Crown-rump Length Measurements Research Articles

Prediction of fetal loss by first-trimester crown-rump length in IVF pregnancies.

To evaluate the association between small crown-rump length (CRL) and fetal loss ≤22weeks in IVF pregnancies. A retrospective analysis of prospectively collected data at a university-affiliated medical center. All singleton IVF pregnancies within a 5-year period, with a live embryo on first-trimester ultrasound and verified pregnancy outcome were included. Rates of fetal loss ≤22weeks were compared between pregnancies with a CRL ≤tenth percentile and above the tenth percentile of our population. Overall, 397 pregnancies met inclusion criteria. Ninety-five percent of CRL measurements were performed at 40-80 gestational days. All live-embryo's CRL measurements, from 40 to 80mm, were plotted against expected gestational age (in 5-day clusters), with calculation of the tenth percentile for every gestational age. Total of 64 pregnancies had CRL ≤tenth percentile for gestational age. The rate of fetal loss in this group was significantly higher than in pregnancies with CRL >tenth percentile (17.2 vs. 6.6%, p=0.005, OR=2.93, 95% CI 1.2-6.7). In both groups, the majority of fetal losses occurred ≤10weeks of gestation. In IVF pregnancies with a live embryo, a small CRL at 40-80days' gestation may predict fetal loss. Repeated ultrasound should be considered after 1-2weeks.

Periconceptional maternal biomarkers of one-carbon metabolism and embryonic growth trajectories: the Rotterdam Periconceptional Cohort (Predict Study)

To study the associations between the periconceptional maternal biomarkers of one-carbon metabolism and embryonic growth. Prospective, periconceptional hospital-based birth cohort. Tertiary medical care center. Between 2010 and 2014, 236 women with early singleton ongoing pregnancies that resulted in 139 strictly dated spontaneous pregnancies and 97 pregnancies conceived after assisted reproductive technology. None. Maternal serum vitamin B12 and plasma total homocysteine (tHcy) assessed at enrollment, and longitudinal first-trimester crown-rump length (CRL), embryonic volume (EV), and absolute growth rates obtained via three-dimensional ultrasound (3D-US) and virtual reality. In early pregnancy, we performed a median of five 3D-US scans (range: 1-7). Vitamin B12 concentrations were positively associated with CRL and EV measurements in the total population (CRL: β 5ˆ10-4 (1ˆ10-4 to 9ˆ10-4) √mm; EV: β 2ˆ10-4 (0ˆ10-4 to 4ˆ10-4) 3√cm3) and in the strictly dated spontaneous pregnancy subgroup. The tHcy concentration was negatively associated with embryonic growth in all study groups. High tHcy concentrations (+2 standard deviation [SD], 10.3μmol/L) were associated with a 1.7mm smaller CRL (-13.4%) at 7weeks and a 3.6-mm smaller CRL (-7.1%) at 11weeks compared with -2 SD tHcy (-3.0μmol/L). A high tHcy concentration was also associated with a 0.10cm3 smaller EV (-33.3%) at 7weeks and a 1.65cm3 smaller EV (-16.1%) at 11weeks. The embryonic growth rate was positively associated with vitamin B12 and negatively associated with tHcy. Minor variations in periconceptional maternal concentrations of one-carbon metabolism biomarkers are associated with human embryonic growth.

Is there any relationship between low PAPP-A levels and measures of umbilical vein and placental thickness during first trimester of pregnancy?

OBJECTIVE:Low pregnancy-associated plasma protein A (PAPP-A) level is associated with adverse perinatal outcomes. The purpose of this study was to evaluate relationship between umbilical cord diameter (UCD), umbilical vein and artery diameters (UVD, UAD), placental thickness, and PAPP-A level at gestational age of between 11 and 14 weeks.METHODS:UCD, UVD, UAD, and placental thickness of 246 women were assessed during ultrasound examination at between 11 and 14 weeks of gestation, as well as measurement of nuchal translucency (NT) and crown-rump length (CRL). Patients were divided into 2 groups according to PAPP-A percentile. Group 1 comprised 23 patients who had low PAPP-A (<0.44 multiple of medians [MoM], <10th percentile) and Group 2 was made up of 223 patients with PAPP-A of >0.44 MoM, >10th percentile. Calipers used for measurement were placed inner edge to inner edge of echogenic boundaries of the vessel. Largest sections of all vessels (UV and both arteries) were evaluated. Thickest part of the placenta was used for placental thickness measurement.RESULTS:Narrow UCD (<4.5±0.6 mm) was associated with low PAPP-A level (p=0.02). There was no significant difference in UVD, UAD, or placental thickness between groups. There was no significant difference in gestational age, CRL, or NT between groups. Fetal birth weight was significantly lower in Group 1 (p=0.03).CONCLUSION:Closer attention to women with low-risk, healthy pregnancies and low PAPP-A level in first trimester screening results is recommended. They should be routinely screened for background medical risk factors and umbilical cord morphology in first trimester scan.

