Anatomy Ultrasound Research Articles

Defining an Evaluation Protocol for the Infant with Fetal Echogenic Bowel.

This study aimed to develop an algorithm for pediatricians to use for infants diagnosed with fetal echogenic bowel (FEB) to ensure that each patient is fully evaluated for possible complications while avoiding unnecessary morbidity and mortality and health care-associated costs. This was a prospective cohort of neonates for which a diagnosis of FEB was made during a Level 2 anatomy ultrasound between February 2016 and January 2017. Women diagnosed with FEB were offered perinatal genetic counseling and testing. These women also received increased third trimester fetal surveillance, including daily fetal kick counts, fetal growth scans every 3 to 4 weeks beginning at 28 weeks, and weekly fetal nonstress test (NST) and/or BPP beginning at 32 weeks. After delivery, neonates received a postnatal evaluation including birth weight, gestational age at birth, presence of other abnormalities, and associated perinatal morbidity and mortality. Comparison between findings was performed using chi-square test. All statistical evaluation was performed using SPSS. Among 919 pregnant patients who received Level 2 anatomy ultrasounds at a Regional Perinatal Center during the study period, 70 received a diagnosis of FEB. Of those diagnosed with FEB, 52 (74.3%) delivered at the same Regional Medical Center. Of these 52 delivered infants, 3 (5.8%) were intrauterine fetal demises (IUFDs) and 4 (7.6%) had unaffected twins. Only one multifetal gestation had the diagnosis of FEB in both the twins. Only 19 of the infants delivered had a kidney, ureter, and bladder X-ray (KUB) performed secondary to prematurity or abnormal exams. This study showed that the majority of infants diagnosed with FEB had a normal exam following delivery, and that most of the neonatal outcomes of neonatal intensive care unit admissions and other neonatal complications are a result of prematurity rather than FEB. Although the algorithm did not have significant results, it is easy to follow and implement in larger studies. · Majority of infants with FEB have a normal physical exam after delivery.. · Majority of neonatal outcomes evaluated were a result of prematurity rather than FEB.. · FEB is a soft marker for potential abnormalities and fetal morbidity/mortality..

AUTOSOMAL RECESSIVE POLYCYSTIC KIDNEY DISEASE ABOUT A NEW CASE REPORT

We present the case of a 25-year-old woman gravida 2, para 01 who presented for childbirth at 40 weeks of gestation. Which Fetal Anatomy Ultrasound showed enlarged, hyperechoic fetal kidneys and a normal amniotic fluid index. Karyotyping was done on umbilical cord blood to look for mutations in the PKHD1 gene for the presumptive diagnosis of autosomal recessive polycystic kidney disease (ARPKD). In our patient, a previously reported pathogenic missense mutation in the PKHD1 gene, c.10444C>T, was found to be maternally inherited. A second previously unknown de novo mutation, c.5909-2delA, was discovered. This mutation is likely pathogenic because it affects the canonical splice site. Our case emphasizes PKHD1 allelic heterogeneity and the importance of prenatal genetic testing in a setting where many other genetic etiologies can phenocopy ARPKD.

Presence and Size of Placental Lakes on 20-Week Fetal Anatomy Ultrasound and Obstetrical Outcomes

Our objective was to determine if placental lake presence or size is associated with adverse pregnancy outcomes. This was a retrospective cohort of patients who had fetal anatomy ultrasounds at 18–22 weeks and delivered between 2018 and 2022. Placental lakes were classified as small (>2.0 to 3.9 cm) or large (≥4 cm). Multiple gestations, placenta previas, and placenta accretas were excluded. Outcomes included low birthweight, cesarean delivery, primary cesarean for non-reassuring fetal heart tracing, fetal growth restriction, preterm birth, and severe preeclampsia. A total of 1052 patients were included; 294 had placental lakes (204 small, 90 large). No differences in pregnancy outcomes were observed.

First trimester anatomy ultrasound for patients with obesity: a randomized controlled trial

