Observed to expected lung area to head circumference ratio (O/E LHR) in fetuses with congenital anomalies of the kidney and urinary tract (CAKUT): assessment and evaluation as predictive factor for acute postnatal outcome-a single center study.

Introduction: To assess the observed to expected lung area to head circumference ratio (O/E LHR) in fetuses with congenital anomalies of the kidney and urinary tract (CAKUT) and to explore its value as a potential predictive factor for postnatal outcome. Methods: A retrospective single-center study was conducted on pregnancies complicated by CAKUT between 2007 and 2018. The lung-to-head ratio (LHR) was calculated for each fetus by two independent observers. Correlations between O/E LHR and various perinatal outcome factors were assessed with Spearman's rank correlation. Furthermore, nominal logistic regression was performed to assess O/E LHR as predictive factor for respiratory distress in newborn. Results: Of 64 pregnancies complicated by CAKUT, 23 were terminated. In the 41 cases of continuation of pregnancy, newborn presenting respiratory distress with need for respiratory support in the delivery room showed earlier gestational age at onset of amniotic fluid abnormalities and at birth. Although median O/E LHR and median single deepest pocket (SDP) of amniotic fluid were significantly smaller in newborn that did develop respiratory distress with need of respiratory support in the delivery room, neither O/E LHR nor SDP were accurate predictors for the development of respiratory distress. Conclusions: Our data show that O/E LHR alone cannot serve as a predictive marker for fetal outcome in pregnancies complicated by CAKUT, though it might still be a helpful parameter together with detailed renal ultrasound evaluation, onset of amniotic fluid abnormality and SDP, particularly in its extreme values.

Role of umbilicocerebral and cerebroplacental ratios in prediction of perinatal outcome in FGR pregnancies.

PURPOSE: Aim of our study was to compare the prognostic value of the Umbilical-to-Cerebral ratio (UCR) directly to the Cerebroplacental ratio (CPR) in the prediction of poor perinatal outcomes in pregnancies complicated by Fetal Growth Restriction (FGR). METHODS: A retrospective study was carried out on pregnant women with either a small-for-gestational age (SGA) fetus or that were diagnosed with FGR. Doppler measurements of the two subgroups were assessed and the correlation between CPR, UCR and relevant outcome parameters was evaluated by performing linear regression analysis, binary logistic analysis and receiver operator characteristic (ROC) curves. Outcomes of interest were mode of delivery, acidosis, preterm delivery, gestational age at birth as well as birthweight and centiles. RESULTS: Boxplots and Scatterplots illustrated the different distribution of CPR and UCR leading to deviant correlational relationships with adverse outcome parameters. In almost all parameters examined, UCR showed a higher independent association with preterm delivery (OR: 5.85, CI 2.23-15.34), APGAR score < 7 (OR: 3.52; CI 1.58-7.85) as well as weight under 10th centile (OR: 2.04; CI 0.97-4.28) in binary logistic regression compared to CPR which was only associated with preterm delivery (OR: 0.38; CI 0.22-0.66) and APGAR score < 7 (OR: 0.27; CI 0.06-1.13). When combined with different ultrasound parameters in order to differentiate between SGA and FGR during pregnancy, odds ratios for UCR were highly significant compared to odds ratios for CPR (OR: 0.065, 0.168-0.901; p = 0.027; OR: 0.810, 0.369-1.781; p = 0.601). ROC curves plotted for CPR and UCR showed almost identical moderate prediction performance. CONCLUSION: Since UCR is a better discriminator of Doppler values in abnormal range it presents a viable option to Doppler parameters and ratios that are used in clinical practice. UCR and CPR showed equal prognostic accuracy conserning sensitivity and specificity for adverse perinatal outcome, while adding UA PI and GA_scan increased prognostic accuracy regarding negative outcomes.

Wave intensity analysis of maternal arterial stiffness: augmentation index and pulse wave velocity in pregnancies complicated by diabetes or hypertension.