Nasal bone in screening for T21 at 11-13 + 6 weeks of gestation - a multicenter study.

Trisomy 21 is one of the most common chromosomal defects diagnosed prenatally. Screening for Down syndrome is based on maternal age, measurement of crown-rump length, nuchal translucency and fetal heart rate, together with free β-hCG and PAPP-A at 11 to 13 + 6 weeks. Introduction of additional ultrasound marker of trisomy 21 (evaluation of the nasal bone) may result in increased DR and decreased invasive diagnostic testing rates (FPR). Ultrasound scan with NB evaluation was performed in 5814 fetuses during routine screening for chromosomal defects at 11 to 13 + 6 weeks of gestation. DR and FPR coefficients were calculated for 4 levels of risk as cut-off points for screening model 1, based on MA, NT, and first trimester biochemistry, as well as for screening model 2, based on MA, NT, first trimester biochemistry and NB. There were 5708 normal cases, 71 cases of trisomy 21 and 35 cases of other chromosomal defects. NB was absent in 46 (64.8%) cases and present in 25 (35.3%) cases of trisomy 21, comparing to present NB in 5463 (95.7%) and absent in 245 (4.3%) of normal cases. First-semester screening with additional NB assessment significantly increases the detection rate for trisomy 21 and decreases the rate of false-positive results. Adding NB evaluation at the risk level of 1:50 causes only a small increase in detection rate. Invasive procedures should be performed in that group regardless NB assessment.

Quelle place pour l’échographie dans la pratique de l’IVG ?

Ultrasound plays a fundamental role in the management of elective abortions. Although it can improve the quality of post-abortion care, it must not be an obstacle to abortion access. We thus studied the role of ultrasound in pregnancy dating and possible alternatives and analyzed the literature to determine the role of ultrasound in post-abortion follow-up. During an ultrasound scan, the date of conception is estimated by measurement of the crown-rump length (CRL), defined by Robinson, or of the biparietal diameter (BPD), as defined by the French Center for Fetal Ultrasound (CFEF) after 11weeks of gestation (Robinson and CFEF curves) (grade B). Updated curves have been developed in the INTERGROWTH study. In the context of abortion, the literature recommends the application of a safety margin of 5days, especially when the CRL and/or BPD measurement indicates a term close to 14weeks (that is equal or below 80and 27mm, respectively) (best practice agreement). Accordingly, with the ultrasound measurement reliable to±5days when its performance meets the relevant criteria, an abortion can take place when the CRL measurement is less than 90mm or the BPD less than 30mm (INTERGROWTH curves) (best practice agreement). While a dating ultrasound should be encouraged, its absence is not an obstacle to scheduling an abortion for women who report that they know the date of their last menstrual period and/or of the at-risk sexual relations and for whom a clinical examination by a healthcare professional is possible (best practice agreement). In cases of intrauterine pregnancy of uncertain viability or of a pregnancy of unknown location, without any particular symptoms, the patient must be able to have a transvaginal ultrasound to increase the precision of the diagnosis (grade B). Various reviews of the literature on post-abortion follow-up indicate that the routine use of ultrasound during instrumental abortions should be avoided (best practice agreement). If it becomes clear immediately after the procedure that the endometrial thickness exceeds 8mm, immediate reaspiration is necessary. Ultrasound examination of the endometrium several days after an instrumental elective abortion does not appear to be relevant (grade B). An analysis of the literature similarly shows that routine ultrasound scans after medical abortions should be avoided. If a transvaginal ultrasound is performed after a medical abortion, it should take place at least two weeks afterwards (best practice agreement). The only aim of an ultrasound examination during follow-up should be to determine whether a gestational sac is present (best practice agreement). Finally, if an ultrasound is performed at any point during pre- or post-abortion care, a report should be drafted, specifying any potential gynecologic abnormalities found, but its absence must not delay the scheduling of the abortion (best practice agreement).

Relation between the quality of the ultrasound image acquisition and the precision of the measurement of the crown-rump length in the late first trimester: what are the consequences?