Second-trimester ultrasound is the standard technique for fetal anatomy evaluation in the United States despite international guidelines and literature that suggest that first-trimester timing may be superior in obese patients. First-trimester imaging performs well in cohorts of obese participants. Our aim was to compare the completion rate of first-trimester fetal anatomy to second-trimester fetal anatomy ultrasound in pregnant people with body mass index (BMI) ≥ 35 kg/m2. This randomized controlled trial enrolled participants with BMI ≥ 35 kg/m2 with singleton gestation, presenting before 14 0/7 weeks of gestation. Participants were randomized to receive ultrasound assessment of anatomy at either 12 0/7 to 13 6/7 weeks, or at 18 0/7 to 22 6/7 weeks. The primary outcome was completion rate (percent of scans that optimally imaged all required fetal structures). Secondary outcomes included the necessity of a transvaginal approach, completion rates of each individual view, number of anomalies identified and missed in each group, scan duration, and patient perspectives. A one-year pilot sample was analyzed using Bayesian methods for the primary outcome with a neutral prior, and frequentist analyses for the remaining outcomes. A total of 128 participants enrolled, 1 withdrew consent; 62 subjects received a first-trimester ultrasound and 62 received a second-trimester ultrasound; 2 did not attend research visits, and 1 sought termination of pregnancy. In the first-trimester group, 66% (41/62) of ultrasounds were completed compared to 53% (33/62) in the second-trimester ultrasound group (Bayesian relative risk (RR) 1.20, 95% credible interval 0.91-1.73). Compared to a second-trimester scan plus one follow-up ultrasound, a first-trimester ultrasound plus a second-trimester ultrasound was equally successful for completing anatomy (76%). First-trimester anatomy ultrasounds required a transvaginal approach in 63% (39/62) of cases and had a longer duration compared to a second-trimester ultrasounds. No anomalies were missed in either group. First-trimester ultrasound participants who responded to a survey described that they were very satisfied with the technique. Inpregnant subjects with BMI>35, a single first-trimester anatomy ultrasound is more likely to obtain all recommended anatomic views compared to a single second-trimester ultrasound. An evaluation of anatomy at 12 0/7 to 13 6/7 weeks, plus an evaluation at 18 0/7 to 22 6/7 resulted in complete evaluation 4 weeks earlier than two second trimester scans. Assessment of ultrasound duration in a clinical setting is needed to ensure feasibility outside of a research setting.

In utero effects of opioids on fetal growth

Background Studies indicate antenatal opioid use is associated with birth size deficits, as evidenced by reductions in birth weight and head circumference. However, there remains a limited understanding of how early this growth restriction occurs, and what specific parameters are affected. This novel study evaluated global and specific growth deficits associated with prenatal opioid exposure between 18–22 weeks’ gestation as assessed during anatomy ultrasounds. Methods Pregnant women who completed an anatomy ultrasound were identified via electronic medical records from a large academic obstetric practice. The study group used opioids, with tobacco and/or marijuana use permitted (n = 41). The control group could have used tobacco and/or marijuana, but not opioids (n = 308). Neither group had alcohol or other drug exposure. Records were reviewed for medical history and ultrasound size parameters, coded as percentiles for gestational age. Results Demographics and medical histories were compared with several significant differences noted. After controlling for these differences, significant (p < 0.05) growth deficits were identified in opioid-exposed fetuses. Specifically, reductions >10 percentile points were observed in head circumference, biparietal diameter, and humerus length for opioid-exposed fetuses compared to controls. Additionally, intrauterine growth restriction (IUGR) was diagnosed five times more often. Femur length was significantly reduced in opioid-exposed fetuses prior to adjustment for confounding (p = .016), but this reduction was not significant (p = .072) after controlling for background differences. Estimated fetal weight (p = .274) and abdominal circumference (p = .633) were not significantly different between exposure groups. Conclusion Fetal opioid exposure predicted various bone growth deficits during routine anatomy ultrasound, indicating the effects of opioid exposure on size deficits may be evident as early as 18–22 weeks’ gestation. These findings may also suggest that in utero opioid exposure negatively impacts bone growth specifically rather than weight or fat/muscle mass. Additional studies with larger sample sizes may also reveal significantly reduced femur length, further supporting a negative impact on bone growth. Future studies evaluating bone health and immune function in children after antenatal opioid exposure may help clarify this specific effect of opioids on bone development.

Performance of comprehensive first trimester fetal anatomy assessment.

Ultrasound assessment of the fetal anatomy and fetal echocardiography are feasible in the first trimester of pregnancy. This study was designed to assess the performance of a comprehensive fetal anatomy assessment in a high-risk population at a tertiary fetal medicine unit. A retrospective review of high-risk patients undergoing comprehensive fetal anatomy ultrasound assessment between 11weeks and 13+6weeks of gestation was conducted. Findings of the early anatomy ultrasound scan were compared with those of the second trimester anatomy scan, and birth outcomes or post-mortem results. Early anatomy ultrasounds were performed in 765 patients. The sensitivity of the scan for detecting fetal anomalies compared to the birth outcome was 80.5% (95% CI 73.5-86.3) and specificity was 93.1% (95%CI 90.6-95.2). Positive and negative predictive values were 78.5% (95% CI 71.4-84.6) and 93.9% (95% CI 91.4-95.8), respectively. The most missed and overdiagnosed abnormalities were ventricular septal defects. The second trimester ultrasound had sensitivity of 69.0% (95% CI 55.5-80.5) and specificity of 87.5% (95% CI 84.3-90.2). In a high-risk population, early assessments had similar performance metrics as the second trimester anatomy ultrasound. We advocate for a comprehensive fetal assessment in the care of high-risk pregnancies.