PURPOSE: The aim of our study was to compare the maternal arterial stiffness in pregnant women with diabetic disease, hypertension and those with normal pregnancies. METHODS: A cross-sectional study was performed involving 65 pregnant women with diabetic disease (DD group), 26 pregnant women with hypertension (RR group) and 448 women with normal pregnancies (control group). The augmentation index (AIx) and the pulse wave velocity (PWV) of the right carotid artery were assessed using non-invasive sonographic wave intensity analysis. Furthermore, the reliability of the measurements was evaluated in 21 healthy women. RESULTS: Compared with the controls, the AIx and PWV were increased in the DD group [11.0 (interquartile range, IQR 7.3, 15.2) vs. 5.7 (IQR 2.4, 9.3), P < 0.001; 5.7 (IQR 5.1, 6.4) vs. 5.2 (IQR 4.6, 6.1), P = 0.001; respectively] and the RR group [9.3 (IQR 6.6, 11.5) vs. 5.7 (IQR 2.4, 9.3), P < 0.001; 7.1 (6.3, 7.9) vs. 5.2 (IQR 4.6, 6.1), P < 0.001; respectively]. The intraclass and interclass correlation coefficients were good to excellent for the AIx (ICC: 0.91, P < 0.001 and 0.74, P < 0.002; respectively) and PWV measurements (ICC: 0.71, P < 0.004 and 0.70, P < 0.005; respectively). CONCLUSION: Pregnancies complicated by diabetic disease or hypertension are associated with increased maternal arterial stiffness. The importance of wave intensity analysis needs to be verified and larger studies are needed to establish both normal and cutoff values that may be relevant for clinical decisions.

Outcome of fetuses with gastroschisis after modification of prenatal management strategies : Prenatal management and outcome of gastroschisis.

PURPOSE: To improve the outcome of fetuses with gastrochisis several studies evaluated prenatal predictors. But there are different guidelines established and therefore the prenatal care is not standardized. With our study we wanted to evaluate the outcome of fetuses with gastroschisis after modification of prenatal management strategies at the Department of Obstetrics and Gynecology of the University Hospital Münster. METHODS: In this explorative retrospective study of 39 fetuses with gastroschisis, we compare the clinical outcome between two management groups. In the first group (group 1, n = 14) prenatal indication for delivery was confirmed by a subjective evaluation of the small bowel diameter and the wall thickness without established cut-off values for these parameters. In the second group (group 2, n = 25) certain limits for the small bowel diameter (25 mm) and the wall thickness (2.5 mm) were used for fetal surveillance. RESULTS: Noticeable differences between the two groups regarding birth weight, weight centile, arterial pH, small bowel diameter, wall thickness, adverse bowel condition and re-operations could not be observed. In group 2, delivery was earlier (p = 0.011), and a lower rate of prenatal complications was observed (p = 0.016). CONCLUSION: To avoid adverse prenatal complications we recommend the observation of fetuses with gastroschisis by sonographic monitoring of the small bowel diameter and the wall thickness.

Evaluation of right ventricular function in fetal hypoplastic left heart syndrome by color tissue Doppler imaging.

OBJECTIVE: Postnatal outcome of fetuses with hypoplastic left heart syndrome (HLHS) is determined mainly by right ventricular function. Our study examines whether there are differences in right ventricular function during gestation of fetuses with HLHS compared with healthy fetuses. METHODS: A prospective study was conducted including 20 fetuses with HLHS and 20 gestational age-matched controls. Peak systolic and diastolic right ventricular free wall velocities were assessed using color tissue Doppler imaging (c-TDI). Subsequently, isovolumic time intervals, ejection time (ET'), E'/A' ratio and tissue Doppler-derived myocardial performance index (MPI') were calculated. Possible changes to c-TDI indices during the course of pregnancy in both the HLHS group and the control group were investigated. RESULTS: Examination of right ventricular function revealed significantly lower E' velocities (13.6 vs 21.0 cm/s; P = 0.017) and E'/A' ratios (0.55 vs 0.76; P = 0.012) and prolonged isovolumic contraction time (ICT') (57.0 vs 45.7 ms; P = 0.008) in the HLHS group compared with healthy fetuses. Furthermore, isovolumic relaxation time and MPI' increased significantly with gestational age in HLHS fetuses but not in controls. Values for systolic and diastolic peak velocities (E', A', S'), ET' and ICT' did not change significantly during gestation in either group. CONCLUSION: Right ventricular function in HLHS is altered as early as in fetal life, well before palliative surgery is performed. Future research should provide further insight into ventricular remodeling during gestation in cases of HLHS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Evaluation of right ventricular function in fetuses with hypoplastic left heart syndrome using tissue Doppler techniques.

