WS10 ... - Wiley Online Library

4±7 October 2000, Zagreb, Croatia

Workshops

Workshops W S 0 1 : F E TA L A N O M A L I E S WS01-01 Prenatal ultrasound diagnosis of fetal malformations D. Cafici ClõÂnica Privada Santa Ana, Buenos Aires, Argentina The prenatal diagnosis of fetal malformations seems to be a very difficult challenge, mainly for those who are beginning with the practice of ultrasound. As it would be impossible to refer to so many fetal malformations the presentation will cover a few interesting issues. These cases are not frequently diagnosed and in many cases present controversial aspects referred to their prognosis and management. Those topics are: Unilateral ventricular dilatation Fetal hyperechogenic lung lesions Umbilical vein varix Facial clefts Unilateral ventricular dilatation may be a difficult diagnosis and its prognosis is variable Fetal hyperechogenic lesions include a broad range of anomalies with a variable behaviour. Even large lesions can disappear in utero but often the lesion can persist with severe prognosis for the fetus. Varix of the umbilical vein is a relatively uncommon abnormality that carries an increased risk for fetal demise, chromosomal abnormality and hydrops. Facial clefts are a relatively common malformation and the fetal face must be properly scanned in every fetal study. 3D ultrasound helps a lot in the diagnosis of these and other malformations and we'll discuss some examples concerning this new technology.

WS01-02 Color Doppler in the diagnosis of fetal malformations N. D. Margulies Juan A. FernaÂndez Hospital, Buenos Aires, Argentina The color and Power Doppler gives us the opportunity to investigate the vascular anatomy as an angiography and furthermore lets us `see' hydro jets. This singular ability leads us to make some diagnosis and confirm others. During this lecture we will show our experience in the diagnosis of some fetal anomalies such as renal agenesis, urachal cysts, megacystis microcolon Hypoperistalsis syndrome, renal displasia, Galeno vein aneurysm, anterior wall defects such as omphalocele and gastroschisis, diaphragmatic hernia, duodenal atresia, coartation of the aorta, single umbilical artery Dandy Walker Malformation, and some fetal tumors.

WS01-03 The posterior fossa: a useful landmark in the evaluation of the fetal ventriculomegaly V. D 0 Addario, V. Pinto, E. Di Naro and L. Di Cagno 4th Unit of Obstetrics and Gynecology, University Medical School, Bari, Italy Objective: The objective of this study was to obtain a nomogram of the clivus-suvraocciput angle as a basis for the diagnosis of Chiari II malformation in fetuses with ventriculomegaly. Design: A cross-sectional study was undertaken on 310 normal pregnant women of 16±34 weeks' gestation. A mid-sagittal section of the fetal skull was obtained and the angle between the clivus and the supraocciput was measured. 44 fetuses with ventriculomegaly due to different causes (13 Chiari II malformation, 12 dysgenesis of the

Ultrasound in Obstetrics and Gynecology

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

WS01-04 Fetal lung abnormalities a spectrum of disease: reclassification system based on embryology, 2-D and Doppler ultrasound R. Achiron, Y. Yuval, S. Lipitz and S. Yagel Department of Obstetrics/Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Hadassa Mount Scoup, Israel Objective: Fetal lung anomalies are traditionally classified into Congenital Cystic Adenomatoid Malformation (CCAM), and Pulmonary Sequestration (PS). During last years we have detected several cases who presented with bizarre and overlapping findings which could not be fitted into this usual classification. We therefore suggest a new approach for classification based on embryology, 2-D and Doppler ultrasound. Method: During 5-year period, patients with fetal lung lesions who were referred for detailed ultrasound evaluation at the Sheba Medical Center from the data base of this study. All cases were analyzed by 2D ultrasound and high resolution Power Doppler technology and were classified into three major categories: I Agenesis of lung; II Lung lesion with normal vascular supply: IIa solid, IIb cystic, IIc mixed; III Lung Lesion with abnormal vascular supply: IIIa chest, IIIb abdomen, IIIc thoracoabdomial. Medical files, natural history and neonatal followup were recorded. Results: Twenty-one fetuses were recruited, two fetuses were detected in group one, 14 in group II of normal vascular supply, and five in group III abnormal lung with abnormal vascular involvement. Conclusions: Based on embryology and ultrasound a new classification system is introduced.

WS01-05 Genitourinary anomalies ± is there anything new? I. Meizner Ultrasound Unit, Department of Ob/Gyn, Rabin Medical Center, Petah-Tikva, Israel Background: Ultrasound malformations of the fetal genitourinary tract are well documented in the sonographic literature. However, we would like to report on some specific observations. These will include a survey of fetal pelvic kidneys, an association between single umbilical artery (SUA) and absence of one of the kidneys, and the `Tulip sign'± an ultrasonic marker for severe penoscrotal hypospadias. Method: All records of patients with ectopic kidneys over a 5-year period (1995±99) have been perused. Sonographic parameters of ectopic kidney have been evaluated.

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10th World Congress on Ultrasound in Obstetrics and Gynecology The same was done for cases of SUA and agenesis of one kidney and for cases with severe penoscrotal hypospadias. Results: Pelvic kidney was diagnosed prenatally in 35 cases, of which, bilateral pelvic kidney was detected in 2 cases. There was no predilection for fetal gender, and no tendency to side of appearance. Most cases were diagnosed in late 2nd trimester of pregnancy. The association of SUA and absent kidney was detected in 6 cases. In all cases the diagnosis was made in the 2nd trimester of pregnancy. In 6 cases, the specific `Tulip sign' was detected prenatally and proven postnatally. Conclusions: Unique presentations of renal anomalies can be detected prenatally. Pelvic kidney is easily dealt with, however, the association of SUA and absent kidney requires further evaluation of the fetus to exclude the VATER association. The `Tulip sign' is helpful in diagnosing severe hypospadias.

WS01-06 Fetal obstructive uropathies: management and outcome C. Sen Department of Perinatology, Obstetrics and Gynecology, Cerrahpasa Medical School, University of Istanbul, Turkey Background: Urinary tract anomalies are among the most common sonographically identified anomalies in utero with the incidence about 1/250±1/1000 pregnancies. The obstruction can be unilateral or bilateral at the level of urethra, ureteropelvic junction (UPJ), ureterovesical junction (UVJ). Method: Obstructive uropathy cases diagnosed antenatally have been retrospectively evaluated in terms of short and long-term outcome. It is important to make early diagnosis and intervention in order to save organ function as possible. Results: During last 7 years in our Department, 58 cases with fetal obstructive uropathy were examined and performed 12 interventions. They were diagnosed antenatally with different type of obstruction including posterior urethral valve syndrome, unilateral and bilateral hydronephrosis, ureteropelvic junction obstruction, multicystic kidney. Intervention was performed in 12 cases at different stage of gestation including needling, vesico-amniotic shunting and pelvic shunting. Out of 12 procedures, there was mortality in 5 cases antenatally or neonatally. Conclusion: Early diagnosis of the obstruction is very important before the kidney becomes dysplastic. The type of anomalies, level and starting time of pathology and duration of severe obstruction are the main factors for prognosis. Early diagnosis and referral to tertiary center is to be encouraged in order to have early management and intervention in the case of severe obstruction and to save kidney function as early as possible.

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

WS01-08 Three-dimensional power Doppler of fetal malformations R. Chaoui Clinic of Obstetrics, University Hospital Zurich, Switzerland Background: The aim of the study was to examine the impact of threedimensional power Doppler ultrasound (3D-PDU) in fetal abnormalities involving the vascular system. Method: Eighty seven selected pregnancies were included in the study. ATL HDI-3000 and 5000 ultrasound equipment with integrated 3DColor Power Angio w software were used. Data acquisition was done by the free-hand-technique and images were reconstructed online. Results: Reconstruction was only possible in 56 out of the 87 (64%) considered pregnancies. These were abnormalities of placenta and umbilical vessels (n 26), intra-abdominal and intrathoracal anomalies (n 12), renal malformations (n 9), central nervous system (n 4) as well as cardiac defects (n 5). The main reasons for failure were fetal position and movements, overlapping with signals from neighboring vessels as well as the reduced attempts in 3D in an on-line system. Details and figures of the potential field of interest in prenatal diagnosis are presented. Conclusions: The study shows that 3D-power Doppler can be applied in prenatal diagnosis. The method enables the visualization of main parts of the fetal vascular system under abnormal conditions with the exception of the fetal heart where a trigger system is still needed.

WS01-09 Diagnostically critical fetal imaging artifacts: identification and management D. H. Pretorius and T. R. Nelson University of California, San Diego, La Jolla, CA, USA

WS01-07 Borderline urinary tract malformations G. D'Ottavio, L. Paduano, M. A. Rustico, Y. J. Meir, P. Lenardon, A. Rosadini and G. P. Mandruzzato Unit of Prenatal Diagnosis, Istituto per l'Infanzia, Trieste, Italy Background: Ultrasonography is an effective diagnostic tool for identifying fetal urinary tract anomalies (UTA). Serious obstructive or dysgenetic abnormalities are often clearly detected and their implications well known. Less clear is the meaning of borderline (asymptomatic at birth) UTA, including: mild pyelectasis (MP), unilateral renal agenesis (URA), unilateral multicystic kidney (UMK) and ectopic kidney (EK). Method: We determined the outcome of pregnancies and long-term renal function in 120 cases of prenatally detected borderline UTA. A prospective protocol was proposed to the parents which comprised ultrasound evaluation every 3 months until the age of 24 months, and renal function assessment in case of suspected worsening of prenatal findings.

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The purpose of this project was to identify sources and clinical significance of 3DUS artifacts on patient diagnosis and to increase clinician and sonographer awareness to reduce misdiagnosis in 3DUS studies. To accomplish this 3DUS data were acquired and reviewed interactively. Artifacts were cataloged according to origin: B-mode, color/power Doppler or unique to 3DUS (acquisition, rendering or volume editing). Original scan planes, re-sliced planes and rendered images were evaluated. Overall our results showed a variety of artifacts. B-mode artifacts included drop-out, shadowing, etc. and depending on relationships between slice and imaging plane orientation. Color/power Doppler artifacts were related to gain, aliasing, and flash and could add apparent structure or confusion to the volume images. Rendering artifacts were due to parameter adjustment, shadowing and motion. Important structures could be removed by improper editing. In conclusion 3DUS and 2DUS are prone to similar artifacts plus others unique to 3DUS. Diagnostically significant artifacts can mimick abnormal development, masses, or missing structures thus requiring careful study before reaching a diagnosis.



