D scanner.Subjects/methods: One hundred and twenty-two consecutivewomen at 12±13 weeks gestation who had a scan in our unit.A complete survey of the fetal anatomy was attempted bytransabdominal and if needed transvaginal 2D scanning. Thenusing the 3D transvaginal probe (Kretz 530D) two volumescontaining the fetus were acquired. A complete anatomical surveywas attempted using the data from these volumes (excluding theanatomy of the heart).Results: A complete anatomical survey was achieved in 93% (113/122) of cases with the 2D scanning comparing to 71% (86/122) withthe 3D volumes (statistically significant difference, P , 0.01). Thenuchal translucency was measured in 97.5% of cases with 2Dscanning and in 82% with the 3D volumes. The mean time to performthe 2D scan was 15 min (SD: 4 min) while the time to examine thestored volumes was 6.6 min (SD: 2.66). Using the stored volumes weobtained the required views in 8 of the 9 cases in which the survey wasincomplete by the 2D scan.Discussion: Real time 2D scanning is still the best way to examinethe fetal anatomy in the first trimester. However, 3D scanning can bea useful addition to clinical practice providing views not easilyobtained by conventional 2D scanning. It can potentially minimise

the actual scanning time and provides an excellent way to storescanned data.

P128Impact of patient initiated three-dimensional ultrasoundexamination

D. H. Pretorius, A. D. Hull, R. Newton, T. R. Nelson and G. JamesUniversity of California, San Diego, La Jolla, CA, USA

Background: News media and the internet have a significant impacton raising patient awareness of new care. Visualization of the fetalface made possible by 3-dimensional ultrasound (3DUS) is one sucharea that has encouraged many pregnant patients to initiate requestsfor these studies. The purpose of this project was to identifyindications, reactions and benefits for these studies.Method: 3DUS examinations were performed on 35 consecutivepatients requesting studies from our service. We require a physician toorder the 3DUS exam in conjunction with conventional 2DUS.Patients had a targeted 3DUS to the area of interest as well as the fetalface. Comments by the parents were recorded at the time of the studyand after delivery.Results: Medical indications for 3DUS studies were: patient reassur-ance (19), patients with prior anomalies (8), hospice patients carryingfetuses with fatal anomalies (2), patient with family history ofanomaly (1), infertility (1), patient carrying a fetus with abnormalkaryotype (1). Although most parents found the 3DUS to be apositive, reassuring experience (28), (7) found it to be extremelybeneficial (previous children with anomalies or demise, fetuses withfatal anomalies, and infertile couples).Conclusion: Patient initiated 3DUS studies had a positive impactand reassured all families and were extremely beneficial to 6/35families.

P129The sonographic appearance of fetal micrognathia using anovel three-dimensional ultrasound system

G. Malinger, T. Lerman-Sagie, A. Gomel and M. GlezermanThe Edith Wolfson Medical Center, Holon, and Sackler School ofMedicine, Tel Aviv University, Tel Aviv, Israel

Background: Fetal micrognathia is difficult to diagnose usingconventional ultrasound and three-dimensional surface renderingmay provide additional information when available. We present twofetuses with micrognathia in whom this technique helped in thediagnosis.Method: Three-dimensional ultrasound examination was performedwith an add-on unit that fits any existing conventional ultrasoundmachine. The system contains a unique positional sensor andextremely powerful segmentation feature that allows to removeobscuring objects from the region of interest (BabyFace, Biomedicom,Jerusalem, Israel).

In both fetuses the diagnosis was suspected during conventionalultrasound examination.Results: Good three-dimensional images of both fetuses were obtainedat the first acquisition intent and provided additional informationabout the severity of the anomaly.Conclusion: We present a novel 3D ultrasound system, which is userfriendly and cost-efficient. Its compatibility as an add-on to existing us



equipment allows for immediate upgrades and increases diagnosticoptions in fetal imaging.

P130Three-dimensional sonographic features of hydrops fetalis

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

Background: The aim of this study was to describe three-dimensional(3-D) sonographic features of hydrops fetalis.Methods: A total of 8 cases with hydrops fetalis from 15 to 32 weeksof gestation were studied with transabdominal 3-D sonography(3.5 MHz).Results: The image clarity of 3-D sonography was subjectivelysuperior than those by 2-D sonography in all cases studied, and itwas possible to obtain finer image quality of internal organs with 3-Dsonography. Before around 20 weeks of gestation, the skin becomes atransparent-like structure, so internal organs can be clearly identified.After 25 weeks, skin edema, pleural effusion, hypoplastic lungs wereclearly recognized.Conclusion: Our results suggest that 3-D sonography provides a novelmeans of visualizing hydrops fetalis in utero.

P131Differential diagnosis between chorioangioma and chorionicvillous haemorrhage by three-dimentional ultrasonography

S. Kondo, Ninomiya, T. Takahashi, H. Soma and T. HataSaitama Medical School, OB/GYN, Saitama 350±0495, Japan

We had 2 cases of `placental tumor' with hydramnion and fetalanemia. Case 1: A 26-y/o G-1, P-1 was introduced to our hospital at25w due to drastic enlargemnet of her lower abdomen. 3-D US examrevealed a tumor on her placental. Its volume was 137.8 ml andabundant bloodflow was observed in the tumor. The tumor andamnionic fluid volume were increased. At 26w, we performed C/S dueto her dyspnea by hydramnion. A 1028 g male infant was deliveredand was transferred to NICU immediately as an imature infant withhis low Hb, 10.6 g/dl. The tumor was histologically diagnosed as

chorioangioma. Case 2: A 26-y/o G-0, P-0 was admitted at 29w due toplacental tumor. By 3-D US exam, we found a placental tumor. Itsvolume was 164.1 ml. C/S was performed because nst showed loss ofvariability. A 1982 g female infant was delivered. Her Hb was 9.1 g/dl.The tumor was diagnosed as chorionic villous hemorrhage. We couldnot differentiate those of `placental tumor' by 2-D US with color flowmapping. But using 3-D US, chorioangioma showed as a hyper-echoicmass although chorionic villous hemorrhage did as hypo-echoic.`Placental tumor' can be differentiated effectively by 3-D US.