OBJECTIVE: The outcome of patients with hypoplastic left heart syndrome (HLHS) is influenced by right ventricular function. This study aimed to investigate whether differences in right ventricular function of fetuses with HLHS are present during gestation. METHODS: This was a prospective study comprising 14 fetuses with HLHS (28 measurements obtained in total) and 28 normal control fetuses (31 measurements obtained in total). The two groups were matched for gestational age. Ultrasound M-mode was used to assess displacement of the tricuspid annulus. Spectral Doppler and myocardial tissue Doppler-derived inflow and outflow velocities were assessed. Tricuspid valve peak early wave to peak active wave (E/A) ratio, the early wave to early diastolic annular relaxation velocity (E/E') ratio and the tissue Doppler-derived myocardial performance index (MPI') were calculated. RESULTS: E-wave velocity was significantly higher in fetuses with HLHS than in control fetuses (mean, 40.14 cm/s vs 35.47 cm/s; P < 0.05, respectively), and A-wave velocity in fetuses with HLHS showed a tendency for higher values in the right ventricle compared with normal control fetuses, but this did not reach statistical significance (61.16 cm/s vs 54.64 cm/s; P = 0.08). The E/A ratio increased during gestation in controls, but this increase was not seen in HLHS fetuses. Peak annular velocity during atrial contraction (A') and the E/E' ratio were significantly lower in controls than in HLHS fetuses: 9.50 cm/s vs 10.39 cm/s (P < 0.05) and 5.77 vs 7.37 (P < 0.05), respectively. There were no differences for right-ventricular MPI' or tricuspid annular plane systolic excursion between HLHS fetuses and controls. CONCLUSION: The results of this study show that altered right ventricular function in HLHS infants may develop antenatally. It is hoped that confirmation of these findings using Doppler-independent techniques will lead to further exploration of ventricular function in HLHS fetuses. Consequently, parental counseling and postnatal management strategies could be influenced.

Correlation between cardiac tissue Doppler and peripheral vascular Doppler in the anemic fetus - an additional method to determine the transfusion threshold?

PURPOSE: To examine the relationship between cardiac tissue Doppler and peripheral vascular Doppler measurements in fetal anemia. MATERIALS AND METHODS: We analyzed high frame rate cardiac Tissue Doppler Imaging (TDI) data files of 26 anemic fetuses. The peak systolic tissue velocity (PSV), peak systolic displacement (PD), and peak systolic strain (PS) were determined in the mid-segment of the ventricular walls (ROI 1 right ventricle (RV), ROI 2 left ventricle (LV)) and in the basal segment of the ventricular walls (ROI 3 tricuspid annulus, ROI 4 mitral annulus). TDI parameters were correlated with established fetal vascular Doppler parameters (peak systolic blood flow velocity (Vmax) in the middle cerebral artery (MCA), pulsatility index (PI) in the MCA, in the umbilical artery (UA), and in the venous duct (DV)). RESULTS: The PSV in the LV correlated significantly negatively with the PI in the MCA. Both the PSV and PD in the LV correlated significantly negatively with the PI in the UA. The PS in the RV correlated significantly negatively with the PI in the UA. The left ventricular PSV and PD correlated significantly positively with the PI in the DV. The Vmax in the MCA did not correlate with any systolic myocardial TDI parameter. CONCLUSION: In fetal anemia, peak systolic myocardial TDI parameters correlate with vascular Doppler parameters, confirming that TDI is a promising method to evaluate myocardial function in the anemic fetus. This suggests combining both techniques to quantify fetal myocardial function in anemia even more accurately, possibly allowing for the determination of the indication for intrauterine transfusion.

Reliability of cervix elastography in the late first and second trimester of pregnancy.