Workshops

W S 0 2 : P R E N ATA L D I A G N O S I S WS02-01 Sonographic measurement of fetal subcutaneous tissue of gestational diabetic mothers: a new criteria for therapy E. Ferrazzi, I. Cetin*, S. Rigano, T. Radaelli*, E. Taricco*, M. Bozzo*, C. Lanzani and G. Pardi* Depts Obstetrics and Gynecology, ISBM Luigi Sacco, DMCO San Paolo*, University of Milan, Italy Objective: The aim of this study was to compare sonographic measurements of subcutaneous tissue (SQ) in fetuses of gestational diabetic mothers (GDM), and in normal fetuses. Methods: SQ was measured as the subcutaneous tissue area of mid upper arm (FMA), mid-thigh (FMT) (cross sectional area minus bone and muscle area), abdominal (FA) and subscapular fat (FS), thickness. Fifty-six GDM were enrolled in the study. Normal values were obtained from fetuses of normal pregnancies (BMI 21.3 ^ 0.64 Kg/ m2; one hour glucose test , 140 mg/dL) (30 patients). Treatment was based on diet alone, or diet plus insulin according to postprandial glicemia. Longitudinal ultrasound examinations were performed every four weeks, in normal pregnancies, and in GDM pregnancies. Results: Fetal SQ measurements were significantly correlated to gestational age both in normal and GDM fetuses (P , 0.05). At the time of diagnosis GDM fetuses had significantly higher values for all SQ measurements compared to AGA fetuses; these differences were not found during therapy.

FA FS FMA FMT

26±32 weeks diagnosis

32±36 weeks therapy

normal

normal

0.32 0.28 1.97 3.12

^ ^ ^ ^

GDM 0.01 0.01 0.12 0.20

0.38 0.36 2.55 4.10

^ ^ ^ ^

0.01 0.17 0.19 0.37

Ns Ns Ns Ns

0.45 0.41 3.83 5.91

^ ^ ^ ^

GDM 0.02 0.36 0.33 0.42

0.47 0.44 4.24 6.94

^ ^ ^ ^

p 0.02 0.02 0.21 0.43

0.001 0.001 0.01 0.01

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

WS02-02 Management of premature rupture of the membranes by ultrasound G. Rizzo*, A. Capponi, E. Angelini, C. Grassi and C. Romanini Department of Ob/Gyn, UniversitaÁ Roma `Tor Vergata' and *G.B. Ospedale Grassi, Rome, Italy Objective: In pregnancies complicated by preterm premature rupture of the membranes (pPROM) there are essentially two causes of perinatal death: prematurity and lung hypoplasia. We used ultrasound to try to predict these complications. Design and methods: The cervical length was measured by transvaginal ultrasound in 167 pregnancies complicated by pPROM , 32 weeks of gestation. Further in 20 pregnancies with pPROM before 24 weeks of gestation peripheral pulmonary artery (PPA) waveforms were recorded by Doppler technique at weekly interval until delivery and the Pulsatility Index (PI) calculated. Pregnancies were managed conservatively according to an Institutional management protocol. The occurrence of preterm delivery and pulmonary hypoplasia was evaluated and related to ultrasound findings. Results: The cervical length at admission predicts the time interval elapsing between pPROM and delivery. Significant differences in PI values from PPA were present from 2 weeks onwards the pPROM


between the fetuses who developed pulmonary hypoplasia and those with a normal outcome. Conclusion: The measurement of the cervical length and of PPA velocity waveforms may help to establish the risk of developing prematurity and pulmonary hypoplasia in pregnancies complicated by pPROM.

WS02-03 What can fetopathology add to the prenatal ultrasound diagnosis? Z. Papp 1st Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary Background: Multiple malformation syndromes are generally heterogeneous diseases with inappropriate clinical delineation most cases. Geneticists are facing problems with lack of proper knowledge inspite of the overwhelming information available regarding a certain syndrome. Emphasis should be placed on the characteristic features of the suspected syndrome, or any major or detectable minor anomaly with significant effect on the course of the pregnancy. Conclusion: Detailed ultrasonography by experienced personnel provides a valuable tool in diagnosing morphological alterations of the fetus in mid-gestation. After termination of the pregnancy, the effected fetus must be examined thoroughly by an experienced fetopathologist. Careful and comprehensive examinations reveals all major and minor morphological alterations that might outline a certain syndrome or other multiple abnormality entity. Computer based syndromological programs are important in this process, for they help geneticists and fetopathologists by matching the most suitable syndrome to the given case. Genetic counseling can be completed only with the establishment of the most probable diagnosis. Declaration of recurrence rate and possible application of other prenatal diagnostic methods must be included in the counseling. Different types of multiple malformation syndromes of the fetus will be presented in the lecture.

WS02-04 Fetal tumours A. G. GonzaÂlez, F. L. Herrero, E. Ch. Alvarez and R. R. Rodriguez Hospital Universitario Materno-Infantil `La Paz', Madrid, Spain Fetal oncology is a chapter of the Obstetrics non well known yet. Fortunately, the improvements in the ultrasonography has let us to obtain an intrauterine diagnosis and to follow its evolution in order to choose the most appropriated obstetrical way. A total of 1326 fetal abnormalities has been diagnosed in the last 10 years in the Hospital `La Paz', Madrid, and we have found 54 cases of fetal tumours detected by ultrasonography (cyst and solid tumours included). This number of fetal tumours is estimated to be the 4.07% of all fetal abnormalities. Most frequent tumours include the fetal central nervous system, fetal lung, fetal heart, fetal genitourinary system, fetal gastrointestinal system. We have reviewed these fetal tumours histology, location and behaviour, trying to study the best obstetrical conduct and its chirurgical treatment. Ultrasonographic characteristic of each fetal tumour has been specified. Besides, we describe the possible differential diagnosis, maternal complications (preeclamptic status, mirror syndrome), obstetrical complications (polyhydramnios, preterm labour and delivery or placentomegaly) and fetal complications (cardiovascular failures, hydrops or death). Finally, we perform the indications for the spontaneous delivery or the preterm delivery induction depending on each case. Although we have not experience in intrauterine surgery, we believe that the best results are obtained in the neonatal surgery, always after an individual study and in agreement with the whole perinatal equipment.

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10th World Congress on Ultrasound in Obstetrics and Gynecology WS02-05 Serial in-utero ultrasonographic measurements of the fetal thyroid: a new complementary tool in the management of maternal hyperthyroidism in pregnancy R. Achiron, E. Sivan, M. Dolizki, S. Lipitz and O. Cohen Department of Ob/Gyn and Institute of Endocrinology, Chaim Sheba Medical Center, Tel-Hashomer, Israel Objective: Treatment of hyperthyroidism during pregnancy is complicated by the lack of readily available measures of the fetal thyroid status. Both hyper- and hypo-thyroidism of the fetus may have short and long-term detrimental effects and thus should be avoided. We therefore followed the fetal thyroidal size during treatment of maternal thyroid disorders and correlated the data with treatment and thyroidal status in the mother.

Workshops

Methods: During 24-month period 20 patients with thyroid disorders were referred for serial fetal thyroid measurements. Thyroid size was measured by transvaginal ultrasonography between 14 and 17 weeks' of gestation and by abdominal ultrasonography between 18 and 38 weeks' gestation. Results: In five women with Grave's diseases correlation between thionamide dosage and fetal thyroid size were noted. Two fetuses had an increase in the size of thyroid gland above the upper 95% confidence interval, one of them developed neonatal Grave's of which it was the only prenatal sign of fetal thyroid abnormalities. In all other three fetuses changes inthyroidal size aided in determining the dosage of the antithyroidal drugs. Conclusions: Inutero ultrasonographic measurements of the fetal thyroid size can be used as a noninvasive tool for the proper management of maternal hyperthyroidism.

W S 0 3 : I N F E RT I L I T Y WS03-01 Selection of candidates for IVF based on color Doppler findings M. M. Biljan McGill Reproductive Centre, Royal Victoria Hospital, Montreal, Quebec, Canada In the last 20 years there have been numerous improvements in IVF techniques leading to an exponetial increase in pregnancy rates. In spite of these improvements the patients undergoing IVF procedure still have more chance of failure than success. This presentation will address the areas in IVF treatment in which the use of color Doppler ultrasound could improve the results of IVF. Discussion will include the appropriate assessment of ovarian reserve as well as why the determination of the initial dose of gonadotropins based solely upon the patient's chronological age or serum FSH or E2 concentrations is imprecise. Recently, baseline ultrasound scans to assess for the presence of polycystic ovaries, and the use of color Doppler sonography to assess stromal perfusion have emerged as valuable tools in the assessment of the optimal dose selection of gonadotropins required for IVF ovarian stimulation. The issue of the assessment of oocyte maturity will additionally be discussed. Traditionally, follicular size has been used to assess oocyte maturity. However, frequently very poor oocytes are obtained from optimally grown follicles. It has been suggested that the assessment of peri-follicular flow could potentially distinguish oocyte maturity in a superior manner than size of follicles. Finally, the value of measurement of endometrial thickness and its structure, as well as uterine and subendometrial flow in the assessment of endometrial receptivity will be discussed.

WS03-02 Doppler assessment of the ovarian blood flow L. T. MerceÂ International Ruber Hospital, Madrid, Spain Background: The aim of this study was to evaluate arterial and venous intraovarian blood flow in infertile patients. Methods: Seventy-six FSH stimulated cycles in 39 patients participating in a timed intercourse or iui program were studied. Transvaginal color and pulsed Doppler measurement of the dominant follicle and corpus luteum resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV), maximum venous velocity (MVV) and serum p levels during mesoluteal phase were recorded. Velocimetric parameters were established and then used to classify ovarian function in normal ovulatory cycle (NOV; n 52), luteal phase defect (LPD; n 15) and luteinized unruptured follicle (LUF; n 9).

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Results: The luteal PSV and MVV in the nov and LPD cycles were significantly higher (NOV: 24.3 ^ 12.2 vs. 13.1 ^ 6.5 and 8.1 ^ 3.30 vs. 3.6 ^ 1.1; LPD: 29.8 ^ 10.3 vs. 14.4 ^ 4.8 and 5.7 ^ 1.5 vs. 4.3 ^ 1.2) and luteal RI and PI were significantly lower (NOV: 0.45 ^ 0.06 vs. 0.55 ^ 0.08 and 0.62 ^ 0.15 vs. 0.83 ^ 0.22; LPD: 0.46 ^ 0.05 vs. 0.54 ^ 0.06 and 0.62 ^ 0.10 vs. 0.81 ^ 0.15) than follicular ones. LUF cycles did not show significant changes during the ovarian cycle (follicular vs. luteal PSV; MVV; RI and PI: 14.4 ^ 4.8 vs. 14.9 ^ 7.3; 4.3 ^ 1.2 vs. 4.2 ^ 2.1; 0.47 ^ 0.07 vs. 0.58 ^ 0.12 and 0.66 ^ 0.12 vs. 0.89 ^ 0.29) and no `luteal conversion' of the Doppler signal was identified. There was significant correlation between luteal MVV and serum p (r 0.36). Conclusions: Arterial and venous intraovarian blood flow remain unaltered during LUF cycles and P levels correlate with luteal MVV. This makes Doppler an effective noninvasive test to assess ovulation and luteal function.

