Anatomic Survey Research Articles

352 Regional heterogeneity in ultrasound and procedural training in maternal-fetal medicine fellowship: a cross-sectional survey

To assess the current maternal-fetal medicine (MFM) ultrasound (U/S) training experience during fellowship. An anonymous survey of 51 questions was distributed to 114 postgraduate year (PGY-6) MFM fellows (from 75 MFM programs) registered to attend the annual Gottesfeld-Hohler Memorial Foundation MFM Fellow Ultrasound Training Course in December 2019. For programs with more than one PGY-6 fellow, instructions were given for only one fellow to represent the program. The survey included continuous, ordinal, and categorical scale questions on U/S training structure, fellows’ self-perception of U/S capabilities, research, mentorship, and technical aspects of sonography. Categorical outcomes were compared using chi-square test and Fisher’s exact test, as appropriate. Completed surveys were submitted by 72 fellows (96% response rate), with 10 (13.9%) from the West, 16 (22.2%) Midwest, 17 (23.6%) South, and 29 (40.3%) Northeast. The majority of fellows reported feeling comfortable performing growth U/S (78%) and uterine artery Doppler interrogations (58%), and feeling uncomfortable with 3D U/S, neurosonography, and fetal echocardiography (Table 1). Fellows undergoing training in the South were less likely to report feeling comfortable performing detailed anatomic surveys and nuchal translucency (NT) when compared to other regions (NT: p=0.046; anatomy: p=0.011) (Table 1). Fellows in the Northeast were more likely to report feeling comfortable performing chorionic villus sampling (CVS) when compared to other regions (p=0.001) (Table 2). There was no difference among fellowship programs in U/S curriculum, bedside teaching, ultrasound-focused research mentorship, or months of U/S training. There is wide geographic variation in fellow comfort with U/S and diagnostic procedures in the United States. This study highlights the need for further optimization and standardization of MFM fellowship U/S training, especially in advanced sonography and diagnostic procedures.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

952 Prenatal phenotype of 47,XXY (Klinefelter syndrome)

The phenotypic description of prenatal Klinefelter syndrome (KS), or 47,XXY, is currently limited to case reports. There is a gap in knowledge regarding prenatal presentation of KS. We hypothesize that a significant percentage of pregnancies complicated by fetal KS will have associated ultrasonographic findings. We retrospectively identified all fetuses with cytogenetically confirmed 47,XXY in the prenatal period or up to age 5 years, with prenatal records available for review from four prenatal diagnostic referral centers between 2006 and 2019. Ultrasound reports were reviewed to assess for the presence of increased nuchal translucency (NT) and abnormalities at the second trimester anatomy ultrasound. Additionally, we reviewed results of cell free DNA and serum analyte testing to inform our understanding of prenatal screening tests in the setting of fetal KS. A total of 42 subjects with confirmed cytogenetic diagnosis of 47,XXY and prenatal records available for review were identified: 38 had a prenatal diagnosis of KS and 4 had a postnatal diagnosis. One case was excluded as cytogenetic analysis demonstrated mosaic KS, leaving a cohort of 41 subjects. NT was increased ≥3.0mm in 6 of 26 (23.1%) of cases that had a documented measurement. A second trimester anatomical survey was available for review in 24/41 affected pregnancies. In 7 of 24 (29.2%) ultrasounds, a fetal abnormality was identified. These include 3 brain anomalies, 1 cardiac abnormality, 1 echogenic bowel, and 2 limb abnormalities (table). In subjects who had cell free DNA performed, 92.6% had a positive result for 47,XXY (25/27); in subjects who had serum analytes performed, 36.3% (4/11) had a positive result. This case series expands our knowledge of the prenatal presentation of KS by identifying 1st and 2nd trimester fetal sonographic abnormalities as well as serum analyte abnormalities.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