PURPOSE: To evaluate the reliability of cervical elastography as a new ultrasound tool for cervical stiffness assessment in pregnancy. MATERIALS AND METHODS: Pilot prospective cohort study including 10 consecutive unselected pregnancies in the late first and second trimester. Ultrasound was performed by two blinded experienced operators using a 9-MHz vaginal probe. One raw dataset per patient was acquired by each operator after two cycles of gentle compression and relaxation of the cervix. Strain values were independently assessed by each operator using commercial offline analysis software (TDI-Q: Tissue Doppler Imaging - Quantification, Toshiba Medical Systems). The interobserver reliability of strain measurements was evaluated using the intraclass correlation coefficient (ICC). RESULTS: The mean ± SD gestational week of the study population was 19 ±â€Š4.1.  Raw data acquirement and strain evaluation were feasible in all ten patients. In total, 40 strain measurements were performed: 20 for each operator (10 for self-acquired raw data and 10 for raw data acquired by the other operator). The mean strain value was 0.33 ±â€Š0.05, the mean of the differences among the measurements was 10.77 % ±â€Š4.41 %. The obtained interobserver ICC agreement values comparing the different subsets of strain measurement ranged between 0.91 and 0.96. CONCLUSION: Late first and second trimester cervical elastography was shown to be feasible and to have a high interobserver reliability. Its clinical value needs to be assessed in further studies on selected obstetric populations.

Accuracy of classification of breast ultrasound findings based on criteria used for BI-RADS.

OBJECTIVE: To assess the accuracy of categorization of breast ultrasound findings based on scoring for malignancy using the sonographic breast imaging-reporting and data system (BI-RADS). METHODS: Breast ultrasound was performed in 2462 patients between 2001 and 2004 at our unit. Sonographic findings were scored using analog criteria as in BI-RADS for breast ultrasound (mass shape, margin, orientation, posterior acoustic features, lesion boundary, echo pattern). Each lesion was described using these features and classified into categories 1 to 5 according to the BI-RADS for breast ultrasound. Categorization and biopsy results were compared. RESULTS: In twenty-two (0.9%) patients breast ultrasound could not be evaluated because of extreme density of tissue. Normal breast ultrasound belonging to Category 1 was found in 871 (35.4%) patients. Simple cysts classified as Category 2 were observed in 712 (28.9%) women. In 491 (19.9%) patients, apparently benign solid masses (Category 3) were found. Suspicious masses were observed in 225 (9.1%) women and masses highly suggestive of malignancy were found in 141 (5.7%) patients (Categories 4 and 5, respectively). Histological examinations were available from 84 (17.1%) masses that had been classified by BI-RADS as Category 3, in 97 (43.1%) from Category 4 and 106 (75.2%) from Category 5. Accordingly, the rate of malignant findings was 1.2% (n = 1) in Category 3, 17% (n = 16) in Category 4 and 94% (n = 100) in Category 5. CONCLUSION: Scoring breast ultrasound findings for malignancy based on criteria used for BI-RADS breast ultrasound has a high accuracy, comparable to that obtained by BI-RADS for mammography.

Sonographic assessment of the extra-abdominal fetal small bowel in gastroschisis: a retrospective longitudinal study in relation to prenatal complications.

OBJECTIVE: An explorative retrospective study following a case-series of fetuses with isolated gastroschisis, to evaluate if small-bowel dilatation may be indicative for emerging obstetric complications. The secondary aim was to establish preliminary normative curves for the external diameter and wall thickness of eventerated fetal small bowel in gastroschisis during the second and third trimester of pregnancy. METHODS AND MATERIALS: Fourteen fetuses with isolated gastroschisis were followed at a single center. Repeated ultrasound examinations for fetal surveillance with measurement of fetal small-bowel diameter and wall thickness over the course of pregnancy until delivery were performed. RESULTS: Longitudinal data analysis showed significantly increasing bowel diameter and wall thickness of eventerated small bowel with advancing gestation. Dilatation of small bowel more than 25 mm in the third trimester of pregnancy was associated with an increased risk of short-term prenatal complications as fetal distress or intrauterine fetal death (PPV 100%; 95% CI: 29.2-100%, NPV 100%; 95% CI: 71.5-100%). CONCLUSIONS: Dilatation of the extra-abdominal fetal small bowel in the third trimester may allow identifying fetuses with increased risk of fetal distress requiring closer monitoring of fetal well-being or delivery in a short interval to prevent impending fetal death.