WS03-03 Three-dimensional digital imaging for assessing oogenesis and follicular development as well as live 3D follicle aspirations W. Feichtinger Institut fuÈr SterilitaÈtsbetreuung, Lainzerstr. 6, A-1130 Wien, Austria The purpose of the first study was to evaluate whether number and size of antral follicles can predict the outcome of IVF-ET. A total of 113 patients was prospectively included into this study. After 19 days of downregulation number and size of follicles were determined by using recent three dimensional transvaginal ultrasound (3-D) technology. We demonstrated that patients with a higher number of follicles between 5 and 10 mm showed a significantly higher pregnancy rate (PR), whereas patients with antral follicles . 11 mm have a higher cancellation rate due to ovarian low-response. Ultrasound visualization of the cumulus has been demonstrated years ago as an occasional finding during follicle scanning. It has never been proven, however, that cumulus-like intrafollicular structures as seen on ultrasound correlated with the recovery of mature oocytes. It was therefore our aim to investigate this possibility by using recent three-dimensional ultrasound (3-D) technology: Cumulus visualization by 3D ultrasound seems to be an indicator for mature oocytes and the fertilization rate. Follicles without visualization of the cumulus in all three planes are unlikely to contain mature, fertilizable oocytes. In the third part we wanted to evaluate the possibility of puncturing procedures under three-dimensional ultrasound control in close to real time using a new commercially available system, and to describe the technique. It will be demonstrated for follicle punctures that recent technology enables the carrying out of three-dimensional puncture procedures in


4±7 October 2000, Zagreb, Croatia real time; but this will be of more importance in other fields, e.g. in fetal medicine, oncology, and surgery.

WS03-04 Three-dimentional-ultrasound in IVF cycles R. L. Schild C. Knobloch, H. Van Der Ven and M. Hansmann University Hospital of Bonn, Department of Obstetrics & Gynaecology, Germany Aim: To investigate the role of 3D-ultrasound in estimating the likelihood of conception in an IVF programme. Materials and methods: We studied a total of 152 women during their stimulation cycle. Apart from conventional 2D-parameters we assessed endometrial and uterine volume (sub-)endometrial blood flow (sub-)endometrial vessel density and ovarian volume by 3Dultrasound. Results: With regard to subendometrial blood flow on day 1 of the stimulation cycle, all 3D-indices were significantly lower in the conception vs. non-conception group. On the day of oocyte retrieval, any difference between the two groups failed to reach statistical significance. The same applied to endometrial volumes. The latter showed a significant corrrelation with uterine size. Ovarian volumes # 3 mm (1 SD below the mean) on day 1 of the stimulation cycle were associated with a nonsignificant lower conception rate. Conclusion: Quantitative assessment of spiral artery blood flow and vessel density may be an early predictor of IVF success.

WS03-05 Ultrasound based simplified infertility investigation S. Granberg³, K. Hauge*, K. Flo* and M. Riedhart² Departments of Obstetrics and Gynecology, *RITé University Hospital, TromsoÈ, Norway, ²University Hospital, Innsbruck, Austria and ³Central Hospital in Hedemark, Elverum, Norway Objectives: To compare the use a simplified ultrasound based infertility investigation of the infertile couple with the current use of laparoscopy and hysteroscopy. Study design: Thirty-three infertile couples underwent transvaginal ultrasound and hystero-salpingo-contrast-sonography. A diagnosis was formulated based on the results of the ultrasound investigations, a semen analysis and endocrine parameters. The following day all subjects underwent a laparoscopic chrompertubation and hysteroscopy by a surgeon unaware of the ultrasound findings. A diagnosis based on the findings at laparoscopy and hysteroscopy, the same semen analysis and endocrine parameters, was then made. The two diagnoses were compared. Results: A 90.9% agreement was found between the diagnoses made from the two methods used. When considering laparoscopic diagnosis the Gold Standard of tubal patency, the sensitivity to diagnose occluded tubes using hystero-contrast-sonography was 92.8%. The corresponding figures for specificity, PPV and NPV were 96.2%, 92.8% and 98.1%, respectively. Conclusions: A simple, ultrasound based approach to investigate the infertile couple, can be used effectively as an initial examination modality during the couple's work-up. However, there is a need for a larger study to confirm these results.

WS03-06 Tubal patency as assessed by three-dimensional power Doppler imaging (3D-PDI) and hystero-salpingo-contrast sonography (HyCoSy) P. Sladkevicius The Diana, Princess of Wales Centre for Reproductive Medicine, St. George's Hospital Medical School, London, UK Background: The purpose of the study was to evaluate the feasibility of three-dimensional power Doppler imaging (3D-PDI) in the assessment of the patency of the fallopian tubes during hysterosalpingo-contrast sonography (HyCoSy).


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

WS03-07 Which information about follicular development in unstimulated cycles can be obtained by ultrasound? V. VlaisavljevicÂ Department of Reproductive Medicine and Gynecologic Endocrinology, Maribor Teaching Hospital, Maribor, Slovenia Unstimulated cycles offer a simpler, quicker and less invasive form of IVF and ICSI than the most conventional stimulated cycles. The objective of the study was to evaluate the effectiveness of different approaches for follicle monitoring in unstimulated cycles. This monitoring includes studies of follicle growth during the follicular and luteal phase of the cycle, measurements of blood flow in perifollicular vessels and studies of perifollicular perfusion in vascular network using power Doppler. These studies include 3D analysis of follicular growth, development and its vascularization. A retrospective chart review of all patients undergoing IVF and ICSI in unstimulated cycles at our institution was performed. The outcome measurements used were oocyte recovery rate, fertilization rate, implantation and delivery rate. Unstimulated cycles monitored by ultrasound only were compared with those monitored with different protocols of ultrasound monitoring combined with serum estradiol level and urinary LH. IVF and ICSI were performed in 708 unstimulated cycles. A higher pregnancy rate and lower cancellation rate was obtained when hCG was applied in lower values of serum E2 and smaller follicle diameter. The actual pregnancy rate per embryo transfer in IVF cycles was 23.8% and 26.4% in ICSI cycles when embryo transfer was performed on day 1 2 or day 1 3. When blastocyst stage embryo transfer was performed the implantation rate per embryo transfer was 37.5%.

WS03-08 Diagnosis and treatment of PCO syndrome ± what is the place of ultrasound V. SÏimunic University Dept of Obstetrics and Gynecology Petrova, Zagreb, Croatia Ultrasound characterization of ovarian morphology and vascularisation has become an important part of gynaecological endocrinology. PCO syndrome is the most prevalent endocrinological problem in women during reproductive period of life. The us diagnostic accuracy has advanced from recognition of ovarian size (volume), characteristic follicular distribution and volume of dense ovarian stroma, to blood flow changes in the uterine and ovarian stromal vessels. Improvement has been made by using innovations such as 3D US, colour and pulsed Doppler US, which allows US quantitative analysis of the ovarian stroma. In the PCOS the ovarian stroma is the source of hyperandrogenemia.

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10th World Congress on Ultrasound in Obstetrics and Gynecology One hundred and thirty-two patients with PCOS, diagnosed by us and endocrinological findings, underwent further clinical, US and endocrine evolution during various kinds of therapy (metformine, ovarian drilling, oral contraception, flutamide and finasteride treatment). Mean age of the PCO patients was 25.5 years (range 15±48), 59.3% were obese (BMI 28), 75.6% had signs of hirsutism, 43.02% presented with acne and 88.5% have had irregular menstrual cycle. Ultrasound findings (TVUS, colour and pulsed Doppler, 3D US) and hormonal evaluation (FSH, LH Androstendion, DHEA-a, T, Free T, SHBG, 3 a diol) were performed prior, during and at the end of the therapy. Comparison has been made between these five groups of patients.

WS03-09 Unilateral early timed vaginal ultrasound guided follicular aspiration (ETFA) 10±12 h after hCG prevents the syndrome of serious ovarian hyperstimulation T. TomazevicÏ, H. Meden-Vrtovec, K. GersÏak and E. Bokal University Medical Center, Ljubljana, SÏlajmerjeva 3, Slovenia Aim: To prevent the syndrome of severe ovarian hyperstimulation in IVF/ET cycles at high risk for the syndome of ovarian hyperstimulation by early timed unilateral ultrasound guided aspiration of one ovary (12 h after hCG). Method.: We evaluated the preventive effect of ETFA by analysing the data on 821 cycles at high risk for SOHSS performed during the years 1987±99. In all cycles the high risk for SOHSS was defined by the estradiol values . 3000 pg/ml and more than 8 follicles . 14 mm plus intermediate and small follicles in each ovary on ultrasound. Results: In the group of :729 female infertility cycles at high risk for SOHSS with preventive ETFA there were no cases of SOHSS. In the control group of 92 IVF/ET female infertility without ETFA there were 12 cases of SOHSS (P , 0.0001). No difference in live birth rate (17% vs. 16%) was noted. The results prove the preventive effect of ETFA. It is based on early timed withdrawal of paracine substances which are present in the follicular fluid.

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Conclusion: The vaginal ultrasound guided ETFA is another successful option to decrease the incidence of severe OHSS in assisted reproduction.

WS03-10 Vasoactive substances and infertility C. Battaglia, G. Regnani and A. Volpe Department of Obstetrics and Gynecology, University of Modena, Italy The regulation and significance of ovarian and uterine haemodynamics in human reproductive pathophysiology has been largely studied. In women, ovarian vascularization seems to be responsible for the selection and maturation of follicles both in spontaneous and stimulated IVF cycles while endometrial receptivity is related to uterine blood flow and implicated in the achievement of pregnancy. In patients who underwent to IVF cycles, the PI of both uterine and spiral arteries is significantly lower in patients who became pregnant in comparison with nonpregnant and is associated with significantly lower endometrial cell thromboxane concentrations than non pregnant patients. In poor responders women it has been demonstrated the role of L-arginine in improving uterine and follicular Doppler flow and in increasing ovarian response to gonadotrophin. Recently, in a total of 41 patients undergoing to assisted reproduction, an higher number of oocytes collected and embryos transferred was observed in normo-responders than in poor-responders patients. Furthermore follicular vascular endothelial growth factor (VEGF) resulted inversely correlated with retrieved oocytes (r 20.942; p 0.0017). In addition significant higher uterine and perifollicular Doppler flow resistances were observed in poor-responders women. The pregnancy rate/cycle was significantly higher in normo-responders (26%) than poor-responders (6%; p 0.037) patients. In conclusion, vasoactive substances improve ovarian response to gonadotrophin and allow a better management of ovarian stimulation in infertile patients.

W S 0 4 : M E N O PA U S I S WS04-01 Transvaginal sonography of the endometrium and sonohysterography in the menopause D. Zoricic General Hospital Pula, Croatia Background: All endometrial sampling methods are invasive. Therefore in sympyomatic women and for women at risk of developing endometrial pathology in menopause a technique that could reduce the number of biopsy procedures would be of a great value. This technique would be relatively non-invasive, easy to learn and perform, cost effective and well accepted by the patients. The objective of this study was the assessment of the diagnostic potency of ultrasound measurements by comparison with the usual histological investigation. Method: Endovaginal ultrasonography (measurement of endometrial thickness and morphology of endometrium) prior to endometrial sampling was done in 160 postmenopausal patients. 143 D&C, 15 hysteroscopies and 2 laparotomies were performed to collect endometrial tissue. Indications for endometrial sampling were bleeding in 72%, ultrasound suspicion of endometrium in 18%, or other (cervical or adnexal pathology) in 10% of patients. Sonohysterography, as an improvement over conventional ultrasound methods, was done in 12 cases (7.5%). Pathologic findings were compared to preoperative ultrasonography. Results: Ultrasound measurement of endometrial thickness combined with morphology and sonohysterography detected more than 90% endometrial pathology (sensitivity 96%, specificity 92%).