309 Resolved low-lying placenta and placenta previa is associated with increased risk of postpartum hemorrhage

Second trimester diagnosis of low placentation, defined as low-lying placenta and placenta previa, is a risk factor for postpartum hemorrhage (PPH), but it is unknown if resolved low placentation leads to higher rates of PPH. Initial implantation of the placenta in the lower uterine segment increases vascularity and may cause unsuccessful contraction of the vascular beds at delivery. We hypothesize despite resolution of low placentation, women are at increased risk of PPH at delivery. This retrospective cohort includes women who delivered at Mount Sinai Hospital from 2015-2019, diagnosed with low placentation at mid-trimester anatomy survey with resolution on subsequent ultrasound. Women with normal placentation at mid-trimester anatomy survey were randomly selected for comparison. Demographic and neonatal characteristics were compared. Primary outcome was PPH. Secondary outcomes included blood transfusion, use of additional uterotonic medication or procedures to control bleeding. Outcomes were assessed using a logistic regression model adjusting for age, BMI and race/ethnicity. Resolved low placentation was associated with older age, lower BMI, White race, IVF and a posterior placenta (p<0.01). Patients with resolved low vs. normal placentation had greater odds of PPH (aOR 3.3, 95% CI 1.9-5.7; p<0.01), additional uterotonic use (aOR 2.1, 95% CI 1.5-3.1; p<0.01) and a trend toward increased rates of additional procedures (aOR 3.6, 95% CI 1.2-11.0; p=0.02) and blood transfusion (aOR 2.0, 95% CI 0.9-4.2; p=0.07). Composite neonatal morbidity was increased in the resolved low placentation cohort (9.1% vs. 4.0%, p<0.01), likely driven by higher rates of hypoglycemia (p<0.01). Women with resolved low placentation are at increased risk of PPH compared to those with normal placentation throughout pregnancy. The trend toward higher rates of additional procedures and blood transfusion suggest women with resolved low placentation may be at increased risk of morbidity. This may alter counseling and delivery management and increase preparation for PPH in these patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Visualization of the fetal anus by prenatal ultrasound for the diagnosis of anorectal malformations: is it feasible?

The goal of this study was to determine the feasibility of identifying the anal dimple (AD) on routine prenatal ultrasound. Using the presence, absence, appearance, and location of the anal dimple as an indirect sign for possible underlying anorectal malformations (ARM), we hypothesize that evaluation of the anal dimple as part of the fetal anatomic survey may increase the sensitivity in detecting less severe ARMs. In a prospective longitudinal observational study, pregnant women who underwent prenatal ultrasound (US) at the Colorado Fetal Care Center between January 2019 and 2020 were enrolled. The variables recorded included gestational age, singleton versus multiple pregnancy, gender of the fetus, visualization of the AD, and reason for non-visualization of the AD. A total of 900 ultrasounds were performed, evaluating 1044 fetuses, in 372 different pregnant women. Gestational ages ranged from 16 to 38weeks. The AD was visualized in 612 fetuses (58.6%) and not seen in 432 (41.4%). The two most common reasons for non-visualization were extremes in gestational age (n = 155; 36%) and fetal position (n = 152; 35.3%). The optimal gestational age range for AD visualization was 28-33weeks + 6days, with 78.1% visualization rate. Visualization of the anal dimple by ultrasound is feasible and may aid in the detection of less severe ARMs, ultimately impacting pregnancy management and family counseling. The optimal timing for anal dimple visualization is late second and third trimester.

A Rare Arthrogryposis Syndrome with Multiple Anomalies Diagnosed by Whole Exome Sequencing

A 31-year-old gravida 1 para 0 was referred to our institution following a fetal anatomic survey demonstrating clubbed feet, flexed wrists, and skin edema. Ultrasound evaluation demonstrated these findings in addition to hemivertebrae, short long bones, contractures of the elbows, wrists, knees, and ankles with limited movement at the shoulders and hips. Further, macrocephaly, microphthalmia, low set ears, micrognathia, hepatomegaly, and an omphalocele were noted. Following termination of the pregnancy, whole exome sequencing ultimately identified compound heterozygous mutations in the NEK9 gene. One mutation in our case, c.136G>T, has never been reported; the other, c.1432del, has been reported once. To date, NEK9 mutations have been documented in three families with all affected individuals diagnosed with arthrogryposis. Our patient underwent targeted gene variant testing in two subsequent pregnancies, confirming identification of one of the two familial NEK9 gene mutations each time. Both pregnancies culminated in term deliveries of healthy neonates. This case illustrates a diagnosis of an extremely rare single gene disorder in the pregnancy of a non-consanguineous German couple, providing further evidence toward arthrogryposis with other anomalies as a recessive disease associated with NEK9 gene mutations. Finally, this case demonstrates whole exome sequencing as a valuable adjunct tool for investigating etiology when multiple fetal anomalies are identified without diagnosis on more standard tests.