P132Three-dimensional ultrasound: A new diagnostic optionmonitoring cervical incompetence in higher order multiplegestation

A. Strauss, I. Heer and S. FuchshuberDepartment of Obstetrics and Gynecology ± Groûhadern, Universityof Munich, Germany

Background: Preterm birth is the greatest threat to the infants of amultiple pregnancy. Incompetent cervix is still a diagnostic andtherapeutic dilemma. Is three dimensional volumetry of the cervixuteri the key to predict preterm birth in higher order multiples?Method: From May 1999 to May 2000 we prospectively comparedconventional measurements of cervical length to 3D-volumetry in 10triplet pregnancies.Results: 29 volume scans as well as conventional length measurementsof the cervix in 10 triplet pregnancies were analyzed. 2.9 examinationsper patient (1±5) were done on a weekly basis. The mean cervicallength was 27 mm (4±50). The mean cervical volume decreased withgestational age parallel to the two dimensional data. In three womenlength-assessment could not be obtained as the presenting part of theleading triplet obstructed a longitudinal scan of the cervix. In contrast,these anatomic difficulties did not present an obstacle in (transverse)3D-scans which were possible in all patients.Conclusion: Transabdominal 3D-volumetry as compared to 2Dcervical length measurements represents an exact and potentiallysuperior method to monitor cervical incompetence. We believe it avaluable parameter to predict preterm birth.

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

P133The endometrium after 50: sonographic-histologic correlation

A. Joutindo, J. P. Lescrainier and C. Van PachterbekeCHU Brugmann, Obstetrics and Gynecology Department, Place VanGehuchten 4, B1020 Bruxelles, Belgium

We wanted to test the accuracy of sonography in detectingendometrial pathology, in women over 50. Retrospectively, weenrolled 100 consecutive women over 50-year-old, who have had amonographic endometrial thickness measurement followed by ahistological endometrial analysis, though endometrial biopsy,dilatation and curetage, or hysterectomy. The mean age was64.3 years; 54% of the women presented metrorragies and 40%of them did not use hormonal replacement therapy (HRT). Wefound 6 endometrial cancers and 2 atypical hyperplasia (all ofthem were symptomatic); we found 7 simple hyperplasia (2 wereasymptomatic) and 18 polyps (6 were asymptomatic). No seriousendometrial anomaly (simple or atypical hyperplasia or adeno-carcinoma) were found under 5 mm of double endometrial layer.The first endometrial cancer was encountered in an endometrialthickness of 10 mm, the first atypical hyperplasia at 9 mm, thefirst simple hyperplasia at 7 mm, and the first polyp in a 2-mmendometrial thickness. If we used the endometrial thickness cut-off level of , 5 mm for symptomatic women and for asympto-matic women without hormonal replacement therapy and the

endometrial thickness cut-off level of , 8 mm for asymptomaticwomen with HRT, we obtain a sensitivity in detecting anyendometrial pathology of 85%, and a specificity of 41%; thefalse negative rate is low (5%) and represent in our study onlysmall polyps.

P134Uterus sonographic volume evaluation in post menopausalwomen and its variation

F. F. A. Santos, M. R. M. Machado, M. S. J. Dertkigil andE. F. MarussiState University of Campinas, Campinas, Brazil

Background: The aim of this study was evaluate the uterine volume inpostmenopausal women considering parity, years since the lastmenstrual bleeding, abnormal vaginal bleeding and hormonalreplacement therapy (HRT).Method: Uterine size was measured in 100 postmenopausal women bypelvic and/or transvaginal US, that had gone to routine examinations.Results: The mean age was 61.5 years (^ 9.3) and the meanmenopausal age was 48 years (^ 5). Forty percent was under HTRand the mean parity was 4.0 (^ 3). Abnormal vaginal bleeding waspresent in 13% of the patients. The patients were divided into threegroups: I (nullipara), II (1 or 2 deliveries), III (3 or more deliveries).



The uterine volume was, respectively, 39, 45 and 47 cm3. Patientsunder HTR had the mean uterine volume 51 cm3 and the others42 cm3. Patients with 5 or less years since menopause had a meanuterine volume of 51 cm3 and the women with 6 or more years had44 cm3. The mean uterine volume in patients with abnormal vaginalbleeding was 62 cm3 (^ 35) and in the assynthomatic ones was43 cm3(^ 21).Conclusions: The uterine volume had a tendency to be smaller inpatients without HTR, low parity and more years since lastmenstrual period, but have no statistical significance. Howeverthe volume was significantly bigger in women with abnormalvaginal bleeding.