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Conclusion: We found endovaginal ultrasound as useful tool at identifying endometrial diseases in menopause. For a postmenopausal woman with vaginal bleeding with a 10% pretest probability of endometrial cancer, her probability of cancer is less than 1% following a normal endovaginal sonography and sonohysterography. Ultrasound should be considered as investigational and cannot be used as the only methods to evaluate abnormal bleeding in menopausal patients.

WS04-02 Should all unilocular ovarian cysts be removed in postmenopausal women? S. Granberg*, E. Ekerhovd*, H. Wienerroith² and A. Staudach² Departments of Obstetrics and Gynecology, Sahlgrenska University Hospital*, GoÈteborg, Sweden and University Hospital of Salzburg², Salzburg, Austria Objectives: Our purpose was to evaluate the risks of malignancy in surgically removed ovarian cysts that preoperatively were characterized as unilocular by transvaginal sonography. Study design: This prospective analysis included 1307 women operated at two European university Hospitals between January 1992 and December 1997. Based on ultrasonographic findings the cysts were characterized either as echo-free, without solid parts or papillary formations (group I) or cysts with solid parts/papillary formations or echogenic cyst content (group II). Ultrasonographic and macroscopic appearance of the cysts were compared with histopathological diagnosis.


4±7 October 2000, Zagreb, Croatia Results: In group I seven of 670 (1.1%) proved to be borderline or malignant, and all measured $ 75 mm in diameter. The corresponding figures for cysts in group II were 24 of 634 (3.8%). The frequency of borderline/malignant cysts increased significantly with the size of the cysts. Conclusion: Unilocular, echo-free cysts (group I) with a mean diameter above 50 mm and all unilocular cysts with solid parts/ papillary formations should be removed surgically. Serial ultrasound follow-up should be the standard procedure of unilocular, echo-free cysts less than 50 mm.

WS04-03 Doppler assessment of postmenopausal patient C. Battaglia, G. Regnani and A. Volpe Department of Obstetrics and Gynecology, University of Modena, Italy Menopause is associated with an increase in the incidence of ischemic heart disease and stroke. Loss of ovarian function is characterized by significantly high values of blood and plasma viscosity. After the menopause, thromboxane production increases and correlates with duration of menopause. Large studies have shown that postmenopausal HRT is associated with reduction in the risk of cardiovascular disease. The aim of the study was to evaluate the plasma thromboxane and plasma viscosity in relation with Doppler flow parameters in postmenopausal patients treated with HRT. Thirty-two postmenopausal (FSH . 40 UI/L and estradiol , 100 pmol/L) women (mean age ^ SD, 54.7 ^ 2.9 years) participated in the study and were submitted to continuous estradiol transdermal supplementation and 12-day courses of medroxyprogesterone acetate every second month. Doppler resistances at the level of uterine and internal carotid arteries, thromboxane plasma levels and plasma viscosity were analyzed in basal condition and after 1, 3 and 6 months. During hormone supplementation, the pulsatility index significantly decreased at the level of analyzed arteries. Similarly, plasma thromboxane levels and plasma viscosity were significantly reduced. Significant correlations were found between thromboxane plasma concentrations, plasma viscosity and uterine artery resistances. Thus HRT seems to be responsible for both direct and indirect modifications at the level of the vessel wall physiology.

WS04-04 Vascular impedance of uterine, inferior vesicle and ophthalmic arteries in postmenopausal women receiving hormonal replacement therapy: comparative Doppler study I. Bekavac, S. Kupesic, D. Mihaljevic and A. Kurjak Department of Obstetrics and Gynecology, University of School Medicine and Sveti Duh Hospital, Zagreb, Croatia Background: To investigate the effects of combined hormone replacement therapy (HRT) on the vascular impedance of the uterine, inferior vesicle and ophtalmic artery. Method: Thirty-five postmenopausal patients were analysed in basal condition and during a HRT phase at 1, 3 and 6 months. Patients were divided in two groups: 21 patients whose last menstrual bleeding

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

WS04-05 Doppler ultrasound and hormonal replacement therapy (HRT) I. Zalud Division of Maternal Fetal Medicine, Kapiolani Medical Center for Women & Children, University of Hawaii John Burns School of Medicine, Honolulu, HI, USA Hormonal replacement therapy (HRT) offers multiple benefits and some risks to many postmenopausal women, especially to those whose menopause occurred before age 45. Improvements of image resolution by transvaginal sonography allow the investigation of very delicate anatomical structures such as the endometrium. Various diagnostic criteria including thickness and volume of endometrium, internal structure and myometrial involvement help to identify endometrial abnormality. The benefits of technologies such as sonohysterography, Doppler and 3D ultrasound are being assessed. In the postmenopausal patient without hormonal substitution, endometrial pathology may be diagnosed by measuring endometrial thickness alone. In women with postmenopausal bleeding, endometrial atrophy as the must common cause has been differentiated from endometrial cancer with a high success rate. Considering that the majority of diagnostic endometrial biopsies reveal a benign pathology, Doppler ultrasound may significantly reduce the number of these procedures. In patients with HRT, the measurement of endometrial thickness is not reliable to predict pathology. In this situation, ultrasound examination of the endometrial/myometrial border or endometrial blood flow is advantageous. Transvaginal ultrasound and Doppler blood flow analysis could prove helpful in selection and follow up of patients on HRT and maybe to prevent some unwanted endometrial effects.

W S 0 5 : E N D O M E T R I A L PAT H O L O G Y WS05-01 Ultrasound in endometrial pathology H. Haller Department of Ob/Gyn, Rijeka, Croatia Background: This study was undertaken to evaluate the accuracy of transvaginal ultrasound combined with vaginal and endometrial


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

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10th World Congress on Ultrasound in Obstetrics and Gynecology vaginal and endometrial cytology show very high sensitivity and specificity for endometrial cancer. The combined use of three diagnostic methods show no benefit for other pathologic conditions. Conclusion: Combination of transvaginal ultrasound, vaginal and endometrial cytology can not absolutely replace histologic findings obtained by D & C. However, in the cases with thin endometrium and negative cytology D & C could be avoided. Usefulness of these three methods has to be found in providing more information resulting in better understanding of endometrial condition.

WS05-02 Sonohysterography in patient treated with SERMs A. C. Fleischer Vanderbilt University Medical Center, Nashville, TN, USA Sonohysterography (SHG) is an established method for detection of polyps, evaluation of submucosal intracavitary fibroids and adhesions as well as abnormal areas of endometrial thickening. This presentation will describe SHG findings for evaluation of punctate cysts both within and adjacent to the endometrium seen in women on selective estrogen receptor modulators (SERMS) Tamoxifenw, and Roloxifenew. The clinical significance of these findings will be discussed. Cystic endometrial atrophy and focal adenomyosis of patients receiving SERMS may the histologic correlate of abnormal sonographic appearances.

WS05-03 Ultrasound in the diagnosis of endometrial abnormalities L. Valentin University Hospital, MalmoÈ, Sweden There is a potential role of ultrasound examination in the management of women with postmenopausal (PMP) bleeding. Because women with an endometrium 4 mm at transvaginal ultrasound examination rarely have endometrial pathology, it may be justified not to sample their endometrium. However, endometrial pathology is common among women with endometrium 5 mm. In our prospective study, 105 consecutive women with PMP bleeding and endometrium 5 mm underwent hydrosonography, hysteroscopy, D & C, and hysteroscopic resection. 80% of these women had endometrial pathology, including 24% with endometrial malignancy. 94% of the pathological lesions manifested a focal growth pattern. 87% of the focal lesions were only partly removed or remained in situ after D & C, D & C missing 25% of malignancies and 53% of benign pathology. Hydrosonography was as good as hysteroscopy at detecting focally growing lesions in the uterine cavity (agreement between hydrosnography and hysteroscopy being 96%; Kappa 0.77), but neither hysteroscopy nor hydrosnography could reliably discriminate between benign and malignant lesions. In a randomized trial, 49 women with PMP bleeding and endometrium 4 mm were randomized to D & C and 48 to ultrasound follow up. 14 (29%) women in the D & C group and 22 (46%) in the ultrasound group had either rebleeding or manifested endometrial growth during a 12-month follow-up period. Endometrial pathology was not found in women with rebleeding unless the endometrium was 5 mm. Conclusion: Women with PMP bleeding and endometrium 5 mm should undergo hydrosnography. If focal lesions are detected hysteroscopic resection should be carried out. In women with PMP bleeding, rebleeding during the first 12 months is an indication to sample the endometrium only if the endometrium measures 5 mm at ultrasound examination.

WS05-4 Assessment of uterine vascularity in endometrial cancer I. SzaboÂ 1st Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary

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

WS05-05 A role of ultrasound in follow-up of tamoxifen patients M. Predanic Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA Recently suggested role of tamoxifen as a preventive agent in women at high risk of breast cancer has a potential to increase significantly the number of women treated with tamoxifen agent. By the fact that tamoxifen is beneficial in taming the breast cancer, but detrimental to the uterus by increasing the risk of endometrial carcinoma, hyperplasia, and development of endometrial polyps, surveillance of endometrial changes in patients on tamoxifen is needed. However, no cost-effective method has been found for screening for the rare occurrence of endometrial carcinoma. Therefore, the ACOG does not recommend routine endometrial screening of tamoxifen-treated breast cancer patients. Regardless of aforementioned recommendation, ultrasound (US) is very helpful as a first line for diagnosis of endometrial pathology in symptomatic or asymptomatic patients with previous endometrial pathology. Endometrial thickness , 5 mm is reassuring, . 5±8 mm calls for further investigation such as sonohysterography to rule out polyps. If it fails to demonstrate polyps, but cystic structures still present and letter on endometrial biopsy (or D & C) shows atrophic changes of the endometrium or material is insufficient for analysis, likely diagnosis is Cystic Endometrial Atrophy. Additionally, Color Doppler flow measurement helps in differentiation between atrophic cystic endometria and polyps, hyperplasia or even cancer in terms that atrophic endometrial are mainly avascular, whereas endometrial polyps and carcinomas are richly vascularized within the endometrium as well as in surrounding myometrial tissue. How and how often endometrial surveillance should be done?: 1. Recommend us or endometrial biopsy evaluation prior to tamoxifen treatment; 2. Follow up with endometrial biopsy/D & C if symptomatic; or 3. If asymptomatic but patient at high risk (history of previous endometrial disorders, obesity, long duration of tamoxifen treatment), recommend us 6 months. US findings: 1. If endometrial thickness . 5±8 mm, exclude endometrial polyps by sonohysterography; and add color doppler to evaluate vascularity pattern; 2. If no polyps with thick endometrium on sonohysterography and avascular pattern present, perform blind or hysteroscopic guided endometrial biopsy; 3. If findings are atrophic endometrium or insufficient material for


4±7 October 2000, Zagreb, Croatia diagnosis, assume atrophic (^ cystic) endometrial changes and continue annual/semiannual endometrial evaluation (^ US); 4. If (1) simple hyperplasia, consider progestin and/or D & C treatment;

Workshops 5. Consider hysterectomy as final option if endometrial pathology persists.

