WS17-11Amniotic fluid erythropoietin concentration and cerebro-umbilical Doppler flow ratio in diabetic pregnancies and pregnancies complicated by hypertension, pre-eclampsia or/and

4±7 October 2000, Zagreb, Croatia Workshops

Workshops

W S 0 1 : F E TA L A N O M A L I E S

WS01-01Prenatal ultrasound diagnosis of fetal malformations

D. CaficiClõÂnica Privada Santa Ana, Buenos Aires, Argentina

The prenatal diagnosis of fetal malformations seems to be a verydifficult challenge, mainly for those who are beginning with thepractice of ultrasound.

As it would be impossible to refer to so many fetal malformationsthe presentation will cover a few interesting issues.

These cases are not frequently diagnosed and in many cases presentcontroversial aspects referred to their prognosis and management.

Those topics are:Unilateral ventricular dilatationFetal hyperechogenic lung lesionsUmbilical vein varixFacial cleftsUnilateral ventricular dilatation may be a difficult diagnosis and its

prognosis is variableFetal hyperechogenic lesions include a broad range of anomalies

with a variable behaviour. Even large lesions can disappear in uterobut often the lesion can persist with severe prognosis for the fetus.Varix of the umbilical vein is a relatively uncommon abnormality thatcarries an increased risk for fetal demise, chromosomal abnormalityand hydrops.

Facial clefts are a relatively common malformation and the fetalface must be properly scanned in every fetal study.

3D ultrasound helps a lot in the diagnosis of these and othermalformations and we'll discuss some examples concerning this newtechnology.

WS01-02Color Doppler in the diagnosis of fetal malformations

N. D. MarguliesJuan A. FernaÂndez Hospital, Buenos Aires, Argentina

The color and Power Doppler gives us the opportunity to investigatethe vascular anatomy as an angiography and furthermore lets us `see'hydro jets. This singular ability leads us to make some diagnosis andconfirm others.

During this lecture we will show our experience in the diagnosis ofsome fetal anomalies such as renal agenesis, urachal cysts, megacystismicrocolon Hypoperistalsis syndrome, renal displasia, Galeno veinaneurysm, anterior wall defects such as omphalocele and gastroschisis,diaphragmatic hernia, duodenal atresia, coartation of the aorta, singleumbilical artery Dandy Walker Malformation, and some fetal tumors.

WS01-03The posterior fossa: a useful landmark in the evaluation of thefetal ventriculomegaly

V. D 0Addario, V. Pinto, E. Di Naro and L. Di Cagno4th Unit of Obstetrics and Gynecology, University Medical School,Bari, Italy

Objective: The objective of this study was to obtain a nomogram ofthe clivus-suvraocciput angle as a basis for the diagnosis of Chiari IImalformation in fetuses with ventriculomegaly.Design: A cross-sectional study was undertaken on 310 normalpregnant women of 16±34 weeks' gestation. A mid-sagittal section ofthe fetal skull was obtained and the angle between the clivus and thesupraocciput was measured. 44 fetuses with ventriculomegaly due todifferent causes (13 Chiari II malformation, 12 dysgenesis of the

corpus callosum, 7 aqueductal stenosis, 6 borderline ventriculomegaly,3 Dandy-Walker malformation, 2 porencephaly, 1 schizencephaly)were also included into the study and the values of the angle found inthe pathological cases were compared with that found in the normalpopulation.Results: The clivus-supraocciput angle did not change during gestationand was almost constant with an average value of 79,38 ^ 68. Allcases of Chiari II malformation showed a value below the 10th centileof our nomogram; all the remaining cases of ventriculomegaly showednormal values of the angle.Conclusions: The evaluation of the posterior fossa and particularly themeasurement of the clivus-supraocciput angle is a useful parameter todifferentiate the various causes of fetal ventriculomegaly andparticularly to recognize Chiari II malformation. The measurementof the angle could be also useful to screen for spina bifida which isalmost constantely associated to Chiari II malformation.

WS01-04Fetal lung abnormalities a spectrum of disease: reclassificationsystem based on embryology, 2-D and Doppler ultrasound

R. Achiron, Y. Yuval, S. Lipitz and S. YagelDepartment of Obstetrics/Gynecology, Chaim Sheba Medical Center,Tel-Hashomer, Hadassa Mount Scoup, Israel

Objective: Fetal lung anomalies are traditionally classified intoCongenital Cystic Adenomatoid Malformation (CCAM), and Pul-monary Sequestration (PS). During last years we have detected severalcases who presented with bizarre and overlapping findings whichcould not be fitted into this usual classification. We therefore suggest anew approach for classification based on embryology, 2-D andDoppler ultrasound.Method: During 5-year period, patients with fetal lung lesions whowere referred for detailed ultrasound evaluation at the Sheba MedicalCenter from the data base of this study. All cases were analyzed by 2-D ultrasound and high resolution Power Doppler technology and wereclassified into three major categories: I Agenesis of lung; II Lung lesionwith normal vascular supply: IIa solid, IIb cystic, IIc mixed; III LungLesion with abnormal vascular supply: IIIa chest, IIIb abdomen, IIIcthoracoabdomial. Medical files, natural history and neonatal follow-up were recorded.Results: Twenty-one fetuses were recruited, two fetuses were detectedin group one, 14 in group II of normal vascular supply, and five ingroup III abnormal lung with abnormal vascular involvement.Conclusions: Based on embryology and ultrasound a new classifica-tion system is introduced.

WS01-05Genitourinary anomalies ± is there anything new?

I. MeiznerUltrasound Unit, Department of Ob/Gyn, Rabin Medical Center,Petah-Tikva, Israel

Background: Ultrasound malformations of the fetal genitourinarytract are well documented in the sonographic literature. However, wewould like to report on some specific observations. These will includea survey of fetal pelvic kidneys, an association between singleumbilical artery (SUA) and absence of one of the kidneys, and the`Tulip sign'± an ultrasonic marker for severe penoscrotal hypospadias.Method: All records of patients with ectopic kidneys over a 5-yearperiod (1995±99) have been perused. Sonographic parameters ofectopic kidney have been evaluated.

Ultrasound in Obstetrics and Gynecology 5

The same was done for cases of SUA and agenesis of one kidney andfor cases with severe penoscrotal hypospadias.Results: Pelvic kidney was diagnosed prenatally in 35 cases, of which,bilateral pelvic kidney was detected in 2 cases. There was nopredilection for fetal gender, and no tendency to side of appearance.Most cases were diagnosed in late 2nd trimester of pregnancy. Theassociation of SUA and absent kidney was detected in 6 cases. In allcases the diagnosis was made in the 2nd trimester of pregnancy. In 6cases, the specific `Tulip sign' was detected prenatally and provenpostnatally.Conclusions: Unique presentations of renal anomalies can be detectedprenatally. Pelvic kidney is easily dealt with, however, the associationof SUA and absent kidney requires further evaluation of the fetus toexclude the VATER association. The `Tulip sign' is helpful indiagnosing severe hypospadias.

WS01-06Fetal obstructive uropathies: management and outcome

C. SenDepartment of Perinatology, Obstetrics and Gynecology, CerrahpasaMedical School, University of Istanbul, Turkey

Background: Urinary tract anomalies are among the most commonsonographically identified anomalies in utero with the incidence about1/250±1/1000 pregnancies. The obstruction can be unilateral orbilateral at the level of urethra, ureteropelvic junction (UPJ),ureterovesical junction (UVJ).Method: Obstructive uropathy cases diagnosed antenatally have beenretrospectively evaluated in terms of short and long-term outcome. Itis important to make early diagnosis and intervention in order to saveorgan function as possible.Results: During last 7 years in our Department, 58 cases with fetalobstructive uropathy were examined and performed 12 interventions.They were diagnosed antenatally with different type of obstructionincluding posterior urethral valve syndrome, unilateral and bilateralhydronephrosis, ureteropelvic junction obstruction, multicystic kid-ney. Intervention was performed in 12 cases at different stage ofgestation including needling, vesico-amniotic shunting and pelvicshunting. Out of 12 procedures, there was mortality in 5 casesantenatally or neonatally.Conclusion: Early diagnosis of the obstruction is very importantbefore the kidney becomes dysplastic. The type of anomalies, level andstarting time of pathology and duration of severe obstruction are themain factors for prognosis. Early diagnosis and referral to tertiarycenter is to be encouraged in order to have early management andintervention in the case of severe obstruction and to save kidneyfunction as early as possible.

WS01-07Borderline urinary tract malformations

G. D'Ottavio, L. Paduano, M. A. Rustico, Y. J. Meir, P. Lenardon,A. Rosadini and G. P. MandruzzatoUnit of Prenatal Diagnosis, Istituto per l'Infanzia, Trieste, Italy

Background: Ultrasonography is an effective diagnostic tool foridentifying fetal urinary tract anomalies (UTA). Serious obstructive ordysgenetic abnormalities are often clearly detected and their implica-tions well known. Less clear is the meaning of borderline (asympto-matic at birth) UTA, including: mild pyelectasis (MP), unilateral renalagenesis (URA), unilateral multicystic kidney (UMK) and ectopickidney (EK).Method: We determined the outcome of pregnancies and long-termrenal function in 120 cases of prenatally detected borderline UTA. Aprospective protocol was proposed to the parents which comprisedultrasound evaluation every 3 months until the age of 24 months, andrenal function assessment in case of suspected worsening of prenatalfindings.

Results: A total of 120 fetuses had a borderline UTA (MP n � 58,URA n � 14, UMK n � 32, EK n � 16). Eighteen of them showedsome postnatal complication including: associated anomalies (3cases), need for surgical intervention (6 cases), vesico-ureteral reflux(VUR, 5 cases) and repeated infection (4 cases).Conclusions: Fetal pyelectasis, rarely requires neonatal intervention ifthe diameter of pelvis is included between 5 and 10 mm in the secondtrimester. Nevertheless, the risk of associated chromosome abnorm-alities should be ruled out if other risk factors are present. Unilateralmulticystic kidney carries a high risk of nephrectomy and contralateralVUR, whereas unilateral agenesis or ectopic kidneys seem to carrylimited, if any, negative implications, with the exception of possibleundetected, associated anomalies.

WS01-08Three-dimensional power Doppler of fetal malformations

R. ChaouiClinic of Obstetrics, University Hospital Zurich, Switzerland

Background: The aim of the study was to examine the impact of three-dimensional power Doppler ultrasound (3D-PDU) in fetal abnormal-ities involving the vascular system.Method: Eighty seven selected pregnancies were included in the study.ATL HDI-3000 and 5000 ultrasound equipment with integrated 3D-Color Power Angio w software were used. Data acquisition was doneby the free-hand-technique and images were reconstructed online.Results: Reconstruction was only possible in 56 out of the 87 (64%)considered pregnancies. These were abnormalities of placenta andumbilical vessels (n � 26), intra-abdominal and intrathoracal anoma-lies (n � 12), renal malformations (n � 9), central nervous system(n � 4) as well as cardiac defects (n � 5). The main reasons for failurewere fetal position and movements, overlapping with signals fromneighboring vessels as well as the reduced attempts in 3D in an on-linesystem. Details and figures of the potential field of interest in prenataldiagnosis are presented.Conclusions: The study shows that 3D-power Doppler can be appliedin prenatal diagnosis. The method enables the visualization of mainparts of the fetal vascular system under abnormal conditions with theexception of the fetal heart where a trigger system is still needed.

WS01-09Diagnostically critical fetal imaging artifacts: identificationand management

D. H. Pretorius and T. R. NelsonUniversity of California, San Diego, La Jolla, CA, USA

The purpose of this project was to identify sources and clinicalsignificance of 3DUS artifacts on patient diagnosis and to increaseclinician and sonographer awareness to reduce misdiagnosis in 3DUSstudies. To accomplish this 3DUS data were acquired and reviewedinteractively. Artifacts were cataloged according to origin: B-mode,color/power Doppler or unique to 3DUS (acquisition, rendering orvolume editing). Original scan planes, re-sliced planes and renderedimages were evaluated. Overall our results showed a variety ofartifacts. B-mode artifacts included drop-out, shadowing, etc. anddepending on relationships between slice and imaging plane orienta-tion. Color/power Doppler artifacts were related to gain, aliasing, andflash and could add apparent structure or confusion to the volumeimages. Rendering artifacts were due to parameter adjustment,shadowing and motion.

Important structures could be removed by improper editing. Inconclusion 3DUS and 2DUS are prone to similar artifacts plus othersunique to 3DUS. Diagnostically significant artifacts can mimickabnormal development, masses, or missing structures thus requiringcareful study before reaching a diagnosis.

10th World Congress on Ultrasound in Obstetrics and Gynecology Workshops

6 Ultrasound in Obstetrics and Gynecology

W S 0 2 : P R E N ATA L D I A G N O S I S

WS02-01Sonographic measurement of fetal subcutaneous tissue ofgestational diabetic mothers: a new criteria for therapy

E. Ferrazzi, I. Cetin*, S. Rigano, T. Radaelli*, E. Taricco*, M. Bozzo*,C. Lanzani and G. Pardi*Depts Obstetrics and Gynecology, ISBM Luigi Sacco, DMCO SanPaolo*, University of Milan, Italy

Objective: The aim of this study was to compare sonographicmeasurements of subcutaneous tissue (SQ) in fetuses of gestationaldiabetic mothers (GDM), and in normal fetuses.Methods: SQ was measured as the subcutaneous tissue area of midupper arm (FMA), mid-thigh (FMT) (cross sectional area minus boneand muscle area), abdominal (FA) and subscapular fat (FS), thickness.Fifty-six GDM were enrolled in the study. Normal values wereobtained from fetuses of normal pregnancies (BMI 21.3 ^ 0.64 Kg/m2; one hour glucose test , 140 mg/dL) (30 patients). Treatment wasbased on diet alone, or diet plus insulin according to postprandialglicemia. Longitudinal ultrasound examinations were performed everyfour weeks, in normal pregnancies, and in GDM pregnancies.Results: Fetal SQ measurements were significantly correlated togestational age both in normal and GDM fetuses (P , 0.05). At thetime of diagnosis GDM fetuses had significantly higher values for allSQ measurements compared to AGA fetuses; these differences werenot found during therapy.

Conclusions: GDM is associated with increases in fetal SQ from thesecond trimester. A strict glycemic control can reduce these differencesto negligible values. These new measurements can be adopted tomonitor the efficacy of therapy in GDM pregnancies.

WS02-02Management of premature rupture of the membranes byultrasound

G. Rizzo*, A. Capponi, E. Angelini, C. Grassi and C. RomaniniDepartment of Ob/Gyn, UniversitaÁ Roma `Tor Vergata' and *G.B.Ospedale Grassi, Rome, Italy

Objective: In pregnancies complicated by preterm premature ruptureof the membranes (pPROM) there are essentially two causes ofperinatal death: prematurity and lung hypoplasia. We used ultrasoundto try to predict these complications.Design and methods: The cervical length was measured by trans-vaginal ultrasound in 167 pregnancies complicated by pPROM, 32 weeks of gestation. Further in 20 pregnancies with pPROMbefore 24 weeks of gestation peripheral pulmonary artery (PPA)waveforms were recorded by Doppler technique at weeklyinterval until delivery and the Pulsatility Index (PI) calculated.Pregnancies were managed conservatively according to anInstitutional management protocol. The occurrence of pretermdelivery and pulmonary hypoplasia was evaluated and related toultrasound findings.Results: The cervical length at admission predicts the time intervalelapsing between pPROM and delivery. Significant differences in PIvalues from PPA were present from 2 weeks onwards the pPROM

between the fetuses who developed pulmonary hypoplasia and thosewith a normal outcome.Conclusion: The measurement of the cervical length and of PPAvelocity waveforms may help to establish the risk of developingprematurity and pulmonary hypoplasia in pregnancies complicated bypPROM.

WS02-03What can fetopathology add to the prenatal ultrasounddiagnosis?

Z. Papp1st Department of Obstetrics and Gynecology, SemmelweisUniversity, Budapest, Hungary

Background: Multiple malformation syndromes are generally hetero-geneous diseases with inappropriate clinical delineation most cases.Geneticists are facing problems with lack of proper knowledge inspiteof the overwhelming information available regarding a certainsyndrome. Emphasis should be placed on the characteristic featuresof the suspected syndrome, or any major or detectable minor anomalywith significant effect on the course of the pregnancy.Conclusion: Detailed ultrasonography by experienced personnelprovides a valuable tool in diagnosing morphological alterations ofthe fetus in mid-gestation. After termination of the pregnancy, theeffected fetus must be examined thoroughly by an experiencedfetopathologist. Careful and comprehensive examinations reveals allmajor and minor morphological alterations that might outline acertain syndrome or other multiple abnormality entity. Computerbased syndromological programs are important in this process, forthey help geneticists and fetopathologists by matching the mostsuitable syndrome to the given case. Genetic counseling can becompleted only with the establishment of the most probable diagnosis.Declaration of recurrence rate and possible application of otherprenatal diagnostic methods must be included in the counseling.Different types of multiple malformation syndromes of the fetus willbe presented in the lecture.

WS02-04Fetal tumours

A. G. GonzaÂ lez, F. L. Herrero, E. Ch. Alvarez and R. R. RodriguezHospital Universitario Materno-Infantil `La Paz', Madrid, Spain

Fetal oncology is a chapter of the Obstetrics non well known yet.Fortunately, the improvements in the ultrasonography has let us toobtain an intrauterine diagnosis and to follow its evolution in order tochoose the most appropriated obstetrical way.

A total of 1326 fetal abnormalities has been diagnosed in the last 10years in the Hospital `La Paz', Madrid, and we have found 54 cases offetal tumours detected by ultrasonography (cyst and solid tumoursincluded). This number of fetal tumours is estimated to be the 4.07%of all fetal abnormalities. Most frequent tumours include the fetalcentral nervous system, fetal lung, fetal heart, fetal genitourinarysystem, fetal gastrointestinal system.

We have reviewed these fetal tumours histology, location andbehaviour, trying to study the best obstetrical conduct and itschirurgical treatment. Ultrasonographic characteristic of each fetaltumour has been specified. Besides, we describe the possibledifferential diagnosis, maternal complications (preeclamptic status,mirror syndrome), obstetrical complications (polyhydramnios, pre-term labour and delivery or placentomegaly) and fetal complications(cardiovascular failures, hydrops or death).

Finally, we perform the indications for the spontaneousdelivery or the preterm delivery induction depending on eachcase. Although we have not experience in intrauterine surgery,we believe that the best results are obtained in the neonatalsurgery, always after an individual study and in agreement withthe whole perinatal equipment.

26±32 weeks diagnosis 32±36 weeks therapy

normal GDM normal GDM p

FA 0.32 ^ 0.01 0.38 ^ 0.01 Ns 0.45 ^ 0.02 0.47 ^ 0.02 0.001

FS 0.28 ^ 0.01 0.36 ^ 0.17 Ns 0.41 ^ 0.36 0.44 ^ 0.02 0.001

FMA 1.97 ^ 0.12 2.55 ^ 0.19 Ns 3.83 ^ 0.33 4.24 ^ 0.21 0.01

FMT 3.12 ^ 0.20 4.10 ^ 0.37 Ns 5.91 ^ 0.42 6.94 ^ 0.43 0.01



WS02-05Serial in-utero ultrasonographic measurements of the fetalthyroid: a new complementary tool in the management ofmaternal hyperthyroidism in pregnancy

R. Achiron, E. Sivan, M. Dolizki, S. Lipitz and O. CohenDepartment of Ob/Gyn and Institute of Endocrinology, Chaim ShebaMedical Center, Tel-Hashomer, Israel

Objective: Treatment of hyperthyroidism during pregnancy iscomplicated by the lack of readily available measures of the fetalthyroid status. Both hyper- and hypo-thyroidism of the fetus may haveshort and long-term detrimental effects and thus should be avoided.We therefore followed the fetal thyroidal size during treatment ofmaternal thyroid disorders and correlated the data with treatment andthyroidal status in the mother.

Methods: During 24-month period 20 patients with thyroid disorderswere referred for serial fetal thyroid measurements. Thyroid size wasmeasured by transvaginal ultrasonography between 14 and 17 weeks'of gestation and by abdominal ultrasonography between 18 and38 weeks' gestation.Results: In five women with Grave's diseases correlation betweenthionamide dosage and fetal thyroid size were noted. Two fetuses hadan increase in the size of thyroid gland above the upper 95%confidence interval, one of them developed neonatal Grave's of whichit was the only prenatal sign of fetal thyroid abnormalities. In all otherthree fetuses changes inthyroidal size aided in determining the dosageof the antithyroidal drugs.Conclusions: Inutero ultrasonographic measurements of the fetalthyroid size can be used as a noninvasive tool for the propermanagement of maternal hyperthyroidism.

W S 0 3 : I N F E RT I L I T Y

WS03-01Selection of candidates for IVF based on color Dopplerfindings

M. M. BiljanMcGill Reproductive Centre, Royal Victoria Hospital, Montreal,Quebec, Canada

In the last 20 years there have been numerous improvements in IVFtechniques leading to an exponetial increase in pregnancy rates. Inspite of these improvements the patients undergoing IVF procedurestill have more chance of failure than success. This presentation willaddress the areas in IVF treatment in which the use of color Dopplerultrasound could improve the results of IVF. Discussion will includethe appropriate assessment of ovarian reserve as well as why thedetermination of the initial dose of gonadotropins based solely uponthe patient's chronological age or serum FSH or E2 concentrations isimprecise. Recently, baseline ultrasound scans to assess for thepresence of polycystic ovaries, and the use of color Dopplersonography to assess stromal perfusion have emerged as valuabletools in the assessment of the optimal dose selection of gonadotropinsrequired for IVF ovarian stimulation. The issue of the assessment ofoocyte maturity will additionally be discussed. Traditionally, follicularsize has been used to assess oocyte maturity. However, frequently verypoor oocytes are obtained from optimally grown follicles. It has beensuggested that the assessment of peri-follicular flow could potentiallydistinguish oocyte maturity in a superior manner than size of follicles.Finally, the value of measurement of endometrial thickness and itsstructure, as well as uterine and subendometrial flow in the assessmentof endometrial receptivity will be discussed.

WS03-02Doppler assessment of the ovarian blood flow

L. T. MerceÂInternational Ruber Hospital, Madrid, Spain

Background: The aim of this study was to evaluate arterial and venousintraovarian blood flow in infertile patients.Methods: Seventy-six FSH stimulated cycles in 39 patientsparticipating in a timed intercourse or iui program were studied.Transvaginal color and pulsed Doppler measurement of thedominant follicle and corpus luteum resistance index (RI),pulsatility index (PI), peak systolic velocity (PSV), maximumvenous velocity (MVV) and serum p levels during mesolutealphase were recorded. Velocimetric parameters were established andthen used to classify ovarian function in normal ovulatory cycle(NOV; n � 52), luteal phase defect (LPD; n � 15) and luteinizedunruptured follicle (LUF; n � 9).