P135Endometrial thickness ultrasound evaluation and itsvariations

F. F. A. Santos, M. R. M. Machado, M. S. J. Dertkigil andE. F. MarussiState University of Campinas, Campinas, Brazil

Background: The aim of this study was to evaluate the variations inendometrial thickness considering years since the last menstrualbleeding, abnormal vaginal bleeding and hormonal replacementtherapy (HRT). It was also studied the histological diagnosis.Method: Endometrial thickness (ET) was measured in 100 post-menopausal women by pelvic and/or transvaginal US, that had gone toroutine examinations.Results: The mean age was 61.5 years (^ 9.3) and the meanmenopausal age was 48 years (^ 5). Forty percent was under HTRand abnormal vaginal bleeding was present in 13% of the patients.Endometrial thickness in patient with 5 or less years sincemenopause was 5.5 mm (^ 0.9) and 4.3 mm (^ 0.5 mm) in thosewith 6 or more years. Patients under HTR the mean thickness was5.07 mm (^ 5.6) and without HTR was 4.35 mm (^ 3.9). Womenwith abnormal bleeding had mean endometrium of 6.9 mm (^ 6.2),against 4.2 (^ 4.3) from assyntomatic patients. The histologicaldiagnosis from patients with ET $ 6 mm were: endometrial polyps(9); endometrial cancer (1); proliferative endometrium (1); submu-cous mioma (1) and endometrial atrophy (1). All histological studiesfrom patients with bleeding and ET , 6 mm showed atrophicendometrium.Conclusions: The ET had no significant statistical variation whenanalised time since menopause and use of HRT. All patients withbleeding and ET , 6 mm had endometrial atrophy. 85% (11/13)patients with ET $ 6 mm had pathological finds in histological study,including one endometrial cancer.

P136Color flow mapping and Dopplerometry of myometrialand endometrial arteries in patients with hyperplasiaand polyps

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

Background: The aim is to investigate the influence of the benignhyperplastic process of endometrium over the uterine blood flowresistance.Method: The transvaginal ultrasound with Color Flow Mapping andDopplerometry was used for examination of 90 patients (28 withhyperplasia, 30 with glandular and 32 with fibroid polyps) and of 30healthy women (in 1st phase of menstrual cycle). Arteries visualizationrate and values of Doppler indices for myometrial (the main uterine,arcuate, radial) and endometrial (basal, spiral) vessels were assessed.Results: The main uterine and arcuate arteries were visualized in allcases. As crossing from feeding uterine vessels deeper to theendometrium, the tendency of reduction possibility of its visualization

was marked. That probably corresponds with reduction of arteriessize. The resistance indices were:

Conclusion: Benign hyperplastic process of endometrium wasaccompanied by lowering Doppler indices values in all arteries incomparison with normal condition, that show intensification of theblood supply.

P137Ultrasound in the detection of endometrial pathologies inbreast cancer patients with Tamoxifen treatment

M. R. M. Machado, F. F. A. Santos, E. F. Marussi and V. M. Neder, SUniversidade Estadual de Campinas, SaÄo Paulo, Brazil

Background: The tamoxifen (TAM) is an antiestrogen that is widelyused as adjuvant therapy for postmenopausal breast cancer patientswith positive estrogen receptor proteins. It has been reported that thepatients who have been treated for more than 12 months with TAMare at increased risk for endometrial carcinoma. The aim of this studywas to investigate the relationship between histological endometrialfindings in breast cancer patients and transvaginal ultrasound.Method: Medical records and sonograms of 238 women treated forbreast cancer with TAM were reviewed retrospectively. We includedall patients using adjuvant therapy for breast cancer patients withTAM 20 mg of Tamoxifen. The exam was performed using atransvaginal probe 7.5 MHz transducer on a TOSHIBA 140 SSAand ACUSON XP-4A ultrasonography set. Sonographic endometrialthickness was correlated to histologic findings and symptoms.Results: A hundred-55 (65.12%) had endometrial thickness of 8 mmor lower, measured by transvaginal ultrasound. We did not found anycase of endometrial cancer, even with bleeding. From 51 patients withdiagnostic hysteroscopy, the more frequent findings were: atrophicendometrium, endometrial polyps and insufficient material forhistology exam.Conclusions: Transvaginal sonography is an useful tool for the follow-up of tamoxifen treated patients used as trial for invasive diagnosticprocedures.

P138A case of bilateral mature cystic teratoma with calcifiedelements in an old age postmenopausal woman

Z. N. Kavak and A. BasËguÈ lDepartment of Gynaecology, University Hospital, Marmara, Istanbul,Turkey

Background: Dermoid cysts are interesting tumours in which all bodytissues may be represented. Neither presence of calcified elements, norpostmenopausal age, nor bilaterality are usual for them. We presenthere, a case of postmenopausal woman in whom bilateral dermoidcysts were found with calcified elements. Ultrasonographic features,clinical presentation, differential diagnosis and treatment modalitiesof this rare case are presented and discussed.Case: 70-year-old woman gravida 0 para 0 was referred to ourDepartment complaining of postmenopausal bleeding for the last twomonths. She was postmenopausal for the last 27 years during whichshe had never been treated with estrogen replacement therapy. On agynaecologic examination, bilateral adnexal mass found. Ultrasono-graphic scanning demonstrated a normal sized anteverted uterus with

Healthy HyperplasiaGlandularpolyps

Fibroidpolyps

Uterine arteries 0.88 0.81 0.83 0.83Arcuate arteries 0.78 0.75 0.73 0.73Radial arteries 0.71 0.68 0.67 0.63Basal arteries 0.57 0.52 0.51 0.52Spiral arteries ± 0.53 0.50 ±Polyp arteries 0.58 0.49



an endometrial thickness of 4 mm with an hypoechoic ring around it.Transverse ultrasonogram showed bilateral adnexal highly reflectiveechogenic well circumscribed mass with solid and cystic components.Endometrial biopsy showed granulomatous endometritis. At surgery,a bilateral ovarian tumour measuring 4 � 5 cm in diameter was seen.A pathologic examination confirmed bilateral dermoid cysts with nomalignant component. Peritoneal washing was also negative. Totalabdominal histerectomy with bilateral salphingooopherectomy wasperformed. On discharging from Hospital, estrogen replacementtherapy was given.