W S 0 6 : F E TA L E C H O C A R D I O G R A P H Y WS06-01 Human fetal cardiac function during the first trimester of pregnancy P. Jouppila, K. MaÈkikallio and J. RaÈsaÈnen Department of Obstetrics and Gynecology, University of Oulu, Oulu, Finland Introduction: The hypothesis was tested whether the improvement in the human fetal cardiac diastolic and systolic functions are associated with changes in the cardiac volume blood flow, inflow blood velocity waveform characteristics, systemic venous blood flow parameters, umbilical artery velocimetry and fetal nuchal translucency. By a longitudinal study protocol the inflow and outflow blood velocity waveforms were obtained in 16 uncomplicated pregnancies at 6, 7, 8, 9 and 10 weeks. Results: The proportion of isovolumetric relaxation time decreased and the proportions of filling and ejection times of the cardiac cycle increased significantly from 6 to 7 weeks. The proportion of isovolumetric contraction decreased between 8 and 9 weeks. Every inflow waveform was monophasic before 9 weeks but it was biphasic in all cases at 10 weeks. Mean velocity of inflow and outflow increased between 6 and 7 weeks and Vmean of inflow increased further after 8 weeks. At 9 and 10 weeks, atrioventriculu valve recurgitation (AVVR) was present in 4 and 7 fetuses, respectively. Nuchal translucency was greater in fetuses with AVVR present at 10 weeks compared with non-AVVR cases. Conclusion: Improvement in the diastolic function of fetal heart between 6 and 7 weeks is accompanied by simultaneous increase in the mean velocities across inflow and outflow tracts. Appearance of biphasic inflow pattern is associated with significant change in systolic function between 8 and 9 weeks. AVVR is a common finding at 10 weeks of gestation.

WS06-02 Cardiac anomalies in early pregnancy U. Gembruch, U. Germer and J. Smrcek Division of Prenatal Medicine, Medical University, LuÈbeck, Germany Fetal echocardiography including colour and spectral Doppler facilitates the diagnosis of the great majority of major structural and functional cardiac abnormalities in the late first and early second trimester of gestation. Based on more than 4000 echocardographic examinations between 10 and 16 weeks of gestation (4/1993±3/2000) following data are demonstrated: 1. The four-chamber view and cross-over of the pulmonary trunk and aorta were visualised in 44% of the fetuses at 10 weeks and in 100% at 13 weeks of gestation. 2. Normative biometric data of the fetal heart has been established. The ratio of the right and left ventricle and of the pulmonary trunk and ascending aorta were constant during this period of pregnancy (approximately 1.00 and 1.10, respectively). 3. The detection rate for cardiac malformations was greater than 60%. Colour Doppler increased the detection rate by easier demonstration of the great arteries and of abnormal cardiac blood flow pattern (valvular incompetence and stenosis). 4. In fetuses with increased nuchal translucency ( 3 mm) (30% of those with general hydrops) the rate of aneuploidy was twice as high in fetuses with abnormal echocardiographic findings compared to fetuses with normal echocardiogram. In some aneuploid fetuses with


normal cardiac structures transient tricuspid regurgitation was observed. 5. Some complex cardiac malformations were diagnosed which are very rare in later gestation, e.g. absent pulmonary valve syndrome with patent ductus arteriosus, polyvalvular stenoses of the semilunar valves.

WS06-03 Ultrasound-detected heart defects associated with aneuploidy G. R. DeVore Fetal Diagnostic Center of Pasadena, Pasadena, CA, USA In North America second trimester genetic ultrasound is offered to patients at risk for trisomy 21 and other chromosomal abnormalities who decline invasive testing. In most major studies in which the prevalence of ultrasound markers used for genetic ultrasound are reported, congenital heart defects are identified in less than 10% of fetuses. When one considers that over 50% of fetuses with trisomy 21 and 90% of fetuses with trisomies 13 and 18 have structural malformations of the heart, the question should be raised as to why the wide discrepancy in prevalence and detection rate of heart defects in these fetuses. The purpose of this presentation is to review the prevalence of CHD in fetuses with trisomy 21, trisomies 13 and 18, and all fetuses with chromosomal defects that were identified following second trimester amniocentesis. To ascertain the presence or absence of CHD, each fetus underwent a fetal echocardiographic study using real-time and color Doppler ultrasound at the time of genetic amniocentesis. The results of the study demonstrated the following: The detection rate for trisomy 21 (n 80) increased from 62% to 91% when examination of the fetal heart was performed. The detection rate for trisomy 18 (n 30) increased from 84%% to 97% when the cardiovascular system was evaluated. For fetuses with any chromosomal abnormality (n 103) advanced maternal age were examined, the examination of the heart increased the detection rate from 61% to 85%. Given the above findings, the inclusion of the fetal echocardiographic evaluation of the fetus significantly increased the detection rate for the above three groups of fetuses. If physicians and/or sonographers desire to increase the ultrasound detection rate for chromosomal abnormalities, examination of the fetal cardiovascular system must occur.

WS06-04 Intracardiac echogenic focus and fetal heart defects R. Chaoui and A. Bierlich Clinic of Obstetrics, University Hospital, ZuÈrich, Switzerland Background: Intracardiac echogenic foci are controversially discussed whether or not they are marker for chromosomal aberrations. The possible association with fetal congenital heart defects (CHD) and its impact were not yet analyzed extensively. Method: During 30 months, prenatally detected structural CHD were prospectively analyzed for the presence of EF. Frequency, localization, number, association with chromosomal defects and pattern of CHD were assessed. Results: 279 fetal CHD could be examined and EF were found in 31 cases (11.1%). The localization was in 17 cases (54%) the left, in 7 (22%) the right, and in 7 (22.5%) both ventricles. Multiple EF were

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10th World Congress on Ultrasound in Obstetrics and Gynecology found in 10 cases. 14 cases (42%) were associated with a chromosomal aberration (T18 n 2; T21 n 5, T13 n 3, Triploidy n 2, Del22q n 1, others n 1). Among the remaining 17 fetuses with normal chromosomes following heart defects were found: 3 VSD, 3 Left-persistent SVC, 2 TGA, 2 TOF, 2 Coarctation, and 1 PS, PA, Ebstein, TAC, AS each. Conclusions: Compared to low-risk groups EF are more frequent in the presence of CHD and show another distribution involving more right ventricular or bilateral EF. The combination of EF and CHD is highly associated with aneuploidies. Since associated CHD include also conotruncal anomalies EF can be considered as an indication for targeted fetal echocardiography especially when EF is localized in the RV or in both ventricles.

WS06-05 Disproportion of the four chamber view of the fetal heart: what does it mean? M. Respondek-Liberska Institute `Polish Mother's Memorial Hospital', èoÂdzÂ, Poland Background: The aim of the study was a retrospective analysis of fetal heart disproportion. Method: From the database of 3941 fetuses disproportion based on 4 chamber view was diagnosed in 136 fetuses (3.5%). There were 96 fetuses with the complete neonatal follow-up. Results: Fifty-nine fetuses presented with different extracardiac malformations. Three other fetuses presented with heart defects. Thirty-four fetuses with disproportion had `normal heart anatomy' and no extracardiac malformations. Gestational age at the time of diagnosis was 26±40 weeks (mean 35). Out of 34 fetuses with `pure' disproportion, 15 cases (44%) did not have any clinical or postnatal ECH0 abnormalities. In 19 cases (54%) structural or functional abnormalities were found: 6 neonates presented with ASD secundum, 4 with CoA, 2 with lungs abnormalities (cong. pneumonia and cong. lung emphysema), one neonate had PDA, one had aorto-pulmonary window 1 PDA. In other 5 neonates tricuspid insuffciency was diagnosed. Conclusions: Disproportion in fetal heart was the relatively frequent abnormality at the referral center for fetal echocardiography (3.5%) and in majority of cases it was related to the presence of structural or functional abnormalities. In 44% of neonates fetal disproportion had no clinical implications. The most common neonatal heart defect in cases who prenatally presented with disproportion was ASD sac, followed by CoA (4/19, 21%).

WS06-06 A novel sonographic approach to the fetal echocardiogram M. Bronshtein Haifa, Israel At present there are four concepts guiding the sonographic examination of the fetal heart: (1) the fetal echocardiogram (FEC) is difficult to perform and time-consuming, (2) FEC should be performed only in high risk pregnancies, (3) the optimal time to perform FEC is 18± 22 weeks gestation, (4) FEC relies on several sonographic still views. In our lecture, we will present a new systemic `video' approach to the great vessels and the four chambers in early pregnancy using transvaginal sonography. Transvaginal ultrasound examination of the cardiovascular system was performed in 36 323 consecutive fetuses using a dynamic `video' multidirectional approach. Cardiovascular anomalies were detected in 173 fetuses giving an overall incidence of 1 in 210 pregnancies and 1 in 238 low-risk pregnancies. Fifty-six percent of the fetuses had associated anomalies. The prenatal diagnosis was confirmed in 90 cases. In 10 fetuses a different cardiac anomaly was observed. In four fetuses the cardiovascular anomaly was not detected in early pregnancy. In the remaining cases, postmortem examination was not performed. Early fetal heart examination is suggested in all pregnancies. Conclusions: Fetal ECC should be performed: (a) transvaginally, (b) in

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

WS06-07 Examination of the fetal heart by five short-axis views: The optimal screening method for fetal cardiac anomalies? S. Yagel Hadassah University Hospital, Mt. Scopus, Jerusalem, Israel `Classic' fetal echocardiography is based on 7 transverse planes: the upper abdomen, the traditional four-chamber view, the five-chamber view in which the aortic root is visualized, and the fourth transverse view revealing the bifurcation of the pulmonary arteries, and long-axis views of the outflow tracts and aortic arch. We recently proposed the three vessel and trachea (3VT) plane of insonation be added, to facilitate and expedite fetal heart evaluation. The (3VT) is the most cephalad transverse view, visualized on a plane crossing the fetal upper mediastinum. It is obtained easily by moving the transducer cephalad and slightly oblique from the FCV, and shows the main pulmonary trunk (MPA) in direct communication with the ductus arteriosus (DA). A transverse section of the aortic arch is seen to the right of the MPA and DA. Cross sections of the superior vena cava (SVC), and posterior to it the trachea, are visualized. The clinical applicability of the 3VT was demonstrated in a recent study encompassing 1263 low-and high-risk cases scanned between 14 and 24 weeks' gestation. We consider one of the greatest advantages of our novel approach the ease with which the examiner can scan the fetal heart, beginning with the caudal upper-abdomen view. By sliding the transducer cephalad in one continuous motion, all the pertinent views are readily visualized. It was also shown to be effective in the diagnosis of such aortic arch anomalies as right and double aortic arch, among others. We showed that five short axis views including the 3VT simplified and streamlined fetal cardiac examination, without compromising diagnostic effectiveness.