Omphalocele and gastroschisis trends among states with vs without 20-week abortion bans from 2012-2018

Prior to recent legislature changes, many states enacted 20-week abortion bans. As related laws are implemented, understanding associated impacts may help guide future care. Gastroschisis and omphalocele diagnoses are often diagnosed at 20-week anatomy ultrasounds. Omphalocele is more often associated with other anomalies and carries a greater mortality rate compared to gastroschisis. We sought to examine trends in rates of gastroschisis and omphalocele diagnoses between states with and without 20-week abortion bans in the US during 2012-2018. A retrospective cohort study of all deliveries in the US between 2012-2018 using linked vital statistics data. Data analysis stratified gastroschisis vs omphalocele. States were categorized as those with or without a 20-week abortion ban. States that enacted bans later than 2014 were included in the no-ban group. We used Cochrane-Armitage tests to assess trends and multivariable logistic regressions to control for maternal age, race, education, insurance, and ≥ 5 prenatal visits. Our cohort consisted of 17,444,271 deliveries in states without 20-week abortion bans and 8,763,579 deliveries in states with such bans. Diagnoses of gastroschisis significantly decreased over time in both states with and without 20-week abortion bans (p=0.0001, p< 0.0001) (Figure 1). In states with bans, omphalocele rates increased significantly over time (p=0.0042) (Table 1). In states without bans, no significant change in rates were shown (p=0.4971). Between 2012-2018, omphalocele rates increased significantly in states with 20-week abortion bans, while displaying no significant change in states without bans. Gastroschisis rates decreased significantly in both states with and without abortion bans, with no significant differences between the two groups. As many 20-week abortion bans were enacted near the beginning of the time period of this study, it’s possible that the differences seen are related to these policies, indicating that such legislation may inhibit patient autonomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Changes in prenatal testing during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic disrupted healthcare delivery, including prenatal care. The study objective was to assess if timing of routine prenatal testing changed during the COVID-19 pandemic. Retrospective observational cohort study using claims data from a regional insurer (Highmark) and electronic health record data from two academic health systems (Penn Medicine and Yale New Haven) to compare prenatal testing timing in the pre-pandemic (03/10/2018-12/31/2018 and 03/10/2019-12/31/2019) and early COVID-19 pandemic (03/10/2020-12/31/2020) periods. Primary outcomes were second trimester fetal anatomy ultrasounds and gestational diabetes (GDM) testing. A secondary analysis examined first trimester ultrasounds. The three datasets included 31,474 pregnant patients. Mean gestational age for second trimester anatomy ultrasounds increased from the pre-pandemic to COVID-19 period (Highmark 19.4 vs. 19.6 weeks; Penn: 20.1 vs. 20.4 weeks; Yale: 18.8 vs. 19.2 weeks, all p < 0.001). There was a detectable decrease in the proportion of patients who completed the anatomy survey <20 weeks' gestation across datasets, which did not persist at <23 weeks' gestation. There were no consistent changes in timing of GDM screening. There were significant reductions in the proportion of patients with first trimester ultrasounds in the academic institutions (Penn: 57.7% vs. 40.6% and Yale: 78.7% vs. 65.5%, both p < 0.001) but not Highmark. Findings were similar with multivariable adjustment. While some prenatal testing happened later in pregnancy during the pandemic, pregnant patients continued to receive appropriately timed testing. Despite disruptions in care delivery, prenatal screening remained a priority for patients and providers during the COVID-19 pandemic.

Abstract 13695: Is There Utility of Fetal Echocardiogram for Isolated in vitro Fertilization Pregnancies?

Introduction: Risk of congenital heart disease (CHD) for in vitro fertilization (IVF) pregnancies is higher than the general population, though other factors may be involved. IVF is an indication for fetal echocardiogram (FE), however there is center variation to perform FE without a secondary indication if the anatomy ultrasound (AU) is normal. We aim to assess the number of new CHD diagnoses following normal AU in IVF-only pregnancies. Hypothesis: We hypothesize that there is minimal benefit to a FE in IVF-only pregnancies with a normal AU and may result in overutilization of resources. Methods: Retrospective chart review from 2016-2021 of all IVF pregnancies with and without a secondary indication for FE at our center. Those without FE during the COVID-19 pandemic were included to assess postnatal CHD detection. Patients were classified as IVF-only if they had a normal AU and no secondary indication for FE; all others classified as IVF+other. Maternal and fetal demographics, AU, FE, and postnatal echo (post-echo) data was obtained. Results: A total of 556 maternal and 628 fetal patients from IVF pregnancies were included; 401 fetuses were IVF-only with a FE, 116 were IVF-only with no FE, the remaining were IVF+other. There was no complex CHD (CCHD) in either IVF-only groups, the FE group detected several minor findings, and the no FE group detected three small septal defects on post-echo (Table 1). The probability of a normal postnatal evaluation in IVF-only with a normal FE was 94% and with no FE was 96%. Minor variations found on FE triggered additional testing (71 total FE in 43 fetuses) and detected a few minor CHD, none requiring intervention. Conclusions: Given low-risk for CCHD in IVF-only pregnancies, there is minimal benefit to a FE in the setting of a normal comprehensive AU and raises questions of cost vs. benefit of FE. This may impact future recommendations for indications for FE in the setting of IVF-only without added risk factors for CHD.