P139Transvaginal color Doppler study of uterine blood flow inprimary dysmenorrhea

R. DmitrovicÂOpca bolnica Nova GradisÏka, Croatia

Background: The pain in primary dysmenorrhea is caused by excessiveprostaglandin production that leads to vasoconstriction and uterineischemia. Changes in uterine blood flow are important factor inpatophysiology of primary dysmenorrhea. The aim of the study was todetermine if vasoconstriction of the uterine vessels in patients withprimary dysmenorrhea is detectable by transvaginal color Dopplerultrasound.Methods: Forty-two women with primary dysmenorrhea and 50healthy controls were included in this prospective study. Women wereexamined with transvaginal color Doppler ultrasound on first day ofthe cycle, once in the follicular and once in the luteal phase.Measurements of pulsatility index in uterine, arcuate, radial andspiral arteries were performed. Student's t-test was used to establishstatistical significance between groups.Results: Women in dysmenorrhea group had significantly higheruterine blood flow indices than healthy controls in all threemeasurements periods. This includes all vessels studied on the firstday of the cycle, the radial and spiral arteries during the follicularphase and the arcuate, radial and spiral arteries during the lutealphase.Conclusions: We found that women with primary dysmenorrhea haveelevated Doppler indices in uterine arteries not only on first day of thecycle but throughout the whole cycle. Therefore we postulated thatprimary dysmenorrhea is not only the disorder of menstruation butalso a disease of a menstrual cycle in whole.

P140A case of an old age postmenopausal woman with a giantmyoma uteri


Background: Since leiomyomas are estrogen dependent, the occur-rence of myoma uteri in in a large size, in late postmenopausal years isunusual and should be evaluated carefully for underlying malignancy.We report here, a case of an old age postmenopausal woman with agiant myoma uteri. Ultrasonographic features, clinical presentation,differential diagnosis and treatment modalities of this rare case arepresented and discussed.Case: 74-year-old woman gravida 4 para 4 was referred to our clinicwith the complaint of genital bleeding and pelvic discomfort. On hergynecologic examination a pelvic mass was discovered. Detailedsonographic examination of her showed solid uterine tumor, measuring10 � 12 � 10 cm in diameter in fundo corporal portion of the uterus. Ithas got typical whorled appareance with increased echogenicitycompared with the uterus. Irregular sonolucent areas were seen withinthe tumor and thought as a possible myoma uteri with cysticdegeneration. Endometrial lining was distorted and 4 mm in size.Endometrial biopsy revealed no evidence of malignancy. Since a tumorwith such a size in a postmenopausal woman should be encouraged forearly surgery. Surgery was performed and total abdominal histerectomywith bilateral salphingooopherectomy was performed. Laparatomy

revealed a solid tumor on the uterine corpus and histologically wasdiagnosed as leimyoma of uteri. Postoperative follow up of her wasuneventful and hormone replacement therapy was given.

P141Benign mucinous ovarian cysts: transvaginal sonography withcolor Doppler features

MÃ .A. Pascual, F. Tresserra*, A. Ubeda, P.J. Grases, L. Hereter andR. LabastidaInstitut Universitari Dexeus de Barcelona, Department of Obstetricsand Gynecology and Pathology*, Spain

Aim: To evaluate the accuracy of transvaginal sonography with colorDoppler (TVSCD) in identifying mucinous ovarian cysts.Material and methods: Five hundred 18 adnexal masses werediagnosed by TVSCD before surgery. We identified those adnexalmasses in which an ultrasonographic diagnosis of mucinous ovariancyst was done. This diagnosis was based on the presence of a cysticlesion with thin, grape-like appearing septa and diffuse internalechoes. This diagnosis was compared with the pathological features.Results: A total of 49 mucinous cysts were diagnosed by TVSCD, 26of them were histologically confirmed. Twenty-three cysts weremisdiagnosed (9 were serous, 4 were interpreted as malignant andone was an endometrioma). TVSCD was unable to diagnose 14 out of40 mucinous cysts confirmed by histology. The ultrasonographicfeatures most frequently seen as suspicious of malignancy were thin,grape-like appearing septa (84.6%) and diffuse internal echoes(53.8%). The sensitivity, specificity, and positive and negativepredictive values and accuracy of TVSCD were 65%, 95.2%,53.1%, 97%, and 92%, respectively.Conclusions: The accuracy of TVCD for the diagnosis of benignmucinous cysts is very high, being the most frequently cause ofconfusion simple serous cysts.Acknowledgements: The authors are grateful to the CaÁtedrad'InvestigacioÂ en ObstetrõÂcia i Ginecologia (Universitat AutoÂnomade Barcelona).

P142Endometrioma simulating ovarian cancer in apostmenopausal woman ± report of one case


Background: External endometriosis is principally a disease of activereproductive life which is seldom found during postmenopausal yearsbecause of estrogen deprivation. Endometriosis is a great mimicker ofother pelvic pathologies especially in postmenopausal years. We reporthere, a case of ovarian endometrioma in a postmenopausal womansimulating ovarian cancer. Ultrasonographic features, clinical pre-sentation, differential diagnosis and treatment modalities of this rarecase are presented and discussed.Case: 76-year-old woman gravida 3 para 2 presented with anasymptomatic pelvic mass discovered on gynecologic examination.An ultrasound examination was requested to investigate the nature ofthis mass. She was otherwise symptom-free surprisingly except foroccasionally occuring bilateral pelvic pain. Longitidunal sonogramsshowed an irregular, partially solid and cystic mass in the rightadnexal region. A transverse scan showed the presence of a complexright adnexal mass measuring 6 � 7 � 7 cm in diameter which wasconsidered most likely to be malignant. CA-125 level of her wasslightly elevated. Urgent laparatomy revealed no evidence ofmalignancy and the mass proved to be an endometrioma histologi-cally. Most possibly, the presence of old blood within the tumorsimulated a solid component. The patient was vigorously reassuredand hormone replacement therapy was given in the postoperativefollow up period.