WS06-08 Real-time three-dimensional fetal echocardiography: imaging and volume measurement T. R. Nelson and D. H. Pretorius University of California, San Diego La Jolla, CA, USA The objective of this work was to assess the feasibility of real-time three-dimensional echocardiography (which acquires data as a volume, instead of a series of planes, eliminating gating) to evaluate fetal cardiac anatomy and function. We evaluated 10 human fetuses including several with congenital heart disease. Transabdominal scanning was performed using a real-time three-dimensional echocardiography system. Four 1.5 second volume clips at 20 volumes/ second were obtained for each fetal heart and stored for off-line analysis. Data were reviewed on a graphics workstation. Our results showed that fetal heart data could be acquired rapidly. Fetal heart data were displayed as 3 simultaneous planes. The reviewer could manipulate plane orientation and position in the volume to optimize views. Cardiac motion could be accelerated, slowed, stopped or viewed at its original speed. Although image quality did not equal high-end equipment, cardiac structures, views and function could be consistently visualized. Abnormal structures were readily detected. In conclusion, real-time three-dimensional fetal echocardiography is a feasible and potentially important new technique that will gain importance as equipment performance improves.

WS06-09 Prenatal detection of congenital heart disease: the need for a cost-effectiveness analysis D. Paladini, A. Teodoro, A. Lamberti, M. Arienzo and P. Martinelli Fetal Cardiology Unit ± Department of Obstetrics and Gynecology ± University Federico II of Naples, Naples, Italy


4±7 October 2000, Zagreb, Croatia Background: Recent reports have shown a significantly improved survival for complex congenital heart disease (CHD) when detected antenatally. This has further substantiated the need to detect CHD in utero. Since the performance of the 4-chamber view as a screening tool is rather insufficient, the issue is now to find more effective and not too expensive alternative methods to reach this aim. Method: The cost-effectiveness analysis (CEA) is an efficient method to assess health outcomes and resource costs of health interventions. We have applied this tool to prenatal detection of CHD, comparing 3 models: (1) 4-chamber view at level I; (2) outflow tracts at level I; (3) Outflow tracts at level II. To perform the analysis we have made the following assumptions: (1) the incidence of CHD at 20 weeks is 10/1000; (2) the percentage of severe CHD is 40%; (3) the monthly salary are 2500 USD and 3500 USD for level I and level II operators, respectively; (4) detection rate for CHD detectable on the 4-chamber view and on outflows only are 35%/20%, 60%/60%, and 90%/90% for the three options (level I 4-chamber, level I outflows, level II outflows).

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

Costs Outcome

Level I 4-ch.

Level I Outflows

Level II Outflows

Det. Any CHD Det Severe CHD TOP Any CHD TOP Severe CHD

1796 6510 5314 9300

1157 2894 2893 4133

324 USD 810 USD 810 USD 1157 USD

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W S 0 7 : F E TA L E N D O S C O P Y A N D I N VA S I V E P R O C E D U R E S WS07-01 Fetal hydrolaparoscopy and endoscopic cystotomy in complicated cases of lower urinary tract obstruction R. A. Quintero, P. W. Bornick, W. J. Morales, M. H. Allen and P. K. Johnson Florida Institute for Fetal Diagnosis and Therapy, St. Joseph's Women's Hospital, Tampa, FL, USA Background: Vesicoamniotic shunting may be difficult or impossible in selected cases of fetal lower obstructive uropathy (LOU). The purpose of this paper is to describe the performance of fetal hydrolaparoscopy (FHL) and endoscopic fetal cystotomy (EFC) in fetuses with complicated LOU. Method: FHL-EFC was performed in one patient with a markedly thickened bladder that could not be entered percutaneously. A peritoneoamniotic shunt was also placed. FHL-EFC was performed in a second patient with a collapsed bladder from a previous vesicocentesis, as vesicoinfusion resulted in further ascites. Fetal cystoscopy was performed after EFC, and posterior urethral valves were ablated with YAG-laser. A vesicoamniotic shunt was inserted. Results: Adequate bladder drainage was obtained in both cases. The first baby required bilateral nephrostomies and a permanent cystotomy at birth, and is scheduled for a bladder expansion procedure at one year of age. The second patient had premature rupture of membranes and fetal demise from treatment of this complication 5 days after the original procedure. Conclusion: FHL-EFC can be performed in complicated LOU cases. The procedure involves the creation of a defect in the bladder dome under direct endoscopic visualization within a hydroperitoneum. Peritoneo or vesicoamniotic shunting, or ablation of posterior urethral valves may then be performed. FHL-EFC should be reserved only for complicated cases of LOU where conventional vesicoamniotic shunting is not possible.

WS07-02 Treatment for TTS should be done within a trial Y. Ville Principal Investigator of the Eurofoetus Trial, Paris, France Over a year I invited you here to participate to the rct for treating twin-to-twin transfusion syndrome (TTS). Are there any data available to reconsider this? The answer is clearly no, on the contrary. Indeed large series on amniodrainage or laser therapy have become available. With serial amniodrainage overall survival for both twins is 49% or 71% where at least one baby survive. In cases where one fetus dies in


utero, 20% of the survivors die, and in another 20% they have severe neurological morbidity. Laser treatment has now a survival rate of 54% for both twins and 81% for at least one survivor. Neurological morbidity seems to be less than 10%. Has this larger experience contributed to solve the question whether one or the other therapy is better? No, it only underscores that our estimate of the number of patients needed in a rct was right: 10% difference in survival rate and 15% for severe neonatal morbidity. All new data, all new studies are an urgent call for randomisation. If not, both patients and their obstetricians will continue to argue based on unsubstantiated views. Further case series will not bring any critically new element. Results: Over 45 patients have now been included, all but a few in France. If we would extrapolate the number of patients randomised at our centre, only three other groups would have to recruit at the same pace to reach the 142 patients needed by the end of next year. Discussion: There are many arguments to try to finish the study within a few years. It avoids the obvious bias due to improvements of perinatal resuscitation. It would keep high motivation amongst referring clinicians. I would dare to say more: at this point it has become unethical not to randomise cases with TTTS. Not laser, neither amniodrainage have become established yet as the best treatment and there is no room for empirical new techniques until the trial is completed.

WS07-03 Stage-based treatment of twin±twin transfusion syndrome: preliminary study R. A. Quintero, P. W. Bornick, W. J. Morales, M. H. Allen and P. K. Johnson Florida Institute for Fetal Diagnosis and Therapy, St. Joseph's Women's Hospital, Tampa, FL, USA Background: The purpose of this study was to test the value of sonographic staging of twin±twin transfusion syndrome (TTTS) in predicting the outcome of patients treated with amniocentesis or selective laser photocoagulation of communicating vessels (SLPCV). Methods: TTTS was defined as a deep vertical pocket (DVP) in the recipient twin of . 8 cm and in the donor twin , 2 cm. TTTS was staged as follows: Stage I: bladder of donor visible; Stage II: bladder of donor not visible; Stage III: critically abnormal Dopplers; Stage IV: hydrops; Stage V: demise. Patients were treated with amniocentesis or SLPCV. Results: There were a statistically significant difference by stage for at least one survivor between the two techniques (Chi-square 2.63,

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10th World Congress on Ultrasound in Obstetrics and Gynecology p 0.05), but analysis was limited by sample size (amniocentesis n 9, SLPCV n 70). In the amniocentesis group there was an 83% (n 5) survival rate for two survivors in Stage I and no survivors (n 3) in stages II or III. In the SLPCV group, at least one fetus survived 83% of the time, regardless of stage.

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Conclusion: Our preliminary data suggests that analysis of survival data by in TTTS needs stratification by stage. Early stages may be amenable to treatment with amniocentesis, while later stages may not benefit. SLPCV is uniformly effective, regardless of stage, but may not be warranted in early stages of TTTS.

W S 0 8 : F E TA L B R A I N WS08-01 Three-dimensional-ultrasound of the embryonic/early fetal brain H.-G. K. Blaas National Center for Fetal Medicine, Norwegian University of Science and Technology, Trondheim, Norway In the growing embryo, the brain is the first organ system to develop in such a way that it can be imaged in detail with transvaginal ultrasound. The extension of the transvaginal ultrasound technique to 3D imaging makes it possible to obtain new ultrasound images of the developing embryonic brain in planes not available in the original scan plane, to present form and shape, and to calculate volume. New information about the embryonic brain development can be obtained: volume measurements of the embryonic brain compartments reflect the phylogenetic development. The òld' rhombencephalon is large during the early phase, while the `young' hemispheres are very small. During a few weeks, this correlation becomes reversed. Using 3D animations this dynamic developmental process can be visualized. Ultrasound technology has reached a level where the diagnosis of embryonic malformations can be made. At present, we are at the borderline of being able to diagnose holoprosencephaly when the embryo is seven to eight weeks. At nine weeks, 3D images of anomalies such as holoprosencephaly and spina bifida have been made. We may expect the rapidly developing 3D technology, with the option of anyplane slicing, to help us establish early diagnoses in the future. Such multiplane presentations of a diagnosis will contribute to increasing the diagnostic accuracy.

WS08-02 Three-level view (TLV) of fetal brain imaging in the prenatal diagnosis of congenital anomalies I. Goldstein and E. Reece Department of Obstetrics and Gynecology, Rambam Medical Center, the B. Rappaport Faculty of Medicine, Technion, Haifa Israel, and Department of Obstetrics, Gynecology and Reproductive Sciences at Temple University School of Medicine, Philadelphia, Pennsylvania, PA, USA The purpose of this study was to determine whether a systematic stream-lined approach could be routinely used in the evaluation of the fetal intracranal anatomy, and which could be used to effectively and efficiently exclude all major intracranial malformation. Three planes were determined to be independent without overlay. Following the establishment of these three independent oblique planes across the intracranial anatomy, there were applied clinically to determine whether such planes would be sufficient to diagnose the major intracranial abnormalities. After retrospectively examining the various imaging levels taken, it was independently determined that three levels of intracranial imaging provided the greatest anatomic view of the entire fetal brain: the lateral ventricular level (Level I); the medial-thalamic level (Level II); and the inferior-posterior fossa view (Level III). We examined 131 cases of intracranial abnormalities that were prenatally diagnosed between 14 and 24 weeks gestation. One investigator was given the three-level view protocol to determine if the anomalies could be identified using this system. It was determined that, of the 131 abnormal cases, 126 (96.2%) were diagnosed using

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Levels I, II or III, independently or in combination. There were no false-positive test results. The present study investigated the efficacy of a three level view (TLV) imaging of the fetal brain representing a complete 2-D examination. We found this approach to be applicable throughout pregnancy and suitable for visualization of normal intracranial structures as well as the identification of abnormalities.

WS08-03 Prenatal diagnosis of congenital and acquired brain abnormality R. K. Pooh Department of Obstetrics and Gynecology, The Taijukai Foundation, Kaisei Hospital, Japan The intrauterine development of the central nervous system (CNS) is one of the most interesting fields in perinatology. The brain has threedimensional structure and rapidly changes its appearance during pregnancy. Therefore, the fetal brain should be evaluated threedimensionally with consideration of gestational age. Sonoembryology has been established by high-frequency transvaginal sonography. Premature brain structure and ventricular system of early fetuses can be clearly demonstrated and prenatal diagnosis of congenital anomalies has been done earlier and earlier. Application of transvaginal approach to the fetal brain in the second and third trimesters has enabled brain imaging from fetal parietal direction through fontanelles and cranial sutures, and `neurosonography' has been established. Recent introduction of 3D ultrasound in neurosonography produced skull imaging, serial parallel images of the brain structure, volume extraction of target organ and brain circulatory images. Furthermore, advanced technology of magnetic resonance imaging (MRI) can demonstrate CNS morphology including the brain stem, which is not clearly depicted by sonography. By using all those technologies, prenatal diagnosis of CNS abnormalities has been more objective and accurate. Intracranial changes in cases with CNS anomalies have been objectively demonstrated in vivo. Furthermore, intrauterine acquired brain damage such as periventricular leukomalacia, which is one of the controversial issues in perinatology, has been proven by sonography in a few cases. Further case studies will be required for investigation of CNS pathology in utero.