Impact of the COVID-19 Pandemic on Prenatal Care Utilization at a Public Hospital.

The aim of the study is to compare rates of prenatal care utilization before and after implementation of a telehealth-supplemented prenatal care model due to the coronavirus disease 2019 (COVID-19) pandemic. Using electronic medical record data, we identified two cohorts of pregnant persons that initiated prenatal care prior to and during the COVID-19 pandemic following the implementation of telehealth (from March 1, 2019 through August 31, 2019, and from March 1, 2020, through August 31, 2020, respectively) at Grady Memorial Hospital. We used Pearson's Chi-square and two-tailed t-tests to compare rates of prenatal care utilization, antenatal screening and immunizations, emergency department and obstetric triage visits, and pregnancy complications for the prepandemic versus pandemic-exposed cohorts. We identified 1,758 pregnant patients; 965 entered prenatal care prior to the COVID-19 pandemic and 793 entered during the pandemic. Patients in the pandemic-exposed cohort were more likely to initiate prenatal care in the first trimester (46.1 vs. 39.0%, p = 0.01), be screened for gestational diabetes (74.4 vs. 67.0%, p <0.001), and receive dating and anatomy ultrasounds (17.8 vs. 13.0%, p = 0.006 and 56.9 vs. 47.3%, p <0.001, respectively) compared with patients in the prepandemic cohort. There was no difference in mean number of prenatal care visits between the two groups (6.9 vs. 7.1, p = 0.18). Approximately 41% of patients in the pandemic-exposed cohort had one or more telehealth visits. The proportion of patients with one or more emergency department visits was higher in the pandemic-exposed cohort than the prepandemic cohort (32.8 vs. 12.3%, p < 0.001). Increases in rates of labor induction were also observed among the pandemic-exposed cohort (47.1 vs. 38.2%, p <0.001). Rates of prenatal care utilization were similar before and during the COVID-19 pandemic. However, pregnant persons receiving prenatal care during the pandemic entered care earlier and had higher utilization of certain antenatal screening services than those receiving prenatal care prior to the pandemic. · Patients initiated prenatal care earlier during the COVID-19 pandemic.. · Uptake of telehealth services was low.. · Rates of diabetes screening and ultrasound use increased during the pandemic..

Impact of a Potential 20-Week Abortion Ban on Likelihood of Completing Required Views in Second-Trimester Fetal Anatomy Ultrasound.

The aim of this study was to quantify the likelihood of assessing all mandated fetal views during the second-trimester anatomy ultrasound prior to the proposed federal 20-week abortion ban. Retrospective cohort study of a random sample of 1,983 patients undergoing anatomy ultrasound in 2017 at a tertiary referral center. The difference in proportion of incomplete anatomic surveys prior compared with after 20-week gestation was analyzed using X 2 and adjusted logistic regression; difference in mean days elapsed from anomaly diagnosis to termination tested using t-tests and survival analysis. Incomplete views were more likely with initial ultrasound before 20 weeks (adjusted relative risk: 1.70; 95% confidence interval: 1.50-1.94); 43.5% versus 26.1% were incomplete before and after 20 weeks, respectively. Fetal structural anomalies were identified in 6.4% (n = 127/1,983) scans, with 38.0% (n = 49) identified at follow-up after initial scan was incomplete. 22.8% (n = 29) with an anomaly terminated. A complete assessment of fetal views during an anatomy ultrasound prior to 20-week gestation is often not technically feasible. Legislation limiting abortion to this gestational age would greatly impact patient's ability to make informed choices about their pregnancies. · It is often not technically possible to complete anatomy ultrasound prior to 20-week gestation.. · Often, anomalies are missed during early, incomplete anatomy ultrasounds.. · After the diagnosis of a structural anomaly, one in five chose to terminate the pregnancy..