P143Primary bilateral fallopian tube cancer ± case report

M. Wojcieszyn, K. Bøaszczyk, M. Biernat, M. Krzystyniak andR. PorebaIV Department of Obstetrics and Gynaecology Silesian UniversitySchool of Medicine, Katowice, Poland

Introduction: Fallopian tube cancer is one of the rarest neoplasm offemale reproductive tract. Primary, bilateral presence of the cancer isespecially rare. Diagnostic difficulties cause, that it is often found invery advanced state. The authors have presented the case of primarybilateral cancer of the fallopian tube, qualified to surgical treatmenton the base of sonographic examination.

57 years-old women was examined using transvaginal ultrasounddue to increasing pain in the lower part of the abdomen and abnormaldischarge out of the vagina. During the examination fluid in the uteruscavity and cystic, oblong, winding structures in both adnexa, lookinglike distended oviducts were found. Typical ovary tissue wasn't visible.On the base of history and examination laparotomy was ordered.During the surgery multiple adhesions in the pelvis and extended fluidfilled fallopian tubes were found. The hysterectomy and bilateraladnexectomy was performed. Pathological examination revealedpresence of bilateral papillary adenocarcinoma of the fallopiantubes. Out of the oviduct no neoplastic cells was found.Conclusion: Extended fluid filled oviducts found during sonographicexamination may be the first sign of fallopian tube cancer.

P144Color Doppler imaging of the testis in azoospermic subjects asa predictor of spermatozoa retrieval on testicular spermextarction

J. Har-Toov, G. Fait, R. Houser, I. Wolman, I. Gull, R. Amster,H. Yavetz and A. J. JaffaUS Unit in Ob/Gyn, Lis Maternity Hospital, Tel Aviv Medical Center,Israel

Background: There are no clinical parameters for identification ofspermatogenic tissue within the testis of azoospermic subjects.Consequently, multiple biopsies are performed until spermatozoa arefound. The aim of this study was to evaluate whether testicular bloodflow can be a predictor of spermatozoa retrieval on TESE.Method: Color Doppler ultrasound was performed in 13 azoospermicsubjects affected by primary testicular pathology and in 7 fertilesubjects. The PI, RI, and S/D ratio reflecting resistance to flow weremeasured in the mid-portion of the testis in the longitudinal view. Allazoospermic subjects underwent TESE in which a biopsy was takenfrom the head, mid, and tale portion of the testis. The specimens wereevaluated for structure and for the presence of spermatozoa.Results: Blood flow indices were similar in azoospermic subjects ascompared to fertile subjects. (mean ^ SD; PI � 0.99 ^ 0.64,RI � 0.52 ^ 0.16, S/D � 2.16 ^ 0.74; PI � 0.99 ^ 0.19, RI �0.59 ^ 0.07, S/D � 2.51 ^ 0.48, respectively). In seven patients,spermatozoa was found in one or more of the testicular specimens.Blood flow indices in this group were similar to the indices inazoospermic patients in whom spermatozoa was not found.Conclusion: At present testicular blood flow as evaluated by colorDoppler can not serve as a predictor of spermatozoa retrieval onTESE.

P145Ultrasound evaluation of ectopic pregnancy and laparoscopicapproach

S. SijanovicÂ, Z. Popovic, A. Lovric and Z. HrgovicDepartment of Gynecology and Obstetrics, Clinical Hospital Osijek,Croatia

In our department we prefer laparoscopic treatment ectopicpregnancy. In 1999 and 2000 years we were laparoscopically treated70% ectopic pregnancy. For promtly and safely diagnosis we use

clinical, ultrasound and beta choriongonadotropine hormon exam-ination. In this period we treated 26 women with diagnosis ofectopic pregnancy. In 96% patients ultrasound examination wasmade. Ultrasound examination showed in 88% women adnexalmasses or free fluid in Douglas space. In most cases ectopicpregnancy was in right tube (69%). Ultrasound evaluation incorrelation with beta choriongonadotropin hormone creates earlyand safely diagnosis ectopic pregnancy and provides laparoscopicapproach. Laparoscopic approach in treatment ectopic pregnancy ismethod of choice.

P146Early detection of ectopic pregnancy with ultrasound

M. Simic, M. Kopjar, T. Viskovic and M. ZadroGeneral Hospital Zabok, Ob/Gyn Department, Zabok, Croatia

Objective: To determine if the typical appearance of endometrium forlate proliferative phase and early secretary phase could be used as apatognomonic sign for early detection of ectopic pregnancy incombination with other patognomonic signs for ectopic pregnancy.Methods: Over a period of four 76 patients were admitted at ourdepartment as a result of suspicion of ectopic pregnancy.Results: In three patients out of those 76 at the time of admissionectopic pregnancy was not visible neither on ultrasound nor onlaparoscopy. One of them was a cervical pregnancy, and two otherswere cornual pregnancies. Sixty-six patients have had tubar abortions,including two pregnancies with live embryo in the tube.Conclusion: Typical late endometrial look for late proliferative phaseand early secretary phase can be used as a patognomonic ultrasoundfinding for ectopic pregnancy especially in combination with otherpatognomonic ultrasound findings and in combination with serumprogesterone measurement.