ObjectiveTo assess the extent to which the distribution of crown-rump length (CRL) values may be correlated with different criteria for the quality of the CRL images. Study designThis is a retrospective analysis of a series of 977 CRL images, by two independent observers, for the presence or the absence of 14 quality hallmarks. Inter-observer agreement for the hallmarks was assessed by the proportion of agreement and Cohen’s kappa. The association between the quantiles of the CRL distribution and the presence or absence of the 14 quality hallmarks was modeled using quantile regression. ResultsThe overall inter-observer agreement across the 14 hallmarks was 91.7%, kappa=0.81, 95% CI [0.80–0.82]. Distribution of CRL measurements varied considerably as a function of image quality: when the fetus was in extension, the mean CRL was +5.7mm (vs. not in extension, p<0.001), when the fetus was in flexion (vs. not), the mean CRL was −4.7mm (p<0.001) and when the image magnification was <65% (vs. >65%), the mean CRL was −4.2mm (p<0.001). There was a global trend to over-estimate the CRL for the higher deciles and to under-estimate the CRL for the lower deciles when the sagittal quality hallmarks were absent. No significant impact on CRL distribution was observed in association with the precise placement of the calipers nor with the horizontal orientation of the fetus. ConclusionDistribution of CRL measurements was influenced by the quality of CRL images. In particular, inadequate position of the fetus (flexion/extension) and insufficient image magnification were associated with systematic changes in the values of CRL. Our results show that as the quality of CRL images decreases, the associated variations in the distribution of CRL can have an impact on the chromosomal risk assessment and may lead to inappropriate obstetrical decisions.

Prediction of Gestational Age in Osmanabadi Goats by Ultrasonic Measurement of Crown-Rump Length

The objective of this study was to predict gestational age of Osmanabadi goats by realtime ultrasonography using measurements of Crown Rump Length (CRL). CRL was measured in 15 Osmanabadi goats, by transabdominal ultrasonography carried out on days 35, 42, 49, 56, 63 and 70 of gestation, those became pregnant after oestrus detection and natural mating following oestrus synchronization in 30 does using double PGF2α injections 11 days apart. Gestational age was calculated by using gestational equations derived from the linear regression analysis. Results clearly demonstrated that biometric parameter CRL was significantly (P ios less than 0.01) correlated with gestational age (r= 0.988) and was a reliable index to predict gestational age in Osmanabadi goats.

Symphysis-pubis fundal height charts to assess fetal size in women with a normal body mass index.

To construct symphysis-pubis fundal height (SFH) charts to estimate fetal size in pregnant women with a normal body mass index (BMI) and to describe the variation of SFH measurements according to BMI. cross sectional study was carried out at Ampara and Gampaha Districts in Sri Lanka. Women with normal nutritional and health status, normal BMI and minimal environmental constraints on fetal growth, with ultra sound confirmation of dates by fetal crown-rump length measurements between 11 weeks and 13 weeks + six days,had their SFH measured, using non-elastic tape and standard techniques, between 24 and 41 weeks gestation. Only one measurement of SFH was obtained from each pregnant woman. Linear and polynomial regression models were fitted separately to the means and standard deviations (SD) as functions of gestational age to identify the model with the best fit. Centiles were derived from the mean and SD at each gestational age. Pregnant women from the districts of Ampara (n=387) and Gampaha (n=200) were recruited. Other than a difference of -1.5 cm (95% CI -2.27 to -0.23) at 38 weeks of gestation, there were no significant differences between the SFH measurements obtained from women with normal BMI in Ampara and Gampaha Districts. Using the SFH measurements from the Ampara sample, charts were created for 10th, 50th and 90th centile values of SFH. At 40 weeks of gestation these were 34 cm, 37 cm and 41 cm respectively. At 40 weeks gestation, the variation in SFH measurements between BMI sub groups within the normal range was approximately 1.4 cm to 1.6 cm. These SFH charts could be used to estimate fetal size in pregnant women with normal BMI.

Determination of gestational time and prediction of parturition in dogs and cats: an update.