Accuracy and Completion Rate of the Fetal Anatomic Survey in the Super Obese Parturient.

To determine the completion rate of ultrasound in with a body mass index (BMI) ≥ 50 to women with BMI 18.5 to 29.9. This study was a retrospective cohort study. Women with a singleton pregnancy, age 18 to 45 with a BMI ≥50 that delivered between 2013-2016 were compared to women with a BMI 18.5 to 29.9 during that same time period to assess the accuracy and, as a second aim, the completion rate of the fetal anatomic survey. Data were analyzed using two-sample t test, chi-square test, or logistic regression as appropriate. Eighty-one cases with a BMI ≥50 were compared with 81 patients with a BMI 18.5 to 29.9. Maternal demographics and timing (gestational age) at the time of the ultrasound were similar between groups. In women with a BMI 18.5 to 29.9, completion of anatomy was 58% of the time with the first ultrasound, 81% with second ultrasound, and 84% with the third ultrasound. In women with BMI ≥50, completion of anatomy was 10% of the time with the first ultrasound, 33% with the second ultrasound, and 42% with the third ultrasound. Each time frame was statistically significant. Agreement level on the accuracy to detect fetal anomalies between groups were not statistically significant between the groups. In women with a BMI ≥50 compared to women with BMI of 18.8 to 29.9, more ultrasounds are needed to complete the anatomic survey although overall accuracy in fetal anomaly detection is similar.

Comparing fetal biometric growth velocity versus estimated fetal weight for prediction of neonatal small for gestational age

Objective Growth velocities derived from fetal biometrics have been proposed to improve prediction of small for gestational age (SGA) neonates. We sought to determine if ultrasound growth velocities for abdominal circumference (AC) and estimated fetal weight (EFW) improve the prediction of SGA infants when compared to using EFW alone. Study design This is a secondary analysis from a prospective study of women referred for growth ultrasounds during the third trimester. Growth velocities for AC and EFW were derived from the difference in Z-scores between measurements at the anatomy survey (18–22 weeks gestation) and later growth ultrasound (26–36 weeks gestation). Change in AC and EFW growth velocities <10th percentile were compared with prenatally suspected SGA from Hadlock EFW <10th percentile for prediction of SGA neonates. The primary outcome was defined as the sensitivity and specificity of the growth velocities and Hadlock EFW in predicting SGA neonates. Logistic regression modeling was used to determine if the growth velocities improved prediction of neonatal SGA. Area under the ROC curves (AUC) were determined and compared. Results Of 612 singleton pregnancies meeting inclusion criteria, 68 (11.1%) resulted in SGA neonates. Hadlock EFW <10th percentile had higher sensitivity and specificity when compared to AC growth velocity and EFW growth velocity. Only AC growth velocity and Hadlock EFW had significant odds ratios for association with neonatal SGA. The AUC were 0.54, 0.53, and 0.61 using AC growth velocity, EFW growth velocity, and Hadlock EFW, respectively. The AUC did not significantly improve when the growth velocities were combined with Hadlock EFW (0.63). Adjustment of Z-scores for gestational age at anatomy scan or third trimester growth scan did not significantly change these results (AUC = 0.69). Conclusion EFW determined by Hadlock formula has the highest predictive value in detecting SGA neonates when compared to both AC and EFW growth velocities.

Dandy-Walker Malformation

Dandy-Walker Malformation

A Matter of Time: Does Gestational Age Affect the Duration of the Fetal Anatomic Survey?