P147Preoperative evaluation of endometriosis with transvaginalultrasound

M. Kopjar and I. AlvirGeneral Hospital Zabok, Zabok, Croatia

Objective: To show the use of transvaginal ultrasound in the diagnosisof endometriosis, and based on that in the decision on the choice oftreatment.Patients and methods: Ultrasound finding of round shaped adnexalmass with thick wall and homogeneous, low level echo pattern wasconsidered suspected for endometriosis. From 1995 to 1999 inwomen with chronic pelvic pain and palpable mass, transvaginalultrasound confirmed the endometriosis, according to the abovecriteria in IS patients. Eleven patients were treated preoperativelywith GnRH agonists (goserelin depot 3.6 mg) for 6 months. Afterthe treatment operative laparoscopy was performed. In 7 patientslaparoscopy was performed immediately, and patients receivedmedicated treatment after the operations, also GnRH agonists for6 months.Results: During the preoperative treatment with GnRH most patientsreported a reduction of pain after 3 months of treatment, and withpatients operated immediately reduction of pain was reported 2 weeksfollowing operation. Operation was shorter in patients with pre-operative treatment with GnRH.Conclusion: Disadvantages of preoperative treatment of endome-triosis include changes in appearance of endometriosis, price ofthe medication, side-effects, dilate of accurate diagnosis, anddilate in eventual pregnancy. For some patients it can be usefulto start the preoperative medicated treatment to suppressovulatory activity, so functional cysts would not be misdiagnosedfor endometriosis. Patients with chronic pelvic pain should beevaluated laparoscopically to diagnose mild endometriosisadequately.



148Blood flow changes after uterine artery embolization in thetreatment of adenomyosis and myomis: preliminary report

E.-H. Lee, T. W. Sunwoo, C. S. Ahn, M.-H. Lee and W. H. LeePundang CHA Hospital, Sungnam, Korea

Background: The aim of this study was to evaluate prospectively thechanges of blood flow following permanent embolization of uterinearteries using polyvinyl alcohol in the treatment of uterine adeno-myosis or myomas.Methods: From August 1998 to May 1999, 114 cases of uterine arteryembolization were performed for the patients having symptomaticadenomyosis (n � 63) or myomas (n � 51). They were underwentbaseline (n � 114) and follow-up ultrasound on 1 week (n � 106), 3(n � 102) and 6 months (n � 23) after embolization. The peaksystolic velocity (PSV) and resistive index (RI) were calculated in theisthmic portion of uterine arteries and intratumoral vessels.Results: One week after embolization, uterine blood flow wasmarkedly decreased comparing with pre-embolization status. After3 months, blood flow was recovered up to 56% of pre-embolizationstate but not increased significantly on 6 months examination. Colorflow was not detected within the myomas after embolization.

Conclusion: Uterine blood flow was markedly decreased immediatelyafter embolization and increased up to the half level of pre-embolization status on 3 months examination.

P149Ultrasound in the diagnosis and treatment of female stressurinary incontinence

A. Lukanovic and B. Kralj

Abstract not available.

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

P150Illustration of a cervical pregnancy medically treated

M. Guizani, V. Vernaeve and C. Van PachterbekeC.H.U Brugmann, Brussels, Belgium

A 26 year old woman, without any previous medical history and whohas done two pregnancies interruptions, came at the visit for inquieriesfor a third pregnancy termination. She was in amenorrhea, the timeelapsed from the last period was unknown. The patient had abdominalpain progressing since a few weeks. The clinical examination showed apainful cervix mobilisation. An ultrasound scan was performed showinga seven weeks nonevolutive cervical pregnancy. The uterine cavity wasenlarged and filled with blood clots. To avoid hemorragic complicationsthat could be life-threatening, the patient received a single intramuscularinjection of 60 milligrams of methotrexate. We followed the evolutionwith ultrasounds scans and measurements of plasmatic bHCG andprogesteron. The course of the diesease ended succesfully. The posterwill summerise the clinical, biological and sonographic evolution duringthe four weeks following the medical treatment.

P151Transvaginal ultrasonography in detection of cervicalincompetency

M. Podobnik, M. Podgajski, S. Ciglar and B. GebauerDept. Ob/Gy n, University Hospital Merkur, Zagreb, Croatia

Objectives: To examine the relationship between transvaginal ultra-sound cervical changes and pregnancy outcome in women at risk ofcervical incompetency and preterm delivery.Method: In 100 pregnancies with clinical and ultrasonic signs ofcervical incompetency, the length of the cervix, the thickness of theanterior wall of a lower uterine segment and the width of theendocervical canal have been evaluated ultrasonically. These para-meters were followed longitudinally from the 10th to 36th gestationalweek in the healthy pregnancies and pregnancies at risk of cervicalincompetency and preterm delivery.Results: In patients from 10 weeks to 14 weeks the cervix issignificantly longer than in the 25±36 week group and the anteriorwall of the lower uterine segment in the 10±14 week group issignificantly thicker than in the 20±36 week group. In pregnancies atrisk of cervical incompetency, cervical lengths and wall thickness weresignificantly different from those in comparable controls. Forty-five

percent of the patients in the at-risk group, with cervical cerclage,delivered at 37.5 weeks and 8.5% of pregnancies ended in abortionwhen the amnictic membrane herniated into the cervical canal. Thefrequencies of preterm delivery were 60%, 38% and 15% for cervicallengths of , 10 mm, 10±20 mm and 20±30 mm.Conclusion: A shortened cervix with decreased thickness of the anteriorwall of lower uterine segment and dilatated endocervical canal shows astrong association with cervical incompetency and preterm birth.