Accurate prediction of delivery date in canine and feline allows a better management of parturition, reducing the loss of neonates. This review evaluates the most common methods adopted to accurately predict the day of delivery: determination of ovulation and hormonal assays, first appearance of embryonic/foetal structures using ultrasound or radiography, echographic measurement of extra-foetal and foetal structures, or evaluation of foetal flux and heart rate. Determination of ovulation and hormonal assays at the time of breeding and close to pregnancy term is widely used to predict parturition in dogs (Concannon etal. American Journal of Veterinary Research 44, 1983, 1819; Hayer etal. Journal of Reproduction and Fertility, Suppl. 47, 1993, 93; Hase etal. Journal of Veterinary Medical Science, 62, 2000, 243; Kutzler etal. Theriogenology, 60, 2003a, 1187). In cats, some studies have been carried out, but no hormonal parameters for accurate prediction of parturition have been described so far (Buff etal. Journal of Reproduction and Fertility, Suppl. 57, 2001, 187; De Haas van Dorsser etal. Biology of Reproduction, 74, 2006, 1090; DiGangi etal. Journal of the American Veterinary Medical Association, 237, 2010, 1267; Dehnhard etal. Theriogenology, 77, 2012, 1088). Many studies suggested that gestational timing can be obtained by observation using ultrasound or radiography of specific structures in relation to the time of appearance during gestation (Concannon and Rendano American Journal of Veterinary Research, 44, 1983, 1506; Rendano etal. Veterinary Radiology, 25, 1984, 132; Shille and Gontarek Journal of the American Veterinary Medical Association, 187, 1985, 1021; Davidson etal. Veterinary Radiology, 27, 1986, 109; England etal. Journal of Small Animal Practice, 31, 1990, 324; Yeager etal. American Journal of Veterinary Research, 53, 1992, 342; Zambelli etal. Theriogenology, 57, 2002a, 1981; Zambelli etal. Journal of Feline Medicine and Surgery, 4, 2002b, 95; Zambelli and Prati 2006; Lopate Theriogenology, 70, 2008, 397; Davidson and Baker Topics in Companion Animal Medicine, 24, 2009, 55). Ultrasonographic measurement of extra-foetal and foetal structures is a common and accurate method for the prediction of parturition day during pregnancy, when specific formulae are used depending on the ultrasonographic parameter, the species and, in canines, the size of the bitch (Shille and Gontarek Journal of the American Veterinary Medical Association, 187, 1985, 1021; England etal. Journal of Small Animal Practice, 31, 1990, 324; Luvoni and Grioni Journal of Small Animal Practice, 41, 2000, 292; Luvoni and Beccaglia Reproduction in Domestic Animals, 41, 2006, 27; Lopate Theriogenology, 70, 2008, 397; Michel etal. Reproduction in Domestic Animals, 46, 2011, 926; Beccaglia and Luvoni Reproduction in Domestic Animals, 47, 194, 2012). Recent studies demonstrated that in dogs, the imminence of parturition could be predicted by evaluating foetal flux and foetal heart rate by ultrasound (Gil etal. Theriogenology, 82, 2014, 933; Giannico etal., Animal Reproduction Science, 154, 2015, 105). For an accurate prediction of parturition date, the combination of different methods is desirable.

Frontal space distance in facial clefts and retrognathia at 11-13 weeks' gestation.

To examine the frontal space (FS) distance in first-trimester fetuses with bilateral, unilateral or median cleft lip and palate and in those with retrognathia. This was a retrospective study using stored two-dimensional ultrasound images of fetal profiles that were recorded at the time of the nuchal translucency (NT) scan at three prenatal medical centers. Images of 300 normal fetuses and 53 fetuses with facial defects were obtained. To measure the FS distance, a line was drawn between the anterior edge of the mental protuberance of the mandible and anterior edge of the maxilla (MM line) and extended upwards in front of the forehead. The perpendicular distance (FS distance) between the MM line and the skin at the point of largest excursion of the fetal forehead was measured. In cases in which the MM line was located anteriorly to the forehead, the distance was measured in the same fashion but was multiplied by -1. Two operators measured the FS distance twice, independently of each other. FS distances were transformed into Z-scores based on the linear relationship with crown-rump length (CRL) in normal fetuses. The distribution of FS distances in fetuses with bilateral, unilateral or median cleft lip and palate and those with retrognathia were compared with that in the normal group using Student's t-test. A search of the centers' databases identified 53 abnormal cases including 20, nine and eight with a bilateral, unilateral and median cleft lip and palate, respectively, and 16 cases of retrognathia. In fetuses with bilateral, unilateral and median clefts and those with retrognathia, median delta NT was 1.00 mm, 0.37 mm, 4.00 mm and 0.26 mm, respectively. Among these affected groups, 12 (60.0%), six (66.7%), two (25.0%) and eight (50.0%) fetuses had an abnormal karyotype. In the normal population, FS distance was dependent on CRL measurement (FS = 6.62 - (0.08 × CRL); r = -0.539; P < 0.0001). In fetuses with a bilateral and median cleft and in those with retrognathia, FS distance was significantly different from that in the normal population (all P < 0.0001), however, the difference was not significant in fetuses with unilateral clefts (P = 0.103). The respective Z-scores of FS distance for fetuses with bilateral, unilateral and median clefts and retrognathia were -9.7 ± 2.0, -3.1 ± 5.1, 8.2 ± 3.4 and -7.3 ± 2.3. Measurements were ≥ 99(th) and ≤ 1(st) centiles in all but one (98.1%) case. The FS distance appears to be a helpful tool in the detection of facial clefts at 11-13 weeks' gestation. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Gestational length assignment based on last menstrual period, first trimester crown-rump length, ovulation, and implantation timing.