Results: The luteal PSV and MVV in the nov and LPD cycles weresignificantly higher (NOV: 24.3 ^ 12.2 vs. 13.1 ^ 6.5 and8.1 ^ 3.30 vs. 3.6 ^ 1.1; LPD: 29.8 ^ 10.3 vs. 14.4 ^ 4.8 and5.7 ^ 1.5 vs. 4.3 ^ 1.2) and luteal RI and PI were significantly lower(NOV: 0.45 ^ 0.06 vs. 0.55 ^ 0.08 and 0.62 ^ 0.15 vs.0.83 ^ 0.22; LPD: 0.46 ^ 0.05 vs. 0.54 ^ 0.06 and 0.62 ^ 0.10vs. 0.81 ^ 0.15) than follicular ones. LUF cycles did not showsignificant changes during the ovarian cycle (follicular vs. luteal PSV;MVV; RI and PI: 14.4 ^ 4.8 vs. 14.9 ^ 7.3; 4.3 ^ 1.2 vs. 4.2 ^ 2.1;0.47 ^ 0.07 vs. 0.58 ^ 0.12 and 0.66 ^ 0.12 vs. 0.89 ^ 0.29) andno `luteal conversion' of the Doppler signal was identified. There wassignificant correlation between luteal MVV and serum p (r � 0.36).Conclusions: Arterial and venous intraovarian blood flow remainunaltered during LUF cycles and P levels correlate with luteal MVV.This makes Doppler an effective noninvasive test to assess ovulationand luteal function.

WS03-03Three-dimensional digital imaging for assessing oogenesis andfollicular development as well as live 3D follicle aspirations

W. FeichtingerInstitut fuÈ r SterilitaÈ tsbetreuung, Lainzerstr. 6, A-1130 Wien, Austria

The purpose of the first study was to evaluate whether number andsize of antral follicles can predict the outcome of IVF-ET. A total of113 patients was prospectively included into this study. After 19 daysof downregulation number and size of follicles were determined byusing recent three dimensional transvaginal ultrasound (3-D) technol-ogy. We demonstrated that patients with a higher number of folliclesbetween 5 and 10 mm showed a significantly higher pregnancy rate(PR), whereas patients with antral follicles . 11 mm have a highercancellation rate due to ovarian low-response.

Ultrasound visualization of the cumulus has been demonstratedyears ago as an occasional finding during follicle scanning. It has neverbeen proven, however, that cumulus-like intrafollicular structures asseen on ultrasound correlated with the recovery of mature oocytes. Itwas therefore our aim to investigate this possibility by using recentthree-dimensional ultrasound (3-D) technology: Cumulus visualiza-tion by 3D ultrasound seems to be an indicator for mature oocytes andthe fertilization rate. Follicles without visualization of the cumulus inall three planes are unlikely to contain mature, fertilizable oocytes.

In the third part we wanted to evaluate the possibility of puncturingprocedures under three-dimensional ultrasound control in close to realtime using a new commercially available system, and to describe thetechnique.

It will be demonstrated for follicle punctures that recent technologyenables the carrying out of three-dimensional puncture procedures in



real time; but this will be of more importance in other fields, e.g. infetal medicine, oncology, and surgery.

WS03-04Three-dimentional-ultrasound in IVF cycles

R. L. Schild C. Knobloch, H. Van Der Ven and M. HansmannUniversity Hospital of Bonn, Department of Obstetrics &Gynaecology, Germany

Aim: To investigate the role of 3D-ultrasound in estimating thelikelihood of conception in an IVF programme.Materials and methods: We studied a total of 152 women during theirstimulation cycle. Apart from conventional 2D-parameters weassessed endometrial and uterine volume (sub-)endometrial bloodflow (sub-)endometrial vessel density and ovarian volume by 3D-ultrasound.Results: With regard to subendometrial blood flow on day 1 of thestimulation cycle, all 3D-indices were significantly lower in theconception vs. non-conception group. On the day of oocyte retrieval,any difference between the two groups failed to reach statisticalsignificance. The same applied to endometrial volumes. The lattershowed a significant corrrelation with uterine size. Ovarian volumes# 3 mm (1 SD below the mean) on day 1 of the stimulation cycle wereassociated with a nonsignificant lower conception rate.Conclusion: Quantitative assessment of spiral artery blood flow andvessel density may be an early predictor of IVF success.

WS03-05Ultrasound based simplified infertility investigation

S. Granberg³, K. Hauge*, K. Flo* and M. Riedhart²Departments of Obstetrics and Gynecology, *RITé UniversityHospital, TromsoÈ , Norway, ²University Hospital, Innsbruck, Austriaand ³Central Hospital in Hedemark, Elverum, Norway

Objectives: To compare the use a simplified ultrasound basedinfertility investigation of the infertile couple with the current use oflaparoscopy and hysteroscopy.Study design: Thirty-three infertile couples underwent transvaginalultrasound and hystero-salpingo-contrast-sonography. A diagnosiswas formulated based on the results of the ultrasound investigations, asemen analysis and endocrine parameters. The following day allsubjects underwent a laparoscopic chrompertubation and hystero-scopy by a surgeon unaware of the ultrasound findings. A diagnosisbased on the findings at laparoscopy and hysteroscopy, the samesemen analysis and endocrine parameters, was then made. The twodiagnoses were compared.Results: A 90.9% agreement was found between the diagnoses madefrom the two methods used. When considering laparoscopic diagnosisthe Gold Standard of tubal patency, the sensitivity to diagnoseoccluded tubes using hystero-contrast-sonography was 92.8%. Thecorresponding figures for specificity, PPV and NPV were 96.2%,92.8% and 98.1%, respectively.Conclusions: A simple, ultrasound based approach to investigate theinfertile couple, can be used effectively as an initial examinationmodality during the couple's work-up. However, there is a need for alarger study to confirm these results.

WS03-06Tubal patency as assessed by three-dimensional powerDoppler imaging (3D-PDI) and hystero-salpingo-contrastsonography (HyCoSy)

P. SladkeviciusThe Diana, Princess of Wales Centre for Reproductive Medicine, St.George's Hospital Medical School, London, UK

Background: The purpose of the study was to evaluate the feasibilityof three-dimensional power Doppler imaging (3D-PDI) in theassessment of the patency of the fallopian tubes during hystero-salpingo-contrast sonography (HyCoSy).

Methods: HyCoSy using contrast medium echovist was done on 67subfertile women. 3D-PDI and two-dimensional (2D) gray-scaleimaging were used to visualize the contrast medium in the tubes.Results: Contrast medium echovist produced prominent signals on the3D-PDI image. Free spill of the fallopian tubes which had had theproximal part visualized was demonstrated in 114 (91%) tubes using3D-PDI technique and in 58 (46%) tubes using conventional HyCoSy.The mean duration of imaging procedure was less than 3D-PDI. Asignificantly lower volume of contrast medium (5.9 1 0.6 ml) wasused for 3D-PDI in comparison with volume (11.2 1 1.9 ml) used forconventional HyCoSy.Conclusions: The 3D-PDI method appeared to have advantages overthe conventional HyCoSy technique, especially in terms of visualiza-tion of spill from the distal end of the tube which was achieved twiceas often with the 3D technique. The shorter duration of the imagingand lower volume of the contrast medium used suggested that the 3D-PDI technique may have a better side-effect profile. The 3D-PDItechnique allowed better storage of the information for re-analysis andarchiving than 2D scanning.

WS03-07Which information about follicular development inunstimulated cycles can be obtained by ultrasound?

V. VlaisavljevicÂDepartment of Reproductive Medicine and GynecologicEndocrinology, Maribor Teaching Hospital, Maribor, Slovenia

Unstimulated cycles offer a simpler, quicker and less invasive form ofIVF and ICSI than the most conventional stimulated cycles. Theobjective of the study was to evaluate the effectiveness of differentapproaches for follicle monitoring in unstimulated cycles. Thismonitoring includes studies of follicle growth during the follicularand luteal phase of the cycle, measurements of blood flow inperifollicular vessels and studies of perifollicular perfusion in vascularnetwork using power Doppler. These studies include 3D analysis offollicular growth, development and its vascularization.

A retrospective chart review of all patients undergoing IVF and ICSIin unstimulated cycles at our institution was performed. The outcomemeasurements used were oocyte recovery rate, fertilization rate,implantation and delivery rate.

Unstimulated cycles monitored by ultrasound only were comparedwith those monitored with different protocols of ultrasound monitor-ing combined with serum estradiol level and urinary LH.

IVF and ICSI were performed in 708 unstimulated cycles. A higherpregnancy rate and lower cancellation rate was obtained when hCGwas applied in lower values of serum E2 and smaller follicle diameter.

The actual pregnancy rate per embryo transfer in IVF cycles was23.8% and 26.4% in ICSI cycles when embryo transfer wasperformed on day 1 2 or day 1 3. When blastocyst stage embryotransfer was performed the implantation rate per embryo transfer was37.5%.

WS03-08Diagnosis and treatment of PCO syndrome ± what is the placeof ultrasound

V. SÏ imunicUniversity Dept of Obstetrics and Gynecology Petrova, Zagreb,Croatia

Ultrasound characterization of ovarian morphology and vascularisa-tion has become an important part of gynaecological endocrinology.PCO syndrome is the most prevalent endocrinological problem inwomen during reproductive period of life. The us diagnostic accuracyhas advanced from recognition of ovarian size (volume), characteristicfollicular distribution and volume of dense ovarian stroma, to bloodflow changes in the uterine and ovarian stromal vessels. Improvementhas been made by using innovations such as 3D US, colour and pulsedDoppler US, which allows US quantitative analysis of the ovarianstroma. In the PCOS the ovarian stroma is the source of hyper-androgenemia.



One hundred and thirty-two patients with PCOS, diagnosed by usand endocrinological findings, underwent further clinical, US andendocrine evolution during various kinds of therapy (metformine,ovarian drilling, oral contraception, flutamide and finasteride treat-ment). Mean age of the PCO patients was 25.5 years (range 15±48),59.3% were obese (BMI � 28), 75.6% had signs of hirsutism,43.02% presented with acne and 88.5% have had irregular menstrualcycle. Ultrasound findings (TVUS, colour and pulsed Doppler, 3D US)and hormonal evaluation (FSH, LH Androstendion, DHEA-a, T, FreeT, SHBG, 3 a diol) were performed prior, during and at the end of thetherapy.

Comparison has been made between these five groups of patients.

WS03-09Unilateral early timed vaginal ultrasound guided follicularaspiration (ETFA) 10±12 h after hCG prevents the syndromeof serious ovarian hyperstimulation

T. TomazevicÏ, H. Meden-Vrtovec, K. GersÏak and E. BokalUniversity Medical Center, Ljubljana, SÏ lajmerjeva 3, Slovenia

Aim: To prevent the syndrome of severe ovarian hyperstimulation inIVF/ET cycles at high risk for the syndome of ovarian hyperstimula-tion by early timed unilateral ultrasound guided aspiration of oneovary (12 h after hCG).Method.: We evaluated the preventive effect of ETFA by analysing thedata on 821 cycles at high risk for SOHSS performed during the years1987±99. In all cycles the high risk for SOHSS was defined by theestradiol values . 3000 pg/ml and more than 8 follicles . 14 mm plusintermediate and small follicles in each ovary on ultrasound.Results: In the group of :729 female infertility cycles at high risk forSOHSS with preventive ETFA there were no cases of SOHSS. In thecontrol group of 92 IVF/ET female infertility without ETFA therewere 12 cases of SOHSS (P , 0.0001). No difference in live birth rate(17% vs. 16%) was noted. The results prove the preventive effect ofETFA. It is based on early timed withdrawal of paracine substanceswhich are present in the follicular fluid.

Conclusion: The vaginal ultrasound guided ETFA is another successfuloption to decrease the incidence of severe OHSS in assistedreproduction.

WS03-10Vasoactive substances and infertility

C. Battaglia, G. Regnani and A. VolpeDepartment of Obstetrics and Gynecology, University of Modena,Italy

The regulation and significance of ovarian and uterine haemody-namics in human reproductive pathophysiology has been largelystudied. In women, ovarian vascularization seems to be responsible forthe selection and maturation of follicles both in spontaneous andstimulated IVF cycles while endometrial receptivity is related touterine blood flow and implicated in the achievement of pregnancy. Inpatients who underwent to IVF cycles, the PI of both uterine and spiralarteries is significantly lower in patients who became pregnant incomparison with nonpregnant and is associated with significantlylower endometrial cell thromboxane concentrations than nonpregnant patients. In poor responders women it has been demon-strated the role of L-arginine in improving uterine and follicularDoppler flow and in increasing ovarian response to gonadotrophin.Recently, in a total of 41 patients undergoing to assisted reproduction,an higher number of oocytes collected and embryos transferred wasobserved in normo-responders than in poor-responders patients.Furthermore follicular vascular endothelial growth factor (VEGF)resulted inversely correlated with retrieved oocytes (r � 20.942;p � 0.0017). In addition significant higher uterine and perifollicularDoppler flow resistances were observed in poor-responders women.The pregnancy rate/cycle was significantly higher in normo-respon-ders (26%) than poor-responders (6%; p � 0.037) patients.

In conclusion, vasoactive substances improve ovarian response togonadotrophin and allow a better management of ovarian stimulationin infertile patients.

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WS04-01Transvaginal sonography of the endometrium andsonohysterography in the menopause

D. ZoricicGeneral Hospital Pula, Croatia

Background: All endometrial sampling methods are invasive. There-fore in sympyomatic women and for women at risk of developingendometrial pathology in menopause a technique that could reducethe number of biopsy procedures would be of a great value. Thistechnique would be relatively non-invasive, easy to learn and perform,cost effective and well accepted by the patients. The objective of thisstudy was the assessment of the diagnostic potency of ultrasoundmeasurements by comparison with the usual histological investiga-tion.Method: Endovaginal ultrasonography (measurement of endometrialthickness and morphology of endometrium) prior to endometrialsampling was done in 160 postmenopausal patients. 143 D&C, 15hysteroscopies and 2 laparotomies were performed to collectendometrial tissue. Indications for endometrial sampling werebleeding in 72%, ultrasound suspicion of endometrium in 18%, orother (cervical or adnexal pathology) in 10% of patients. Sonohyster-ography, as an improvement over conventional ultrasound methods,was done in 12 cases (7.5%). Pathologic findings were compared topreoperative ultrasonography.Results: Ultrasound measurement of endometrial thickness combinedwith morphology and sonohysterography detected more than 90%endometrial pathology (sensitivity 96%, specificity 92%).

Conclusion: We found endovaginal ultrasound as useful tool atidentifying endometrial diseases in menopause. For a postmenopausalwoman with vaginal bleeding with a 10% pretest probability ofendometrial cancer, her probability of cancer is less than 1% followinga normal endovaginal sonography and sonohysterography. Ultrasoundshould be considered as investigational and cannot be used as the onlymethods to evaluate abnormal bleeding in menopausal patients.

WS04-02Should all unilocular ovarian cysts be removed inpostmenopausal women?

S. Granberg*, E. Ekerhovd*, H. Wienerroith² and A. Staudach²Departments of Obstetrics and Gynecology, Sahlgrenska UniversityHospital*, GoÈ teborg, Sweden and University Hospital of Salzburg²,Salzburg, Austria

Objectives: Our purpose was to evaluate the risks of malignancy insurgically removed ovarian cysts that preoperatively were character-ized as unilocular by transvaginal sonography.Study design: This prospective analysis included 1307 womenoperated at two European university Hospitals between January1992 and December 1997. Based on ultrasonographic findings thecysts were characterized either as echo-free, without solid parts orpapillary formations (group I) or cysts with solid parts/papillaryformations or echogenic cyst content (group II). Ultrasonographic andmacroscopic appearance of the cysts were compared with histopatho-logical diagnosis.



Results: In group I seven of 670 (1.1%) proved to be borderline ormalignant, and all measured $ 75 mm in diameter. The correspondingfigures for cysts in group II were 24 of 634 (3.8%). The frequency ofborderline/malignant cysts increased significantly with the size of thecysts.Conclusion: Unilocular, echo-free cysts (group I) with a meandiameter above 50 mm and all unilocular cysts with solid parts/papillary formations should be removed surgically. Serial ultrasoundfollow-up should be the standard procedure of unilocular, echo-freecysts less than 50 mm.

WS04-03Doppler assessment of postmenopausal patient

C. Battaglia, G. Regnani and A. VolpeDepartment of Obstetrics and Gynecology, University of Modena,Italy

Menopause is associated with an increase in the incidence of ischemicheart disease and stroke. Loss of ovarian function is characterized bysignificantly high values of blood and plasma viscosity. After themenopause, thromboxane production increases and correlates withduration of menopause. Large studies have shown that postmeno-pausal HRT is associated with reduction in the risk of cardiovasculardisease. The aim of the study was to evaluate the plasma thromboxaneand plasma viscosity in relation with Doppler flow parameters inpostmenopausal patients treated with HRT. Thirty-two postmeno-pausal (FSH . 40 UI/L and estradiol , 100 pmol/L) women (meanage ^ SD, 54.7 ^ 2.9 years) participated in the study and weresubmitted to continuous estradiol transdermal supplementation and12-day courses of medroxyprogesterone acetate every second month.Doppler resistances at the level of uterine and internal carotid arteries,thromboxane plasma levels and plasma viscosity were analyzed inbasal condition and after 1, 3 and 6 months. During hormonesupplementation, the pulsatility index significantly decreased at thelevel of analyzed arteries. Similarly, plasma thromboxane levels andplasma viscosity were significantly reduced. Significant correlationswere found between thromboxane plasma concentrations, plasmaviscosity and uterine artery resistances. Thus HRT seems to beresponsible for both direct and indirect modifications at the level ofthe vessel wall physiology.

WS04-04Vascular impedance of uterine, inferior vesicle and ophthalmicarteries in postmenopausal women receiving hormonalreplacement therapy: comparative Doppler study

I. Bekavac, S. Kupesic, D. Mihaljevic and A. KurjakDepartment of Obstetrics and Gynecology, University of SchoolMedicine and Sveti Duh Hospital, Zagreb, Croatia

Background: To investigate the effects of combined hormonereplacement therapy (HRT) on the vascular impedance of the uterine,inferior vesicle and ophtalmic artery.Method: Thirty-five postmenopausal patients were analysed in basalcondition and during a HRT phase at 1, 3 and 6 months. Patientswere divided in two groups: 21 patients whose last menstrual bleeding

was 1±5 years ago, and 14 patients with the duration of menopause. 6 years. Color Doppler analysis of the blood flow impedance wasperformed at the level of the uterine, inferior vesicle and ophtalmicartery. Estradiol plasma concentrations were assayed on the day ofDoppler examinations.Results: The analysis of the uterine and inferior vesicle artery flowvelocities demonstrated significant positive correlations betweenresistance index (RI) and years of menopause; higher impedancevalues were obtained in patients with longer interval from lastmenstrual bleeding (P , 0.05). The impedance in patients with. 6 years duration of menopause was 0.94 ^ 0.03 vs., 0.89 ^ 0.04,in the group of patients with 1±5 years duration of menopause foruterine artery, and for inferior vesicle artery (0.91 ^ 0.04 vs.0.98 ^ 0.02). No significant correlation between baseline RI andtime since menopause was noticed (0.72 vs. 0.73, respectively,P . 0.05) at the level of ophtalmic artery. After six months of HRTplasma estradiol levels inversely correlated with RI uterine(r � 20.2556; P � 0.021), inferior vesicle (R � 20.2653;P � 0.023) and opthalmic (r � 20.2211; P � 0.017) arteries.Conclusion: Doppler studies of uterine, inferior vesicle, and ophtalmicartery can provide specific and precise pathophysiological informationto assess blood flow variations in correlation with combined HRTadministration.

WS04-05Doppler ultrasound and hormonal replacement therapy(HRT)

I. ZaludDivision of Maternal Fetal Medicine, Kapiolani Medical Center forWomen & Children, University of Hawaii John Burns School ofMedicine, Honolulu, HI, USA

Hormonal replacement therapy (HRT) offers multiple benefits andsome risks to many postmenopausal women, especially to those whosemenopause occurred before age 45. Improvements of image resolutionby transvaginal sonography allow the investigation of very delicateanatomical structures such as the endometrium. Various diagnosticcriteria including thickness and volume of endometrium, internalstructure and myometrial involvement help to identify endometrialabnormality. The benefits of technologies such as sonohysterography,Doppler and 3D ultrasound are being assessed. In the postmenopausalpatient without hormonal substitution, endometrial pathology may bediagnosed by measuring endometrial thickness alone. In women withpostmenopausal bleeding, endometrial atrophy as the must commoncause has been differentiated from endometrial cancer with a highsuccess rate. Considering that the majority of diagnostic endometrialbiopsies reveal a benign pathology, Doppler ultrasound maysignificantly reduce the number of these procedures. In patients withHRT, the measurement of endometrial thickness is not reliable topredict pathology. In this situation, ultrasound examination of theendometrial/myometrial border or endometrial blood flow is advan-tageous. Transvaginal ultrasound and Doppler blood flow analysiscould prove helpful in selection and follow up of patients on HRT andmaybe to prevent some unwanted endometrial effects.

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WS05-01Ultrasound in endometrial pathology

H. HallerDepartment of Ob/Gyn, Rijeka, Croatia

Background: This study was undertaken to evaluate the accuracy oftransvaginal ultrasound combined with vaginal and endometrial

cytology in detecting endometrial pathology in postmenopausalwomen.Method: In all patients who underwent dilatation and curettage (D &C) for postmenopausal bleeding during four years endometrialthickness, vaginal and endometrial cytology were evaluated.Results: Accuracy of endometrial thickness in detecting pathologiccondition, like as polyp, hyperplasia and carcinoma was high sensitivebut with low specificity. Combined use transvaginal ultrasound,



vaginal and endometrial cytology show very high sensitivity andspecificity for endometrial cancer. The combined use of threediagnostic methods show no benefit for other pathologic conditions.Conclusion: Combination of transvaginal ultrasound, vaginal andendometrial cytology can not absolutely replace histologic findingsobtained by D & C. However, in the cases with thin endometrium andnegative cytology D & C could be avoided. Usefulness of these threemethods has to be found in providing more information resulting inbetter understanding of endometrial condition.

WS05-02Sonohysterography in patient treated with SERMs

A. C. FleischerVanderbilt University Medical Center, Nashville, TN, USA

Sonohysterography (SHG) is an established method for detection ofpolyps, evaluation of submucosal intracavitary fibroids and adhesionsas well as abnormal areas of endometrial thickening. This presentationwill describe SHG findings for evaluation of punctate cysts bothwithin and adjacent to the endometrium seen in women on selectiveestrogen receptor modulators (SERMS) Tamoxifenw, and Roloxife-new. The clinical significance of these findings will be discussed.Cystic endometrial atrophy and focal adenomyosis of patientsreceiving SERMS may the histologic correlate of abnormal sono-graphic appearances.

WS05-03Ultrasound in the diagnosis of endometrial abnormalities

L. ValentinUniversity Hospital, MalmoÈ , Sweden

There is a potential role of ultrasound examination in the manage-ment of women with postmenopausal (PMP) bleeding. Becausewomen with an endometrium � 4 mm at transvaginal ultrasoundexamination rarely have endometrial pathology, it may be justified notto sample their endometrium. However, endometrial pathology iscommon among women with endometrium � 5 mm. In ourprospective study, 105 consecutive women with PMP bleeding andendometrium � 5 mm underwent hydrosonography, hysteroscopy, D& C, and hysteroscopic resection. 80% of these women hadendometrial pathology, including 24% with endometrial malignancy.94% of the pathological lesions manifested a focal growth pattern.87% of the focal lesions were only partly removed or remained insitu after D & C, D & C missing 25% of malignancies and 53%of benign pathology. Hydrosonography was as good as hystero-scopy at detecting focally growing lesions in the uterine cavity(agreement between hydrosnography and hysteroscopy being 96%;Kappa 0.77), but neither hysteroscopy nor hydrosnography couldreliably discriminate between benign and malignant lesions. In arandomized trial, 49 women with PMP bleeding and endometrium� 4 mm were randomized to D & C and 48 to ultrasound followup. 14 (29%) women in the D & C group and 22 (46%) in theultrasound group had either rebleeding or manifested endometrialgrowth during a 12-month follow-up period. Endometrial pathol-ogy was not found in women with rebleeding unless the endometriumwas � 5 mm.Conclusion: Women with PMP bleeding and endometrium � 5 mmshould undergo hydrosnography. If focal lesions are detectedhysteroscopic resection should be carried out. In women with PMPbleeding, rebleeding during the first 12 months is an indication tosample the endometrium only if the endometrium measures � 5 mmat ultrasound examination.