To assess the average duration of detailed fetal anatomic surveys in pregnancy in relation to gestational age (GA) and the maternal body mass index (BMI) to determine optimal timing of the examination. This was a retrospective cohort study of gravidae presenting for detailed fetal anatomic examinations between January 1, 2010, and June 30, 2017. After excluding examinations expected to have longer duration (ie, multifetal, major fetal anomalies), there were a total of 6522 examinations performed between GAs of 18 weeks 0 days and 22 weeks 0 days. Women were grouped by BMI, and results were analyzed by logistic regression. Gravidae of normal weight (BMI, 18.5-24.9 kg/m2 ) had a decrease of 47.47 seconds of the examination time with each increasing week of gestation (P=.036). Overweight (BMI, 25-29.9 kg/m2 ) gravidae similarly had a decrease of 66.31 seconds of the examination time with each additional week of gestation (P=.017). Underweight (BMI, 8.5 kg/m2 ) and obese (BMI, ≥30 kg/m2 ) gravidae did not have differences in the examination time with increasing GA. Increases in suboptimal examinations were noted with an increasing BMI (P < .001). There was a decreased frequency of suboptimal examinations in obese gravidae with a BMI of 40 kg/m2 or higher with increasing GA (P=.037). The duration of detailed fetal anatomic examinations decreased with increasing GA in normal-weight and overweight gravidae but not in obese gravidae. Performing the anatomy scan earlier in class I and II obese gravidae (BMI, 30-40 kg/m2 ) may enable improved pregnancy management options without increasing the examination duration or likelihood of a suboptimal evaluation.

Placental cord insertion distance from the placental margin and its association with adverse perinatal outcomes

ObjectiveThe placental cord insertion (PCI) to the placental margin has not been well studied as a continuous variable in relation to birth outcomes. We sought to evaluate the impact of PCI distance on outcomes associated with placental function and development of fetal growth restriction (FGR). Study DesignThis was a retrospective study of singleton gestations that underwent a fetal anatomy ultrasound from 2011−2013. The PCI was recorded as the distance in centimeters from the placental margin. Patients had FGR if the overall estimated fetal weight was <10 % for gestational age or abdominal circumference <5 % in the third trimester. Delivery, obstetric, and neonatal outcomes were obtained via medical chart review. Logistic and linear regression models were used to assess the impact of PCI distance on maternal and neonatal delivery outcomes. ResultsOf the 1443 women who met inclusion criteria, 93.6 % delivered at term. The mean (±SD) PCI distance was 4.4 ± 1.4 cm. There was no association between PCI and cesarean delivery, peripartum hemorrhage (PPH), pre-eclampsia, 5-min Apgar, or intrauterine fetal demise. PCI distance was statistically significantly shorter in patients requiring neonatal intensive care unit (NICU) admission (4.1 ± 1.5 cm vs. 4.4 ± 1.4 cm, p = 0.02) and was associated with lower birthweight (p = 0.01), though this association was no longer seen when corrected for gestational age. There were 3.5 % of patients who developed FGR; PCI distances from the placental edge were not significantly different for patients who developed FGR compared to those who did not (4.2 ± 1.4 cm vs. 4.5 ± 1.4 cm, p = 0.18). Furthermore, a receiver operating characteristic (ROC) curve for PCI had poor sensitivity (area under the curve [AUC] 0.57, 95 % CI 0.49−0.65). ConclusionPCI distance at the time of fetal anatomic survey is significantly associated with NICU admission, though does not appear to impact rates of preterm birth, pre-eclampsia, PPH or cesarean delivery. PCI distance in singleton gestations does not appear to be predictive of FGR.

VP09.05: Incorporation of screening for anorectal malformations in the detailed anatomic survey

Anorectal malformations (ARM) are congenital abnormalities that occur in up to 1/1,250 births. Prenatal diagnosis can be challenging due to absent or late presentation on ultrasound. We instituted a practice change in 2016 to add a standard “bullseye” view of the fetal anus to our detailed anatomic survey exams performed in our fetal centre. This study aims to demonstrate our experience after adding this view over a 3-year period. This was a retrospective cohort of all neonates diagnosed with ARM from January 2017 to December 2019 at a single academic institution. We collected descriptive data including number, duration, and location of ultrasound exams and coexisting fetal anomalies. All available ultrasound reports and images were reviewed for inclusion and interpretation of the “bullseye” view. Prenatal and postnatal diagnoses were compared for accuracy along with any need for neonatal consultation with pediatric surgery or procedures. 28 neonates were identified with ARM during our study period. Two pregnancies were excluded due to lack of ultrasound data, thus 26 pregnancies were included in our analysis. We attempted visualisation of the bullseye in 20/26 patients during prenatal ultrasounds and diagnosed lower GI tract anomaly correctly in 80%. 90% of neonates born at our hospital without antenatal diagnoses of ARM were imaged at offices outside of our fetal centre. ARM was an isolated anomaly in 7 neonates, thus were at the highest chance to be missed with routine anatomic surveys. Imaging time stamps demonstrated a mean acquisition time to view the fetal anus of 1 min 38 seconds. The inclusion of the “bullseye” view in detailed anatomical surveys is a practical method for prenatal detection of ARM. With continued experience, we may expect improved accuracy and efficiency of this imaging technique. More accurate antenatal diagnosis may prompt delivery at centres with pediatric surgery consultation, thus avoiding neonatal transport.