P152Post-cesarean sonographic evaluation of subfascial hematomain Joel-Cohen and pfannenstiel laparotomies: 5 years ofexperience

A. Malvasi, D. Baldini and V. TrainaDepartment of Obstetrics, Center of Ultrasonography and PrenatalDiagnosis, Casa di cura Santa Maria, Bari, Italy

Background: In this prospective randomized study, some elements ofmorbidity between Joel-Cohen laparotomy (J.-C.-l.) and Pfannenstiellaparotomy (P.-l.) have been evaluated. Using transabdominal sonographypathologic subfascial hematomas have been searched for in 258 cesareansection (c.s.) with J.-C.l. and in 292 c.s. with P.l. We've examined 238 firstc.s. (83.50%) and 47 repeat c.s. (16.49%) carried out through J.-C.l.,while 253 first c.s. (86.05%) and 39 repeat (13.26%) through P.l.Result: The abdominal wall of the patients who underwent c.s. wasexamined sonographically on the 3rd and 10th postoperative day,considering anechogenic areas, with clear wall, with interior echoes,both subfascial with a diameter more than 3 centimetres long. At c.s.through J.C.l. we have observed 3 subfascial hematomas (1.75%) (2surgical treatment) compared to 5 (2.72%) through P.l., (3 surgicaltreatment) with no statistical significancy. On the contrary statisticallysignificant differences have been observed whith regard to openingand closing time of abdominal wall; 4.9 min for J.-C.l. and 14.7 minfor P.l. (P , 0.05), as all operating time.Conclusion: In conclusion, in our clinical and sonographic experience,at first c.s. P.l. does not cause a greater formation of abdominal wallhematomas compared to J.-C.l. as Stark refers, it is clear that surgicaland anaesthesiological time lengthens, suture materials increase withP.l. At repeat c.s. stretching is not always easy, because of thecicatricial condition of the muscles besides an exaggerate manipula-tion of the tissues may favour subfascial hematomas. In the J.-C.l. thesubfascial-hematoma occurs the blood invades the peritoneal cavity

Table: Changes in PSV and RI

Pre 1 week 3 month 6 month

PSV (cm s21) 54.7 23.0 30.5 32.0RI 0.76 0.84 0.80 0.79



changing the clinical and sonographic situation compared to classicsubfascial hematoma with closed peritoneum.

P153Cerebral venous thrombosis and pregnancy: image diagnosis

N. Lagos, C. GarcõÂa, G. Castillo, N. Luengo, I. Hoffmann, P. Ortega,Astorga and I. FerresHospital de Carabineros, Universidad de Santiago, Santiago, Chile

Background: Thrombotic conditions are common complicationsduring pregnancy.

Cerebral venous thrombosis is also more frecuent in pregnantpatients, with a prevalence of 4.5 per 1000 obstetric admissions. Wepresent 3 cases that were managed in our unit.Patient 1: 38-year-old, epileptic, 10 week pregnant. She had occipital,pulsatil headache plus blurred vision. A Magnetic Nuclear Resonance(MNR) showed lackof flow, in the right transverse sinus, andyugular gulf.Patient 2: 32-year-old, with an haemolytic anemia and an occipitalmeningioma. She had a 34-weeks pregnancy and was admittedbecause of edema of the lower extremities.

She has paresthesies and hypoesthesia of the right leg, which progresedto anesthesia. MNR showed her occipital tumor, measuring 10 � 12 mm,and thrombosis of the right transverse and lower sagital sinus.Patient 3: 30-year-old, 10 weeks pregnant, admitted because of aheadache that did not respond to common analgesics. MNR informedthrombosis of the left transverse sinus, and the yugular gulf.

All 3 patients were treated with low molecular weight heparin.Conclusions: The majority of cases of cerebral venous thrombosisinvolve the high sagital sinus. In the pregnant patient study by imagesis recommendable and the test of choise is MNR, which has asensibility of 90%. Recommended treatment is anticoagulant therapy.

P154Psychological stress and ultrasound screening in pregnancy: arisk-group comparison

S. Fuchshuber and A. StraussDepartment of Ob-Gyn, Grosshadern Hospital, Ludwig MaximilianUniversity, Munich, Germany

Background: We intended to assess the psychological stress experi-enced by mothers during ultrasound screenings in pregnancy.Methods: Between 1997 and 1999, 136 women (age 17±41, pregnancyweek 9±41) were asked to record their stress level before, during andafter the ultrasound exam on a scale from 1 to 10. 81 patients weregenerally concerned about their pregnancy, 22 were over age 35, 21 hadspecific pregnancy risks (family history, preeclampsia, first-trimenonmedication-intake/infection, pathological ultrasound findings).Results: Women generally concerned or with known pregnancy riskreport significantly more stress before the exam (mean 3.8 vs. 1.9 and4.6 vs. 2.8; P , 0.01). However, during or after the exam, stress levelsare equal in all groups (5.1 vs. 4.3, 2.9 vs. 2.3; P . 0.01). We also findno significant differences between women above or below age 35 (3.0vs. 3.1 before, 4.3 vs. 4.4 during, 2.5 vs. 2.2 after ultrasound exam;P . 0.01). Overall, all women experienced the most stress during,and the least stress after the exam (P , 0.01).Conclusion: Or results show that we need to anticipate an equal levelof anxiety in all women we examine. We cannot assume that a youngmother without risk will experience the exam any more or lessdistressful than a woman with predisposed risk. The results cautionsus to give adequate consideration to every individual patient,regardless of pregnancy risk.