WS05-4Assessment of uterine vascularity in endometrial cancer

I. SzaboÂ1st Department of Obstetrics and Gynecology, SemmelweisUniversity, Budapest, Hungary

Background: This study was conducted to assess uterine blood flowcharacteristics in endometrial cancer and to evaluate the influence ofmyometrial invasion and cancer grading for uterine circulation.Method: Transvaginal color doppler was performed on 97 womenwith endometrial cancer (11 in stage IA, 33 in stage IB, 37 in stage IC,7 in stage II, 8 in stage III, and 1 in stage IV) and 51 asymptomaticpostmenopausal women (control group). Intratumoral and mainuterine artery blood flow was recorded and the peak systolic velocity(PSV) and impedance indices (RI, PI) were calculated.Results: In 90 of the 97 postmenopausal endometrial cancer patients(92%) abnormal blood flow with low impedance levels (RI:0.39 ^ 0.08; PI: 0.51 ^ 0.15) was found within the endometrialecho or very close to it. Impedance indices in the main uterine arterieswere significantly (P , 0005) lower in women with endometrialcancer than in normal postmenopausal woman. Uterine blood flowwas not modified by the cancer grading. There was, no difference inimpedance indices of the uterine arteries between myometrial invasionof , 50% and . 50%.Conclusion: These results suggest that uterine blood flow analysis inendometrial cancer could not predict the tumor staging and grading,but this examination can provide additional discriminatory informa-tion on tumor vascularity which can then be used with morphologyfor more accurate diagnosis.

WS05-05A role of ultrasound in follow-up of tamoxifen patients

M. PredanicDepartment of Obstetrics and Gynecology, Flushing Hospital MedicalCenter, Flushing, NY, USA

Recently suggested role of tamoxifen as a preventive agent in womenat high risk of breast cancer has a potential to increase significantly thenumber of women treated with tamoxifen agent. By the fact thattamoxifen is beneficial in taming the breast cancer, but detrimental tothe uterus by increasing the risk of endometrial carcinoma,hyperplasia, and development of endometrial polyps, surveillance ofendometrial changes in patients on tamoxifen is needed. However, nocost-effective method has been found for screening for the rareoccurrence of endometrial carcinoma. Therefore, the ACOG does notrecommend routine endometrial screening of tamoxifen-treated breastcancer patients. Regardless of aforementioned recommendation,ultrasound (US) is very helpful as a first line for diagnosis ofendometrial pathology in symptomatic or asymptomatic patients withprevious endometrial pathology. Endometrial thickness , 5 mm isreassuring, . 5±8 mm calls for further investigation such as sono-hysterography to rule out polyps. If it fails to demonstrate polyps, butcystic structures still present and letter on endometrial biopsy (or D &C) shows atrophic changes of the endometrium or material isinsufficient for analysis, likely diagnosis is Cystic EndometrialAtrophy. Additionally, Color Doppler flow measurement helps indifferentiation between atrophic cystic endometria and polyps,hyperplasia or even cancer in terms that atrophic endometrial aremainly avascular, whereas endometrial polyps and carcinomas arerichly vascularized within the endometrium as well as in surroundingmyometrial tissue.How and how often endometrial surveillance should be done?:

1. Recommend us or endometrial biopsy evaluation prior totamoxifen treatment;

2. Follow up with endometrial biopsy/D & C if symptomatic; or3. If asymptomatic but patient at high risk (history of previous

endometrial disorders, obesity, long duration of tamoxifen treatment),recommend us 6 months.US findings: 1. If endometrial thickness . 5±8 mm, exclude endo-metrial polyps by sonohysterography; and add color doppler toevaluate vascularity pattern;

2. If no polyps with thick endometrium on sonohysterography andavascular pattern present, perform blind or hysteroscopic guidedendometrial biopsy;

3. If findings are atrophic endometrium or insufficient material for



diagnosis, assume atrophic (^ cystic) endometrial changes andcontinue annual/semiannual endometrial evaluation (^ US);

4. If (1) simple hyperplasia, consider progestin and/or D & Ctreatment;

5. Consider hysterectomy as final option if endometrial pathologypersists.

W S 0 6 : F E TA L E C H O C A R D I O G R A P H Y

WS06-01Human fetal cardiac function during the first trimester ofpregnancy

P. Jouppila, K. MaÈkikallio and J. RaÈsaÈnenDepartment of Obstetrics and Gynecology, University of Oulu, Oulu,Finland

Introduction: The hypothesis was tested whether the improvement inthe human fetal cardiac diastolic and systolic functions are associatedwith changes in the cardiac volume blood flow, inflow blood velocitywaveform characteristics, systemic venous blood flow parameters,umbilical artery velocimetry and fetal nuchal translucency. By alongitudinal study protocol the inflow and outflow blood velocitywaveforms were obtained in 16 uncomplicated pregnancies at 6, 7, 8,9 and 10 weeks.Results: The proportion of isovolumetric relaxation time decreasedand the proportions of filling and ejection times of the cardiac cycleincreased significantly from 6 to 7 weeks. The proportion ofisovolumetric contraction decreased between 8 and 9 weeks. Everyinflow waveform was monophasic before 9 weeks but it was biphasicin all cases at 10 weeks. Mean velocity of inflow and outflowincreased between 6 and 7 weeks and Vmean of inflow increasedfurther after 8 weeks. At 9 and 10 weeks, atrioventriculu valverecurgitation (AVVR) was present in 4 and 7 fetuses, respectively.Nuchal translucency was greater in fetuses with AVVR present at10 weeks compared with non-AVVR cases.Conclusion: Improvement in the diastolic function of fetal heartbetween 6 and 7 weeks is accompanied by simultaneous increase inthe mean velocities across inflow and outflow tracts. Appearance ofbiphasic inflow pattern is associated with significant change in systolicfunction between 8 and 9 weeks. AVVR is a common finding at10 weeks of gestation.

WS06-02Cardiac anomalies in early pregnancy

U. Gembruch, U. Germer and J. SmrcekDivision of Prenatal Medicine, Medical University, LuÈbeck, Germany

Fetal echocardiography including colour and spectral Dopplerfacilitates the diagnosis of the great majority of major structural andfunctional cardiac abnormalities in the late first and early secondtrimester of gestation.

Based on more than 4000 echocardographic examinations between10 and 16 weeks of gestation (4/1993±3/2000) following data aredemonstrated:

1. The four-chamber view and cross-over of the pulmonary trunkand aorta were visualised in 44% of the fetuses at 10 weeks and in100% at 13 weeks of gestation.

2. Normative biometric data of the fetal heart has been established.The ratio of the right and left ventricle and of the pulmonary trunkand ascending aorta were constant during this period of pregnancy(approximately 1.00 and 1.10, respectively).

3. The detection rate for cardiac malformations was greater than60%. Colour Doppler increased the detection rate by easierdemonstration of the great arteries and of abnormal cardiac bloodflow pattern (valvular incompetence and stenosis).

4. In fetuses with increased nuchal translucency (� 3 mm) (30% ofthose with general hydrops) the rate of aneuploidy was twice as highin fetuses with abnormal echocardiographic findings compared tofetuses with normal echocardiogram. In some aneuploid fetuses with

normal cardiac structures transient tricuspid regurgitation wasobserved.

5. Some complex cardiac malformations were diagnosed which arevery rare in later gestation, e.g. absent pulmonary valve syndromewith patent ductus arteriosus, polyvalvular stenoses of the semilunarvalves.

WS06-03Ultrasound-detected heart defects associated with aneuploidy

G. R. DeVoreFetal Diagnostic Center of Pasadena, Pasadena, CA, USA

In North America second trimester genetic ultrasound is offered topatients at risk for trisomy 21 and other chromosomal abnormalitieswho decline invasive testing. In most major studies in which theprevalence of ultrasound markers used for genetic ultrasound arereported, congenital heart defects are identified in less than 10% offetuses. When one considers that over 50% of fetuses with trisomy 21and 90% of fetuses with trisomies 13 and 18 have structuralmalformations of the heart, the question should be raised as to whythe wide discrepancy in prevalence and detection rate of heart defectsin these fetuses. The purpose of this presentation is to review theprevalence of CHD in fetuses with trisomy 21, trisomies 13 and 18,and all fetuses with chromosomal defects that were identifiedfollowing second trimester amniocentesis. To ascertain the presenceor absence of CHD, each fetus underwent a fetal echocardiographicstudy using real-time and color Doppler ultrasound at the time ofgenetic amniocentesis.

The results of the study demonstrated the following: The detectionrate for trisomy 21 (n � 80) increased from 62% to 91% whenexamination of the fetal heart was performed. The detection rate fortrisomy 18 (n � 30) increased from 84%% to 97% when thecardiovascular system was evaluated. For fetuses with any chromo-somal abnormality (n � 103) advanced maternal age were examined,the examination of the heart increased the detection rate from 61% to85%.

Given the above findings, the inclusion of the fetal echocardio-graphic evaluation of the fetus significantly increased the detectionrate for the above three groups of fetuses. If physicians and/orsonographers desire to increase the ultrasound detection rate forchromosomal abnormalities, examination of the fetal cardiovascularsystem must occur.

WS06-04Intracardiac echogenic focus and fetal heart defects

R. Chaoui and A. BierlichClinic of Obstetrics, University Hospital, ZuÈ rich, Switzerland

Background: Intracardiac echogenic foci are controversially discussedwhether or not they are marker for chromosomal aberrations. Thepossible association with fetal congenital heart defects (CHD) and itsimpact were not yet analyzed extensively.Method: During 30 months, prenatally detected structural CHD wereprospectively analyzed for the presence of EF. Frequency, localization,number, association with chromosomal defects and pattern of CHDwere assessed.Results: 279 fetal CHD could be examined and EF were found in 31cases (11.1%). The localization was in 17 cases (54%) the left, in 7(22%) the right, and in 7 (22.5%) both ventricles. Multiple EF were



found in 10 cases. 14 cases (42%) were associated with achromosomal aberration (T18 n � 2; T21 n � 5, T13 n � 3,Triploidy n � 2, Del22q n � 1, others n � 1). Among the remaining17 fetuses with normal chromosomes following heart defects werefound: 3 � VSD, 3 � Left-persistent SVC, 2 � TGA, 2 � TOF,2 � Coarctation, and 1 � PS, PA, Ebstein, TAC, AS each.Conclusions: Compared to low-risk groups EF are more frequent inthe presence of CHD and show another distribution involving moreright ventricular or bilateral EF. The combination of EF and CHD ishighly associated with aneuploidies. Since associated CHD includealso conotruncal anomalies EF can be considered as an indication fortargeted fetal echocardiography especially when EF is localized in theRV or in both ventricles.

WS06-05Disproportion of the four chamber view of the fetal heart:what does it mean?

M. Respondek-LiberskaInstitute `Polish Mother's Memorial Hospital', èoÂdzÂ, Poland

Background: The aim of the study was a retrospective analysis of fetalheart disproportion.Method: From the database of 3941 fetuses disproportion based on 4chamber view was diagnosed in 136 fetuses (3.5%). There were 96fetuses with the complete neonatal follow-up.Results: Fifty-nine fetuses presented with different extracardiacmalformations. Three other fetuses presented with heart defects.Thirty-four fetuses with disproportion had `normal heart anatomy'and no extracardiac malformations. Gestational age at the time ofdiagnosis was 26±40 weeks (mean 35).

Out of 34 fetuses with `pure' disproportion, 15 cases (44%) did nothave any clinical or postnatal ECH0 abnormalities. In 19 cases (54%)structural or functional abnormalities were found: 6 neonatespresented with ASD secundum, 4 with CoA, 2 with lungs abnorm-alities (cong. pneumonia and cong. lung emphysema), one neonatehad PDA, one had aorto-pulmonary window 1 PDA. In other 5neonates tricuspid insuffciency was diagnosed.Conclusions: Disproportion in fetal heart was the relatively frequentabnormality at the referral center for fetal echocardiography (3.5%)and in majority of cases it was related to the presence of structural orfunctional abnormalities. In 44% of neonates fetal disproportion hadno clinical implications. The most common neonatal heart defect incases who prenatally presented with disproportion was ASD sac,followed by CoA (4/19, 21%).

WS06-06A novel sonographic approach to the fetal echocardiogram

M. BronshteinHaifa, Israel

At present there are four concepts guiding the sonographic examina-tion of the fetal heart: (1) the fetal echocardiogram (FEC) is difficult toperform and time-consuming, (2) FEC should be performed only inhigh risk pregnancies, (3) the optimal time to perform FEC is 18±22 weeks gestation, (4) FEC relies on several sonographic still views.In our lecture, we will present a new systemic `video' approach to thegreat vessels and the four chambers in early pregnancy usingtransvaginal sonography.

Transvaginal ultrasound examination of the cardiovascular systemwas performed in 36 323 consecutive fetuses using a dynamic `video'multidirectional approach. Cardiovascular anomalies were detected in173 fetuses giving an overall incidence of 1 in 210 pregnancies and 1in 238 low-risk pregnancies. Fifty-six percent of the fetuses hadassociated anomalies. The prenatal diagnosis was confirmed in 90cases. In 10 fetuses a different cardiac anomaly was observed. In fourfetuses the cardiovascular anomaly was not detected in earlypregnancy. In the remaining cases, postmortem examination was notperformed. Early fetal heart examination is suggested in allpregnancies.Conclusions: Fetal ECC should be performed: (a) transvaginally, (b) in

early pregnancy (14±16 weeks), (c) in every pregnancy , (d) using thevideo multidirectional approach.

WS06-07Examination of the fetal heart by five short-axis views: Theoptimal screening method for fetal cardiac anomalies?

S. YagelHadassah University Hospital, Mt. Scopus, Jerusalem, Israel

`Classic' fetal echocardiography is based on 7 transverse planes: theupper abdomen, the traditional four-chamber view, the five-chamberview in which the aortic root is visualized, and the fourth transverseview revealing the bifurcation of the pulmonary arteries, and long-axisviews of the outflow tracts and aortic arch. We recently proposed thethree vessel and trachea (3VT) plane of insonation be added, tofacilitate and expedite fetal heart evaluation.

The (3VT) is the most cephalad transverse view, visualized on aplane crossing the fetal upper mediastinum. It is obtained easily bymoving the transducer cephalad and slightly oblique from the FCV,and shows the main pulmonary trunk (MPA) in direct communicationwith the ductus arteriosus (DA). A transverse section of the aortic archis seen to the right of the MPA and DA. Cross sections of the superiorvena cava (SVC), and posterior to it the trachea, are visualized.

The clinical applicability of the 3VT was demonstrated in a recentstudy encompassing 1263 low-and high-risk cases scanned between 14and 24 weeks' gestation. We consider one of the greatest advantagesof our novel approach the ease with which the examiner can scan thefetal heart, beginning with the caudal upper-abdomen view. By slidingthe transducer cephalad in one continuous motion, all the pertinentviews are readily visualized. It was also shown to be effective in thediagnosis of such aortic arch anomalies as right and double aorticarch, among others.

We showed that five short axis views including the 3VT simplifiedand streamlined fetal cardiac examination, without compromisingdiagnostic effectiveness.

WS06-08Real-time three-dimensional fetal echocardiography: imagingand volume measurement

T. R. Nelson and D. H. PretoriusUniversity of California, San Diego La Jolla, CA, USA

The objective of this work was to assess the feasibility of real-timethree-dimensional echocardiography (which acquires data as avolume, instead of a series of planes, eliminating gating) to evaluatefetal cardiac anatomy and function. We evaluated 10 human fetusesincluding several with congenital heart disease. Transabdominalscanning was performed using a real-time three-dimensional echo-cardiography system. Four 1.5 second volume clips at 20 volumes/second were obtained for each fetal heart and stored for off-lineanalysis. Data were reviewed on a graphics workstation. Our resultsshowed that fetal heart data could be acquired rapidly. Fetal heartdata were displayed as 3 simultaneous planes. The reviewer couldmanipulate plane orientation and position in the volume to optimizeviews. Cardiac motion could be accelerated, slowed, stopped orviewed at its original speed. Although image quality did not equalhigh-end equipment, cardiac structures, views and function could beconsistently visualized. Abnormal structures were readily detected. Inconclusion, real-time three-dimensional fetal echocardiography is afeasible and potentially important new technique that will gainimportance as equipment performance improves.

WS06-09Prenatal detection of congenital heart disease: the need for acost-effectiveness analysis

D. Paladini, A. Teodoro, A. Lamberti, M. Arienzo and P. MartinelliFetal Cardiology Unit ± Department of Obstetrics and Gynecology ±University Federico II of Naples, Naples, Italy



Background: Recent reports have shown a significantly improvedsurvival for complex congenital heart disease (CHD) when detectedantenatally. This has further substantiated the need to detect CHD inutero. Since the performance of the 4-chamber view as a screening toolis rather insufficient, the issue is now to find more effective and nottoo expensive alternative methods to reach this aim.Method: The cost-effectiveness analysis (CEA) is an efficient methodto assess health outcomes and resource costs of health interventions.We have applied this tool to prenatal detection of CHD, comparing 3models: (1) 4-chamber view at level I; (2) outflow tracts at level I; (3)Outflow tracts at level II. To perform the analysis we have made thefollowing assumptions: (1) the incidence of CHD at 20 weeks is 10/1000;(2) the percentage of severe CHD is 40%; (3) the monthly salary are2500 USD and 3500 USD for level I and level II operators, respectively;(4) detection rate for CHD detectable on the 4-chamber view and onoutflows only are 35%/20%, 60%/60%, and 90%/90% for the threeoptions (level I 4-chamber, level I outflows, level II outflows).

Results and conclusions: Based on the forementioned assumptions, thecosts for (1) a diagnosis of CHD; (2) a diagnosis of severe CHD; (3) TOPof any CHD; TOP of a severe CHD are reported below. These results,which were also submitted to sensitivity analyses, will be discussed.

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WS07-01Fetal hydrolaparoscopy and endoscopic cystotomy incomplicated cases of lower urinary tract obstruction

R. A. Quintero, P. W. Bornick, W. J. Morales, M. H. Allen and P. K.JohnsonFlorida Institute for Fetal Diagnosis and Therapy, St. Joseph'sWomen's Hospital, Tampa, FL, USA

Background: Vesicoamniotic shunting may be difficult or impossiblein selected cases of fetal lower obstructive uropathy (LOU). Thepurpose of this paper is to describe the performance of fetalhydrolaparoscopy (FHL) and endoscopic fetal cystotomy (EFC) infetuses with complicated LOU.Method: FHL-EFC was performed in one patient with amarkedly thickened bladder that could not be entered percuta-neously. A peritoneoamniotic shunt was also placed. FHL-EFCwas performed in a second patient with a collapsed bladderfrom a previous vesicocentesis, as vesicoinfusion resulted infurther ascites. Fetal cystoscopy was performed after EFC, andposterior urethral valves were ablated with YAG-laser. A vesicoam-niotic shunt was inserted.Results: Adequate bladder drainage was obtained in both cases. Thefirst baby required bilateral nephrostomies and a permanentcystotomy at birth, and is scheduled for a bladder expansionprocedure at one year of age. The second patient had prematurerupture of membranes and fetal demise from treatment of thiscomplication 5 days after the original procedure.Conclusion: FHL-EFC can be performed in complicated LOU cases.The procedure involves the creation of a defect in the bladder domeunder direct endoscopic visualization within a hydroperitoneum.Peritoneo or vesicoamniotic shunting, or ablation of posterior urethralvalves may then be performed. FHL-EFC should be reserved only forcomplicated cases of LOU where conventional vesicoamnioticshunting is not possible.

WS07-02Treatment for TTS should be done within a trial

Y. VillePrincipal Investigator of the Eurofoetus Trial, Paris, France

Over a year I invited you here to participate to the rct for treatingtwin-to-twin transfusion syndrome (TTS). Are there any dataavailable to reconsider this? The answer is clearly no, on the contrary.Indeed large series on amniodrainage or laser therapy have becomeavailable.

With serial amniodrainage overall survival for both twins is 49% or71% where at least one baby survive. In cases where one fetus dies in

utero, 20% of the survivors die, and in another 20% they have severeneurological morbidity. Laser treatment has now a survival rate of54% for both twins and 81% for at least one survivor. Neurologicalmorbidity seems to be less than 10%.

Has this larger experience contributed to solve the questionwhether one or the other therapy is better? No, it only underscoresthat our estimate of the number of patients needed in a rct was right:10% difference in survival rate and 15% for severe neonatalmorbidity.

All new data, all new studies are an urgent call for randomisation. Ifnot, both patients and their obstetricians will continue to argue basedon unsubstantiated views. Further case series will not bring anycritically new element.Results: Over 45 patients have now been included, all but a few inFrance. If we would extrapolate the number of patientsrandomised at our centre, only three other groups would haveto recruit at the same pace to reach the 142 patients needed by theend of next year.Discussion: There are many arguments to try to finish the study withina few years. It avoids the obvious bias due to improvements ofperinatal resuscitation. It would keep high motivation amongstreferring clinicians.

I would dare to say more: at this point it has become unethical notto randomise cases with TTTS. Not laser, neither amniodrainage havebecome established yet as the best treatment and there is no room forempirical new techniques until the trial is completed.

WS07-03Stage-based treatment of twin±twin transfusion syndrome:preliminary study

R. A. Quintero, P. W. Bornick, W. J. Morales, M. H. Allen andP. K. JohnsonFlorida Institute for Fetal Diagnosis and Therapy, St. Joseph'sWomen's Hospital, Tampa, FL, USA

Background: The purpose of this study was to test the value ofsonographic staging of twin±twin transfusion syndrome (TTTS) inpredicting the outcome of patients treated with amniocentesis orselective laser photocoagulation of communicating vessels (SLPCV).Methods: TTTS was defined as a deep vertical pocket (DVP) in therecipient twin of . 8 cm and in the donor twin , 2 cm. TTTS wasstaged as follows: Stage I: bladder of donor visible; Stage II: bladder ofdonor not visible; Stage III: critically abnormal Dopplers; Stage IV:hydrops; Stage V: demise. Patients were treated with amniocentesis orSLPCV.Results: There were a statistically significant difference by stage for atleast one survivor between the two techniques (Chi-square � 2.63,

Costs

Outcome Level I 4-ch.Level IOutflows

Level IIOutflows

Det. Any CHD 1796 USD 1157 USD 324 USDDet Severe CHD 6510 USD 2894 USD 810 USDTOP Any CHD 5314 USD 2893 USD 810 USDTOP Severe CHD 9300 USD 4133 USD 1157 USD



p � 0.05), but analysis was limited by sample size (amniocentesisn � 9, SLPCV n � 70). In the amniocentesis group there was an 83%(n � 5) survival rate for two survivors in Stage I and no survivors(n � 3) in stages II or III. In the SLPCV group, at least one fetussurvived 83% of the time, regardless of stage.