PurposeUnderstanding the natural length of human pregnancy is central to clinical care. However, variability in the reference methods to assign gestational age (GA) confound our understanding of pregnancy length. Assignation from ultrasound measurement of fetal crown-rump length (CRL) has superseded that based on last menstrual period (LMP). Our aim was to estimate gestational length based on LMP, ultrasound CRL, and implantation that were known, compared to pregnancy duration assigned by day of ovulation.MethodsProspective study in 143 women trying to conceive. In 71 ongoing pregnancies, gestational length was estimated from LMP, CRL at 10–14 weeks, ovulation, and implantation day. For each method of GA assignment, the distribution in observed gestational length was derived and both agreement and correlation between the methods determined.ResultsMedian ovulation and implantation days were 16 and 27, respectively. The gestational length based on LMP, CRL, implantation, and ovulation was similar: 279, 278, 276.5 and 276.5 days, respectively. The distributions for observed gestational length were widest where GA was assigned from CRL and LMP and narrowest when assigned from implantation and ovulation day. The strongest correlation for gestational length assessment was between ovulation and implantation (r = 0.98) and weakest between CRL and LMP (r = 0.88).ConclusionsThe most accurate method of predicting gestational length is ovulation day, and this agrees closely with implantation day. Prediction of gestational length from CRL and known LMP are both inferior to ovulation and implantation day. This information could have important implications on the routine assignment of gestational age.

Identification of the pregnancy-associated glycoprotein family (PAGs) and some aspects of placenta development in the European moose (Alces alces L.)

This study describes the identification and a broad-based characterization of the pregnancy-associated glycoprotein (PAG) genes expressed in the synepitheliochorial placenta of the Alces alces (Aa; N = 51). We used: (1) both size measurements (cm) of various Aa embryos/fetuses (crown-rump length) and placentomes (PLCs); (2) PCR, Southern and sequencing; (3) Western-blot for total placental glycoproteins; (4) deglycosylation of total cotyledonary proteins; and (5) double heterologous IHC for cellular immune-localization of the PAGs as pregnancy advanced (50–200 days post coitum). The crown-rump length and PLC size measurements permitted a novel pattern estimation of various pregnancy stages in wild Aa. The PLC number varied (5–21) and was the greatest at the mid and late stages of gestation in females bearing singletons or twins. The genomic existence of the identified PAG-like family was named AaPAG-L. Amplicon profiles of the AaPAG-L varied in the number and length (118–2000 bp). Southern with porcine cDNA probes confirmed specificity and revealed dominant AaPAG-L amplicons in males and females. Nucleotide sequences of the AaPAG-L amplicons shared 86.27% homology with the bovine PAG1 (bPAG1) gene. Amino acid AaPAG sequences revealed in silico 88.23% to 100% homology with the bPAG1 precursor. Western-blots revealed a dominant mature 55 kDa AaPAG fraction, and the major ∼48 kDa glycosylated form that was deglycosylated to ∼44 kDa. The AaPAG-Ls was immuno-localized to mono- and bi-nucleated trophectodermal cells (TRD–chorionic epithelium), where signal intensity resembled intense TRD proliferation within developing PLCs as pregnancy advanced. This is the first study identifying the AaPAG-L family in the largest representative among the Cervidae.

The periconception maternal cardiovascular risk profile influences human embryonic growth trajectories in IVF/ICSI pregnancies.