VP27.12: Evaluation of agenesis of other commissures in fetuses suspected with agenesis of corpus callosum with fetal MRI

To evaluate agenesis of anterior commissure and hippocampal commissure in fetuses with agenesis of corpus callosum. Out of 821 fetal MRI's that were done during 2017–2018, fetuses with 34 fetuses with callosal agenesis entered the study. MRI's done on a Seimens Avanto 1.5T and interpreted with prior knowledge of the midtrimester anatomical survey. Retrospective evaluation of the fetal MRIs for associated commissural agenesis was done. MRI confirmed ventriculomegaly in 94 cases. In 45 (47.8%) out of 94 cases with ventriculomegaly the anomaly of corpus callosum was suspected in ultrasound. Complete corpus callosum agenesis in 19 Cases and partial agenesis of the corpus callosum in 11 cases were identified, and the remaining 15 cases had normal corpus callosum. In fetuses with complete callosal agenesis anterior commissure was visible in 11 out of 19, hippocampal commissure in 2 out of 19 and none in 6 out of 19 fetuses. Anterior commissure is present in many cases of callosal agenesis. Details of other commissural agenesis might become clinically relevant when later follow-up studies establish its association with neurodevelopmental outcome. Supporting information can be found in the online version of this abstract Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

VP02.24: Umbilical vein varix: does it really need stringent monitoring?

Fetal intraabdominal umbilical vein varix (FIUVV) is a focal dilatation of the intraabdominal but extrahepatic portion of the umbilical vein. Here we present two cases where FIUVV was detected in the third trimester – one at 29 weeks and the other at 37 weeks. The detailed structural analysis was normal. Monitoring was done in the form of daily kick count, fortnightly antenatal visits and four weekly ultrasounds. We did not observe any increase in the size of the varix, turbulence in the flow or thrombosis during follow up scans. One was delivered at 37 weeks due to severe FGR and other at 38 weeks due to reduced fetal movements. FIUVV mandates a detailed anatomical survey. Invasive testing is recommended only if there are associated abnormalities. There is no or minimal increased risk of complications during pregnancy. The frequency of monitoring during pregnancy is still not established. Later the diagnosis of the varix, less frequent is the monitoring and better is the outcome. Supporting information can be found in the online version of this abstract Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Anatomical Survey Versus Fetal Echocardiograms for Diagnosis of Cardiac Defects with a Single Umbilical Artery Cases: A Retrospective Cohort Study and Diagnostic Meta-analysis.

To determine the utility of fetal echocardiography in diagnosing cardiac defects in fetuses with a single umbilical artery (SUA). A retrospective cohort study of prenatally diagnosed SUA was conducted over a 10-year period at a single institution. Cardiac anatomy on detailed anatomical survey was compared with fetal echocardiogram for fetuses with prenatally diagnosed SUA. A diagnostic meta-analysis of studies comparing fetal anatomical survey to fetal echocardiogram in fetuses with SUA between 2010 to 2019 was also performed. Three hundred and twenty fetuses with SUA were identified, 113 of which had completed both ultrasound and echocardiography. There were 36 cases of cardiac defects on prenatal echocardiogram and all had abnormal anatomical ultrasounds. There were zero cases of abnormal cardiac exams (0%) when the cardiac views on anatomical survey were normal. The sensitivity, specificity, positive predictive value and negative predictive value of ultrasound were 100%, 77%, 73% and 100%, respectively. A summary ROC curve demonstrated a high predictive value of routine anatomic survey for cardiac defects (AUC: 0.99). Anatomic survey is highly predictive in the detection of cardiac defects in fetuses with SUA. Fetal echocardiogram is unnecessary in SUA when cardiac views are normal on ultrasound.