Conclusion: Our preliminary data suggests that analysis of survivaldata by in TTTS needs stratification by stage. Early stages may beamenable to treatment with amniocentesis, while later stages may notbenefit. SLPCV is uniformly effective, regardless of stage, but may notbe warranted in early stages of TTTS.

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WS08-01Three-dimensional-ultrasound of the embryonic/early fetalbrain

H.-G. K. BlaasNational Center for Fetal Medicine, Norwegian University of Scienceand Technology, Trondheim, Norway

In the growing embryo, the brain is the first organ system to developin such a way that it can be imaged in detail with transvaginalultrasound. The extension of the transvaginal ultrasound technique to3D imaging makes it possible to obtain new ultrasound images of thedeveloping embryonic brain in planes not available in the original scanplane, to present form and shape, and to calculate volume. Newinformation about the embryonic brain development can be obtained:volume measurements of the embryonic brain compartments reflectthe phylogenetic development. The òld' rhombencephalon is largeduring the early phase, while the `young' hemispheres are very small.During a few weeks, this correlation becomes reversed. Using 3Danimations this dynamic developmental process can be visualized.

Ultrasound technology has reached a level where the diagnosis ofembryonic malformations can be made. At present, we are at theborderline of being able to diagnose holoprosencephaly when theembryo is seven to eight weeks. At nine weeks, 3D images ofanomalies such as holoprosencephaly and spina bifida have beenmade. We may expect the rapidly developing 3D technology, with theoption of anyplane slicing, to help us establish early diagnoses in thefuture. Such multiplane presentations of a diagnosis will contribute toincreasing the diagnostic accuracy.

WS08-02Three-level view (TLV) of fetal brain imaging in the prenataldiagnosis of congenital anomalies

I. Goldstein and E. ReeceDepartment of Obstetrics and Gynecology, Rambam Medical Center,the B. Rappaport Faculty of Medicine, Technion, Haifa Israel, andDepartment of Obstetrics, Gynecology and Reproductive Sciences atTemple University School of Medicine, Philadelphia, Pennsylvania,PA, USA

The purpose of this study was to determine whether a systematicstream-lined approach could be routinely used in the evaluation of thefetal intracranal anatomy, and which could be used to effectively andefficiently exclude all major intracranial malformation.

Three planes were determined to be independent without overlay.Following the establishment of these three independent oblique planesacross the intracranial anatomy, there were applied clinically todetermine whether such planes would be sufficient to diagnose themajor intracranial abnormalities.

After retrospectively examining the various imaging levels taken, itwas independently determined that three levels of intracranial imagingprovided the greatest anatomic view of the entire fetal brain: thelateral ventricular level (Level I); the medial-thalamic level (Level II);and the inferior-posterior fossa view (Level III).

We examined 131 cases of intracranial abnormalities that wereprenatally diagnosed between 14 and 24 weeks gestation. Oneinvestigator was given the three-level view protocol to determine ifthe anomalies could be identified using this system. It was determinedthat, of the 131 abnormal cases, 126 (96.2%) were diagnosed using

Levels I, II or III, independently or in combination. There were nofalse-positive test results.

The present study investigated the efficacy of a three level view(TLV) imaging of the fetal brain representing a complete 2-Dexamination. We found this approach to be applicable throughoutpregnancy and suitable for visualization of normal intracranialstructures as well as the identification of abnormalities.

WS08-03Prenatal diagnosis of congenital and acquired brainabnormality

R. K. PoohDepartment of Obstetrics and Gynecology, The Taijukai Foundation,Kaisei Hospital, Japan

The intrauterine development of the central nervous system (CNS) isone of the most interesting fields in perinatology. The brain has three-dimensional structure and rapidly changes its appearance duringpregnancy. Therefore, the fetal brain should be evaluated three-dimensionally with consideration of gestational age.

Sonoembryology has been established by high-frequency transva-ginal sonography. Premature brain structure and ventricular system ofearly fetuses can be clearly demonstrated and prenatal diagnosis ofcongenital anomalies has been done earlier and earlier. Application oftransvaginal approach to the fetal brain in the second and thirdtrimesters has enabled brain imaging from fetal parietal directionthrough fontanelles and cranial sutures, and `neurosonography' hasbeen established. Recent introduction of 3D ultrasound in neurosono-graphy produced skull imaging, serial parallel images of the brainstructure, volume extraction of target organ and brain circulatoryimages. Furthermore, advanced technology of magnetic resonanceimaging (MRI) can demonstrate CNS morphology including the brainstem, which is not clearly depicted by sonography. By using all thosetechnologies, prenatal diagnosis of CNS abnormalities has been moreobjective and accurate. Intracranial changes in cases with CNSanomalies have been objectively demonstrated in vivo. Furthermore,intrauterine acquired brain damage such as periventricular leukoma-lacia, which is one of the controversial issues in perinatology, has beenproven by sonography in a few cases. Further case studies will berequired for investigation of CNS pathology in utero.

WS08-04Fetal brain: cerebral and cerebellar circulation in early fetaljeopardization

D. Arduini, F. Giannini, C. ExacoustoÁ s and C. RomaniniDepartment of Obstetn. and Gynaecol., University of Tor VergataRome, Italy

Background: The aim of this study was to investigate with color-power doppler sonography the arterial and venous circulation in fetalbrain, in normal and pathologic circumstances.Method: We studied 101 appropriate for gestational age (AGA)fetuses, 20 intrauterine growth-retarded fetuses (IUGR), 10 fetuseswith cmv infections and 10 fetuses with supraventricular tachycardia.

In all fetuses we obtained reliable blood flow velocity waveforms ofmiddle cerebral and superior cerebellar artery and trasverse sinus.

The pulsatility index (PI) for arterial vessels and flow velocity for



venous vessels were used. Doppler measurements of AGA fetuses werecompared with other fetuses.Results: An increase in fetal middle cerebral PI and cerebral transversesinus was observed in IUGR and a slightly decrease in case of fetalarrhytmia when compared with AGA fetuses. In 6 of 10 fetusesaffected by cmv infection was observed a reduction in PI cerebral andcerebellar, while no difference was found for venous velocities.

A longitudinal study was performed in 30 AGA and 8 IUGR fetuses.The IUGR fetuses showed a characteristic early reduction of cerebellarPI in respect to cerebral PI about 4±8 days prior the evidence of lateheart rate (HR) decelerations; however, the two vessels did not differsignificantly in the 4 days prior HR decelerations.Conclusion: Venous and arterial cerebral circulation shown a responseto pathological conditions that could affect fetal brain.

WS08-05Ultrasound evaluation of fetal brain space occupying lesions

V. D'Addario, V. Pinto, E. D. I. Naro and A. Anfossi4th Unit of Obstetrics and Gynecology, University Medical School,Bari, Italy

Objective: To evaluate the accuracy of ultrasound in identifying fetalbrain space occupying lesions.Study design: A retrospective evaluation of 14 cases of fetal brainspace occupying lesions has been performed. All prenatal ultrasono-graphic diagnoses (5 teratomas, 1 choroid plexus papilloma and 8arachnoid cysts) were compared with the postnatal findings on theaborted fetuses or on the newborns.Results: In 11 out of 14 cases the antenatal ultrasonographic diagnosiswas confirmed postnatally; 1 case of supratentorial arachnoid cyst wasmistaken for a teratoma and 2 cases of porencephalic cysts were wronglydiagnosed as arachnoid cysts (specificity� 78.5%). The specificity wasbetter in the subgroup of solid or complex masses (5 out of 6 � 83.3%)than in the subgroup of cystic lesions (6 out of 8 � 75%).Conclusions: Prenatal ultrasonography is a useful tool to identify anyintracranial space-occupying lesion. In the present study it has showna 78.5% specificity in the diagnosis of brain masses, with better resultsin the solid than in the cystic lesions. The distinction between thedifferent causes of fetal brain space occupying lesions is clinicallyrelevant, as each one carries different prognostic implications.

WS08-06Fetal hemodynamics, hypoxia index and brain damage

A. SalihagicÂ*, D. JugovicÂ*, J. Tumbri², V. Latin², M. Kos²,A. Kurjak² and P. H. Arbeille³Department of Physiology, Croatian Institute for Brain Research,School of Medicine University Zagreb, Croatia, Department ofObstetrics and Gynecology, School of Medicine University Zagreb,Sveti Duh Hospital, Zagreb, Croatia, INSERM 316, Department ofNuclear Medicine and Ultrasound, CHU Trousseau, Tours, France

Objective: To estimate the value of a new vascular score, hypoxiaindex (HI), in prediction of functional and/or structural brain lesionscaused by fetal hypoxia and to examine the relationship between thisindex, Doppler cerebral-umbilical ratio (C/U) and neonatal neuroso-nography in growth retarded and hypoxia fetuses.Study design: In the prospective study 41 growth retarded fetuses were

included from 29 to 40 weeks of gestation. Flow velocity waveformsthe umbilical and middle cerebral arteries were recorded each otherday, at least two weeks. The C/U ratio and HI were calculated. Afterthe birth, obstetric parameters and ultrasound of neonatal brain wereused as outcome parameters.Results: Doppler C/U ratio , 1 as well as HI . 150 were associatedwith poor perinatal outcome. The neonatal brain damage wasdetected in 16 growth-retarded and hypoxic fetuses. Hypoxia indexhad greater statistic significance in the prediction of neonatal brainlesions. Also, specificity and sensitivity of HI was better than the lastvalue of C/U ratio measured before delivery.Conclusions: The C/U ratio and HI represent the best indicators forearly detecting and assessment of fetal hypoxia. Furthermore, theymay also be parameters for the prediction of poor neurologicaloutcome in pregnancies with growth retardation. So, the use of HIwould represent a significant advance in prevention of hypoxic brainlesions, which are one of the most frequent causes of perinatalmorbidity and mortality.

WS08-07Brain plasticity after perinatal damageÐprospectiveneurodevelopmental and ultrasonographic/magneticresonance study

V. MejasÏki-BosÏnjakChildren's Hospital Zagreb, Department of Pediatrics, Croatia

Objective: To assess long-term neuodevelopmental outcome andstructural reorganisation of children suffering hypoxic-ischemic (H-I) and/or haemorrhagic perinatal brain damage; To test the hypothesisof more successful recovery of prematures and/or unilateral lesionsafter perinatal brain damage; To estimate prenatal events, inparticularly value of pathological findings of Color Doppler (CD) inthe pathogenesis of perinatal brain damage;Study design: 68 children suffering perinatal brain H-I (10) and/orhaemorrhagic lesions (58) diagnosed by ultrasonography (US) under-went neurologic and psycho-linguistic examinations by age 16. Highresolution 2 T MRI was used to assess structural reorganisation; 20children suffering unilateral perinatal brain damage (MCA infarct.)were followed up (neurodevelopmentally, transcranial CD and US/CT,MRI); 25 children with CD findings (C/U ratio , 1) during pregnancyunderwent prospective follow-up postnatally by age 2.Results: All children with H-I lesions have still at age 16 one or moresevere handicaps, while 39 children with mild grade of hemorrhagehad minor neurological dysfunction, 15 were normal. MRI revealeddestructive and/or atrophic lesions in all children with H-I lesions andmild atrophy and/or signs of preiventricular haemorrhage in restchildren. 20 children with unilateral perinatal brain damage havecontralateral hemiparesis and various accompanying neurodevelop-mental disorders. There were no strict correlation between size, site,hemispheral involvement gestational age and neurodevelopmentaloutcome of children examined. Out of the 25 children havingpathological CD findings during pregnancy, 7 revealed mild grade(I±II) of peri-intraventricular haemorrhage, 10 children isolated orcombined H-I and haemorrhagic lesion, 7 children have no apparentperinatal brain damage. Short-term neuro-developmental outcomerevealed mild delay and/or disorders in 10 infants and in the restnormal status.

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WS09-01Role of imaging modalities in pelvic tumor practice

H. Nakano and S. Satoh1: Department of Obstetrics and Gynecology, Graduate School ofMedical Sciences, Kyushu University, 2: Maternity and Perinatal CareUnit, Kyushu University Hospital, Fukuoka, Japan

Background: To clarify the diagnostic usefulness of imaging mod-alities in pelvic tumor practice, inpatients having pelvic neoplasticdisorders in our Institute were reviewed.Methods: For a total of 1506 cases undergoing ultrasonography(US) only, those receiving a combined usage of computedtomography (CT) and US, magnetic resonance imaging (MRI)



and US, and all three modalities, we compared the indications andselected imaging modalities in relation to the stream of therapeuticprocedure.Results: 324 cases (21.5%) judged to have no structural diseasethrough imaging techniques at previous Hospitals underwent nofurther imaging examination. 420 cases (27.9%), most of whichunderwent surgery and/or radiation due to malignant lesions in theovary and/or uterus, had US alone, and 564 cases (37.5%) had CT inaddition to US. The main indications for ordering additional CT weresuspected distant metastasis, including pelvic and paraaortic lymph-nodes. 95 patients (6.3%) had US and MRI under indication of tissuecharacterization in tumors. 103 cases (6.8%) with difficulties indiagnosis had all modalities; US, CT and MRI. In 324 cases withoutimaging modalities, 60 cases (18.5%) undergoing operative procedurewere those with cervical neoplasm, and 70.0% of the cases followedby chemotherapy were for ovarian cancer. Such will be furtherdiscussed in detail.

WS09-02Ultrasound diagnosis of adnexal masses

L. ValentinUniversity Hospital, MalmoÈ , Sweden

The basis of ultrasound diagnosis of adnexal masses is the gray scaleultrasound image. In our prospective study of 173 patients scheduledfor laparotomy because of an adnexal mass, an experienced examinercorrectly discriminated between benign and malignant masses in 95%of cases on the basis of subjective evaluation of the gray scaleultrasound image (sensitivity 92%, i.e. 22/24, specificity 96%, i.e.143/149). A correct specific diagnosis (e.g. dermoid cyst, endome-trioma, etc.) was made in 72 of the 173 women, i.e. in 42%. AddingDoppler ultrasound examination to gray scale imaging did not changethe diagnostic accuracy, but it increased the confidence (as rated on avisual analogue scale) with which a correct diagnosis was made in14% of cases. Increased diagnostic confidence was observed mostoften in stage I ovarian malignancies (83%, i.e. 5/6). Dopplerultrasound examination was not helpfull in the diagnosis of borderlinetumors. For less experienced ultrasound examiners the use ofmathematical models to calculate an individual risk of malignancymight be an alternative to subjective evaluation of the the gray scaleultrasound image. In a study of 136 consecutive women scheduled forlaparotomy because of an adnexal mass, two mathematical formulaswere cross-validated prospectively: that of Tailor et al. (Ultrasound inObstetrics and Gynecology 1997; 10 : 41±7) and that of Timmer-mann et al. (Am J Obstet Gynecol 1999; 181: 157±65). Both modelsperformed less well than in the studies where they were created, thesensitivity and specificity of the first model being 71% and 82%,respectively, and the sensitivity and specificity of the second model72% and 68%, respectively.Conclusion: Subjective evaluation of the gray scale ultrasound imageis an excellent method for discrimination between benign andmalignant adnexal masses. Mathematical models hold promise butmust be fine tuned on the basis of information from a very largenumber of tumors.

WS09-03Association of color Doppler with molecular biology inovarian tumors

K. Hata and K. MiyazakiDepartment of Obstetrics and Gynecology, Shimane MedicalUniversity, Izumo 693±8501, Japan

Color Doppler imaging and pulsed Doppler spectral analysis ultra-sonography were used to scan 44 patients with an overt ovarian massimmediately before laparotomy. Sections of malignant tumors wereanalyzed for the cellular expression of TP and the intratumoral densityof microvessels by immunohistochemistry using antibodies to TP andFactor VIII related antigen, respectively. Moreover, apoptotic index(AI) was evaluated by the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling methods. The proportion of

Stage I tumors that was TP positive (16%) was significantly lower(P � 0.022) that the corresponding value for Stages II±IV (44%),although the values for microvessel count, AI, and peak systolicvelocity (PSV) were similar. AI was significantly lower in TP-positivetumors than that in TP-negative tumors (P � 0.015). The PSV wassignificantly higher in TP-positive tumors (P � 0.02). There was asignificant correlation between the microvessel count and the PSV(r � 0.34, P � 0.024). Moreover, AI was significantly inverselyrelated to the PSV (r � 0.35, P � 0.023). The PSV in a subgroupwith a high microvessel count and low AI was significantly higherthan that in a subgroup with a low microvessel count and high AI(P � 0.0006). These findings significantly associated with TP expres-sion (P � 0.024). The intratumoral PSV, as determined by colorDoppler imaging and spectral analysis might reflect the coordinationof angiogenesis and apoptosis, associating with TP expression inepithelial ovarian cancer.

WS09-04Ultrasound diagnosis of adnexal masses: computer modelling

J. L. AlcaÂzarDepartment of Obstetrics and Gynecology, ClõÂnica Universitaria deNavarra, University of Navarra, Pamplona, Spain

The differential diagnosis of adnexal masses still represents achallenge. The main goal is to determine whether a given mass ismalignant or benign, in order to establish the best therapauticalapproach. When a clinician face to a woman diagnosed as having anadnexal tumor several parameters may be used to determine thenature of the mass, such as patient's age, menopausal status, clinicalcomplaints, physical examination, tumor's sonographic and Dopplerfeatures and serum tumor markers. When these data are collected maybe difficult to interpret them all together and the clinician has to relyin one or two of them to predict the diagnosis and to decide themanagement strategy, guided many times by own experience or strictprotocols.

A possible solution to this question may be the use of computermodelling. This means the use of statistical or mathematical modelsdeveloped, using computer aid, to predict adnexal malignancy.

Currently, there are two methods that may be used: MultipleLogistic Regression Analysis (MLRA) and Artificial Neural Networks(ANN).

Both techniques allow to calculate the probability of a particularevent has occurred, in this case a mass to be malignant or benign.

By computer modelling, actual independent predictors parametersare identified and may be used combined and simultaneously topredict malignancy. Each method has advantages and disadvantages,being MLRA the statistical technique of choice and ANN a potentialnewer alternative to MLRA.

Several studies have been published using one or both technique topredict adnexal malignancy. The results of these studies are encoura-ging showing a high diagnostic performance. All studies comparingMLRA to ANN showed the latter seems to be superior. However, itshould be taken into account that most of these models have not testedprospectively.

WS09-05Sonographic appearance of borderline ovarian tumors

C. ExacoustoÁ s, D. Rinaldo, C. Carusotti, D. Arduini and C. RomaniniDepartment of Obstet. and Gynaecol., University of Tor VergataRome, Italy

Background: The aim of the present study is to individuatesonographic markers which make it possible to distinguish borderlineovarian tumors from benign and malignant cysts, thus allowingconservative treatment.Method: We reviewed transvaginal sonograms in 23 women whopresented borderline ovarian tumors histologically confirmed. Sixteenwere premenopausal and 7 postmenopausal. The size and morpho-logic criteria of each mass and color flow Doppler characteristics wereevaluated. We compared these findings with those of 337 patients with



benign ovarian tumors and those of 40 patients with malignantovarian tumors.Results: Of the 16 borderline ovarian tumors in premenopause 6 weremucinous cystoadenomas and 10 serous cystoadenomas. Of the 7borderline tumors in postmenopause 3 were mucinous cystoadenomasand 4 serous cystoadenomas. The analysis of grey scale morphologicfindings revealed the presence of solid tissue in 92.5% of malignantmasses, in 13.3% of benign tumors (P , 0.01) and in 31% of LMPtumors (P , 0.01 vs. malignant, P � n.s vs. benign tumors). Thepresence of papillae within the cysts was significantly higher inborderline tumors (21%) compared to benign and malignant tumors.Three unilocular cysts with a diameter . 5 cm were borderline tumors.Conclusion: The most frequent diagnostic imaging was that of apapillae inside a cyst without other signs of complexity and also thepresence of septa was frequent. Neither papillae nor septa constitutedsensitive sonographic markers.

WS09-06What does contrast media add to three dimensional powerDoppler evaluation of adnexal masses?

V. SÏparac, S. KupesÏicÂ and A. KurjakDepartment of Obstetrics and Gynecology, Medical School Universityof Zagreb, Sveti Duh Hospital, Zagreb, Croatia

Aim: To investigate the potential usefulness of contrast enhancedthree-dimensional (3D) power Doppler sonography in the differentia-tion of benign and malignant adnexal lesions.Methods: A total of 31 patients with complex adnexal lesions ofuncertain malignancy at transvaginal B mode and/or color Dopplersonography were prospectively evaluated with three-dimensionalpower Doppler sonography before and after injection of the contrastagent. Presence of a penetrating pattern and a mixed penetrating andperipheral pattern suggested adnexal malignancy.

The results were compared with histopathology.Results: There were 10 cases of ovarian malignancy and 21 benignadnexal lesions. Of the 10 ovarian cancers, 6 (60%) showed vasculardistribution suggestive of malignancy at nonenhanced 3D powerDoppler sonography. After injection of contrast agent, a penetratingvascular pattern and/or a mixed penetrating and peripheral patternwere detected in all cases of ovarian malignancy with two benignlesions (fibroma and cystadenofibroma) which were misdiagnosed asmalignant. The use of a contrast agent with three-dimensional powerDoppler sonography showed diagnostic efficiency (96.7%) that wassuperior to nonenhanced 3D power Doppler sonography (93.5%).Conclusion: Contrast enhanced 3D power Doppler sonographyprovides better visualizatoin of tumor vascularity in complex adnexalmasses. If used together with 3D morphological ultrasound assess-ment, enhanced 3D power Doppler imaging might precisely dis-criminate benign from malignant adnexal lesions.

WS09-07Ultrasound, Doppler and contrasts in metastases fromgynecologic tumor

J. SchmillevitchSchmillevitch Diagnostics Center, Cancer Hospital SaÄo Paulo, Brazil

The breast cancer metastases can be analyzed by ultrasound inganglial and visceral organs.

The detection of metastatic lymphonod in the axillar, cervical orsupraclavicular regions and intrammamarian changes both the cancerstaging and therapeutic planning. Benign lymphonode usually have anoval shape, hilum hyperechogenicity, narrow cortex and show hilarvascularization or radical central symmetric vascularization andabsence of peripheral flow at Color Doppler. Malignant lymphonodeare usually rounded hyporechoic, without hilar hyperechogenicity,and, in color Doppler, present multifocal aberrant vascularization,tortuous vessels or flow in the periphery.

The most frequent visceral metastases of breast cancer are hepatic,the suprarenal glands and ovaries.

About 86% of breast cancer hepatic metastases are hypoechoic.Ovarian cancer metastases can be detected mainly in pelvic tumors,peritonium tumors, glanglial, abdominal wall, hepatic and splenicmetastases and ascites.

Our study of 10 cases of splenic metastases of ovarian cancer hasdemonstrated six hyperechoic tumors, two hypoechoic and twotumors with necrosis.

The use of color Doppler and Powerangio has demonstrated weakor moderate vascularization in glanglial and visceral metastases ofgynecological tumors. The use of contrast (Levovist) has shown amore detailed vascular analysis by detecting vessels that were notidentified in color Doppler and Powerangio without contrast.