Implementing a Universal Cervical Length Screening Program in a Large Hospital System: It Takes Some Time to Achieve Consistent Results

Objective: The aim of the study was to describe changes in the acceptance of transvaginal (TV) cervical length (CL) assessment and in the variance of CL measurements among operators, after implementation of universal TV-CL screening at 18+0 – to 23+6 weeks/days of gestation. Design: Retrospective cohort. Participants/Materials, Setting, Methods: This study was performed after universal TV-CL screening was implemented at the University of Texas Health Science Center in Houston, TX, USA, for all women undergoing an anatomy ultrasound (US) between 18 0/6 and 23 6/7 weeks/days of gestation. Pregnant women carrying singletons without prior history of preterm delivery who underwent anatomy US evaluation between September 2017 and March 2020 (30 months) were included. The complete study period was divided into five epochs of 6 months each. Changes in patient’s acceptance for the TV scan, in CL distribution, in the prevalence of short cervix defined as ≤15, ≤20, or ≤25 mm, and in the performance of US operators across the five epochs were evaluated. Success rate was defined as the percentage of TV-CL measurements obtained in relation to the number of second-trimester anatomy scans. Results: A total of 22,207 low-risk pregnant women evaluated by 36 trained sonographers (operators) were analyzed. Overall, the acceptance for TV-CL measurement was 82.3% (18,289/22,207), increasing from 76.7% in the first epoch to 82.8% (p < 0.0001) in the last epoch. The mean CL did not significantly change from 38.6 mm in the first epoch to 38.5 mm in the last epoch (p = 0.7); however, the standard deviation decreased from 7.9 mm in the first epoch to 7.04 mm in the last epoch (p = <0.01). The prevalence of a short cervix ≤25 mm was 2.2% (n = 399/18,289), ≤20 mm was 1.2% (224/18,289), and ≤15 mm was 0.9% (162/18,289). This prevalence varied only for CL ≤25 mm from 3.02% (88/2,907) in the first epoch to 1.77% (64/3,615) in the last epoch (p = 0.0009). There was a variation in CL measurements among operators (mean 3.3 mm). Sonographers with less than 1 year of experience had a lower success rate for completing TV-CL examinations than more experienced sonographers (80.8% vs. 85.8%; p < 0.03). In general, 77% (27/35) of operators had a success rate ≥80% for completing TV-CL scans. Limitations: Characteristics of individuals who accepted versus those who declined TV-CL were not compared; CL values were not correlated with clinical outcomes. Conclusions: During the first 6 months after implementation of a universal CL screening program, there was greater variation in CL measurements, lower acceptance for TV US, and a higher number of women diagnosed with a CL ≤25 mm, as compared to subsequent epochs. After the first 6 months, these metrics improved and remained stable. Most operators improved their performance over time; however, there were a few with a low success rate for TV-CL and others who systematically over- or underestimate CL measurements.

EP460: Diagnostic dilemma in a case of suspected fetal skeletal dysplasia

Intrauterine fetal fractures are a rare finding and can represent lethal skeletal dysplasias such as Osteogenesis Imperfecta, or other metabolic or structural abnormalities. More than 400 skeletal dysplasias have been described; some are associated with classical modes of inheritance, while others are associated with imprinting errors, mosaicism, and teratogen exposure. Accurate prenatal diagnosis is critical for appropriate patient counseling, pregnancy management and expected postnatal outcomes. Prenatal ultrasound (US) remains the standard imaging modality for identifying prenatal structural abnormalities; this, coupled with genetic testing, can aid in establishing diagnoses. Available clinical testing includes chromosome microarray, panel testing, exome, and genome sequencing (ES and GS, respectively). Despite the availability of ES and GS, the genetic or molecular mechanism may remain elusive. Here we present a case of suspected campomelic dysplasia which remains a diagnostic dilemma despite thorough genetic evaluation. A 31-year-old Gravida 2 Para 1-0-0-0 at 20 weeks gestation presented for anatomy US at our Maternal Fetal Medicine clinic. This was an IVF pregnancy. Her obstetric history is complicated by one prior emergency Cesarean delivery for a 35-week fetus with decreased fetal movement and non-reassuring fetal heart tones. The neonate passed 5 days after birth with severe encephalopathy of unknown etiology. The patient and partner are otherwise healthy and have no pertinent medical or surgical history. Family history was non-contributory. Initial anatomy US for current pregnancy revealed a singleton female fetus with severely bowed femurs bilaterally with concern for fracture on the right femur, talipes equinovarus of left foot, with all bones showing normal ossification. The fetus was growth restricted at <10th percentile with all shortened long bones. Markers of lethality of skeletal dysplasia including cardiothoracic (CT) ratio was 53% (normal <50%), and femur length (FL): abdominal circumference (AC) ratio was 0.11 (Normal >0.16). These findings prompted diagnostic genetic work up with amniocentesis sent for FISH, chromosome microarray, and a 700 gene skeletal dysplasia panel; all of which returned normal. Sonographic surveillance continued to show a constellation of findings concerning for skeletal dysplasia including bilateral proximal femoral diaphyseal bowing/fractures, left clubfoot, 11 total ribs, micrognathia, chest-to-abdominal circumference CC/AC ratio 0.87, and FL/AC ratio 0.19 (considered severe when CC/AC <0.60 or FL/AC <0.16). Fetal MRI at 32 weeks demonstrated normal fetal brain structure, short femurs, normal lung volumes, unilateral talipes and micrognathia. The patient underwent prenatal ES, which was negative for pathogenic or likely pathogenic variants associated with the prenatal phenotype. The patient underwent a repeat Cesarean Delivery at 38w2d and delivered a liveborn female neonate weighing 2670 grams with Apgar scores of 7 and 9 at 1 and 5 minutes respectively. ENT was available at bedside for possible neonatal airway compromise. On postnatal physical exam, the neonate was normocephalic with age appropriate fontanelles. There was micrognathia with intermittent airway obstruction and evidence of Pierre Robin sequence. The spine was straight without lesions, both femurs were shortened with clubbing of the left foot. All fingers and toes appeared normal. A skeletal survey revealed 12 ossified rib pairs, hip dislocation, lateral bowing/angulation of the mid femoral diaphyses, as well as club feet bilaterally. No fractures were identified. With exception of hip abduction, she had appropriate movement of her extremities. Postnatal expanded GS was pursued; results revealed no pathogenic, likely pathogenic or variants of uncertain significance. Further research -based testing was pursued through Optical Mapping; this revealed several genomic insertion, deletion, inversion, duplication, and translocation events involving multiple genes. However, after review by our Center for Individualized Medicine (CIM) Genomic Odyssey Board (GOB) team, none of the reported genomic events were felt to be a good fit with the infant’s phenotype. This case remains a diagnostic dilemma. Rapid GS and research based optical mapping failed to identify an underlying genetic etiology. This case illustrates challenges associated with prenatal diagnosis of suspected skeletal dysplasias.