Is the maternal cardiovascular (CV) risk profile associated with human embryonic growth trajectories and does the mode of conception affect this association? This small study suggests that the maternal CV risk profile is inversely associated with first trimester embryonic growth trajectories in in vitro fertilization (IVF)/intra-cytoplasmic sperm injection (ICSI) pregnancies, but not in spontaneously conceived pregnancies. Maternal high-blood pressure and smoking affect placental function, accompanied by increased risk of fetal growth restriction and low-birthweight. Mothers who experience pregnancies complicated by fetal growth restriction are at increased risk of CV disease in later life. In a prospective periconception birth cohort conducted in a tertiary hospital, 111 singleton ongoing pregnancies with reliable pregnancy dating, no pre-existing maternal disease and no malformed live borns were investigated. Spontaneously conceived pregnancies with a reliable first day of the last menstrual period and a regular menstrual cycle of 25-31 days only (n = 66) and IVF/ICSI pregnancies (n = 45) were included. Women underwent weekly three-dimensional ultrasound scans (3D US) from 6- to 13-week gestational age. To estimate embryonic growth, serial crown-rump length (CRL) measurements were performed using the V-Scope software in a BARCO I-Space. Maternal characteristics and CV risk factors were collected by self-administered questionnaires. The CV risk profile was created based on a score of risk factors, including maternal age, body-mass index, CV disease in the family, diet and smoking. Quartiles of the CV risk score were calculated. Associations between the CV risk score and embryonic growth were assessed using square root transformed CRL in multivariable linear mixed model analyses. From the 111 included pregnancies, 696 3D US data sets were obtained of which 637 (91.5%) CRLs could be measured. In the total group, The CV risk score was inversely, but not significantly associated with embryonic growth (-0.03√mm; P = 0.291). Stratified by mode of conception, the CV risk score was inversely and significantly associated with embryonic growth (β = -0.04√mm; P = 0.025, adjusted for possible confounders) in the IVF/ICSI group. Compared with the first quartile, embryos in the upper quartile were 10.4% smaller at 6(+0) weeks (4.4 versus 4.9 mm) and 3.1% smaller at 12(+0) weeks (56.5 versus 58.4 mm) of gestation. Although the CV risk score was slightly, but significantly, higher in women conceiving spontaneously compared with those undergoing IVF/ICSI treatment [CV risk score = 2.06 (SD: 1.23) and 1.60 (SD: 1.15), respectively], no association was established with embryonic growth in that particular group. Participants included in the present cohort are women with a singleton ongoing pregnancy without any pre-existing disease and selected from a tertiary hospital. Hence, they represent a selected group of women. Larger and population-based periconception birth cohort studies are recommended to demonstrate external validity. Differences in embryonic growth between pregnancies conceived spontaneously and after IVF/ICSI treatment in relation with CV risk factors substantiate the importance of more investigation into differences in sensitivity of endometrial, endothelial, placental and embryonic tissues. Funded by the Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands. The authors declare no conflict of interest.

Relationship of Fetal Complications in Monochorionic Diamniotic Twin Pregnancy with Placental Site Cord Insertion: A Retrospective Analysis of 30 Months Data in a Referral Fetal Medicine Center

ABSTRACT Aims Among the increasing twin gestations, monochorionic twins occur in about 12 to 15% of all twin gestations and the occurrence is about 1 in 20 in assistive reproductive technology pregnancies. Early detection of twin to twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR) aids the obstetrician in counseling and therapy as required. Materials and methods This is a retrospective cohort study of monochorionic diamniotic (MCDA) pregnancies referred from January 2011 to June 2013. Those cases that had crown rump length and nuchal translucency measurements done in the first trimester and then at least one subsequent scan at &gt; 16 weeks, at the institution were chosen. The objective was to assess the utility of placental site of cord insertion in early second trimester scan to predict fetal outcome in monochorionic twin pregnancy. The patient characteristics, placental cord insertion site, and neonatal outcomes were compared among TTTS, sIUGR, and normal groups. Discussion Of 89 MCDA pregnancies, only 60 had been referred for second trimester scan. Among these, in 48 (80%) of pregnancies, both babies were delivered and discharged alive and well. Cord insertions that were eccentric or central were classified as “type A”. Marginal and velamentous cord insertions were classified as “type B”. Pregnancies with both types A and B insertions were called “concordant cord insertions group” and the others were classified as “discordant cord insertions” group. The two groups were compared to look for the pregnancy complications — TTTS or sIUGR. Results The concordant cord insertions (n = 33) had 84.8% of pregnancies having a normal pregnancy and 12.1 and 3.1% developing sIUGR and TTTS respectively. The discordant cord insertion group (n = 27) had 59.2% with normal findings at the second scan and 14.8 and 26% developing sIUGR and TTTS respectively. The incidence of TTTS was 30% in twin pairs with discordant cord insertions and 3% in twin pairs with concordant cord insertions (p = 0.0158). Cord insertions did not influence the occurrence of sIUGR in our study. (p = 0.69). Significantly more pregnancies with concordant cord insertions had normal outcomes (p = 0.02). Conclusion Determination of placental site of cord insertion should be incorporated into protocols of twin pregnancy care. This is a window of opportunity to gain valuable information regarding the pregnancy. Further large studies incorporating fetal biometric and Doppler parameters could show the relative utility of each parameter in the detection of MCDA vascular complications. If the MCDA pregnancy can be classified as “low risk” then reassessment intervals can be extended. This would help to reduce patient stress and costs involved in repeated scans. How to cite this article Andrew C, Suresh I, Seshadri S. Relationship of Fetal Complications in Monochorionic Diamniotic Twin Pregnancy with Placental Site Cord Insertion: A Retrospective Analysis of 30 Months Data in a Referral Fetal Medicine Center. J South Asian Feder Obst Gynae 2016;8(4):304-308.