Twin anemia–polycythemia sequence in sex‐discordant monochorionic dizygotic twins

The possibility of monochorionic (MC) dizygotic (DZ) twins was first raised in 1970. As MC sex-discordant twins are rarely observed, MCDZ twins are seldom recognized clinically. Conception by assisted reproductive technology (ART) is associated with an increased frequency of MC diamniotic (DA) twins, with more than 50% of reported MCDZ twins conceived by ART1. With the increased use of ART, it is therefore reasonable to expect that the incidence of MCDZ twins may increase. MC twins share a single placenta and are connected by the placental circulation. They are at risk of transfusion imbalance in this circulation, which may lead to twin–twin transfusion syndrome (TTTS) or twin anemia–polycythemia sequence (TAPS). The diagnosis of TTTS at an early stage is based on discordant amniotic fluid volume. Currently, the diagnosis of TAPS is based on increased middle cerebral artery peak systolic velocity (MCA-PSV) in the donor twin (> 1.5 MoM) and decreased MCA-PSV in the recipient twin (< 1 MoM)2. Postnatally, TAPS can be diagnosed based on an intertwin hemoglobin difference of > 8 g/dL and at least one of the following criteria: (1) reticulocyte count ratio > 1.7; and (2) presence of only small vascular anastomoses on placental examination3. We report a case of TAPS diagnosed prenatally in a MCDZ twin pregnancy. A 32-year-old woman with a spontaneously conceived pregnancy was diagnosed with a MCDA twin gestation at 14 weeks by ultrasound. Sex discordance was noted on the fetal anatomy survey and was suggested on cell-free fetal DNA screening. Sex discordance was confirmed postnatally. A diagnosis of TAPS was suspected at 28 + 6 weeks based on MCA-PSV (1.65 MoM in the donor and 0.48 MoM in the recipient), and worsening of TAPS, with a new finding of placental echogenicity discordance between the donor and recipient sides, was suspected at 30 + 6 weeks (Figure 1). The patient was delivered at 31 + 2 weeks, following administration of corticosteroids and magnesium sulfate for neuroprotection, due to worsening of TAPS. TAPS was confirmed postnatally. Hemoglobin was 25.2 g/dL in the recipient twin and 7.5 g/dL in the donor twin. Reticulocyte count ratio (donor/recipient twin) was 14.7. Monochorionicity was confirmed by pathological examination. In TAPS, the placenta may have a discordant ultrasound appearance (hyperechoic on the donor twin side and hypoechoic on the recipient twin side) and a color difference on gross examination (pale appearance on the donor twin side and dark purple appearance on the recipient twin side)4. The current case demonstrated these findings (Figures 1 and 2). Although a case of TAPS in MCDZ twins was reported recently in a spontaneously delivered pregnancy in which the diagnosis was made postnatally5, we report what we believe to be the first case of TAPS in MCDZ twins that was diagnosed prenatally. Our report demonstrates that discordant MCA-PSV measurements and placental echogenicity differences in MC twin pregnancy are objective ultrasound findings that may indicate a developing and worsening status of TAPS in MCDZ twins. It is important to recognize that MCDZ twin gestations exist. Early determination of chorionicity during the first trimester with confirmation of fetal sex in the second trimester is the key in identifying a MCDZ twin gestation.