WS09-08Sonographic and clinical characteristics of struma ovarii

Y. Zalel, D. S. Seidman, M. Oren, R. Achiron, W. Gotleib, S. Mashiachand M. GoldenbergDepartment of Obstetrics and Gynecology, The Chaim Sheba MedicalCenter, Tel Hashomer, Sackler School of Medicine, Tel AvivUniversity, Israel

Background: To evaluate the preoperative clinical, laboratory andsonographic characteristics of struma ovarii.Method: A retrospective review of gynecologic patients operated formature cystic teratoma over a 10-year period, identified 16 cases ofstruma ovarii. These cases were the subject of this study and werecompared to 32 cases of ovarian dermoid cysts.Results: The incidence of struma ovarii among all cases of dermoidcysts was 4.8%. Most patients were menopausal, the mean lesiondiameter was 57.3 mm, occurred more frequently (68.8%) in the rightadnexa and presented with normal CA-125 level. Blood flow signalswere detected from the center of the lesions in all cases. Rare casespresented with elevated tumor marker and low-resistance blood flow.In dermoid cycsts, blood flow had a higher resistive index. In addition,no blood flow could be detected from the center of the echogeniclesion in dermoid (P , 0.0001).Conclusion: It is difficult to distinguish between struma ovarii anddermoid cysts, based on their sonographic appearance. Nevertheless,Doppler flow may aid in the preoperative diagnosis of struma ovarii.Blood flow signals, detected from the center of the echogenic lesionsand low resistance to flow may be more common in struma ovarii.

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WS10-01Pathophysiology of increased nuchal translucency-abnormalities of the extracellular matrix

C.S. Von Kaisenberg*, W. Jonat*, B. Brand-Saberi², F. Farzaneh³,K.H. Nicolaides§*Department of Ob & Gyn, Kiel University Hospital, ²Institute of

Anatomy, Freiburg, germany, ³Molecular Medicine §HarrisBirthright, King's College, London, UK

Objective: In about 80% of fetuses with trisomies, Turner syndrome,and in fetuses with skeletal abnormalities, genetic syndromes,structural abnormalities and cardiac defects, there is increasedcollection of fluid in the neck region. This can be visualizedsonographically at 11±14 weeks of gestation as increased nuchal



translucency thickness. The pathophysiology of this common pheno-typic expression of different chromosomal abnormalities is uncertain,but there is some evidence that the underlying mechanism may bealtered composition of extracellular matrix components and/orcardiac failure.Methods: We performed a number of studies investigating nuchal skintissue for various extracellular matrix components and cardiac heartfailure using molecular techniques. We used northern blotting,immunohistochemistry, electron-microscopy and in situ hybridization.Results: Studies investigating the heart found increased levels ofmRNA for ANP and BNP, and reduced levels of Calcium ATPase,whereas transcript levels for GATA-4 were unchanged. Studiesinvestigating components of the extracellular matrix in nuchal skinof trisomic fetuses found overexpression of ecm genes in trisomies(collagen type VI, collagen type IV, laminin) or an altered ratio ofgenes between normals and abnormals (collagen type VI).Conclusions: The present data provide some evidence, thatchromosomally abnormal fetuses with increased nuchal translucencyat 12±14 week may suffer from an altered extracellular matrix of theheart and skin or transient heart failure.

WS10-02Nuchal translucency in multiple pregnancies

G. MonniDepartment of Prenatal and Preimplantation Diagnosis, OspedaleMicrocitemico, Cagliari, Italy

Background: The significance of an increased nuchal translucencymeasurement (NT) in relation to the fetal karyotype and pregnancyoutcome has been evaluated in multiple pregnancies.Methods: 115 multiple pregnancies with 252 fetuses, including 100pairs of twins (70 pairs with dichorionic placentas and 30 pairs withnonochorionic placenta), 9 sets of triplets, 5 sets of quadruplets, andone set of quintuplets, were considered.Results: NT was greater than 95th centile in one fetus in 10 out of 70cases of dichorionic twin pregnancies (14%), in two sets ofquadruplets, in 7 out of 30 monochorionic twin pregnancies(23.3%). NT greater than 95th centile in both fetuses was found inone dichorionic twin pregnancy. Two cases of trisomy 21 and one 47,XXY were found. NT greater than 95th centile in 2/2 fetuses with

trisomy 21 (one dichorionic twin pregnancy and one tetrachorionicpregnancy), and not enlarged in the 47, XXY (trichorionic tripletpregnancy). A case of skeletal dysplasia and one goldenhar syndromewere found among the 10 cases of increased NT in dichorionicpregnancies. Three intrauterine deaths of both fetuses, one congenitalheart disease and a case of twin-to-twin transfusion occurred in 7cases of increased NT in monochorionic pregnancies.Conclusions: An enlarged NT in multiple pregnancies indicates fetusesat risk for chromosomal abnormalities and fetal malformation, as wellas monochorionic twin pregnancies at higher risk for an adverseoutcome.

WS10-03Down's syndrome screening by NT measurement: women'sopinion

C. M. Bilardo, M. A. MuÈ ller, G. Bonsel and O. P. BlekerDepartment of Prenatal Diagnosis and Obstet & Gynaec, AcademicMedical Centre, Amsterdam, The Netherlands

In the context of an implementation study of nuchal translucency(NT) screening for Down's syndrome special attention was devoidedto the psycho-social aspects. The impact of age, parity, religion,education together with the reasons for opting in or out for the NTmeasurement were recorded in 5895 patients. On a sample of 800patients more specific aspects were addressed such as the level ofknowledge about prenatal diagnosis before and after screening, thereaction to the offer of NT screening and the general women's opinionon whether this form of screening should be offered to all pregnantwomen. Questionnaires devised to measure the anxiety and depressionproduced by screening (hads) were filled before screening, at20 weeks' gestation and after delivery by the same group of patientsand by 200 controls. Preliminary results are available. 80% of theasked women, with no differences in age, religion and parity choosefor NT screening. Main reason for having the NT measured was thehope of avoiding invasive testing and the wish of having moreinformation on their pregnancy. The majority of women experiencedpositively NT screening even in case of an increased measurement andirrespectively of whether they would terminate an affected pregnancyor not. A slight increase in anxiety level produced by the screeningnormalized by 20 weeks' gestation.

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WS11-01The Croatian ultrasound safety law

B. [email protected]

Legal regulation of the safety of medical applications of ultrasound isimportant for protection of the patients and physicians.

The matter of ultrasound safety has recently been regulated inCroatia within the framework of the law on nonionising radiationprotection. The law as approved by the parliament regulates thegeneral principles and material cornerstones while the details aredefined by rules and regulations issued by the Ministry of Health.

Apart from medical applications ultrasound is used in plastic and metalwelding, food processing, cleaning, electroplating, drillingand metal flawdetection, tomentionbut some.The law had tobegeneral and sufficientlycover the whole spectrum allowing for the special medical exception.Namely, the medical professionalmaybreachthe integrityofhumanbodyand even harm the patient if the expected net final result of the wholeproceeding is expected to help the person who seeks help.

The law in Croatia states that ultrasound may not increase thetemperature of the human body to more than 38.5 8C and may notinduce cavitation there. However medical applications of ultrasoundare specifically excluded from this limitation. The requirement is theapplication of the ALARA principle.

The specifics of the regulation of the total field of medicalapplications of ultrasound are now being prepared under considera-tion of the existing and the presently processed IEC from IECcommittees TC 62 and TC 87 documents and taking into account thepresent regulation in the USA.

WS11-02Collaborative management of three-dimensional ultrasoundbetween medical centers, physicians and patients

T. R. Nelson and D. H. PretoriusUniversity of California, San Diego La Jolla, CA, USA

To purpose of this project was to evaluate the feasibility of performingoff-line sonographic examinations over the internet using 3DUS data.To accomplish this we performed complete OB, pelvic, cardiac andabdominal studies following AIUM guidelines in 100 patients with2DUS/3DUS methods including multiple volumes. Physicians per-formed a `virtual re-scan' of the patient using 3DUS data that wascompared retrospectively to the 2DUS diagnosis. Our overall resultsshowed that both abnormal and normal findings were identified forboth 2DUS and 3DUS studies. Outcome depended on sonographertraining, image quality and patient motion. There were few falsenegative/positive results with either 2DUS or 3DUS studies. Proper



training was essential to acquire sufficient volumes for a completestudy and for complete patient evaluation. In conclusion, off-linevirtual evaluation of patients is feasible using 3DUS data but hasdifferent technical requirements for acquisition and review than 2DUSstudies. Proper training of sonographers, well defined scanningprotocols and acquisition of sufficient volume data are essential toobtain diagnostic studies.

WS11-03How to create multimedia ultrasound teaching programs

G. R. DeVoreFetal Diagnostic Center of Pasadena, Pasadena, CA, USA

For a number of years the teaching of ultrasound principles has reliedon slides of static, nonreal-time images. Although ultrasoundoriginally employed only still images, the development of real-timeultrasound ushered in a new imaging modality. Unfortunately, the

presentation of real-time images has not been incorporated into mostpresentations because of the difficulty of preparing and editing videotape recordings of the examination. With the advent of multimediaprograms available for the laptop and desktop computer, it is nowpossible to display real-time motion sequences that duplicate theactual scanning environment. To accomplish this, however, requiresthe physician to become versed in the various techniques required tocapture video and audio sequences from the ultrasound machine. Inaddition, the proper computer software must be used to optimize theseimages. The purpose of this presentation is to review the methodologyrequired to (1) acquire the highest quality video images from theultrasound machine, (2) convert the ultrasound images from a analog-to-digital format, (3) review programs required to optimize theconverted digital images, and (4) examine the software programs tooptimally display these images for the Windows and Macintoshplatforms. At the conclusion of the presentation, the physician shouldbe able to accomplish these tasks.

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WS12-01Uterine artery velocimetry in the third trimester

K. Marsal, E. Hernandez-Andrade, G. Lingman and S. GudmundssonDepartments of Obstetrics and Gynecology, University HospitalsLund and MalmoÈ , University of Lund, Sweden

Spectral Doppler velocimetry supported by directional color Dopplerimaging became the method of choice for recording blood velocitysignals from the maternal uterine arteries during the third trimester ofgestation. Normally, the uterine artery waveforms show a highproportion of diastolic flow without any early diastolic notch andwith a low resistance (RI) or pulsatility (PI) index. With increasinggestation, there is a slight decrease in the resistance to flow in theplacental circulation. The placental side of the uterus shows lowervalues of the waveform indices than the nonplacental. In high-riskpregnancies, the abnormally high PI or the presence of notch ispredictive of the adverse outcome of pregnancy. Recently, a UterineArtery Score (UAS) has been presented based on a combinedevaluation of RI and notch (Sekizuka et al., J Mat Fet Invest 1997;7: 197). We have modified this approach, using PI and a uniform cut-off value for definition of the abnormal PI, disregarding the placentalocation. The modified UAS in combination with the umbilical arteryBlood Flow Classes possess a high predictive value with regard to theperinatal outcome in high-risk pregnancies, especially in those withplacental hemodynamic dysfunction. In cases of intrauterine growthrestriction, the combined examination of the uterine and umbilicalcirculation improves the clinical value of the third trimester Dopplervelocimetry.

WS12-02Systematic screening with a uterine Doppler in low-riskpregnant women followed by low-dose aspirin in cases withabnormal results: results of the two French multicenterrandomised controlled trial

F. Goffinet²³, D. Aboulker*, D. Subtil¶, Uzan§, G. BreÂart² and S.Uzan***Conseil geÂneÂral de Seine Saint-Denis, Bobigny, ²EpidemiologicalResearch Unit on women and children's health, INSERM U 149,Paris, ³Department of Obstetrics and Gynecology, Maternity Port-Royal, Cochin-Saint Vincent-de-Paul Hospital, Paris, §Department ofObstetrics and Gynecology, Jean Verdier Hospital, Bondy,¶Department of Obstetrics and Gynecology, Jeanne de Flandres, Lille,**Department of Obstetrics and Gynecology, Tenon Hospital, Paris,France

Objectives: Two large multicenter randomised trials were performed

in France to assess whether systematic screening with an arteryuteroplacental Doppler (AUD) in low-risk pregnant women followedby the prescription of low-dose aspirin in cases with abnormal resultsreduced the incidence of intrauterine growth restriction (IUGR) and ofpreeclampsia.Study design and population: The first trial `Seine Saint-Denis' (SSD)trial included 3317 low-risk pregnant women (multi and primigravi-dae) in 17 French maternity Hospitals and the second Èrasme' trialincluded 1869 primigravidae in 12 centres. In the Doppler group, theAUD was performed between 20 and 24 weeks, and women withabnormal results received 100 mg of aspirin daily until the 35th week.Results: In the Doppler group, 232 patients (15.7%) had an abnormalresult in the SSD trial and 20% in the ERASME trial. The predictivevalue of the AUD was comparable to that reported in the studies oflow-risk populations, but with a low sensitivity. Finally, IUGR,whether defined by the third or tenth percentile, and preeclampsia didnot differ significantly between the treatment groups in both trials.Conclusions: There is no proof justifying the recommendation of asystematic AUD in a low-risk population, even if abnormal results arefollowed by aspirin treatment and increase in prenatal surveillance.Future studies must assess predictive tests that can be performed earlyin pregnancy and can identify populations at very high risk ofpreeclampsia and IUGR. Only when all of these conditions arefulfilled can aspirin prove its efficacy.

WS12-03Uteroplacental resistances and maternal cardiac function innormal and hypertensive pregnancy: a Doppler andechocardiographic study

H. Valensise*, B. Vasapollo*, G. P. Novelli², G. Larciprete*,D. Arduini*, A. Galante² and C. Romanini**Department of Obstetrics and Gynaecology-Tor Vergata University-Rome; ²School of Cardiology-Tor Vergata University-Rome, Italy

Objective: To verify the existence of a relationship between maternalcardiac function and peripheral hemodynamic parameters in normaland gestational hypertensive women.Methods: 43 normotensive primigravidae were evaluated at 12 ^ 1,21 ^ 1, and 33 ^ 1 weeks of gestation with uterine artery colorDoppler and maternal echocardiographic examination comparingdata of the third trimester with those of 21 gestational hypertensivewomen.Results: The 43 healthy women showed a decrease in UterineResistance Index (RI) from I8 to II8 trimester (0.72 ^ 0.10 vs.0.54 ^ 0.09, P , 0.001) and modifications in Diastolic functionparameters: E wave velocity and E/A ratio decreased; A wave velocity



and deceleration time of the E wave increased; the left ventricularisovolumetric relaxation time (IVRT) decreased significantly(88.7 ^ 6.7, 75.6 ^ 7.7, 71.1 ^ 5.0 msec, P , 0.001) showing acorrelation with left atrial dimensions and RI (r � 20.38, r � 0.47,P , 0.001). In the third trimester the comparison between normaland hypertensive women showed a significant reduction in (TVR)total vascular resistances (1006 ^ 212 vs. 1620 ^ 469, P � 0.000)and IVRT (71 ^ 5.0 vs. 92.0 ^ 7.6 msec, P � 0.000). Regressionanalysis showed a linear correlation between IVRT and TVR(r � 0.68; P , 0.01), Uterine RI and TVR were directly related(r � 0.59, P , 0.001).Conclusions: Maternal diastolic function analysis may be useful toidentify women who fully adapt to pregnancy and at risk fordevelopment of gestational hypertension.

WS12-04Fetal hemodynamics and growth restriction

G. Clerici and G. C. Di RenzoCentre of Reproductive and Perinatal Medicine, Department ofObstetrics and Gynecology, University of Perugia, Perugia, Italy

Intrauterine growth restriction (IUGR) is a common symptom ofmany possible maternal-fetal pathologies and/or the expression of agenetic alteration; by far, the most common etiology is related tochronic fetal hypoxemia. Fetal hypoxemia may be the result ofdifferent feto-maternal pathophysiological processes which canproduce completely different fetal hemodynamic modifications, notonly in relation to the quality but particularly in relation to thechronology of the hemodynamic events. However, fetal hypoxia ismostly due to placental vascular insufficiency and it is important topoint-out that fetal hypoxemia-acidemia is part of the terminalpathway starting from placental functional and structural alterations,through fetal IUGR, leading to intrauterine fetal death. Dopplerevaluation of fetal arterial districts is important for the diagnosis ofthe fetal hemodynamic adaptation to the hypoxemia. Our observa-tions suggest that, in the evaluation of fetal hemodynamics, it isimportant to consider also the intracardiac and the venous hemody-namics, focusing the study on the evaluation of the output tracts, theatrio-ventricular flow and on vessels like the ductus venosus, inferiorvena cava, umbilical vein. Keeping the time of the hemodynamicalterations in these vessels and/or districts, which are characteristicsigns of the incipient heart failure, may be one of the key for thesolution for one of the main obstetrical problem: the diagnosis of fetaldecompensation phase.

WS12-05Umbilical and fetal cerebral circulation and fetal growth

O. PetrovicÂ and B. RukavinaClinical Hospital Center RIJEKA, Medical Faculty of Rijeka, Croatia

Background: Fetal growth is determined by its genetic potential andgrowth support. The aim of our prospective study was to find out doesthe growth support (placental factor and blood flow) or geneticpotential play a primary role in fetal growth.Method: From 27 to 41 gestational weeks an umbilical artery (RI1), amiddle cerebral artery resistance index (RI2) and umbilical-cerebral(U/C) ratio were measured. Several US measurements in 3±4 weekintervals of the same pregnancy were done. After delivery, fetuses weredivided into the three groups (AGA, LGA, SGA) according to theirbirth-weights. Pregnancies with gestational diabetes were excludedfrom the study.Results: There were not statistically significant differences between theaverage values of RI1 (age related) in the groups of AGA and LGAfetuses. However, the mean values of RI1 (according to gestationalage) in the mentioned two groups of fetuses were significantly lowerthan in the group of SGA fetuses, as well as their mean values of U/Cratios.Conclusion: Placental factor is equally and efficiently functioning inthe both groups of AGA and LGA fetuses. The genetic regulatingfactor of fetal growth can be adequately expressed in conditions of

appropriate uteroplacental and umbilical blood supply. In otherwords, in identical or at least similar conditions of umbilical bloodsupply, fetal growth is exclusively influenced by its geneticpotential.

WS12-06Doppler evaluation of IUGR fetuses

G. P. Mandruzzato, Y. J. Meir, R. Natale and G. P. MasoDepartment of Ob/Gyn, IRCCS `Burlo Garofolo' Hospital, Trieste,Italy

Intrauterine growth restriction (IUGR) is now defined as acondition in which the fetus does not reach the optimal conditionof his growth. In this situation the birthweight can be reducedbelow the 10th percentile or can be superior to that thresholdespecially when the restriction took first place in late part of thepregnancy. Therefore it is possible to identify two groups of IUGRaccording to the intrauterine observation and the birthweightassessment: SGA and AGA IUGR. The most important complica-tion of IUGR is represented by the hypoxaemia caused by placentalvasculopathy. Hypoxaemia is present in about 30% of IUGR fetuseswith not significant difference between SGA and AGA IUGR cases,and is the major cause of the poor perinatal outcome. Afterrecognition of the growth restriction it is necessary to apply secondlevel tests in order to assess the presence or absence of hypoxaemia.When hypoxaemia is present the first mechanism of fetal adaptationis represented by the redistribution of the circulation. Thisphenomenon is easily observable by using Doppler technology.When applying the same technique on the umbilical arteries it ispossible to detect an increase in the peripheral resistance propor-tional to the obliteration of the placental vascular bed that is thecause of the fetal hypoxaemia. By using the information offered byDoppler study on fetal and umbilical vessels it is therefore possibleto optimize the clinical management of the IUGR fetuses.

WS12-07Fetal venous and arterial circulation in hypoxic IUGR. Fromadaptation to decompensation

Y. VilleUniversiteÂ Paris v. CHI Poissy-St Germain, Paris, France

Objective: To evaluate the changes in flow velocity waveforms in themid-cerebral artery and in the transverse cerebral sinus in growthrestricted fetuses and to correlate these changes between them andwith (1) flow velocity waveforms in the ductus venosus and (2)changes in computerized analysis of fetal cardiotocogram.Design: Fetuses between 22 and 37 weeks' gestation with an estimatedfetal weight below the 5th centile were included in this prospectivelongitudinal study. Doppler measurements in the umbilical artery,descending aorta, middle cerebral artery, transverse cerebral sinus andductus venosus were recorded. Fetal heart rate was analyzed by acomputer system according to the Dawes-Redman criteria.Results: Blood flow within the midcerebral artery and that in thecerebral transverse sinus follow a mirror image distribution. Arterialredistribution is already present when alteration in the venous cerebralcirculation develops.

We measured a significant correlation between pulsatility index inthe transverse cerebral sinus and in the ductus venosus over the studyperiod and at delivery. There was a negative correlation between theseindices and short and long-term variability of the fetal heart rate.There was a parallel increase in pulsatility in the ductus venosus andthe transverse cerebral sinus. These changes were inversely correlatedwith fetal heart rate variability and preceded fetal distress.Conclusion: Cerebral venous blood flow in IUGR fetuses may be auseful additional investigation to (1) understand better the mechanismof cerebral redistribution in hypoxemic IUGR and (2) to discriminatebetween fetal adaptation and fetal decompensation in chronichypoxemia.



WS12-08Pulmonary arterial and venous flow velocity waveforms ingrowth restricted fetuses

G. Rizzo, A. Capponi*, E. Angelini, A. Muscatello, C. Grassi and C.RomaniniDepartment of Ob/Gyn UniversitaÁ Roma `Tor Vergata' and *G.B.Ospedale Grassi, Rome, Italy

Objective: To measure peripheral pulmonary artery (PPA) andpulmonary vein (PV) velocity waveforms in growth restricted fetuses(IUGR) and to relate them to different Doppler indices fetalcirculation and to pregnancy outcome.Design and methods: 108 IUGR fetuses from singleton pregnancies(gestational age median 28.4 range 25±32) were prospectivelyconsidered for this study. Entry criteria were an ultrasonographicextimated fetal weight , 5th centile, the absence of structural andchromosomal abnormalities, and a Pulsatility Index (PI) in umbilicalartery . 95th centile of our reference limits for gestation. Velocitywaveforms were recorded from the PPA and in one of the PV inproximity of the inflow in the left atrium. The PI from PPA and thePulsatility Index for the vein from PV (PIV � [S 2 D]/m) werecalculated. Values obtained were compared to our reference limits forgestation and related to other Doppler indices from arterial, cardiacand systemic venous circulation and to fetal outcome.Results: In IUGR fetuses both the PI from PPA (P , 0.001) and thePIV from the PV (P , 0.001) were increased when compared tocontrol fetuses. An inverse relationship was found between PPA andmiddle cerebral artery PI. Changes in PV were present when abnormalvelocity waveforms are present in the systemic venous circulation.Reverse flow during atrial contraction is present in pulmonary vein inthe most severely compromised fetuses and are associated with fetaldistress and imminent fetal death.Conclusions: Abnormalities in arterial and pulmonary flows arepresent in IUGR fetuses. Changes in arterial circulation occur at anearly stage of the disease while modifications in venous flows occurs

later and may be the expression of an impaired function of the leftventricle close to fetal jeopardize.