Utility of Screening Fetal Echocardiogram Following Normal Anatomy Ultrasound for In Vitro Fertilization Pregnancies

In vitro fertilization (IVF) is associated with a higher incidence of congenital heart disease, resulting in universal screening fetal echocardiograms (F-echo) even when cardiac structures on obstetric scan (OB-scan) are normal. Recent studies suggest that when OB-scan is normal, F-echo may add little benefit and increases cost and anxiety. We aim to determine the utility of screening F-echo in IVF pregnancies with normal cardiac anatomy on prior OB-scan. We conducted a retrospective chart review of IVF pregnancies referred for F-echo at the Seattle Children's Hospital between 2014 and 2020. OB-scan results and subspecialty of interpreting physician (Obstetrics = OB; Maternal Fetal Medicine = MFM; Radiology = Rads), F-echoes, and postnatal outcomes were reviewed. Cardiac anatomy on OB-scans was classified as complete if 4-chamber and outflow-tract views were obtained. Supplemental views (three-vessel and sagittal aortic arch views) on OB-scan were also documented. Of 525 IVF referrals, OB-scan reports were available for review in 411. Normal anatomy was demonstrated in 304 (74%) interpreted by OB (128; 42%), MFM (80; 26%), and Rads (96; 32%). F-echo was normal in 278 (91%). Of the 26 abnormal F-echo, none required intervention (17 muscular and 5 perimembranous ventricular septal defects, and 4 minor valve abnormalities). There was no difference in OB-scan accuracy for identifying normal cardiac anatomy when comparing 4-chamber and outflow-tract views vs. addition of supplemental views (91% vs 92% normal F-echo; p > 0.1). Evaluation of OB-scan accuracy by interpreting physician subspecialty demonstrated normal F-echo in 95%, 85%, and 92% (p = 0.95) as read by OB, MFM, and Rads, respectively. A majority of IVF referrals with normal cardiac anatomy visualized on OB-scan using 4-chamber and outflow-tract views resulted in normal F-echo, regardless of interpreting physician subspecialty or addition of supplemental views. Of the minority with abnormal F-echo, none required intervention. Consideration should be given to the cost/benefit of screening F-echo for the indication of IVF if normal cardiac anatomy is demonstrated on OB-scan.

Mandibular Measurements at the 20-Week Anatomy Ultrasound as a Prenatal Diagnostic Predictor of Pierre Robin Sequence.

Pierre Robin Sequence (PRS) is characterized by micrognathia, glossoptosis, and upper airway obstruction. Early recognition and appropriate perinatal management is crucial for optimizing outcomes. This study aimed to evaluate 20-week fetal ultrasounds to determine if specific mandibular measurements could predict PRS diagnosis and disease severity. A retrospective case-control study of 48 patients with PRS and gender-matched controls was performed. Medical records were reviewed for respiratory and surgical interventions. Three parameters to assess micrognathia were measured on mid-sagittal profile ultrasound images: frontal nasal-mental angle (FNMA), facial-maxillary angle (FMA), and alveolar overjet. Student's t-test and univariate logistic regression was performed. P ≤ 0.05 was considered statistically significant. Patients with PRS demonstrated a significantly smaller mean FNMA compared to the control group, 129.3 ± 8.6° and 137.4 ± 3.2°, respectively (p < 0.0001), as well as significantly smaller mean FMA, 63.2 ± 9.2° and 74.8 ± 6.1°, respectively (p < 0.0001). The PRS group also demonstrated significantly larger mean alveolar overjet compared to the control group, 3.9 ± 1.4 mm and 2.1 ± 0.9 mm, respectively (p < 0.0001). The odds of respiratory intervention increased among cases when FMA was <68°. Additionally, there was a significant difference in median overjet between patients with PRS who did and did not require respiratory intervention. Mandibular features on the 20-week ultrasound can be measured to predict diagnosis and severity of PRS. This is an important first step to prepare for potential respiratory intervention at delivery to minimize perinatal hypoxia. Alveolar overjet, previously not described in prenatal ultrasound literature, is measurable and has utility in prenatal screening for PRS, as do FMA and FNMA.