Optimal timing of the second trimester fetal ultrasound in the obese gravida

Objectives Obesity is increasingly prevalent in the obstetric patient population, becoming one of the most commonly occurring risk factors in obstetric practice. Obesity has implications for maternal and fetal morbidity; in fact, some data suggest it is associated with higher rates of fetal anomaly. Coincident with this, maternal obesity poses an inherent challenge for ultrasound quality. The objective of this study is to investigate the relationship between ultrasound completion rates and advancing gestational age in obese gravidas, and to help identify an ideal gestational age to perform the second trimester ultrasound for fetal evaluation in the obese patient population. We hypothesized that in the obese patient, the odds of a completed scan would increase with each gestational age week, as fetal size increases. Methods This is a retrospective cohort study at a single tertiary care center. Inclusion criteria were pregnant women with BMI greater than 30 who had second trimester fetal ultrasound and delivery at our institution. Exclusion criteria were pregnancies without documented BMI, ultrasound not performed between 18 0/6 and 21 6/7 weeks, multiple gestations, or ultrasound performed for indication other than fetal anatomic assessment. Ultrasound reports were considered incomplete if they indicated suboptimal or non-visualization of any anatomic structures included in the comprehensive anatomic survey. Demographic data was compared using Student’s t test and chi-square analysis where appropriate. Chi-square analysis was used to compare rates of completed surveys. p < .05 was considered significant. Results After application of eligibility criteria, our cohort included 1,954 subjects. When comparing subjects with a completed scan to those with an incomplete scan, there were more white subjects in the incomplete group (p = .012), but other analyzed demographics were similar between groups. When using 18 weeks as a referent group, with each additional completed week of gestation, subjects were more likely to have a completed scan, at 19 weeks (OR 1.29, CI 1.05–1.58); at 20 weeks (OR 1.46, CI 1.1–1.95); at 21 weeks (OR 2.12, CI 1.42–3.17) (p < .05 for each). This association persisted when adjusting for demographic factors. To identify the optimal timing for the second trimester ultrasound for fetal evaluation, we re-analyzed the data using each completed week of gestational age as the referent group. When using 19 weeks as the referent group, the odds of a complete scan were lower at 18 weeks, and higher at 21 weeks, but not different at 20 weeks. When using 20 weeks as the referent group, the odds of a complete scan were lower at 18 weeks, but not different at 19 or 21 weeks. Finally, when using 21 weeks as the referent group, the odds of a complete scan were lower at 18 and 19 weeks, but not different at 20 weeks. Conclusions In this cohort of obese gravidas, the odds of having a completed anatomic survey continued to improve until 21 weeks gestational age. When comparing completed scans between each week, 18 weeks demonstrated consistently lower odds of a complete scan, however 20 weeks did not differ significantly from 19 weeks. Therefore, consideration should be made to perform the initial second trimester ultrasound for fetal evaluation in obese patients at 19 weeks gestational age to optimize completion rates while minimizing scans performed at advancing gestational ages.

Maternal Outcomes of Ongoing Pregnancies Complicated by Fetal Life-Limiting Conditions.

This study aimed to examine maternal outcomes of ongoing pregnancies complicated by fetal life-limiting conditions. This was a retrospective matched cohort study of women with a diagnosis of fetal life-limiting condition between 2010 and 2018 in a single academic center. Cases were matched to controls (women who had normal fetal anatomic survey) according to year of delivery, body mass index, and parity in a 1:4 ratio. Bivariable and multivariable analyses were performed to compare the prevalence of the primary composite outcome, which included any one of the following: preeclampsia, gestational diabetes, cesarean delivery, third and fourth degree laceration, postpartum hemorrhage, blood transfusion, endometritis or wound infection, maternal intensive care unit admission, hysterectomy and maternal death, between cases and controls. During the study period, we found 101 cases that met inclusion criteria, matched to 404 controls. The rate of the composite maternal outcome did not differ between the two groups (39.6 vs. 38.9%, p = 0.948). For individual outcomes, women with diagnosis of fetal life-limiting condition had higher rates of blood transfusion (2.0 vs. 0%, p = 0.005) and longer length of the first stage of labor (median of 12 [6.8-22.0] hours vs. 6.6 [3.9-11.0] hours; p < 0.001). In a multivariable analysis, first stage of labor continued to be longer by an average of 6.48 hours among women with a diagnosis of fetal life-limiting condition compared with controls. After controlling for confounding factors, except a longer first stage of labor, women diagnosed with fetal life-limiting conditions who continued the pregnancy did not have a higher rate of adverse maternal outcomes. · The rates of ongoing pregnancies with fetal life-limiting conditions are increasing.. · Women with ongoing pregnancies with fetal life-limiting conditions had longer first stage of labor.. · The rest of the adverse maternal outcomes were not increased in this obstetric population..