First trimester combined screening test in pregnancies derived from blastocyst transfer

ObjectiveTo investigate whether first trimester combined screening for major fetal trisomies is influenced by assisted reproduction techniques from blastocyst transfer, with or without cryopreservation. Study designretrospective case-control analysis involving 298 singleton pregnancies with euploid fetuses recruited between 2012 and 2014. Forty-seven women conceived with fresh blastocysts from in vitro fertilization cycles (fresh-blasto), 51 with frozen–thawed blastocysts (frozen-blasto) and 200 were natural conceptions (controls). All cases underwent ultrasound assessment at 11+0–13+6 weeks with measurements of crown rump length, nuchal translucency, free β-hCG and PAPP-A concentrations. The outcome of pregnancy was recorded (gestational age at birth, birth weight, obstetric complications). ResultsBaseline characteristics and pregnancy outcomes did not differ substantially among the study groups. The median delta nuchal translucency was significantly higher both in frozen-blasto group (median: 0.27mm; Interquartile Range [IQR]: 0.02–0.44; p<0.001) and in fresh-blasto group (median: 0.17mm; IQR: 0.04–0.39; p=0.014) as compared to control group (median: 0.06mm; IQR: −0.08 to 0.20), whereas it was not different in the frozen-blasto compared to the fresh-blasto group. The median free β-hCG multiples of the median (MoMs) was significantly higher both in frozen-blasto group (median 1.15; IQR 0.83–2.11; p=0.001) and in fresh-blasto group (median 0.95; IQR 0.52–1.48; p=0.001) as compared to control group (median 0.99; IQR 0.57–1.26), and it was also higher in frozen-blasto group compared to fresh-blasto group (p<0.001). The three groups showed no significant differences in the median PAPP-A MoMs. The median delta crown rump length was also not significantly different among the three groups. Conclusionsin assisted reproduction technique pregnancies from blastocyst transfer, with or without cryopreservation, both the nuchal translucency measurement and free β-hCG concentration are higher as compared to spontaneous conceptions, whereas PAPP-A does not show any significant difference. These features are apparently unrelated to the outcome of pregnancy and may be due to alterations or delays in embryogenesis or placentation with potential relevance for the screening test performance.

Influence of medically assisted reproduction techniques on crown-rump length and biochemical markers of trisomy 21 in the first trimester of pregnancy

To determine whether there is a difference between the known gestational age in pregnancies conceived after IVF and the estimated gestational age based on the crown-rump length (CRL) measurement during the first trimester. We retrospectively (between 2007 and 2012) studied a cohort of 6,739 patients who underwent ultrasonography between 11 and 13+6weeks of amenorrhea. Hospital. Group A consisted of 6,621 patients with regular menses whose term was calculated based on the date of their last menstrual period (LMP). Group B consisted of 529 patients whose pregnancies had been achieved by IVF and in whom term was calculated based on the date of fresh or frozen ET. None. The gestational age difference was obtained by comparing the age obtained by measuring the CRL (Robinson's curve) with the gestational age calculated in accordance with LMP in group A or with ET day in group B. The gestational age difference was significantly more in group B (2.3days vs. 0.84days in group A). We found a significant difference regarding biochemical markers for trisomy 21 to the detriment of group B with a significantly reduced pregnancy-associated protein P-A multiple of median (0.78 vs. 0.92). There appears to be a small difference in CRL development between spontaneous pregnancies and pregnancies conceived by assisted reproductive technology (ART). Specific ultrasonographic curves for pregnancies conceived by ART would be more relevant and precise. The underlying pathophysiological mechanisms are not very clear and offer possibilities for future research.