WS12-09Absent or reversed end diastolic flow: clinical implications

G. P. Mandruzzato, Y. J. Meir, R. Natale and G. P. MasoDepartment of Ob/Gyn, IRCCS `Burlo Garofolo' Hospital, Trieste,Italy

The acronym ared indicates two characteristic patterns of the DopplerVelocity Waveform (DVWF) namely the observation of absence(EDFA) or reverse (RF) blood flow in diastole. ARED flow areusually observed in fetuses presenting severe intrauterine growthrestriction (IUGR) or sometime are concomitant to fetal abnormalitieslike hydrops. The fetal condition is always severely affected mainly byhypoxaemia and/or acidaemia but at different levels according to thetwo patterns that are observed. Usually in the literature ared cases arepresented and discussed without making difference between the twopossible conditions. This approach cannot be considered correctbecause large differences in many clinical aspects are evident whenevaluating separately EDFA or RF in 94 cases observed in ourInstitute. Gestational age, mean birth weight are significantly lowerwhile perinatal mortality rate and prevalence of handicaps amongsurvivors are significantly higher in the group presenting RF ascompared to EDFA cases. As a consequence the clinical managementis also different. In case of EDFA the timing of the delivery should betaken into consideration but it is not always urgent. On the contrarywhen RF is observed intrauterine death has to be expected within fewdays. Therefore the delivery should be immediate at the firstobservation of RF. The critical point is that also applying this policythe prevalence of handicaps among survivors is very high (35%). As aconsequence when facing those clinical condition a careful andcomplete information must be offered to the family before choosing, ifno maternal indications are present, an aggressive management.

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WS13-01The effect of treatment of twin-to-twin transfusion syndromeon the diagnosis to delivery interval

D. Skupski, K. Gurushanthaiah and S. ChasenNew York Presbyterian Hospital-Weill Cornell Ctr & New YorkHospital Med, Ctr. of Queens, USA

Purpose: No randomized controlled trials of treatment of twin-to-twintransfusion syndrome (TTTS) exist. Since severely preterm neonatalsurvival has increased over time, survival as an outcome measure isconfounded by calendar time. The diagnosis-to-delivery interval is acalendar year independent measure of success of treatment. We wishedto evaluate whether treatment of TTTS is associated with alengthening of the diagnosis-to-delivery interval.Methods: MEDLINE search supplemented by careful referencereview. All TTTS series were included where the following informa-tion on each patient was available: survival, fetal demise, gestationalage (GA) at diagnosis and diagnosis to delivery interval in days.Inclusion criteria: GA # 29 weeks and diagnosis by ultrasound in theabsence of maternal symptoms. Cases undergoing multiple types oftreatment were excluded. Data were evaluated by Kruskal±WallisANOVA, logistic regression & Wilcoxon rank sum testing.Results: The 8 publications used included the following cases: controls(n � 16), amnioreduction (n � 61), septostomy (n � 12), and feto-scopic laser occlusion of chorioangiopagus vessels (FLOC) (n � 51).FLOC therapy showed a significantly longer diagnosis-to-deliveryinterval compared to amnioreduction (median 75 vs. 56 days)(p � 0.01). There was no difference in overall survival, at least onesurvivor, or number of fetal deaths between the 4 groups. Logistic

regression using at least one survivor as the dependent variablerevealed a positive association with GA at diagnosis and withdiagnosis to delivery interval, a negative correlation with fetaldeath, and no correlation with treatment group.Conclusions: FLOC therapy for TTTS is associated with a longerdiagnosis-to-delivery interval compared to amnioreduction without asignificant increase in survival. The lack of increase in survival appearsto be due to a small sample size.

WS12-02Anticipating twin-to-twin transfusion syndrome: the putativerole of venous return evaluation in the first trimester

A. Matias and N. MontenegroDep. Obstetrics/Gynecology, University Hospital of S. Joao, Porto,Portugal

Background: Twin-to-twin transfusion syndrome (TTTS) complicates10±15% of monochorionic (MC) and is associated with high perinatalmortality and morbidity.Method: Sixteen MC twin pairs were evaluated between 10±14 weeksfor delta nuchal translucency (DNT) and Doppler blood flow in ductusvenosus (DV). Sequential scans were performed to identify TTTS.Results: Neither the 12 cases with DNT,0.7 mm/normal flow, nor thetwo cases with DNT.0.7 mm/normal flow in DV, developed TTTS.The two cases that combined DNT.0.7 mm and abnormal flow inDV eventually developed TTTS.Conclusion: The presence of abnormal blood flow in the DV in MCtwins, at 10±14 weeks, may be a precocious anticipatory sign ofTTTS.



WS13-03Dynamics and clinical significance of placental shunt flow inmonochorionic diamniotic twins

K. Maeda, M. Utsu, T. Hirai, M. Sakata, N. Yamamoto and S. Ohki*Departments of Obstetrics & Gynecology and *Pediatrics, SeireiMikatahara Hospital, Hamamatsu, Japan

Background: The aim is to clarify placental shunt flow patterns inmonochorionic diamniotic (MD) twins and their clinical outcomeafter the intervention under unique criteria.Method: Thirteen (13) MD twin pregnancies were studied from earlypregnancy with 2D and 3D B-mode, color Doppler, power-angiomode, Doppler flow velocimetry, cardio-thoraxarea ratio (CTAR) andpreload index (PLI) under tocolysis.Results: Artery to artery shunt flow was detected by fetalbeat-to-beatDoppler color change and cyclic bidirectionalflow at placental surfacein 8 MD twin cases but not in 5. Shunt was more clear with 3D colorDoppler and power-angio. Umbilical vein flow pulsation, variableFHR deceleration andcord complications were more in placentalshunt flow casesthan its absence. Deep shunt flow was prenatallydetected in 2 cases and small anastomses in all postnatal placenta.Pregnancy was terminated by emergency C-section in cases ofuncontrollable contractions, unidirectional shunt flow, large CTARand PLI (. 0.4) which were frequent in large twins after 30 weeks.Neonatal cardiac failure was more in shunt flow cases than its absencebut the outcome was normal. Neonatal PVL and perinatal deaths wereless than the MD twins in the past.

WS13-04Doppler velocimetry determined brain sparing effect:correlations with neonatal outcome in diamnioticmonochorionic and diamniotic dichorionic twins

E. P. Gaziano, C. Gaziano, R. Hoesktra and C. TerrellAbbott North-western Hospital and Children's Healthcare, Universityof Minnesota, Minneapolis, Minnesota, USA

Objective: Neonatal outcome was studied in 169 infants fromdiamniotic monochorionic (DAMC) and diamniotic dichorionic(DADC) twin pregnancies in relation to a measure of blood flowredistribution, the cerebroplacental ratio (CPR).Study design: Two groups were assessed, 50 infants from DAMC, and119 infants from DADC twin pregnancies. Targeted ultrasound andDoppler recordings of umbilical artery (UA) and middle cerebralartery (MCA) were obtained. The resistance index (RI) and CPR werecalculated for each fetus.Results: DAMC twins had lower birth weight (1979 vs. 2223 g forDADC, p#.01) and prolonged lengths of nicu stay (8.5 days vs.3.5 days for DADC, p#.05). For total group, DAMC compared withDADC twins spent greater numbers of days on a ventilator. SGAinfants were significantly more frequent in DAMC twins compared toDADC twins. Among antenatal Doppler variables only the CPRdemonstrated a significant difference between twin types. For DAMCtwins CPR was 1.15 vs. 1.21 for DADC twins, p#.05.Conclusions: Monochorionic twins from the lower birth weightgroups demonstrate a greater number of growth restricted infants andprolonged hospitalizations compared to DADC twins. AmongDoppler measures, the CPR is superior to UA-RI, and/or MCA-RIfor the prediction of adverse events.

WS13-05Selective photocoagulation of communicating vessels in thetreatment of selective growth retardation in monochorionictwins: a functional dichorionization procedure

R. A. Quintero, P. W. Bornick, W. J. Morales, M. H. Allen and P. K.JohnsonFlorida Institute for Fetal Diagnosis and Therapy, St. Joseph'sWomen's Hospital, Tampa, FL, USA

Background: Intrauterine fetal demise (IUFD) of a selectively growth-retarded (IUGR) monochorionic (MC) twin is associated with high

morbidity/mortality in the appropriately grown (AGA) twin. Selectivelaser photocoagulation (SLPCV) allows precise separation of thecirculations of both twins. The aim of this study was to assess SLPCVin the treatment of MC-IUGR.Methods: Patients with previable MC-IUGR were offered SLPCV.Absent or reverse end-diastolic velocity in the umbilical artery of theIUGR twin was also required for entry.

Communicating vessels were identified endoscopically as deepartery-to-vein or superficial artery-to-artery or vein-to-vein aspreviously described. The communications were photocoagulatedwith Nd:YAG laser.Results: SLPCV was performed in 11 patients (GA mean �20.9 weeks). Survival of both fetuses was n � 5 (45%), IUFD of theIUGR twin alone was n � 4 (36%) and IUFD of the AGA twin alonewas n � 2 (18%). There were no dual losses, or adverse effects of anIUFD on the surviving twin. Previously undescribed superficial artery-to-vein anastomosis occurred in three patients.Conclusions: SLPCV can effectively create a `functionally dichorionic'placenta. SLPCV allows the AGA twin to avoid the adverse effectsassociated with IUFD of the IUGR twin.

Unexpected IUFD of the AGA twin may reflect more complexplacentation. A new type of vascular communication, superficialartery-to-vein, may have important pathophysiologic implications.

WS13-06Multiple pregnancy-considerations of antenatal diagnostics

B. Hodek, V. KosÏec and N. TucÏkarDepartment of Gynaecology and Obstetrics, University of Hospital`Sestre Milosrdnice', Zagreb, Croatia

The aim of this study is to retrospectively evaluate the complications,safety and accuracy of midtrimester amniocentesis (MTAcz) inmultiple pregnancy (MP). The indications and complications ofMTAcz are the same for singleton pregnancies (SP) and MP, butwhat's different is the technique of the procedure and frequency ofcomplications. Various techniques are here quoted, the purpose ofwhich is to prove that samples have been taken from separate sacs. Ingeneral, the efficacy in amniotic fluid collection is 92±98%, and95.6% in autors' cases. The number of insertion needles may have theinfluence on the abortion rate, but the opposite opinion also exists.The rate of spontaneous abortions has been analysed retrospectively ina group of SP with and without amniocentesis. The same parameterswere also evaluated for MP. The risk of spontaneous abortionsfollowing MTAcz is nearly 2.5 times higher in MP (1.7% vs. 3.89%)than in SP, but is still within the range of normally elevated biologicalrisk (4.5%) of this group of subjects.

WS13-07The dilemma of selective termination of a malformed fetus inmultifetal pregnancy

S. LipitzSheba Medical Center, Tel-Hashomer, Israel

The incidence of fetal malformation is higher in multifetal pregnanciesthan in singletons. In a dizygotic twin gestation there is slightly morethan twice the risk per pregnancy of a fetal malformation. In amonozygotic twin gestation the rates of chromosomal and mendelianabnormalities are identical to those of a singleton pregnancy.However, there is an increased risk of structural malformations.Selective termination in a bichorionic biamniotic twin pregnancy isdone with intracardiac injection of potassium chloride. The interna-tional experience show that it can be performed in all 3 trimesters withgood outcomes in . 90% of cases and the loss rate is approximately7%. In monochorionic twin gestation the aim is to arrest the umbilicalcord flow completely and permanently. Several methods to achievethis goal are embolization, ligation (fetoscope of U/S guidance), lasercoagulation, monopolar and bipolar thermocoagulation. The lattertechnique became more popular, with estimated loss rate of 20%. Thetechniques and results will be presented (including video), and theethical issue will be discussed.



WS13-08Multifetal pregnancy reduction: clinical andpathophisiological aspects

A. Mikhailov and A. KoroteevOtt Institute of Obstetrics and Gynecology of Russian Academe ofMedical Sciences, St. Petersburg, Russia

Background: To decrease perinatal mortality and morbidity rate incase of multifetal pregnancy fetal reduction (MFPR) in the firsttrimester was introduced.Methods: Combine ultrasound and Doppler evaluation of fetalchromosomal abnormality markers, fetal structure and biometry,

chorionicity and amnionicity, arterial and venous circulation in fetal-placental-maternal functional system were introduced as an algorithmbefore MFPR.Results: 355 fetuses in 112 women were examined before 141 MFPR.NT thickness was above 2.5 mm in 1,7% of fetuses and one fetus hadreverse DV flow. But no fetal chromosomal defects were detected afterCVS. No specific severe complications for multifetal pregnancy wereregistered in completed pregnancies. Average gestational age at birthwas 35,5 w that was less then in essential twins but perinatal mortalityrate was 5.8½ and 12.8½ correspondingly.Conclusion: MFPR with combine fetal examination seems to be theway to improve multifetal pregnancy outcome.

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WS14-013-D ultrasound in routine check-up of infertility patients

E. RadoncÂicÂ, B. Funduk-Kurjak, Sanja KupesÏicÂ and A. Kurjak

Objective: The aim of this study was to determine whether three-dimensional ultrasound (3-D US) can improve the diagnostic ability ina routine check-up of patients undergoing in vitro fertilisation (IVF) inan office practice.Methods: Three-dimensional and power Doppler ultrasound wereperformed on 267 patients undergoing IVF on the first visit, duringovulation induction and aspiration of the oocytes. Patients withsuspected uterine anomalies and/or abnormalities of the endometrium(N � 108) were treated by operative hysteroscopy. On the day ofoocyte collection, multiplanar imaging and 3-D reconstructiondemonstrated cumuli in follicles greater than 15 mm. Cumulusassessment inside the ovarian follicles was correlated to the numberof mature oocytes. Power Doppler reconstruction was performed inthe cases when superponing vessels did not allow correct placing ofthe puncture needle.Results: Of 108 patients with suspected uterine abnormality, thediagnosis was correct in all cases of endometrial polyp, submucousmyoma, arcuate uteri and septate uteri, as confirmed by an officehysteroscopy. Intrauterine synechiae was correctly diagnosed pre-operatively in one out of the four cases. The mean (^ SD) number offollicles . 18 mm was 8.2 ^ 5.8, and total number of folliclesdemonstrating cumulus in all three planes was 6.4 ^ 5.1. The ratiocumuli/retrieved oocytes, cumuli/fertilised oocytes and cumuli/matureoocytes was 6.2 ^ 4.2, 5.4 ^ 2.8 and 5.9 ^ 2.6, respectively.Conclusions: Three dimensional ultrasound can become a standard ofroutine check-up of infertility patients allowing improved recognitionof the uterine anatomy, characterisation of the surface features, andprecise depiction of the ovaries during stimulation cycles. It canenhance and facilitate the morphologic and functional evaluation ofthe anatomic structures of the inner reproductive organs, thusavoiding the need of invasive diagnostic procedures. Various punctur-ing procedures can be more precisely performed. The built-inapplication of live 3-D mode may be very helpful in performinginvasive procedures, such as oocyte collection.

WS14-023D color histogram: principles and practice in transvaginaland abdominal sonography

H. Pairleitner and H. Steiner

Objective: The 3D Color Histogram gives quantitative informationsabout (changes) of perfusion and vascularisation packed in indices.Aim of the presentation is to illustrate the information gained by thevascularisation and perfusion indices. In addition, to show thereproducibility of the indices according to published studies,

preliminary results (transvaginal) obtained in ovarian tumors andpreliminary results in phantom measurements to correct the decreasein signal power with depth of insonation using a 3D abdominal probe.Results: Color Histogram indices are reproducible. Differences ofperfusion and vascularisation between benign and malignant ovariantumors could be observed in a limited number of investigations. Thephysical component of the decrease in signal power with depth ofinsonation could be calculated by mathematical algorythms accordingto first phantom measurements.Conclusion: The 3D Color Histogram gives new possibilities toanalyse neoangiogenesis.

WS14-03Fetal extremities ± three-dimentional approach

M. KosDepartment of Obstetrics and Gynecology, Sveti Duh GeneralHospital, Zagreb, Croatia

Background: To assess particular features of fetal extremitiesevaluation using three-dimensional ultrasound.Methods: Total of 276 patients were selected from our routineoutpatient clinic or sent for supervision from other clinics because of asuspected fetal anomaly. Patients were examined during a three yearperiod (Jan1997-Dec1999). Pre-selected patients were examined withstandard 2-D ultasonic devices, and their gestation age rangedbetween 12 and 40 weeks. 3-D ultrasound devices were Combison530D and Voluson 530D MT (Kretztechnik, Zipf, Austria) with a 3±5 MHz annular array transducer for three dimensional volumescanning.Results: In 28/276 patients the initial diagnosis was suspected by 2-Dsonography at entry in the study. In 18/28 suspected cases diagnosiswas determined after examination by 3-D sonography (15/28 club-foot, 3/28 other limb anomalies). The diagnosis of clubfoot wasconfirmed In 17/28 cases after delivery or termination of pregnancy,meaning that 2/18 cases of clubfoot were not detected usingultrasonography. In all of 3 other cases the sonographic diagnoses ofhand contractures and micromelia were confirmed after terminationof pregnancy.Conclusion: 3-D sonography accurately visualized angular andstructural limb anomalies. In two cases of severe oligohydramnioswe missed clubfoot by 3-D sonography.

WS14-04Improved fetal weight estimation by three-dimensionalultrasound

R. L. Schild and M. HansmannDepartment of Obstetrics and Gynaecology, University HospitalBonn, Germany



Aim: To investigate the value of 3D-ultrasound in predicting fetalweight at delivery.Patients and methods: The study group consisted of 251 pregnantwomen (formula-finding group: n � 125; evaluation group: n � 126)with a singleton pregnancy and an ultrasound examination withinseven days of delivery. Pregnancies with major structural orchromosomal anomalies were excluded. Ultrasound examinationsincluded standard biometry as well as three-dimensional volumetry ofthe upper arm, the thigh and the abdomen of the fetus. Allexaminations were performed with a Voluson 530D MT system(Kretztechnik, Zipf, Austria). The results were compared withcommonly used weight formulas.Results: All measurements were completed successfully. Polynomialregression analysis with standard biometric parameters and volumesof the upper arm, the thigh and the abdomen was employed to yieldthe best-fit formula for prediction of fetal weight at birth. The new 3Dformula (Estimated fetal weight (EFW) � ± 1478.557 1 7.242 *thigh volume 1 13.309 * upper arm volume 1 852.998 * lgabdominal volume 1 0.526 * BIP3) proved to be superior toestablished two-dimensional equations with the lowest mean error(25.8 ^ 194.4 g), the lowest mean absolute error (155.2 ^ 118.2 g)and the lowest mean absolute percentage error (6.1 ^ 5.0%) whenstudied prospectively in the evaluation group.Conclusion: Fetal weight estimation by 3D±ultrasound comparesfavourably with conventional 2D±formulas.

WS14-05Technique of `three-dimensional' volume mode sectionalplanar imaging

D. N. Jackson, L. Aptekar and K. K. ThompsonSt. Vincent's Health Center, Department of Fetal Imaging, Billings,Montana, USA

Background: Three-dimensional imaging of superficial fetal abnorm-alities is well established. We prospectively evaluated if a technique ofsectional planar imaging could interrogate nonsurface fetal abnorm-alities without changing transducers or requiring postrenderingsoftware.Method: Patients referred for perinatal consultation received tradi-tional 2-D scanning and simultaneous volume mode imaging. Fetalabnormalities were visualized with a sectional technique similar to`tomogram' slices. No post image rendering manipulation wasrequired. Twelve patients had correlative MRI scanning. Neonatalimages were obtained when possible.Results: Structural fetal abnormalities amenable to volume renderingwere found in 192 of 600 referral patients. Of these, 49% (94/192)benefited from 3-D planar imaging. Consistently improved counselingoccurred with abdominal wall defect (11/11), cystic hygroma (8/8),neural tube defect (8/8), skeletal dysplasia (5/5), hydrops (5/5),ovarian mass (4/4), myoma (9/11), and fetal chest mass (2/3).Moderate image concordance was seen for nuchal thickness (4/8),renal dysgenesis (27/50), and placental mass or separation (7/12).Lowest concordance was seen for echogenic bowel (0/17), isolatedSUA (0/9), and CPC (4/41).Conclusion: Complex syndromes with superficial and deep architec-ture are accessible with a simple volume mode planar scanningtechnique. The additional information is immediately available anduseful in counseling of these syndromes.

WS14-06Implemented three-dimensional power Doppler for evaluationof fetal and placental circulation: implications for clinicalmanagement

Jin-Chung Shih, Hsi-Yao Chen and Fon-Jou HsiehDepartment of Obstet/Gynecol, National Taiwan UniversityHospital, Taipei, Taiwan

Background: The study of fetal and placental circulation has focusedon the interaction betweens fetal hypoxia and abnormal flowregulation. The assessed methods including spectral and color Doppler

US. However, their uses in the depiction of angioarchitecture to makethe specific diagnosis are limited.Methods: We use three-dimensional (3D) power Doppler sonography(Voluson 530D, Medison; and HDI 3000, ATL) a to detect andvisualize the fetal vasculature since 8 weeks gestation. We also use thesame method to render the angioarchitecture of placenta as early as5 weeks gestation. The scanning methods were using either free-handed or built-in mechanical probe. We also assess its application indecision making for difficult cases.Results: Power Doppler provides excellent visualization of fetalcirculation (including umbilical vein, portal vein systems, ductusvenosus, hepatic veins, etc.). Furthermore, these data can be renderedin 3D perspectives, which is more comprehensive for understandingthe complicated vasculature of fetus. It can correlates the embryonicfindings in vivo, therefore can confirm the normalcy and alsocontribute in the diagnosis of pathological state.Conclusion: Our results indicate 3D power Doppler is a promisingtool in evaluation of complicated fetal and placental anatomy, andmight help to make decision in clinical dilemmas.

WS14-07Volume sonography of the female pelvic floor after childbirth

J. WisserDepartment of Obstetrics, University Hospital Zurich, Switzerland

Objective: To evaluate the sonomorphologic changes of the femalepelvic floor after childbirth. Furthermore the timing of the appearanceof these defects labor are examined.Methods: We examined three groups of patients. 104 primiparae aftervaginal delivery, 26 primiparae after elective cesarean section and 77primiparae after secondary cesarean section within 3±7 days afterdelivery. To assess the morphology of the pelvic floor we used toexamine the anal morphology, whereas the transrectal route was usedto assess the paraurethral fixation of the lateral vaginal edges.Paravaginal defect was defined as descent of the lateral vaginal edgesbelow the suburethral portion of the vagina and defects of the internalanal sphincter is defined by anterior vs. posterior thickness-ratiobelow 0.5. Clinical symptoms were documented using a standardizedquestionnaire.Results: Primiparae after elective cesarean section served as controlgroup. After vaginal delivery 7.3% of women showed urinary and17.7% anal incontinence. Mode of delivery is significantly associatedwith anal and urinary incontinence. Paraurethral defect is predictivefor urinary incontinence. Morphological defects of the pelvic floorcould be documented after dilatation of the cervix to more than 7 cm.Conclusions: Volume sonography after childbirth allows to documenttrauma to the pelvic floor due to vaginal delivery. Defects of theanterior compartment are predictive for the development of urinaryincontinence. To study the timing of the appearance of pelvic floordefects during the course of vaginal delivery may be helpful forobstetrical decision making.