Is there a seasonal variation in the frequency of gastroschisis?

PURPOSE: There have been conflicting reports on the incidence of gastroschisis and its seasonal variation. Studies have found an increased risk of gastroschisis in deliveries occurring in the winter months in the northern hemisphere. Other studies have not found a seasonal variation. To evaluate the existence of a seasonal variation in the incidence of gastroschisis in our patients, a retrospective database analysis was conducted. MATERIALS AND METHODS: Second and third trimester pregnancy screening was performed on 8031 patients between October 2001 und September 2005. Patients were evaluated throughout the year separately for their expected date of delivery and date of conception during the summer months (April-September) and the winter months (October-March). RESULTS: We diagnosed 17 fetuses having gastroschisis with a mean gestational age at diagnosis of 24 weeks (range 11-33). The number of second and third trimester screening examinations and the number of patients with an expected date of delivery was not different during summer and winter months, 3980 vs. 4051. The expected date of birth (corrected for early ultrasound measurement) of fetuses with gastroschisis was more common during the winter months (n=11) than during summer months (n=6). However, this difference is not statistically significant (p=0.21) as was also the case for the date of conception. CONCLUSION: There seems to be no seasonal variation in the frequency of gastroschisis depending on the estimated date of birth or date of conception.

[Tissue Doppler imaging of the fetal heart--a new parametric ultrasound technique in prenatal medicine]. / Tissue Doppler Imaging am fetalen Herzen--eine neue parametrische Ultraschalltechnik in der pränatalen Medizin.

Tissue Doppler imaging is a new ultrasound technique for the acquisition and analysis of myocardial velocity and deforming parameters in the human heart. In cardiology this innovative technique is used to identify ischemic regions and stunned areas after cardiac infarction and to diagnose dyssynchrony. In the last two years, our research group has been using this technique extensively on fetal hearts. It is possible to establish the fetal cardiac cycle clearly just by analyzing the typical courses of myocardial velocity curves. The quality of the curves is comparable to the results in adult cardiology. Consequently, many innovative analysis options can be acquired, e.g., the comparison of the kinetics of several myocardial regions in the cardiac cycle, the determination of pre- and post-systolic intervals (isovolumic contraction time, isovolumic relaxation time), the evaluation of diastolic function by analyzing the E(m) and A(m) waves and the detection of the atrial contraction. These parameters are currently used in cardiology for extended function analysis. Tissue Doppler imaging is the first step in parametric imaging of the fetal heart and consequently marks the beginning of a new era in fetal echocardiography.

Implications of low vascular flow resistance in the umbilical artery--difference between the second and third trimester of pregnancy.

PURPOSE: An abnormally high (above 95th percentile) pulsatility index (PI) in the umbilical artery (UA) indicates impaired fetal outcome, whereas the impact of an ''abnormally'' low (below 5th percentile) PI in the second trimester is unknown. MATERIALS AND METHODS: Between 2001 and 2004, second trimester pregnancy screening was performed at our institution on 5220 patients, and additional UA Doppler ultrasound on 547 (10.5%) of these patients, between 16th and 25th week of pregnancy. Files were available for analysis in our electronic database (PIA Fetal Database (GE, USA)). To evaluate the association of a UA PI below the 5th percentile in the second trimester of pregnancy with fetal anomalies and outcome, a retrospective database analysis was conducted. RESULTS: In 25 fetuses (3.6%), a UA PI below the 5th percentile was found. In 7 of these fetuses (28%), abnormalities of the urogenital tract were diagnosed. There were multiple pregnancies in 7 cases (28%), consisting of two triplets, each including one fetus with malformation, as well as five monochorial twin pregnancies, including 2 fetuses with malformations. In 11 pregnancies (44%), second trimester screening showed no anomalies. CONCLUSION: Only in 11 cases (44%) of fetuses with UA PI below 5th percentile in the second trimester, course and outcome of pregnancy were favourable, if defined as live birth without fetal malformations and uneventful neonatal period. The aetiology of an abnormally low UA PI in the second trimester seems to be diverse. Possible aetiological mechanisms will be discussed.