556 Resolved but not forgotten: does a diagnosis of resolved placenta previa affect labor and delivery?

Placenta previa (PP) is diagnosed in up to 15% of pregnancies at the anatomy ultrasound (US) and 0.5% persist to term. There is limited data regarding pregnancy outcomes with resolved previa (RPP). We aim to examine patients with RPP to determine if abnormal placentation at any time during pregnancy is associated with adverse events during labor. Anatomy US done at the Mount Sinai West Fetal Evaluation Unit between Mar 2018 - June 2020 were reviewed. Patients with PP were identified, included if PP resolved with placental edge >2cm from os, excluded if PP persisted to term, resolution occurred prior to 20 weeks, prior cesarean delivery or missing outcomes. Time matched controls identified among patients with normal placentation. Demographic data and outcomes collected. Student t-test, Wilcoxon rank-sum test, Chi-square, Fisher exact test, Univariable and multivariable logistic regression were used as appropriate A total of 8,881 US were performed, 560 with PP, 275 identified as RPP, 285 excluded. RPP patients were significantly older with lower pre pregnancy BMI. Patients with RPP were significantly more likely to be a current smoker, have used assisted reproductive technology, have had previous uterine surgeries (Table 1). Patients with RPP were 5.2 times more likely to have a post partum hemorrhage (PPH) (OR 5.2, 95% CI 2.1-12.7; p<0.01) and 3.4 times more likely to require extra uterotonic medications (OR 3.4, 95% CI 1.9-6.2; p<0.01). As the placental edge gets farther away from the os at resolution, the risk of PPH decreases (OR 0.9, 95% CI 0.9-1.0; p=0.03). There is no difference with regards to rates of operative delivery or cesarean delivery for fetal distress (OR 1.2, 95% CI 0.7-1.9; p=0.48), or Cat II/III fetal heart tracing at delivery. Patients with RPP had a higher rate of PPH and use of uterotonic agents. They were also more likely to have similar underlying risk factors of patients with persistent PP. This information might have important clinical implications and could be incorporated into the hemorrhage risk assessment during labor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abstract 17104: Utility of Screening Fetal Echocardiogram Following Normal Anatomy Ultrasound for In Vitro Fertilization Pregnancies

Introduction: In-vitro fertilization (IVF) is associated with a higher incidence of congenital heart disease (CHD), resulting in universal screening fetal echocardiograms (F-echo) even when obstetric scan (OB-scan), including cardiac structures is normal. Recent studies suggest that when OB-scan is normal, F-echo may add little benefit and increases cost and anxiety. We aim to determine the utility of screening F-echo in IVF pregnancies with normal cardiac anatomy on prior OB-scan. Methods: We conducted a retrospective chart review of IVF pregnancies referred for F-echo at the Seattle Children’s Hospital between 2014 and 2020. OB-scan results and subspecialty of interpreting physician (Obstetrics=OB; Maternal Fetal Medicine=MFM; Radiology=Rads), F-echos, and postnatal outcomes were reviewed. Cardiac anatomy on OB-scans was classified as complete if 4-chamber and outflow-tract views were obtained. Supplemental views (three-vessel and sagittal aortic arch views) on OB-scan were also documented. Results: Of 525 IVF referrals, 450 had normal F-echo. OB-scan reports were available for review in 411; 304 (74%) demonstrated normal cardiac anatomy and were interpreted by OB (42%), MFM (61%) and Rads (31%). F-echo was normal in 270 (88%). Of the 34 abnormal F-echo, none required intervention (16 muscular and 5 perimembranous ventricular septal defects, 9 minor valve abnormalities, 2 mild ventricular hypertrophy, 2 arrhythmia). There was no difference in OB-scan accuracy for identifying normal cardiac anatomy when comparing 4-chamber and outflow-tract views vs. addition of supplemental views (88% vs 90% normal F-echo; p&gt;0.1). Evaluation of OB-scan accuracy by interpreting physician subspecialty demonstrated normal F-echo in 93%, 80%, 91% read by OB, MFM and Rads, respectively. Conclusions: A majority of IVF referrals with normal cardiac anatomy visualized on OB-scan using 4-chamber and outflow-tract views resulted in normal F-echo, regardless of interpreting physician subspecialty or addition of supplemental views. Of the minority with abnormal F-echo, none required intervention. Consideration should be given to the cost/benefit of screening F-echo for the indication of IVF if normal cardiac anatomy is diagnosed on OB-scan.