WS08-04 Fetal brain: cerebral and cerebellar circulation in early fetal jeopardization D. Arduini, F. Giannini, C. ExacoustoÁs and C. Romanini Department of Obstetn. and Gynaecol., University of Tor Vergata Rome, Italy Background: The aim of this study was to investigate with colorpower doppler sonography the arterial and venous circulation in fetal brain, in normal and pathologic circumstances. Method: We studied 101 appropriate for gestational age (AGA) fetuses, 20 intrauterine growth-retarded fetuses (IUGR), 10 fetuses with cmv infections and 10 fetuses with supraventricular tachycardia. In all fetuses we obtained reliable blood flow velocity waveforms of middle cerebral and superior cerebellar artery and trasverse sinus. The pulsatility index (PI) for arterial vessels and flow velocity for


4±7 October 2000, Zagreb, Croatia venous vessels were used. Doppler measurements of AGA fetuses were compared with other fetuses. Results: An increase in fetal middle cerebral PI and cerebral transverse sinus was observed in IUGR and a slightly decrease in case of fetal arrhytmia when compared with AGA fetuses. In 6 of 10 fetuses affected by cmv infection was observed a reduction in PI cerebral and cerebellar, while no difference was found for venous velocities. A longitudinal study was performed in 30 AGA and 8 IUGR fetuses. The IUGR fetuses showed a characteristic early reduction of cerebellar PI in respect to cerebral PI about 4±8 days prior the evidence of late heart rate (HR) decelerations; however, the two vessels did not differ significantly in the 4 days prior HR decelerations. Conclusion: Venous and arterial cerebral circulation shown a response to pathological conditions that could affect fetal brain.

WS08-05 Ultrasound evaluation of fetal brain space occupying lesions V. D'Addario, V. Pinto, E. D. I. Naro and A. Anfossi 4th Unit of Obstetrics and Gynecology, University Medical School, Bari, Italy Objective: To evaluate the accuracy of ultrasound in identifying fetal brain space occupying lesions. Study design: A retrospective evaluation of 14 cases of fetal brain space occupying lesions has been performed. All prenatal ultrasonographic diagnoses (5 teratomas, 1 choroid plexus papilloma and 8 arachnoid cysts) were compared with the postnatal findings on the aborted fetuses or on the newborns. Results: In 11 out of 14 cases the antenatal ultrasonographic diagnosis was confirmed postnatally; 1 case of supratentorial arachnoid cyst was mistaken for a teratoma and 2 cases of porencephalic cysts were wrongly diagnosed as arachnoid cysts (specificity 78.5%). The specificity was better in the subgroup of solid or complex masses (5 out of 6 83.3%) than in the subgroup of cystic lesions (6 out of 8 75%). Conclusions: Prenatal ultrasonography is a useful tool to identify any intracranial space-occupying lesion. In the present study it has shown a 78.5% specificity in the diagnosis of brain masses, with better results in the solid than in the cystic lesions. The distinction between the different causes of fetal brain space occupying lesions is clinically relevant, as each one carries different prognostic implications.

WS08-06 Fetal hemodynamics, hypoxia index and brain damage A. SalihagicÂ*, D. JugovicÂ*, J. Tumbri², V. Latin², M. Kos², A. Kurjak² and P. H. Arbeille³ Department of Physiology, Croatian Institute for Brain Research, School of Medicine University Zagreb, Croatia, Department of Obstetrics and Gynecology, School of Medicine University Zagreb, Sveti Duh Hospital, Zagreb, Croatia, INSERM 316, Department of Nuclear Medicine and Ultrasound, CHU Trousseau, Tours, France Objective: To estimate the value of a new vascular score, hypoxia index (HI), in prediction of functional and/or structural brain lesions caused by fetal hypoxia and to examine the relationship between this index, Doppler cerebral-umbilical ratio (C/U) and neonatal neurosonography in growth retarded and hypoxia fetuses. Study design: In the prospective study 41 growth retarded fetuses were

Workshops included from 29 to 40 weeks of gestation. Flow velocity waveforms the umbilical and middle cerebral arteries were recorded each other day, at least two weeks. The C/U ratio and HI were calculated. After the birth, obstetric parameters and ultrasound of neonatal brain were used as outcome parameters. Results: Doppler C/U ratio , 1 as well as HI . 150 were associated with poor perinatal outcome. The neonatal brain damage was detected in 16 growth-retarded and hypoxic fetuses. Hypoxia index had greater statistic significance in the prediction of neonatal brain lesions. Also, specificity and sensitivity of HI was better than the last value of C/U ratio measured before delivery. Conclusions: The C/U ratio and HI represent the best indicators for early detecting and assessment of fetal hypoxia. Furthermore, they may also be parameters for the prediction of poor neurological outcome in pregnancies with growth retardation. So, the use of HI would represent a significant advance in prevention of hypoxic brain lesions, which are one of the most frequent causes of perinatal morbidity and mortality.

WS08-07 Brain plasticity after perinatal damageÐprospective neurodevelopmental and ultrasonographic/magnetic resonance study V. MejasÏki-BosÏnjak Children's Hospital Zagreb, Department of Pediatrics, Croatia Objective: To assess long-term neuodevelopmental outcome and structural reorganisation of children suffering hypoxic-ischemic (HI) and/or haemorrhagic perinatal brain damage; To test the hypothesis of more successful recovery of prematures and/or unilateral lesions after perinatal brain damage; To estimate prenatal events, in particularly value of pathological findings of Color Doppler (CD) in the pathogenesis of perinatal brain damage; Study design: 68 children suffering perinatal brain H-I (10) and/or haemorrhagic lesions (58) diagnosed by ultrasonography (US) underwent neurologic and psycho-linguistic examinations by age 16. High resolution 2 T MRI was used to assess structural reorganisation; 20 children suffering unilateral perinatal brain damage (MCA infarct.) were followed up (neurodevelopmentally, transcranial CD and US/CT, MRI); 25 children with CD findings (C/U ratio , 1) during pregnancy underwent prospective follow-up postnatally by age 2. Results: All children with H-I lesions have still at age 16 one or more severe handicaps, while 39 children with mild grade of hemorrhage had minor neurological dysfunction, 15 were normal. MRI revealed destructive and/or atrophic lesions in all children with H-I lesions and mild atrophy and/or signs of preiventricular haemorrhage in rest children. 20 children with unilateral perinatal brain damage have contralateral hemiparesis and various accompanying neurodevelopmental disorders. There were no strict correlation between size, site, hemispheral involvement gestational age and neurodevelopmental outcome of children examined. Out of the 25 children having pathological CD findings during pregnancy, 7 revealed mild grade (I±II) of peri-intraventricular haemorrhage, 10 children isolated or combined H-I and haemorrhagic lesion, 7 children have no apparent perinatal brain damage. Short-term neuro-developmental outcome revealed mild delay and/or disorders in 10 infants and in the rest normal status.

WS09: ADNEXAL MASSES WS09-01 Role of imaging modalities in pelvic tumor practice H. Nakano and S. Satoh 1: Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, 2: Maternity and Perinatal Care Unit, Kyushu University Hospital, Fukuoka, Japan


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

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10th World Congress on Ultrasound in Obstetrics and Gynecology and US, and all three modalities, we compared the indications and selected imaging modalities in relation to the stream of therapeutic procedure. Results: 324 cases (21.5%) judged to have no structural disease through imaging techniques at previous Hospitals underwent no further imaging examination. 420 cases (27.9%), most of which underwent surgery and/or radiation due to malignant lesions in the ovary and/or uterus, had US alone, and 564 cases (37.5%) had CT in addition to US. The main indications for ordering additional CT were suspected distant metastasis, including pelvic and paraaortic lymphnodes. 95 patients (6.3%) had US and MRI under indication of tissue characterization in tumors. 103 cases (6.8%) with difficulties in diagnosis had all modalities; US, CT and MRI. In 324 cases without imaging modalities, 60 cases (18.5%) undergoing operative procedure were those with cervical neoplasm, and 70.0% of the cases followed by chemotherapy were for ovarian cancer. Such will be further discussed in detail.

WS09-02 Ultrasound diagnosis of adnexal masses

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Stage I tumors that was TP positive (16%) was significantly lower (P 0.022) that the corresponding value for Stages II±IV (44%), although the values for microvessel count, AI, and peak systolic velocity (PSV) were similar. AI was significantly lower in TP-positive tumors than that in TP-negative tumors (P 0.015). The PSV was significantly higher in TP-positive tumors (P 0.02). There was a significant correlation between the microvessel count and the PSV (r 0.34, P 0.024). Moreover, AI was significantly inversely related to the PSV (r 0.35, P 0.023). The PSV in a subgroup with a high microvessel count and low AI was significantly higher than that in a subgroup with a low microvessel count and high AI (P 0.0006). These findings significantly associated with TP expression (P 0.024). The intratumoral PSV, as determined by color Doppler imaging and spectral analysis might reflect the coordination of angiogenesis and apoptosis, associating with TP expression in epithelial ovarian cancer.

WS09-04 Ultrasound diagnosis of adnexal masses: computer modelling

L. Valentin University Hospital, MalmoÈ, Sweden

J. L. AlcaÂzar Department of Obstetrics and Gynecology, ClõÂnica Universitaria de Navarra, University of Navarra, Pamplona, Spain

The basis of ultrasound diagnosis of adnexal masses is the gray scale ultrasound image. In our prospective study of 173 patients scheduled for laparotomy because of an adnexal mass, an experienced examiner correctly discriminated between benign and malignant masses in 95% of cases on the basis of subjective evaluation of the gray scale ultrasound image (sensitivity 92%, i.e. 22/24, specificity 96%, i.e. 143/149). A correct specific diagnosis (e.g. dermoid cyst, endometrioma, etc.) was made in 72 of the 173 women, i.e. in 42%. Adding Doppler ultrasound examination to gray scale imaging did not change the diagnostic accuracy, but it increased the confidence (as rated on a visual analogue scale) with which a correct diagnosis was made in 14% of cases. Increased diagnostic confidence was observed most often in stage I ovarian malignancies (83%, i.e. 5/6). Doppler ultrasound examination was not helpfull in the diagnosis of borderline tumors. For less experienced ultrasound examiners the use of mathematical models to calculate an individual risk of malignancy might be an alternative to subjective evaluation of the the gray scale ultrasound image. In a study of 136 consecutive women scheduled for laparotomy because of an adnexal mass, two mathematical formulas were cross-validated prospectively: that of Tailor et al. (Ultrasound in Obstetrics and Gynecology 1997; 10 : 41±7) and that of Timmermann et al. (Am J Obstet Gynecol 1999; 181: 157±65). Both models performed less well than in the studies where they were created, the sensitivity and specificity of the first model being 71% and 82%, respectively, and the sensitivity and specificity of the second model 72% and 68%, respectively. Conclusion: Subjective evaluation of the gray scale ultrasound image is an excellent method for discrimination between benign and malignant adnexal masses. Mathematical models hold promise but must be fine tuned on the basis of information from a very large number of tumors.