Complicated grief after traumatic loss: a 14-month follow up study.

The traumatic loss of an unborn child after TOP due to fetal malformation and/or severe chromosomal disorders in late pregnancy is a major life-event and a potential source of serious psychological problems for those women. To obtain information on the course of grief following a traumatic loss, 62 women who had undergone TOP between the 15th and 32nd gestational week were investigated in a longitudinal study design and compared with 65 women after spontaneous delivery of a full-term healthy child. Grief, posttraumatic stress, depression, anxiety and psychiatric disorders were evaluated 14 days, 6 months and 14 months after the event, implementing validated self-report and clinician rated instruments. Compared to women after spontaneous delivery, women after induced TOP were significantly more stressed regarding all psychological outcomes at all three measuring points. Especially, 14 months after TOP 13.7% of the women fulfilled all criteria of a complicated grief diagnoses following Horowitz et al. (1997, Am J Psychiat 154:7904-7910). 16.7% were diagnosed as having a manifest psychiatric disorder according to DSM-IV. All in all, 25% of these women were critically affected by the traumatic loss. TOP for fetal anomaly is to be seen as a major life event, which causes complicated grief reactions and psychiatric disorders for a substantial number of women.

Maternal serum free beta-hCG and PAPP-A in patients with habitual abortion-influence on first-trimester screening for chromosomal abnormalities.

OBJECTIVE: To explore if maternal serum free beta-hCG and pregnancy-associated plasma protein A (PAPP-A) levels in the first-trimester of pregnancy are altered in patients with habitual abortions and if there is an effect on first-trimester screening for Down syndrome. METHODS: A retrospective study was conducted on 913 normal singleton fetuses that underwent first-trimester combined screening for Down syndrome. Maternal serum PAPP-A and free beta-hCG were compared between patients with (n = 64) and without habitual abortions (n = 849). RESULTS: The medians +/- SD log(10) MoM of PAPP-A and free beta-hCG +/- SD in patients with and without habitual abortions were 0.063 +/- 0.28 versus - 0.014 +/- 0.27 and - 0.001 +/- 0.27 versus - 0.018 +/- 0.31, with a p value of 0.042 and 0.87, respectively. The screen positive rate setting the cut off at 1:350 looking at the background risk for trisomy 21 was 71.4% in women with and 81.2% in women without habitual abortion, after combined first-trimester screening it was 7.8% in women with and 10.1% in women without recurrent abortion. CONCLUSIONS: Patients with habitual abortions have slightly increased maternal serum PAPP-A levels in the first-trimester. This marginal difference seems not to effect risk calculation in combined first-trimester screening for trisomy 21.

Influence of maternal systemic lupus erythematosus on first-trimester combined screening for chromosomal abnormalities.

OBJECTIVE: To explore the effect of maternal systemic lupus erythematosus (SLE) on first-trimester screening markers for Down syndrome. METHODS: A retrospective study was conducted on 1150 normal singleton fetuses that underwent first-trimester combined screening for Down syndrome. Fetal delta nuchal translucency (NT), maternal serum PAPP-A and free beta-hCG were compared between pregnancies with SLE (n = 10) and without preexisting maternal disease (n = 1140). RESULTS: The medians +/- SD for delta NT, log(10) MoM of PAPP-A and free beta-hCG +/- SD in pregnancies with SLE and without maternal disease were - 0.18 +/- 0.29 versus - 0.18 +/- 0.33, 0.005 +/- 0.32 versus 0.02 +/- 0.26, and 0.22 +/- 0.19 versus - 0.014 +/- 0.28, with a p value of 0.7, 0.98 and 0.03, respectively. CONCLUSIONS: Patients with preexisting SLE have increased maternal serum-free beta-hCG levels in the first-trimester. But, because of the multimodal procedure of risk calculation there is no significant difference in the screen-positive rate after the combined first-trimester screening for trisomy 21.

Does vaginal bleeding influence first-trimester markers for Down syndrome?