Successful Management of Severe Idiopathic Fetal Hydrops With Thoracoamniotic Shunts [34P

INTRODUCTION: This case report describes successful management of severe idiopathic fetal hydrops with thoracoamniotic shunts. METHODS: Patient is a 38 y/o G2P0010 who initiated care at 6 weeks. She was evaluated by perinatology for AMA and a fibroid uterus. First trimester and anatomy ultrasounds were unremarkable. She had low-risk genetic screening and normal MSAFP. A growth ultrasound at 23 weeks demonstrated bilateral pleural effusions. Evaluation included: normal fetal echocardiogram, Rh positive with no antibodies, negative serum TORCH titers, normal microarray, and negative amniotic fluid TORCH PCR. Due to worsening bilateral pleural effusions and development of fetal hydrops, patient underwent left-sided thoracoamniotic shunt placement at 25 and 26 weeks after receiving antenatal corticosteroids with resolution of left-sided pleural effusion and hydrops. She was admitted at 31 weeks for re-accumulation of left-sided pleural effusion and administration of rescue corticosteroids. At 32 weeks the fetus was again noted to have fetal hydrops and delivery was recommended. A primary LTCS was performed due to nonreassuring fetal heart tones. Patient delivered a female fetus weighing 1845 gram with APGARS of 2/7. The neonate spent 25 days in NICU with no evidence of pulmonary hypoplasia and was discharged home in stable condition. There was no identified etiology for hydrops and neonate was thriving at 6 week postpartum visit. CONCLUSION: Fetal intervention in a severe case of fetal hydrops can lead to an excellent neonatal outcome. Placement of thoracoamniotic shunts allowed for fetal lung development in setting of severe pleural effusions and allowed an additional 6 weeks of intrauterine growth.

Outcomes of Isolated Antenatal Hydronephrosis at First Year of Life

To compare the grade of hydronephrosis between the antenatal and first postnatal ultrasound (US) and their clinical outcomes. This retrospective study included all cases of isolated hydronephrosis detected by antenatal US from August 2005 to February 2011. Hydronephrosis was classified based on the standard criteria into mild, moderate, or severe. Cases associated with other major congenital anomalies were excluded. All patients were followed-up postnatally and outcomes available were analyzed at one year of age. A total of 105 cases were included out of which 83 (79.0%) were males and 22 (20.9%) were females with a median gestational age of 38 weeks. First postnatal US of 105 cases showed that 20 (19.0%) were free of hydronephrosis, 39 (37.1%) had mild, 29 (27.6%) moderate, and 17 (16.1%) had severe hydronephrosis. Half (50.4%) of hydronephrosis cases improved in their clinical presentation while 13.3% showed deterioration and 36.3% remained the same. Almost half of all cases (52 cases) were diagnosed by US at the end of first year without any effect on renal function. Antenatal and postnatal US are sensitive tools for detecting hydronephrosis as well as for postnatal counseling. Fetal anatomy US is usually done at 18 weeks gestation and if this reveals any evidence of hydronephrosis, the patient is followed according to the severity. Postnatal US is not done routinely for cases where hydronephrosis resolves completely during pregnancy. Although newborns with antenatal hydronephrosis due to secondary causes are at greater risk for renal impairment, surgical intervention reserves renal function.

The Utility of Repeat Midtrimester Anatomy Ultrasound for Anomaly Detection.

Although guidelines recommend repeat ultrasound in the setting of an incomplete fetal anatomic survey, the clinical utility of this practice has not been established. As such, we aimed to assess the yield of repeat ultrasound for anomaly detection following an incomplete survey. This is a retrospective cohort study of all singletons who underwent a midtrimester anatomic ultrasound at University of Alabama at Birmingham (UAB) from 2006 to 2014. Patients with an incomplete ultrasound underwent repeat examinations until completion. The population was divided into cohorts FIRST, SECOND, and THIRD, corresponding to the ultrasound at which the exam was deemed complete. Each detected anomaly was tallied. The number of ultrasounds needed to detect an anomaly was then assessed per group. Of 15,768 ultrasounds performed on 13,740 patients, 11,828 exams were completed on first attempt; 1,796 patients required a second, while 116 patients required a third scan or more. We detected 324 anomalies; 93.8% in FIRST, 5.9% in SECOND, and 0.3% in THIRD. The number of scans needed to detect an anomaly was 39, 189, and 348 for FIRST, SECOND, and THIRD, respectively. Over 90% of anomalies are detected on the initial fetal anatomic survey. The incremental diagnostic yield then decreases, requiring appreciably more repeat scans to detect one anomaly.