Early fetal growth in progesterone-treated IVF pregnancies.

The aim of this study was to compare fetal growth in the first and second trimesters of pregnancy and final birth weights between two groups of women: (a) spontaneous conceptions with reliable menstrual dates and (b) IVF pregnancies on progesterone supplementation during the first trimester. We included in the study 73 singleton IVF pregnancies and 138 singleton spontaneous pregnancies. Exclusion criteria were: medications or presence of medical conditions affecting fetal growth. Fetal crown-rump length (CRL) at 10+1 to 13+6weeks of gestation, and head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC) and femur length (FL) at 18-24weeks, were measured prospectively. The birth weights of the babies born were collected and compared. Independent sample t test was applied for comparing quantitative variables with normal distribution, and Wilcoxon-Mann-Whitney test was used for comparison of quantitative variables without normal distribution. IVF fetuses on progesterone supplementation had larger CRL measurements when compared to their counterparts from spontaneous pregnancies (p value=0.045). Similarly, in the second trimester, the BPD was significantly larger but HC, AC and FL, although larger, did not reach statistical significance. The birthweights of babies between the two groups showed no statistically significant difference, although some IVF babies were born prematurely. Enhanced fetal growth during the first trimester has been observed with progesterone supplementation in IVF pregnancies. Aspects of enhanced fetal growth were observed in the second trimester but not at birth. The effect of progesterone supplementation on fetal growth needs further investigation.

Une auto-évaluation simplifiée des images échographiques du premier trimestre

ObjectivesThe objective of this study was to establish a minimum subset of simple criteria for the self-assessment of the quality of first-trimester ultrasound images of nuchal translucency (NT) and crown-rump length (CRL). MethodsWe designed 162 simplified image-scoring methods (ISM) based on 1, 2, 3 or 4 binary criteria derived from the 8 criteria of the original image scoring method of the French College of Fetal Ultrasound (CFEF). These ISM were assessed on 68,250 consecutive scans of the French national audit conducted by the CFEF on NT and CRL images. The ISM associated with the best precision to identify excellent/reasonable quality scans were selected. ResultsSimplified ISM based on 1, 2, 3 and 4 criteria showed maximum positive predictive values of 95.3% (95.11–95.50) 98.0% (97.87–98.14), 99.3% (99.17–99.35) and 99.7% (99.68–99.79), respectively, to identify excellent/reasonable quality scans. The proportion of excellent/reasonable scans was 2.8 to 16.7% when three criteria among the 8 were insufficient, and 0.17 to 3.95% when four criteria were insufficient. ConclusionsThe best performing ISM was based on the following four quality criteria: (i) sagittal plane of the NT, (ii) calipers placement for measuring the NT, (iii) image magnification of NT images and (iv) CRL measurement. This score might be the most relevant in clinical practice in the first-trimester screening.

Nuchal translucency in normal fetus and its variation with increasing crown rump length (CRL) and gestational age.

Nuchal translucency (NT) is the fluid collection behind the fetal neck which can be measured by ultrasound at 11-14 weeks of gestation. Increase in the nuchal translucency thickness is associated with various congenital anomalies. To study the relationship between nuchal translucency thickness, crown rump length and gestational age in normal fetus. Prospective analytical study conducted on 211 pregnant women from March 2011 to August 2012. Measurement of Nuchal translucency thickness and crown rump length was performed by ultrasound at 11-14 weeks of gestation. The relationship between nuchal translucency thickness, crown rump length and gestational age was studied by using linear regression analysis. The mean CRL was 63.67+13.48mm (range 41.2-88mm) and mean NT thickness was 1.55+0.35mm (range 0.8-2.7mm), respectively. The median gestational age was 12.9 weeks. The regression equation which shows relation between median NT thickness and CRL was described as follows: expected NT thickness = 0.013CRL+0.725, (R2 = 0.258, p <0.001). There was increase in the incidence of NT thickness more than or equal to 2.5mm; 1.7% in fetus between 12-12.9 weeks of gestation to 15.1% in fetus between 14.0-14.9 weeks. Our study offers normative data of NT thickness in normal fetus, which can be used as reference to screen various chromosomal and congenital abnormalities between 11- 14 weeks of gestation. NT thickness increased with increasing CRL and a false positive rate increases with increasing gestational age.

P13.04: Accuracy and learning curves of crown–rump length measurements performed by certified nurse midwives

P13.04: Accuracy and learning curves of crown–rump length measurements performed by certified nurse midwives