P155The pathological breast in gestation-puerperal period

M. R. M. Machado, F. F. A. Santos, E. F. Marussi, S. L. Pereira and S.L. VissottoUniversidade Estadual de Campinas, SaÄo Paulo, Brazil

Background: The aim of this study was to describe the appearance ofbreast tissue in a breast inflammatory disease and in the inflammatory

breast tumour during gestational-puerperal period using ultrasoundand to evaluate the contribution of this exam in differential diagnosis.Method: We will describe two cases with increase of volume breast,analysed by two-dimensional ultrasound, performed on an ACUSONXP4A using a 7,5 MHz linear, focused probe with Colour Doppler.Results: The two patients showed typical inflammatory character-istics, similar symptoms and the same appearance of breast tissue inultrasound. The two exams appears as parenquymal disorganisationbreast tissue, increase width skin, hypoechoic ill undefined masseswith some internal echoes, thick walls and septations.Conclusions: In some cases, the differential diagnosis between breasttumours associated to inflammatory appearance and inflammatorydiseases, during pregnancy and puerperal period are very difficult. TheDoppler evaluation is helpful as well as clinical history andepidemiology. Sometimes, only the hystological aspects will providethe right diagnosis.

P156Teaching in ultrasound ± new methods in training

I. Heer, S. Fuchshuber and A. StraussDepartment of Obstetrics and Gynaecology, Groûhadern, Universityof Munich, Germany

Introduction: The purpose of this study was to evaluate a new trainingsystem for transvaginal ultrasound.Methods: We used a software-based 3D-ultrasound which allowsoffline re-evaluation of structures recorded in a 3D-voxelcube duringan actual exam. The software assigns a specific plane to each possibleposition of the transducer within the 3D-cube. This allows virtual `re-scanning' of recorded exams. In the teaching model, an vaginalultrasound transducer is used to examine a life-size model pelvis. Thetransducer is linked to a computer which displays the virtualultrasound scan. We tested the system on 30 Munich-University 3rdyear medical students. None had previous ultrasound experience. Allwere shown an 8 minute teaching video. Each student was allowed a 1minute practice period, then asked to find a proper plane and measurethe endometrial thickness.Results: All students were able to find a proper plane for measurementwithin 30 s. The results of measurments varried between 5 and 9 mm(actual thickness 8 mm). All rated the session as an excellenttheoretical introduction into the field of transvaginal ultrasound,and as extremely valuable skill-training.Conclusion: In this software based re-evaluation model, we believe tohave found an optimal new training tool for transvaginal ultra-sonound. As a consequence, we intend to establish a case-library forthe future basic training of younger doctors.

P158The representation of obstetric ultrasound scan amongobstetricians and ultra-sonographers: a descriptiveexploratory study

J. Quayle, V. Wojciechowski, L. S. Ueno, V. Bunduki, S. Miyadahira,M. C. S. De Lucia and M. ZugaibPsychology Division and Obstetric Department, Hospital dasClõÂnicas, SaÄo Paulo University Medical School, SaÄo Paulo, Brazil

Background: Ultrasound is one of the most known exams performedduring prenatal period for diagnosis and screening, but little is knownabout obstetricians' perceptions associated to the exam. The aim ofthis study was to assess psychological representations related toobstetric ultrasound scan among obstetricians who were alsoultrasonographists and those who were not.Method: Psychological interview with 54 obstetricians of ourInstitution with different level of specialization.Results: 55% believe that only a specific training is necessary to be anultrasonographist, while 35% consider a title essential to perform theexam. Most of the subjects (98%) believe the exam has influences onthe pregnant woman bonding with her baby, due to fetal visualizationand the proximity feeling it favors. Almost all (93%) consider thepossibility of early diagnosis the main feature of the exam while 20%



mention the possibility of diagnostic mistakes and their repercussion.When asked to produce projective associations, content analysispoints out to aspects associated to the qualities of the exam,particularly `fidelity', precision and power.Conclusion: There is a massive idealization of the exam and littledifference between ultrasonographists and obstetricians. This shouldbe approached during professional training to help them deal with thebonding aspects they themselves consider important.

P159Three-dimensional ultrasound reconstruction andtelemedicine. Image analysis

O. Ferrer-Roca*, J. M. Troyano², J. Vilarchao-Cavia*,M. T. Clavijo², O. Y. Marco² and C. M. Feo²*CATA, UNESCO Chair of Telemedicine ²Ultrasound Division andFetal Medicine, University Hospital of Canary Islands, Tenerife, Spain

Background: In the present study the 3D US images reconstruction iscombined with the distant consultation through internet or through anISDN line.

Method: Trial consists of explorations done during 1999/2000 in ourUS unit at the Obstetrics and Gynaecology Department. Theequipment is integrated by: a standard Aloka-SSD 680 ultrasounddevice, a Dual Pentium II workstation with 256 Mb RAM memoryand Windows NT operative system, a falcon framegrabber board, andthe TeleInvivo 3D reconstruction and teleconsultation software byMEDCOM.

Echograph images are acquired by the workstation through a falcondigitising board, and the TeleInVivo software generates a 3D volume.These volumes can be sent to a remote host via internet or via anISDN line, allowing an on-line teleconsultation and telediagnosis.Results: During the trial we made 149 teleconsultations of differentpathologies. 3d reconstruction was time consuming (20 min to 4 h)and of a limited diagnostic value, but of future relevance to reducepatient multiple explorations due image constraints such as suboptimal foetal position among others. The final volumes are sentwavelet lossless compressed through internet or an ISDN line, and fora normal size of 1.5 MB the time consuming is from 4 to 8 min to betransmitted.Conclusion: The use of internet or an ISDN line is a fast method forsending and consulting 3D ultrasound images, and it is possible due tothe selected volume rendering techniques that provide an effectivecompression of the original data.



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