The value of fetal growth biometry velocities to predict large for gestational age (LGA) infants

Objective The use of growth velocities derived from fetal biometrics have been suggested to improve prediction of large for gestational age (LGA). Our objective was to determine if ultrasonographic growth velocities (GV) for abdominal circumference (AC) and estimated fetal weight (EFW) improve the prediction of LGA infants when compared to Hadlock EFW. Methods This was a secondary analysis of data from a prospective study of women referred for growth ultrasounds during the 3rd trimester. Growth velocities (GV) for AC (AC − GV) and EFW (EFW − GV) were derived from the difference in Z-scores between measurements at the time of anatomy survey (18–24 week) and third trimester ultrasound (26–36 weeks). Change in AC − GV and EFW − GV >90th %ile alone or in combination with Hadlock EFW >90th%ile were compared for prediction of a LGA neonate. The primary outcome was the sensitivity and specificity of the (1) Hadlock EFW >90%ile, (2) AC − GV, (3) EFW − GV, (4) Hadlock EFW + AC − GV, and (5) Hadlock EFW + EFW − GV for the prediction of neonatal LGA. Test characteristics and area under the ROC curve (AUC) were determined. The association between the ultrasound predicted growth and adverse neonatal outcome was assessed using logistic regression. Results Of 630 women meeting inclusion criteria, 85 (13.5%) had LGA neonates. Hadlock EFW showed a better NPV (98.0%) and sensitivity (71.1%) when compared to AC − GV (NPV 87.5%, sensitivity 17.7%) and EFW − GV (NPV 88.0%, sensitivity 22.6%). Combining Hadlock EFW and AC-GV or EFW − GV did little to improve the test characteristics for the prediction of LGA (AUC 0.65 and 0.64, respectively). All five measurements were unable to predict a composite of adverse neonatal outcome or need for maternal cesarean delivery. Adjustment of the growth velocities for gestational age at anatomy scan or 3rd trimester growth scan did not change these results. Conclusion AC and EFW growth velocities do not appear to improve the prediction of LGA infants when compared to using the third trimester Hadlock EFW.

Is a Fetal Echocardiography Necessary in IVF-ICSI Pregnancies After Anatomic Survey?

In vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) is generally regarded as an indication for fetal echocardiography due to a reported increased risk of congenital abnormalities including cardiac anomalies. In this study we evaluated the utility of fetal echocardiography after anatomic survey in an experienced center. This was a retrospective case review of in vitro fertilization with intracytoplasmic sperm injection pregnancies who had echocardiography in our institution from January 1996 to October 2010. Records from 85 mothers and 110 fetuses were identified. During anatomic survey, six cardiac anomalies were identified, including four ventricular septal defects, one pulmonary-aortic disproportion, and one post-valvular pulmonary artery dilatation. At fetal echocardiography, two of the four ventricular septal defects were confirmed and an additional three were identified. The most common cardiac anomaly seen in our population of IVF-ICSI pregnancies was ventricular septal defect, which was identified in 3.6% of all cases in the neonatal period. Of ventricular septal defects identified in the prenatal period, 71% resolved before birth. In experienced centers, a fetal echocardiography may not be necessary if the 3 vessels tracheal view of the heart is evaluated and the heart is evaluated carefully for a ventricular septal defect.

Neonatal Outcomes and Frequency of Ultrasound in Pregnant Women With Prior Bariatric Surgery [26O

INTRODUCTION: Infants of women who have undergone bariatric surgery are more likely to be born small for gestational age (SGA). We sought to identify whether increased ultrasound surveillance lead to better neonatal outcomes. We hypothesized that women with less than 2 ultrasounds (US) after their anatomical survey were more likely to have poor neonatal outcomes. METHODS: IRB approval was obtained. This was a single center, retrospective cohort study of 189 singleton pregnancies after bariatric surgery between 2005–2019. Patients were placed in 2 categories: those with less than 2 ultrasounds after fetal anatomic survey (FAS) or those with greater than or equal to 2 ultrasounds after FAS. US information and neonatal outcomes were compared between these two groups. A neonatal composite was utilized as a measure of adverse neonatal outcome. RESULTS: Of the 189 patients, 165 had documentation of FAS or beyond. 48 patients had less than 2 US and 117 had greater than or equal to 2 US. Women with less than 2 US had their last US at approximately 26.7 weeks (vs 36.5, P&lt;.001), they were more likely to deliver at an earlier gestational age (36.6 vs. 38.2 weeks, P=.005), and had an increased likelihood of a composite adverse neonatal outcome (aOR 0.36, 95%CI 0.15–0.86) including NICU admission, jaundice, hypoglycemia, respiratory distress, and macrosomia, after controlling for confounders. CONCLUSION: Less frequent ultrasound surveillance in women with previous bariatric surgery is associated with earlier gestational age at delivery and higher rates of adverse neonatal outcomes.