WS14-08Three dimensions in neonatal period

M. StanojevicDepartment of Obstetrics and Gynecology, Medical School Universityof Zagreb, Sveti Duh Hospital, Zagreb, Croatia

Background: The aim of this study was to compare the application of2D neurosonography (USG) and 3D USG in newborns with respect tothe time required to obtain the data for analysis.Method: All newborns in whom neurosonography was indicatedunderwent 2D USG and 3D USG by the same investigator. TheVoluson 530 D Color System was used with vaginal 5±8 MHz 3Dprobe for 3D imaging. 2D real-time imaging was performed withAloka SSD 121 device using 5 MHz sector probe. The time needed toperform the examination was determined. Non-parametric Kruskal±Wallis rank sum test was used in statistical analysis.Results: A total of 30 newborn infants of different gestational ages(ranging from 25 to 40 weeks) underwent USG after delivery at



different postnatal ages (ranging from 2 to 60 days). The median timerequired to perform the 2D USG was 14 min (10±21). The mediantime required to perform the investigation by 3D USG was 5 min(ranging from 3 to 10). The difference was statistically significant(H � 24.88; P � 0.0031). The median time of data interpretation for2D USG was 25 min (15±35), and for 3D USG it was 45 min (30±63).The difference was not statistically significant (H � 13.22;P � 0.1531).

Conclusion: The time necessary to obtain 3D USG compared to 2DUSG images was shorter, which made it less stressful for the newborns.3D USG provides more reliable information than 2D USG performedin the same patient at the same age. The time needed to interpret thedata is longer for 3D USG but it can be performed after the imagingwas terminated.

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WS15-01High pathological Doppler flow findings (absent or reverseenddiastolic flow) and fetal outcome

W. Schmidt and A. K. ErtanDepartment of Ob & Gyn, University of Saarland, Homburg/Saar,Germany

Background: Reversed enddiastolic Doppler flow velocity waveformson umbilical velocimetry is regarded to be associated with catastro-phical perinatal outcome with a high perinatal mortality ranging from35% to 100%. This study focused on the differences of fetal morbidityand mortality between the cases with reverse flow and other Dopplerflow velocity waveforms.Method: During a 10-year period we found 30 cases with reverse flowin the umbilical artery or fetal aorta (gr. I), we selected 30 cases withabsent end diastolic velocities (gr. II), 30 cases with high A/B-ratio (gr.III) and 30 cases with normal A/B-ratio (gr. IV). All cases in this studywere patients with similar para, gravida, maternal age and gestationalages by delivery (# 36 weeks).Results: The fetuses with reverse flow showed the highest perinatalmortality of 27% (7% in the gr. II, 10% in the gr. III and 0% in the gr.IV). In the gr. I the neonatal morbidity of 78% was also the highest(59% in the gr. II, 36% in the gr. III and 30% in the gr. IV). 80% ofintrauterine fetal death (IUFD) were within this group, while no IUFDhas been found in the gr. IV. Furthermore, the incidence of cerebralhaemorrhage by the neonates in the gr. I (28%) was also much higherthan those in the gr. III (4%) and IV (0%).Conclusions: Our study suggests that reverse flow represents severefetal condition with the highest perinatal mortalities. The fetaloutcome in cases with reverse flow is further worse than those withabsent end diastolic flow velocity waveforms. A highest morbidity wasalso observed by those fetuses, especially high incidences of cerebralhaemorrhage. Colour Doppler-sonography is a very useful tool toidentify high risk pregnancy leading worse perinatal outcome andallows to select worst perinatal prognosis if reverse end diastolic flowis detected.

WS15-02Fetal biophysical profile and kinetic measurement: Dopplercontribution

J. M. TroyanoUltrasound Division, University Hospital of Canary Islands, Tenerife,Spain

Background: Two methods are presented for the assessment of fetalbehaviours under the application of Doppler effects: (a) Measurementof the velocity wave of fetal limb by vibroacustic stimulating. (b)Hydrodynamic evaluation of the transnasal amniotic velocity waveand its relation to gastric peristalsis.Method: A Doppler device was employed to assess the velocimetrywave from the `FEMORAL BONE' in motion, following vibro-acoustic stimulation in 138 phisiological pregnancy and Doppler-aided evaluation of transnasal amniotic hydrodynamics.Results and conclusion: Assessment of normal fetal behaviour.Quantification of patterns of reactivity of any body structure.Reduction in the duration of explorations for biophysical profiles.

(3±4 min). Fetal reflex responses slow down and become increasinglycomplex as maturation carries on. Both mean velocity and accelera-tion of fetal reactive responses experience a gradual decline through-out gestation. The time a fetus takes to respond to a stimulus increasesdirectly with gestational age. Simultaneousness between fetal respira-tion episodes and phases of gastric distention and activity. (physio-logical conditions). Fetal active respiration can be unequivocallyaccounted for by Doppler assessment of the activity of intake/releaseof amniotic fluid along the high respiratory branches of the pulmonarytree. Amniotic respiratory dynamics are always transnasal inphysiological conditions. Velocities of transnasal, decreasing steadilyfrom the 32nd gestational age to the end of gestation.

WS15-03Fetal centralization

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

We have been studying fetal centralization in the toxemic/IUGR modelsince 1992, by means of Doppler of the umbilical and middle cerebralarteries and ductus venosus, computerized CTG and cordocentesis.

The natural history of fetal centralization may be divided into 3phases: normoxemic centralization, hypoxemic centralization anddecompensation. The natural history of fetal hypoxemia in thesemodels and the patterns of computerized CTG were also described.

Having analysed 105 cases of very high-risk pregnancies in thetoxemic/IUGR model with fetal centralization, we tried to define thebest parameter to indicate the ideal timing for delivery, and thepresence of centralization after 28 weeks gestation appears to seems toindicate it.

WS15-04The value of evaluation of adrenal circulation in predictinghypoxia of the fetus

G. H. Breborowicz and M. DubielDepartment of Perinatology and Gynecology, University School ofMedical Sciences, Poznan, Poland

From animal studies it is known that fetus during hypoxiaredistributes it's blood flow preferentially to the brain, heart andadrenal glands. In animal studies, a three-fold increase in adrenalblood flow has been demonstrated during hypoxia. The adrenals arerelatively large organs in the fetus. Compared to fetal body weight,they are 20 times bigger than in the adult. The fetal adrenals respondto stress, such as hypoxemia by increased production of dihydroan-drostendion (DHA), DHA sulfate and their metabolites. The adrenalgland is supplied by three arteries: the superior, coming from theinferior phrenic artery; the middle, from the abdominal aorta andinferior, arising from the renal artery. In the recent studies the Dopplersignals were obtained from fetal middle adrenal artery. The normaladrenal PI shows decreasing values with the gestational age, whichmight suggest lower vascular resistance and high blood flow to theadrenals. From our observations the adrenal Doppler velocimetry iseasier to record in fetuses from high-risk pregnancies than in normals,



probably due to the adrenal sparing effect. Recent results suggest thatthe adrenal artery velocimetry might be useful in fetal assessment andpredicting outcome. The àdrenal-sparing' effect might be maintainedat the same time the brain-sparing signs disappear.

WS15-05Fetal venous Doppler: is it helpful in timing of delivery ofhypoxic fetus?

V. Latin and T. HafnerDepartment of obstetrics and Gynecology, `Sveti Duh' Hospital,University of Zagreb, Zagreb, Croatia

Background: The aim of this study was to investigate the potential offetal venous Doppler in detection of fetal hypoxia and timing of thedelivery.Methods: The study group consisted of patients with increased risk fordeveloping fetal hypoxia. These were patients with diagnosed fetalintrauterine growth retardation (IUGR) and patients with pregnancyinduced hypertension (PIH), or a combination of both problems. Allpatients had Doppler assessment of fetal arterial (umbilical artery,aorta, middle cerebral artery) and venous circulation (ductus venosusand umbilical vein), and cardiotocography 24 h before delivery.Collection of postnatal data included pH of umbilical chord blood,admission in neonatal intensive care unit, and perinatal death.Results: A total of 360 patients were included in the study (IUGR48%, PIH 20%, IUGR 1 PIH 32%). Deterioration in fetal venousreturn developed after fetal arterial circulation had been severelycompromised. The decrease in end-diastolic flow in ductus venosusanticipated development of umbilical vein pulsatile flow. Patients withpulsations in umbilical vein blood flow had high incidence of perinatalacidosis, morbidity, and mortality.Conclusion: Delivery should be performed before umbilical veinpulsations develop. Careful monitoring of ductus venosus blood flowis helpful predictor of this event.

WS15-06Doppler ultrasonography of the human fetal pulmonarycirculation and its role in the prediction of pulmonaryhypoplasia

J. A. M. Laudy, D. Tibboel, S. G. F. Robben, R. R. De Krijger, M. A. J.De Ridder and J. W. WladimiroffDepartment of Ob. & Gyn, University Hospital Rotterdam-Sophia/Dijkzigt, The Netherlands

Objectives: To determine the value of Doppler flow velocity wave-forms from the fetal arterial pulmonary branches relative to fetalbiometric indices and clinical correlates in the prenatal prediction oflethal lung hypoplasia (LH) in prolonged oligohydramnios.Study design: 42 singleton pregnancies with oligohydramnios asso-ciated with premature rupture of membranes (PROM, n � 31) orbilateral renal pathology (n � 11) were examined using a combinedcolor coded Doppler and 2d real-time ultrasound system. Thoracic(TC), cardiac (CC) and abdominal circumference (AC) and the largestvertical amniotic fluid pocket were measured. Pulsed Dopplermeasurements of the arterial pulmonary branches were made at thelevel of the cardiac four-chamber view after visualization with colorDoppler. Diagnosis of LH was based on pathological, clinical andradiological criteria.

Results: The prevalence of lethal LH was 43%. In the PROM-subset,combination of onset of PROM � 20 weeks; duration of oligohy-dramnios � 8 weeks and degree of oligohydramnios � 1 cm,presented the highest clinical prediction rate for lethal LH. For boththe total group and the PROM-subset, the highest prediction rate forlethal LH from biometric and Doppler parameters was presented byTC/AC ratio, peak systolic velocity in the proximal branch and time-averaged and end-diastolic velocity in the middle branch of thepulmonary artery. In the prom subset, combination of all threeclinical, biometric and Doppler parameters revealed the mostfavorable combination to predict lethal LH (PPV 100%, accuracy93%, and sensitivity 71%).Conclusion: Doppler velocimetry may detect changes in blood velocitywaveforms from the arterial branches of the fetal pulmonarycirculation in the presence of LH, but fails to be the ultimate testfor the prenatal prediction of lethal LH. The best prediction can beachieved by combining clinical, biometric and Doppler parameters.

WS15-07Assessment of a formula using Doppler velocimetry tocalculate fetal hemoglobin (Hb)

L. S. Voto, O. B. Mulki, J. L. Zapaterio, A. Falco, E. R. Mathet,R. L. Lede and M. MarguliesMaternal Fetal Department, j.A. FernaÂndez Hospital, University ofBuenos Aires, Argentina

Aim: To assess agreement between fetal cord blood Hb concentrationby Doppler velocimetry and a formula (Oepkes et al, Br J ObstetGynaecol 1994; 101:680±4), and the actual Hb concentration by cordblood sampling.Material and methods: A prospective cohort of 31 Rh isoimmunisedfetuses undergoing Doppler cord blood velocity measurements withinthe 24 hs previous to cordocentesis or delivery was included. Meanaortic velocity at descent fetal aorta and maximum umbilical vein flowat intrahepatic portion were measured blindly by a single operatorwith pulsed Doppler and a 3.5 Mhz transducer. Cord Hb was the goldstandard. Abnormality and normality were defined as a Hb levellower and higher, respectively, than the cut-off point (,7, ,8, ,9,,10, ,11 and ,12 g/dL were tested). Likelihood ratio was alsocalculated.Results: Interval between Doppler study and cordocentesis/deliverywas 24±48 hs. Fetal blood sampling was performed by cordocentesisin 4 cases, following a C-section in 24, and following vaginal deliveryin 3.Conclusion: An acceptable agreement was found. Further population-based studies are required to corroborate its clinical significance.

Table 2 (abstract WS15-07) Agreement at different cut-off points in the diagnosis of abnormality and normality [point estimate (CI)]

Cut-off ,7 ,8 ,9 ,10 ,11 ,12

Abn. 50(5±100) 83(36±99) 43(21±69) 58(37±77) 79(60±91) 84(66±94)Norm. 97(81±100) 96(78±100) 62(41±80) 41(17±67) 25(4±64) 0(0±54)LR 30(2.3±129.8) 26(4.2±132.4) 2.7(1.2±5.9) 1.6(1±3) 1.3(1±2.4) 1(0.9±2)

Table 1 Distribution of cases according to results obtained (n cases)

Cut-off point ,7g ,8g ,9g ,10g ,11g ,12g

True1 1 5 7 14 23 26False1 1 1 7 7 6 5True± 29 25 15 7 2 0False± 0 0 2 3 0 0



WS15-08Physiologic change of spiral arteries ± what ultrasound canadd?

R. MatijevicDepartment of obstetrics and Gynecology, University of SchoolMedicine and Sveti Duh Hospital, Zagreb, Croatia

Physiologic change of spiral arteries is important adaptation ofmaternal vascular network for ongoing pregnancy. It is characterisedby destruction of muscular layer of these vessels changing them to alow resistance vascular channels. Physiologic change was found to beincomplete in pregnancies complicated by pregnancy induced hyper-tension (PIH) and intrauterine growth retardation (IUGR). Thesechanges were detected in vitro in histrologic studies but recently wereinvestigated in vivo using Doppler ultrasound. In normal pregnancythe impedance to blood flow in spiral arteries measured by resistance(RI) and pulsatility (PI) indices significantly decrease toward the midtrimester (P , 0.05) and then remains stable. Similar observation wasfound in pregnancies complicated by PIH and IUGR. Both of theserepresent the second wave of trophoblastic invasion of spiral arteries.In pregnancies complicated by PIH and IUGR measured impedanceindices were significantly higher compared to the matched normoten-sive women with normal fetal growth (P , 0.05), representing htfailure of the complete physiologic change of the spiral arteries. This isin concordance with histologic studies. Comparing the significancelevels of blood flow in proximal and distal parts of uteroplacentalcirculation between investigated groups, the higher significance levelswere obtained in terminal parts. This can have serious implication indesigning further research protocols of the screening programmes forthe PIH and IUGR based on the blood flow in uteroplacentalcirculation.

WS15-09Three-dimensional ultrasound examination of fetal andplacental vessels

J. WisserDepartment of Obstetrics, University Hospital Zurich, Switzerland

Objective: Since August 1998 we used the integrated 3-D softwarewith the Siemens Elegra in order to evaluate fetoplacental vesselsin the 3-D mode. Aim of the evaluation was to examine thefeasibility of the application and to demonstrated potential clinicaladvantages.Methods: In our antenatal clinic we recruited pregnant womenbetween 12 and 38 weeks of gestation to take part in a feasibilitystudy in order to evaluate the free-hand 3-D application using the5.0 MHz transducer for routine antenatal scanning. We examinedvasculatore within the placenta, intrathoracoabdominal and intracra-nial fetal vessels with the integrated powermode. Acquisition time fora volume date set is between 3 and 20 s depending on the resolutionselected.Results: Three-dimensional examination of the fetoplacental vessels iseasily available using the Siemens Elegra, because no change intransducer is necessary. Our preliminary data show that we are able todemonstrate the complexity of intraplacental vasculature, which maybe clinically helpful in the evaluation of twin placentas. Within thefetus the spatial arrangement of the vessels and their relation to eachother can be depicted. This allows to study the fetal vascular tree andclearly discloses vascular anomalies.Conclusions: Application of the integrated 3-D software within theSiemens Elegra for the first time allows the examination of thecomplex fetoplacental vascular tree in vivo. This may be clinicallyhelpful in the differential diagnosis of fetal anomalies.

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WS16-01The value of first trimester sonography for the diagnosis ofstructural and chromosomal abnormalities

D. L. EconomidesFetal Medicine Unit, Department of Obstetrics and Gynaecology,Royal Free Hospital, Pond Street, London NW3 2QG, UK

Objectives: To assess the value of first trimester scanning for thediagnosis of structural and chromosomal abnormalities.Population/methods: An unselected group of 7447 pregnant womenwho had a first trimester scan in our unit. In all the cases ananatomical survey was performed and the nuchal translucency wasmeasured. Four thousand and 84 women also had second trimesterbiochemical screening. We assessed the performance of first trimesterscanning in the detection of structural and chromosomal abnormal-ities.Results: The incidence of anomalous fetuses was 1.4%, including 43chromosomal abnormalities. The detection rate for structuralabnormalities was 59% (37/63). Seventy-eight percent of chromoso-mal abnormalities were diagnosed at 11±14 weeks either because of anuchal translucency measurement above the 99th centile or due to thepresence of structural abnormalities. Second trimester biochemicalscreening detected half of the fetuses with trisomy 21 which weremissed by first trimester screening, increasing the sensitivity to 90.5%(19/21; 95%C.I. 69.6% to 98.8%). However, the positive predictivevalue of the biochemical test was very low (0.5%).Conclusion: First trimester NT measurement is an effective screeningtest for the prenatal detection of fetuses with structural andchromosomal abnormalities. Although the measurement of bio-chemical markers in the second trimester can detect additionalaffected fetuses this may be out-weighted by the delay in diagnosis,the extra visits and cost so that the right time for biochemicalscreening still needs to be determined. Second trimester anomaly

scanning should continue to be an essential part of a prenatalscreening programme.

WS16-02Sonoembryology using intrauterine sonography

T. HataDepartment of Perinatology, Kagawa Medical University, Kagawa,Japan

Our first purpose was to describe embryonic anatomic structures byuse of IUS with a 20-MHz flexible catheter-based, high resolutions,real-time miniature transducer. The number and the clarity ofstructures increased from 7 to 8 weeks of gestation; however, theimage quality was degenerated because of the increasing fetal size at9 weeks. At 8 weeks secondary brain vesicles, spine, midgut hernia-tion, liver, upper and lower limb buds, and sacral tail were visualizedin all fetuses. The four-chamber view was first identified at 8 weeks, aswere fingers or toes. The stomach was first noted at 9 weeks.

Second purpose was to compare the ultrasound visualization of theearly first-trimester embryo using TVS and IUS as 6±8 weeks ofgestation. The ability to view most organs was better with IUScompared to TVS, and this was especially true for the brain, spine,heart, liver, midgut herniation, extremities, and sacral tail. Moreover,it was possible to obtain finer image quality of very small embryonicstructures with IUS than with TVS.

Third purpose was to evaluate embryonic organ growth (liver,heart, and brain vesicles) using IUS in the early first trimester ofpregnancy. The significant good correlation between each parameterand gestational age was obtained.

Fourth purpose was to visualize normal embryonal surfaceanatomic structures using 3D-IUS at 7±9.9 weeks gestational age.At week 8, prominent forehead was evident, and upper and lowerlimbs and midgut herniation were clearly depicted. At week 9, fingers



and toes were depicted as small digital rays, and the sacral tailprotruded caudally. At week 10, embryonic face and fingers wereclearly shown.

WS16-03Three-dimensional-ultrasound in the assessment of embryonicanatomy

H.-G. K. BlaasNational Center for Fetal Medicine, Norwegian University of Scienceand Technology, Trondheim, Norway

Diagnostic ultrasound in the early pregnancy deals with therecognition of normal anatomy and/or the detection of anomalies invery early viable pregnancies. There are clinical situations where theposition of the embryo does not allow imaging of the optimal sectionof a certain organ. This is often the case with the transvaginalapproach, where movements of the transducer are limited.

Deriving new 2D images by anyplane slicing is an importantpresentation mode of embryonic 3D ultrasound. Geometric 3Dreconstructions can also be helpful for the understanding of theembryonic anatomy. High quality 2D tomograms are the prerequisiteof 3D imaging of the tiny embryo and its organs. Such ultrasoundtomograms can be achieved by using annular array transducers, whichhave a thin elevation plane due to symmetric focussing.

Examples of multiplane imaging and geometric volume reconstruc-tions in the assessment of the embryonic anatomy will be presented,and the limitations will be discussed.

WS16-04Doppler ultrasound: potential in early pregnancy

I. ZaludDivision of Maternal Fetal Medicine, Kapiolani Medical Center forWomen & Children, University of Hawaii John Burns School ofMedicine, Honolulu, HI, USA

Remarkable changes and continuous growth and development of theearly maternal-fetal circulation could be studied by Doppler ultra-sound. This approach seems to give more light in understanding of theearly pregnancy development. Doppler ultrasound was reportedaccurate to separate different segments of uterine blood flow duringpregnancy. Color flow is used to anatomically locate arcuate, radialand spiral arteries. Pulsed Doppler is then used to study different flowpatterns of visualized vessels. Studies of maternal-fetal circulation inearly pregnancy may help for better understanding of physiologicaland pathophysiological hemodynamic changes in the circulation.Investigation of maternal (main uterine, arcuate, radial and spiral)arteries; placental (umbilical, chorionic arterioles) vessels andembryonic/fetal (heart, aorta and intracranial circulation) arteriesflow patterns may help to diagnose abnormal implantation andembryonic development. More studies are necessary in order theDoppler technique to be used for clinical assessment in earlypregnancy. Safety aspects should also be considered. However,potentials of this technique are promising in study of early pregnancyfailure, chromosomal abnormalities, development of pre-eclampsiaand IUGR.

WS16-05Doppler assessment of early pregnancy

M. Ruiz-FloresMedical School, University of Chile

Doppler velocimetry give possibility of making noninvasive evaluationof the vascular modifications from the beginning of pregnancy.

We have studied following vessels:Retrocorial arteries: The flow increases since sixth to twelfth weeks,progressively which is explained by the increment of the conductancyand the reduction of resistance. Trophoblastic invasion of spiralsarteries in the coral bed, and hormones produced during the gestationaffect both values.

Uterine arteries: The resistance of the uterine arteries diminish sincesixth to twelfth weeks, in normal pregnancy. The low incrementdepends on the modifications in the coral bed and of hormonalvasodilator effect.OVF Luteum gravidicus: When ovary flow is greater in first stage ofpregnancy suggest a favorable early gestation, and vice versa, a regressin those measures had a negative character. We could evaluate the roleof Doppler examinations in the following situations:

X Abortion in any stage and variationsX Blighted ovumX Ectopic pregnancyIn all these conditions, Doppler showed to be a trusty, predictive,

prognostical and diagnostical instrument of great utility. Clinicalapplication of Doppler Uterus Corial could be used in a preventiveway when the increment of the resistance in the uterine arteriesappears before clinical abortion symptoms.

We also applied Doppler exploration in AVF patients confirmingthat the deficit in uterine perfusion is significantly related with thefailures in embryonary implantation. Recently, we are performingendovaginal color Doppler in the diagnoses of early ectopic gestationand trophoblastic disease with very satisfactory results.

WS16-06Three-dimensional ultrasound assessment of the first trimesterfetus ± a òne step' approach

A. D. Hull, G. James, T. R. Nelson and D. H. PretoriusUniversity of California San Diego, La Jolla, California, USA

Background: The optimal time at which to perform obstetricultrasound remains controversial. Late first trimester imaging offersthe possibility for early diagnosis of structural and genetic abnorm-alities. Three-dimensional ultrasound (3DUS) allows the entire firsttrimester conceptus to be contained within one or two volumes ofdata. Subsequent processing of this data allows optimized views of thefetus, placenta and cord to be obtained.Method: Late first trimester (,12 week) pregnancies were imaged withtransvaginal 3DUS. A fetal structural survey was performed, standardbiometry obtained and nuchal translucency thickness (NTT) measured.The time taken to perform and assess the scans was recorded.Results: A comprehensive fetal survey was obtained, fetal measure-ments made and NTT measured in most fetuses with average scantimes of less than one minute and average volume assessment times ofless than 10 min in all cases. There were no abnormal findings in thisseries.Conclusion: 3DUS appears to be a useful tool in the ultrasoundevaluation of the 12 week fetus. A detailed examination of the fetusmay be performed with minimal scan time offering excitingpossibilities for the use of transvaginal 3DUS as a òne step' screeningexamination.