OBJECTIVES: To examine the effect of early vaginal bleeding on first-trimester screening markers for Down syndrome. METHODS: A retrospective study was conducted on 1755 normal singleton fetuses that underwent first-trimester combined screening for Down syndrome on the basis of ultrasound and maternal serum markers. Fetal delta-nuchal translucency (NT), maternal serum pregnancy-associated plasma protein A (PAPP-A) and free beta-hCG were compared between pregnancies with (n = 252) and without (n = 1503) an episode of vaginal bleeding. Subgroup analysis for the intensity of bleeding (spotting n = 191; light n = 32; heavy n = 29) was performed. RESULTS: The median +/- SD (log(10)) for delta-NT, multiple of medians (MoM) PAPP-A and MoM free beta-hCG (corrected for maternal weight, smoking and ethnicity) was - 0.17 +/- 0.62, 1.10 +/- 0.28, 1.1 +/- 0.28 and - 0.15 +/- 0.51, 0.98 +/- 0.26, 0.94 +/- 0.3 in pregnancies with and without a history of early vaginal bleeding, which were not significantly different. Exclusion of patients with spotting from the vaginal bleeding group revealed significantly higher maternal serum free beta-hCG MoM values (median +/- SD (log(10))) compared to patients without bleeding, 1.29 +/- 0.27 vs 0.96 +/- 0.3(p = 0.011). Screen-positive (cut off of 1:350) rate after combined first-trimester screening was 28.1% in patients with light vaginal bleeding and 8.4% in patients without bleeding (p = 0.001). CONCLUSIONS: Light vaginal bleeding before first-trimester combined screening for Down syndrome leads to a higher screen-positive rate after combined first trimester screening, without a significant difference in serum levels of the screening markers.

Ductus venosus blood flow velocity waveforms as a predictor for fetal outcome in isolated congenital heart disease.

OBJECTIVE: To investigate whether pulsatility of ductus venosus (DV) flow velocity waveforms is of diagnostic value in predicting survival in fetuses with congenital heart disease (CHD). METHODS: In a cross-sectional study, Doppler investigation of DV and umbilical artery blood flow was performed in 58 fetuses with isolated structural CHD, without other sonographically detectable structural or chromosomal abnormalities or tachyarrhythmia. The pulsatility index for veins of DV (DV-PIV) waveforms was expressed as multiples of the 95th centile (Mo95th) of the reference ranges for gestational age. The PIV was related to intrauterine and neonatal mortality within the first 6 months of life. Terminations of pregnancies and neonates with additional abnormalities detected after birth were excluded from statistical analysis. For statistical analysis, the different types of heart defects were separated into atrial and/or ventricular (AV) septal defects, right or left ventricular in- and outflow tract abnormalities and others. RESULTS: After exclusion of 9 pregnancies (2 cases with failure of measurements of DV-PIV, 2 neonates with additional malformations, and 5 terminations of pregnancies), 49 cases were available for statistical analysis. The umbilical artery pulsatility index was within normal ranges in all but 1 case with AV canal and hydrops. In 7 pregnancies intrauterine fetal deaths occurred and 6 of them were hydropic. The median gestational age at birth for liveborn neonates was 39.0 weeks (range 27.8-41). There were 6 postnatal deaths, all but 1 within 28 days of delivery. The remaining fetuses survived for at least 6 months. The overall mortality rate was 27% (13/49). The DV-PIV was significantly higher in non-survivors than in survivors (median of Mo95th and interquartile ranges 1.48 (1.04-1.95) vs. 0.81 (0.70-1.15); p = 0.01). Analysis of subgroups showed significant differences for AV septal defects and abnormalities affecting predominantly the right ventricle (p = 0.046 and 0.043, respectively). Ten out of 13 non-survivors showed an abnormal DV-PIV (sensitivity 77%) as compared to 12 out of 36 survivors (specificity 67%). All hydropic fetuses (n = 6) showed an abnormal DV-PIV and ended in intrauterine deaths. CONCLUSIONS: Evaluation of the DV pulsatility is a useful additional variable for predicting the risk for mortality in fetuses with isolated structural CHD, in particular in fetuses with defects of the AV septum and with defects affecting predominantly right ventricular function. As there is no fetal hydrops without abnormal DV, this is another sign for the association of DV and cardiac failure.