WS16-07Stem cell therapy in the first trimester: the role of ultrasoundvs. embryoscopy

D. V. SurbekDepartment of Obstetrics and Gynecology, University of Basel, Basel,Switzerland

Intrauterine allogeneic hematopoietic stem cell transplantation hasbeen successfully used for the prenatal treatment of severe combinedimmunodefiency syndrome. However, this treatment has not beensuccessful in other conditions in which the fetus is immunologicallycompetent. The main obstacles to success are lack of competitiveadvantage of donor vs. host stem cells preventing stable engraftmentand graft rejection by the host immune system. Strategies to overcomethese hurdles include, among others, early transplantation before12 weeks of gestation, and increase of cells dose in the target organs(fetal liver and fetal bone marrow) which might be best achieved bythe intravascular administration route. However, whilst ultrasound-guided intraperitoneal administration of the graft in the first trimesteris feasible, access to the fetal circulation in the first trimester is more



difficult. Combined ultrasound-guided/embryofetoscopic approach isa promising technique to achieve this goal. Thin-gauge embryofeto-scopes allow the exact visualization of the optimal funipuncture site

and the intravenous insertion of a 25G needle through a side-port.They thus provide an additional tool to deliver the stem cell graft tothe preimmune fetus.

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WS17-01Hormone replacement therapy reduces impedance to flow indifferent vascular beds

W. M. Van Baal, P. Kenemans, C. D. A. Stehouwer, J. M. G. Van Vugtand M. J. Van Der MoorenProject Àgeing Women', Institute for Cardiovascular Research-VrijeUniversiteit (ICaR-VU), Departments of Obstetrics & Gynecologyand Internal Medicine, University Hospital Vrije Universiteit,Amsterdam, The Netherlands

An HRT-associated reduction of the pulsatility index (PI) has beenreported in the literature, although cross-sectional studies have shownconflicting data. In a prospective, controlled study we randomized 30healthy postmenopausal women (mean age 52 ^ 3 years) into twogroups. Women in the HRT group (N � 15) received 1 mg micronized17b-estradiol daily (E2) sequentially combined with 5 or 10 mgdydrogesterone for 14 days of each 28-day cycle during 12 months,and, thereafter, 2 mg E2 combined with 10 mg dydrogesterone for aperiod of 3 months. The control group (N � 15) received notreatment. Color Doppler ultrasound was used to measure theimpedance to flow (pulsatility index [PI]) within the uterine, centralretinal and ophthalmic arteries in the E2-phase at baseline and after 3,12 and 15 months. Compared to controls, 12 months of HRT wasassociated with a significant decrease in the mean PI of the uterineartery of 239% (HRT 225%, controls 114%) and in that of thecentral retinal artery of 229% (HRT 29%, controls 120%). After3 months this effect was already evident. During HRT, the reductionsin mean PI of the uterine and central retinal arteries vs. baseline werelarger (both P � 0.002) in the women with high pretreatment PIvalues when compared to those with low pretreatment values. Thebaseline PI of the uterine artery correlated positively with age and withduration of amenorrhoea (r � 0.42, P � 0.01 and r � 0.48,P � 0.008, respectively). Our 12-month study expanded on earlierreports of a reduced PI of the uterine artery. We used a combinedregimen containing a low-dose of oestrogens. These results areimportant because the recent trend is to recommend combined HRTthat contain lower dosages of oestrogens than before. Furthermore, a29% reduction of the PI of the central retinal artery was observed,which suggests that HRT has a positive influence on the impedance ofthe cerebral circulation. From the point of view of atherothromboticrisk these observations are beneficial and possibly helpful in under-standing the decreased risk of cardiovascular disease, and of theimpairment of cognitive functions associated with oestrogens inepidemiological data.

WS17-02Utero-ovarian arterial blood flow and hormonal profile inpatients with polycystic ovaries

E. VrtacÏnik-BokalDepartment of Ob/Gyn, University Medical Centre Ljubljana,Slovenia

Background: To review the literature of utero-ovarian arterial bloodflow and serum hormonal profile in the patients with polycysticovaries (PCO) compared to the patients with normal menstrual cyclesundergoing in-vitro fertilization treatment.Method: Pertinent studies were identified through a computerMEDLINE search. References of selected articles were hand-searchedfor additional citations.Results: The vascular impedance to uterine artery blood flow is higherduring the luteal phase of PCO patients compared to the normally

cycling patients and it does not show any dynamics throughout themenstrual cycle. In the normally cycling patients the active ovaryshows dramatic hemodynamic changes during the cycle, therefore thevascular impedance to ovarian artery blood flow is almost constantthroughout the menstrual cycle in the inactive ovary. In PCO patientsthe ovarian arterial blood flow in both ovaries is about the same as ininactive ovaries in the normally cycling patients. High vascularimpedance to utero-ovarian arterial blood flow is associated withtypical low vascular impedance of stromal ovary vascularization inPCO patients. In stimulated cycles a strong negative correlationbetween the vascular impedance to the uterine artery blood flow andthe serum E2 concentration is found on the day of HCG administra-tion. Taking only anovulatory PCO cycles into consideration, theabove correlation is not confirmed.Conclusion: Doppler analysis can be a valuable method for theassessment of utero-ovarian arterial blood flow in spontaneous and instimulated cycles.

WS17-03Relationship between ultrasound-determined follicular sizeand DNA ploidy of human granulosa cells

K. Gersak, J. Lavrencak, M. Us-Krasovec and T. TomazevicDepartment of Obstetrics and Gynaecology, University MedicalCentre Ljubljana and Department of Cytopathology, Institute ofOncology Ljubljana, Slovenia

Background: The possibility that the hyperstimulatory effect ofgonadotropins may be important etiologically in the genesis of somecases of ovarian cancer is still under discussion. Few flow and imagecytometric studies report on DNA aneuploid granulosa cells infollicular fluid from women undergoing in vitro fertilization (IVF).The reports are very controversial. The aim of the study was toanalyse relationship between ultrasound-determined follicular sizeand DNA ploidy of granulosa cells from gonadotropin-stimulatedfollicles.Method: The granulosa-luteal cells were obtained from womenundergoing an IVF-ET program at the University Department ofobstetrics and Gynecology Ljubljana. Seventy aspirates of individualfollicles (transvaginal determined size, range 15 mm ± 30 mm indiameter) from gonadotropin-stimulated cycles were analysed. Cytos-pins were prepared and fixed in delaunay fixative. All the slides werestained by the feulgen thionin method. Image DNA analyses wasperformed on automated high-resolution image cytometer. The DNAindex was calculated to define DNA ploidy.Results: All granulosa cell samples were found to be diploid.Conclusion: Regardless of different ultrasound-determined size offollicles, all analysed granulosa cells have diploid DNA content.Acknowledgements: Supported by grants from ministry of Researchand technology republic of Slovenia (No. j3-0428±032±98).

WS17-04Operative histeroscopy in treating intrauterine abnormalitiesas a factor in marital infertility

S. IzetbegovcÂDepartment of Obstetrics and Gynecology, University MedicalCenter, Sarajevo

We have researched operative histeroscopy in treating endometrialabnormalities as a cause of marital infertility. A group of 320 infertilepatients was included in the study. Color Doppler examination



detected endometrial abnormalities (subseptus, polyp, synechiae,myoma, uterus bicornuate, and uterus arcuate). The controllinggroup consisted of 100 patients suffering endometrial abnormalities,who have not underwent the operation. In research group, there were9 pregnancies following operative histeroscopy over a period of18 months. That is 34.6%, out of which 89 (27.8%) have been carriedout and delivered. We have also studied the surgical risk of operativehisteroscopy. According to the results, operative histeroscopy isminimally invasive, surgically comfortable, economically acceptable.The influence of histeroscopy on the endometrium during pregnancyand delivery is such that there is no significant difference incomparison to the patients that were not operated. The pregnancyfollowing operative histeroscopy is phsysiological. The delivery has noimplication of pathological nature, nor difference in duration, type, orany other component. The enonathological parameters do not differfrom physiological

WS17-05Placentation studied by three dimensional power Dopplersonography

T. HafnerDepartment of Ob/Gyn, `Sveti Duh' Hospital, University of Zagreb,Zagreb, Croatia

Objective: The aim of this study is to investigate processes ofplacentation by the use of three-dimensional sonography.Methods: A group of 25 pregnant women in gestational age rangingsix to 10 weeks underwent a detailed assessment. The ultrasounddevice was Voluson 530D MT, by Kretztechnik, Zipf, Austria.Measurements in three-dimensional B-mode were gestational sacvolume, chorion volume, and embryonic volume. Volumes weremeasured by the use of an integrated software. Structures wereoutlined manually in multiple parallel sections. The machineintegrated and calculated the volume. The hemodynamical changescorrelated to the process of placentation were assessed by the use ofthree-dimensional power Doppler (angio mode). Three-dimensionalimaging of vascular changes was expressed and quantified by the useof volume flow index (VFI). The analysis of the results includedcorrelation of morphological and hemodynamical parametersobtained by measurements.Results: The volume of gestational sac, chorion and embryo increasesduring the weeks of gestation under investigation. The amount ofvascular spaces in the chorion and surrounding myometrium increasewith gestational age and correlates with the gestational sac andchorion volume.Conclusion: 3D power Doppler sonography is a valuable tool forassessment and quantification of hemodynamic changes involved inplacentation.

WS17-06Three-dimensional power Doppler ultrasound as a second linescreening tool in ovarian cancer screening ± preliminaryresults

T. Zodan, M. Gregov, V. Sparac, A. Kurjak, S. Kupesic and M. IlijasSveti Duh General Hospital, Zagreb, Croatia

Introduction: In this screening program, 2D color Doppler (2D CD)was used as the first, and CA-125 and 3D power Doppler (3D PD)were used as second-line screening tools when 2D scoring systemindicated possible malignancy. The study was designed to showwhether early stages of ovarian cancer can be correctly diagnosed by3D PD and whether 3D would perform better than CA-125.Methods: All patients were either postmenopausal, or premenopausalwith positive family history, or they had a persistent ovarian cyst.They were all examined by 2D CD and if values of scoring systemwere over cut-off point, 3D PD analysis was performed and CA-125was tested.Results: A total of 108 patients (97 postmenopausal and 11premenopausal with family history) had a 2D scan. In 5 cases 2Dscoring indicated possible malignancy after which 3D analysis was

done as well as test for CA-125. In 2 cases 3D PD scoring wasnegative, as well as CA-125 and the lesions were simple cystsurrounded by chronic inflammatory process in the first patient andovarian fibroma in the second. In 3 cases 3D PD scoring was positivewhile CA-125 measurement showed increased values only in 1 case.PHD analysis confirmed the diagnosis of ovarian carcinoma in allthree lesions. 3D PD correctly predicted benign or malignant nature ofthe lesion, while CA-125 failed to do so in two stage 1 ovariancancers.Conclusion: Although now expensive and in most hospitals unavail-able, 3D power Doppler is a future screening tool in ovarian cancerscreening programs. However, a lot more women should be screenedbefore proper statistical analysis could be done.

WS17-07Fetal and neonatal echocardiographic features in twin-to-twintransfusion syndrome

T. Murakoshi, Seguchi*, H. Naruse, Y. Torii and K. MaedaObstetrics and Pediatric Cardiology*, Maternal and Perinatal CareCenter, Seirei Hamamatsu Hospital, Hamamatsu, Japan

Background: Twin-to-Twin transfusion syndrome (TTTS) is a severecomplication in monochorionic twin pregnancies. Particularly severefetal and neonatal cardiac dysfunction is complicated in recipient twinand attended with high perinatal morbidity and mortality. The aim ofthis study was to evaluate the abnormal echocardiographic featuresand clinical complications of cardiac disease in TTTS.Method: We studied 20 pregnancies complicated with TTTS. Serialfetal and neonatal echocardiography were carried out and evaluatedthe following parameters: cardiothoracic area ratio, aortic andpulmonary artery Doppler peak velocities, umbilical arterial resistanceindex, preload index of inferior vena cava, ventricular valveregurgitation and structural heart abnormalities.Result: In recipients, all features had cardiomegaly, tricuspid valveregurgitation and high preload condition with increased preload indexof inferior vena cava. Aortic and pulmonary artery peak velocitieswere increased in the recipients than those in the donors. Three casesof recipients had pulmonary valve stenosis and received balloonpulmonary valvuloplasty. Furthermore, three cases of donors hadcoarctation of aorta and also received surgical repair.Conclusion: In addition to the severity of cardiac dysfunction,pulmonary stenosis and coarctation of aorta would be the importantfactors to evaluate perinatal prognosis of TTTS.

WS17-08Fetal biochemical markers in severe placental insufficiency ±comparison with fetal Doppler findings

J. RaÈsaÈnen, K. MaÈkikallio, O. Vuolteenaho and P. JouppilaDepartments of Obstetrics and Gynecology, and Physiology,University of Oulu, Oulu, Finland

Background: The aims of this study were to assess the activity of thehuman fetal atrial natriuretic peptide system in hypertensivepregnancies with and without signs of increased fetal systemic venouspressure and to investigate the association between severe placentalinsufficiency and fetal myocardial cell destruction.Method: Control group consisted of 50 newborns with uncomplicatedpregnancy and labor. In group 1, 22 newborns after hypertensivepregnancies were included. Doppler ultrasonography revealed abnor-mal umbilical artery (UA) blood velocity waveform in five cases, andnormal nonpulsatile umbilical vein (UV) blood velocity profile inevery case. Group 2 consisted of five newborns after pregnanciescomplicated by maternal hypertensive disorder. Atrial pulsations inthe UV and retrograde diastolic blood velocity pattern in the UA weredetected in every case. Immediately after birth blood samples werecollected from the UA and plasma N-terminal peptide of proatrialnatriuretic peptide (NT-proANP) and serum cardiac specific troponin-T concentrations were measured.Results: In group 1, nt-proANP concentrations were higher(P , 0.001) than in the control group. In group 1, newborns with



abnormal UA blood velocity pattern had higher (P , 0.006) NT-proANP concentrations than newborns with normal UA Dopplerfindings. Troponin-T concentrations in group 1 did not differ from thecontrol group. In group 2, NT-proANP (P , 0.002) and troponin-T(P , 0.0001) concentrations were higher than in the control groupand study group 1.Conclusion: Maternal hypertensive disorder stimulates fetal atrialnatriuretic peptide production, being greatest in fetuses with severeplacental insufficiency and a rise in systemic venous pressure. Thesefetuses also have evidence of myocardial cell destruction.

WS17-09Doppler flow measurements and neuromotoric morbidity

A. K. Ertan and W. SchmidtDepartment of Ob & Gyn, University of Saarland, Homburg/Saar,Germany

Background: Absent enddiastolic flow (AEDF) velocities are asso-ciated with fetal distress and adverse fetal outcome. The aim of thisstudy was to evaluate perinatal findings of fetuses with an AEDF infetal vessels and to investigate the neurological long-term-outcome.Method: The analytical program `Munich functional developmentaldiagnostics' (MFDD) was applied to the 90 children at different timeintervals. The results of 40 children with an AEDF (Gr. I) and 20children with pathological S/D-Ratio (Gr. II) were compared to thegroup of 30 children with normal Doppler-flow-findings (Gr. III) withthe same pregnancy weeks at birth.Results: The rate of C-section (92% vs. 71% vs. 36%), birthweight(1140g vs. 1725g vs. 2570g), 5 0min. APGAR-Score (31% vs. 5%both) were significantly different in three groups. Brain sparing effectin the middle cerebral arteries was found in 81% in Gr. I, in 21% Gr.II and only 8% in Gr. III. At the time of neurological assessment theage of children was between 12 and 36 months. The developmentalage for each functional category was evaluated and the differencebetween corrected age and developmental age was calculated. In 33%of all infants with a AEDF had a pathological neuromotoricdevelopment vs. 22% in Gr. II and only 15.3% in Gr. III.Conclusions: The children with pathological Doppler-flow-measure-ments during pregnancy have not only very high risk of perinatalabnormality but also show a distinctly increased risk of impairedgrowth and neurodevelopmental disability comparing to the caseswith a normal Doppler-flow-finding. Most of these fetuses showedbrain-sparing effect. These aspects are very important to be discussedwith the parents before the definitive perinatal decision is made.

WS17-10Sonographic evaluation of the umbilical cord throughoutgestation

E. Di Naro, L. Raio, F. Ghezzi, Franchi, D. Bolla, V. D'Addario andH. SchneiderDepartments. Ob/Gyn, University of Bari, Italy; University of Bern,switzerland, University of Insubria, Varese, Italy

Traditionally, the prenatal assessment of the umbilical cord (UC) islimited to the assessment of the number of vessels and to theevaluation of umbilical artery blood flow parameters. Morphologic

aspects of the UC have usually been studied by pathologists andretrospectively correlated with the perinatal outcome. The introduc-tion of more sophisticated imaging techniques have offered thepossibility to investigate the UC characteristics during fetal life fromearly to late gestation. A number of investigations have demonstratedthat an altered structure of the UC can be associated with pathologicconditions (i.e. preeclampsia, fetal growth restriction, diabetes, fetaldemise). Nomograms of the various UC components have beengenerated and allow the identification of lean or large umbilical cords,entities frequently associated with fetal growth abnormalities anddiabetes, respectively. Of note, lean UC in the second and thirdtrimester differs from normal UC not only from a structural point ofview but also in the umbilical vein blood flow characteristics. On theother hand a thin UC in the first trimester seems to be a marker foridentifying a subset of fetuses at risk for spontaneous abortion andpre-eclampsia. A Wharton's jelly reduction has also been invoked as apossible cause of fetal death in the presence of single umbilical artery.Prenatal morphometric and morphologic UC characteristics as well asUC arterial and venous blood flow parameters in normal andpathologic conditions will be presented and discussed.

WS17-11Amniotic fluid erythropoietin concentration and cerebro-umbilical Doppler flow ratio in diabetic pregnancies andpregnancies complicated by hypertension, pre-eclampsiaor/and intrauterine growth restriction

V. Stefanovic, H. Markkanen and K. TeramoDepartment of Obstetrics and Gynecology, Helsinki UniversityCentral Hospital, Haartmaninkatu 2, 00290, Helsinki, Finland

Subacute or chronic fetal hypoxia is associated with an increase infetal erythropoietin (EPO) synthesis irrespective of the etiology ofhypoxia. Amniotic fluid (AF) EPO level is often elevated in diabeticpregnancies (especially in macrosomic fetuses), and in pregnanciescomplicated by hypertension (HT), pre-eclampsia (PE) or/andintrauterine growth restriction (IUGR). It is shown that cerebro-umbilical arterial flow ratio (RIC/RIU) is often abnormal (less than 1)in the case of fetal hypoxia. We studied AF EPO levels in 29 diabeticpregnancies, 18 pregnancies with HT, PE or/and IUGR and 19 healthycontrols. The samples were obtained during the elective amniocentesesin the case of suspected fetal hypoxia or during caesarean sections.Doppler measurements were performed not more than 24 h beforeamniocenesis. AF EPO levels were significantly elevated in diabeticswith abnormal fetal growth (either macrosomia or IUGR) andnondiabetics with HT, PE or/and IUGR as compared with healthycontrols or diabetics with normal fetal growth. AF EPO levels offetuses with normal fetal growth in diabetic mothers were notdifferent from those of healthy controls. There was no correlationbetween AF EPO levels and RIC/RIU in any of the diabetic ornondiabetic group. However, 5 fetuses had either absent end-diastolicor reversed umbilical flow. All had elevated AF EPO levels (range 16±15 800 mU/ml). We conclude that both fetal macrosomia and IUGRin diabetic pregnancies seem to cause chronic fetal hypoxia. Normalfetal growth in diabetic pregnancies is not associated with chronicfetal hypoxia. Single measurement of RIC/RIU is of little value in thediagnosis of chronic fetal hypoxia in abnormal pregnancies.

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WS18-01Ultrasounds of the breast ± the role of the gynecologist

E. V. Cosmi, G. L. Cascialli, P. Nusiner, L. Meggiorini and A. Patella2nd Institute of Gynecology and Obstetrics, University `La Sapienza'± Rome, Italy

Early detection of breast cancer is of paramount importance for its

management. Therefore, new diagnostic tools are continouslysearched, including 3D-US and 3D Power Doppler, and for latermanagement, the study of the sentinel node.

3D ultrasonography (3-D US) may be of value in the differentialdiagnosis of the following conditions.Cysts: Not all cysts display a typical US appearance. Small cysts maylack the distal sound enhancement. Inflammatory cysts may exhibit a



thickened wall. However, the major problem it the not so rarepresence of intracystic echoes, which may be either real or artifactual.Fibroadenomas: A refraction artifact (edge shadowing) is often notedat each lateral margin of smooth-marginated fibroadenomas. Con-tours are irregular in about 25% of cases, and in about 5% shadowingmakes it impossible to rule out malignancy.Carcinomas: Shadowing is associated only with those carcinomas thathave a significant amount of fibrosis (, 50% of cases in ourexperience). Some partial shadowing seen with some carcinomasmay also be caused by beam scattering by jagged margins, with 3Dscan potentially useful for diagnosis. The sentinel node. Axillarylymph node status is the most important pathological determinant ofprognosis in early breast cancer, whereas local axillary lynphadenect-omy is the most reliable staging procedure. However, routine axillarydissection does not benefit the majority of patients with early breastcancer who are node-negative, thereby sustaining the potentialmorbidity of the procedure. Sentinel node is the first regional nodeto receive lymph from the breast and accurately represents themetastatic status of the primary cancer. Sentinel node biopsy appearsto offer an alternative to routine axillary lymph node dissection forstaging patients with breast cancer. (Supported in part my MURSTand CNR, Italy)

WS18-02Modern breast ultrasound

B.-Joackhim HackeloerHamburg, Germany

Development during the past 5 years increased significantly thequality of ultrasound mammography. After trying to receive betterimage quality by using higher and higher frequencies up to 20 Mhz thetodays breakthrough was reached by better scan converter andtransducer technology. Broadband tranducers, harmonic imaging,Siescape, Angio-powerdoppler, SonoCT, 3-D imaging and the use ofcontrast agent improved not only image but diagnostic quality of themethod. The better scin, nipple, ductal an microcalcificationvisualization in combination with better mass delineation allowed adiagnostic accuracy equally or better than X-ray mammography.Ultrasound mammography is the logical examination following breastpalpation, can complement mammography in all patients, substitutetoo frequent mammography controls and save unnecessary MRIs.Unfortunately the method suffers from lack of qualified education &training, qualified users and qualified payment. Gynecologists,radiologists and surgeons should struggle together to establish themethod in a appropriate way ± in the interest of all women.



Documents

WS17-11Amniotic fluid erythropoietin concentration and cerebro-umbilical Doppler flow ratio in diabetic pregnancies and pregnancies complicated by hypertension, pre-eclampsia or/and