The differential diagnosis of adnexal masses still represents a challenge. The main goal is to determine whether a given mass is malignant or benign, in order to establish the best therapautical approach. When a clinician face to a woman diagnosed as having an adnexal tumor several parameters may be used to determine the nature of the mass, such as patient's age, menopausal status, clinical complaints, physical examination, tumor's sonographic and Doppler features and serum tumor markers. When these data are collected may be difficult to interpret them all together and the clinician has to rely in one or two of them to predict the diagnosis and to decide the management strategy, guided many times by own experience or strict protocols. A possible solution to this question may be the use of computer modelling. This means the use of statistical or mathematical models developed, using computer aid, to predict adnexal malignancy. Currently, there are two methods that may be used: Multiple Logistic Regression Analysis (MLRA) and Artificial Neural Networks (ANN). Both techniques allow to calculate the probability of a particular event has occurred, in this case a mass to be malignant or benign. By computer modelling, actual independent predictors parameters are identified and may be used combined and simultaneously to predict malignancy. Each method has advantages and disadvantages, being MLRA the statistical technique of choice and ANN a potential newer alternative to MLRA. Several studies have been published using one or both technique to predict adnexal malignancy. The results of these studies are encouraging showing a high diagnostic performance. All studies comparing MLRA to ANN showed the latter seems to be superior. However, it should be taken into account that most of these models have not tested prospectively.

WS09-03 Association of color Doppler with molecular biology in ovarian tumors

WS09-05 Sonographic appearance of borderline ovarian tumors

K. Hata and K. Miyazaki Department of Obstetrics and Gynecology, Shimane Medical University, Izumo 693±8501, Japan Color Doppler imaging and pulsed Doppler spectral analysis ultrasonography were used to scan 44 patients with an overt ovarian mass immediately before laparotomy. Sections of malignant tumors were analyzed for the cellular expression of TP and the intratumoral density of microvessels by immunohistochemistry using antibodies to TP and Factor VIII related antigen, respectively. Moreover, apoptotic index (AI) was evaluated by the terminal deoxynucleotidyl transferasemediated dUTP-biotin nick end labeling methods. The proportion of

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C. ExacoustoÁs, D. Rinaldo, C. Carusotti, D. Arduini and C. Romanini Department of Obstet. and Gynaecol., University of Tor Vergata Rome, Italy Background: The aim of the present study is to individuate sonographic markers which make it possible to distinguish borderline ovarian tumors from benign and malignant cysts, thus allowing conservative treatment. Method: We reviewed transvaginal sonograms in 23 women who presented borderline ovarian tumors histologically confirmed. Sixteen were premenopausal and 7 postmenopausal. The size and morphologic criteria of each mass and color flow Doppler characteristics were evaluated. We compared these findings with those of 337 patients with


4±7 October 2000, Zagreb, Croatia benign ovarian tumors and those of 40 patients with malignant ovarian tumors. Results: Of the 16 borderline ovarian tumors in premenopause 6 were mucinous cystoadenomas and 10 serous cystoadenomas. Of the 7 borderline tumors in postmenopause 3 were mucinous cystoadenomas and 4 serous cystoadenomas. The analysis of grey scale morphologic findings revealed the presence of solid tissue in 92.5% of malignant masses, in 13.3% of benign tumors (P , 0.01) and in 31% of LMP tumors (P , 0.01 vs. malignant, P n.s vs. benign tumors). The presence of papillae within the cysts was significantly higher in borderline tumors (21%) compared to benign and malignant tumors. Three unilocular cysts with a diameter . 5 cm were borderline tumors. Conclusion: The most frequent diagnostic imaging was that of a papillae inside a cyst without other signs of complexity and also the presence of septa was frequent. Neither papillae nor septa constituted sensitive sonographic markers.

WS09-06 What does contrast media add to three dimensional power Doppler evaluation of adnexal masses? V. SÏparac, S. KupesÏicÂ and A. Kurjak Department of Obstetrics and Gynecology, Medical School University of Zagreb, Sveti Duh Hospital, Zagreb, Croatia Aim: To investigate the potential usefulness of contrast enhanced three-dimensional (3D) power Doppler sonography in the differentiation of benign and malignant adnexal lesions. Methods: A total of 31 patients with complex adnexal lesions of uncertain malignancy at transvaginal B mode and/or color Doppler sonography were prospectively evaluated with three-dimensional power Doppler sonography before and after injection of the contrast agent. Presence of a penetrating pattern and a mixed penetrating and peripheral pattern suggested adnexal malignancy. The results were compared with histopathology. Results: There were 10 cases of ovarian malignancy and 21 benign adnexal lesions. Of the 10 ovarian cancers, 6 (60%) showed vascular distribution suggestive of malignancy at nonenhanced 3D power Doppler sonography. After injection of contrast agent, a penetrating vascular pattern and/or a mixed penetrating and peripheral pattern were detected in all cases of ovarian malignancy with two benign lesions (fibroma and cystadenofibroma) which were misdiagnosed as malignant. The use of a contrast agent with three-dimensional power Doppler sonography showed diagnostic efficiency (96.7%) that was superior to nonenhanced 3D power Doppler sonography (93.5%). Conclusion: Contrast enhanced 3D power Doppler sonography provides better visualizatoin of tumor vascularity in complex adnexal masses. If used together with 3D morphological ultrasound assessment, enhanced 3D power Doppler imaging might precisely discriminate benign from malignant adnexal lesions.

WS09-07 Ultrasound, Doppler and contrasts in metastases from gynecologic tumor J. Schmillevitch Schmillevitch Diagnostics Center, Cancer Hospital SaÄo Paulo, Brazil

Workshops The breast cancer metastases can be analyzed by ultrasound in ganglial and visceral organs. The detection of metastatic lymphonod in the axillar, cervical or supraclavicular regions and intrammamarian changes both the cancer staging and therapeutic planning. Benign lymphonode usually have an oval shape, hilum hyperechogenicity, narrow cortex and show hilar vascularization or radical central symmetric vascularization and absence of peripheral flow at Color Doppler. Malignant lymphonode are usually rounded hyporechoic, without hilar hyperechogenicity, and, in color Doppler, present multifocal aberrant vascularization, tortuous vessels or flow in the periphery. The most frequent visceral metastases of breast cancer are hepatic, the suprarenal glands and ovaries. About 86% of breast cancer hepatic metastases are hypoechoic. Ovarian cancer metastases can be detected mainly in pelvic tumors, peritonium tumors, glanglial, abdominal wall, hepatic and splenic metastases and ascites. Our study of 10 cases of splenic metastases of ovarian cancer has demonstrated six hyperechoic tumors, two hypoechoic and two tumors with necrosis. The use of color Doppler and Powerangio has demonstrated weak or moderate vascularization in glanglial and visceral metastases of gynecological tumors. The use of contrast (Levovist) has shown a more detailed vascular analysis by detecting vessels that were not identified in color Doppler and Powerangio without contrast.

WS09-08 Sonographic and clinical characteristics of struma ovarii Y. Zalel, D. S. Seidman, M. Oren, R. Achiron, W. Gotleib, S. Mashiach and M. Goldenberg Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Israel Background: To evaluate the preoperative clinical, laboratory and sonographic characteristics of struma ovarii. Method: A retrospective review of gynecologic patients operated for mature cystic teratoma over a 10-year period, identified 16 cases of struma ovarii. These cases were the subject of this study and were compared to 32 cases of ovarian dermoid cysts. Results: The incidence of struma ovarii among all cases of dermoid cysts was 4.8%. Most patients were menopausal, the mean lesion diameter was 57.3 mm, occurred more frequently (68.8%) in the right adnexa and presented with normal CA-125 level. Blood flow signals were detected from the center of the lesions in all cases. Rare cases presented with elevated tumor marker and low-resistance blood flow. In dermoid cycsts, blood flow had a higher resistive index. In addition, no blood flow could be detected from the center of the echogenic lesion in dermoid (P , 0.0001). Conclusion: It is difficult to distinguish between struma ovarii and dermoid cysts, based on their sonographic appearance. Nevertheless, Doppler flow may aid in the preoperative diagnosis of struma ovarii. Blood flow signals, detected from the center of the echogenic lesions and low resistance to flow may be more common in struma ovarii.

W S 1 0 : C H R O M O S O M O PAT H I E S WS10-01 Pathophysiology of increased nuchal translucencyabnormalities of the extracellular matrix C.S. Von Kaisenberg*, W. Jonat*, B. Brand-Saberi², F. Farzaneh³, K.H. Nicolaides§ *Department of Ob & Gyn, Kiel University Hospital, ²Institute of


Anatomy, Freiburg, germany, ³Molecular Medicine §Harris Birthright, King's College, London, UK Objective: In about 80% of fetuses with trisomies, Turner syndrome, and in fetuses with skeletal abnormalities, genetic syndromes, structural abnormalities and cardiac defects, there is increased collection of fluid in the neck region. This can be visualized sonographically at 11±14 weeks of gestation as increased nuchal

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10th World Congress on Ultrasound in Obstetrics and Gynecology translucency thickness. The pathophysiology of this common phenotypic expression of different chromosomal abnormalities is uncertain, but there is some evidence that the underlying mechanism may be altered composition of extracellular matrix components and/or cardiac failure. Methods: We performed a number of studies investigating nuchal skin tissue for various extracellular matrix components and cardiac heart failure using molecular techniques. We used northern blotting, immunohistochemistry, electron-microscopy and in situ hybridization. Results: Studies investigating the heart found increased levels of mRNA for ANP and BNP, and reduced levels of Calcium ATPase, whereas transcript levels for GATA-4 were unchanged. Studies investigating components of the extracellular matrix in nuchal skin of trisomic fetuses found overexpression of ecm genes in trisomies (collagen type VI, collagen type IV, laminin) or an altered ratio of genes between normals and abnormals (collagen type VI). Conclusions: The present data provide some evidence, that chromosomally abnormal fetuses with increased nuchal translucency at 12±14 week may suffer from an altered extracellular matrix of the heart and skin or transient heart failure.

WS10-02 Nuchal translucency in multiple pregnancies G. Monni Department of Prenatal and Preimplantation Diagnosis, Ospedale Microcitemico, Cagliari, Italy Background: The significance of an increased nuchal translucency measurement (NT) in relation to the fetal karyotype and pregnancy outcome has been evaluated in multiple pregnancies. Methods: 115 multiple pregnancies with 252 fetuses, including 100 pairs of twins (70 pairs with dichorionic placentas and 30 pairs with nonochorionic placenta), 9 sets of triplets, 5 sets of quadruplets, and one set of quintuplets, were considered. Results: NT was greater than 95th centile in one fetus in 10 out of 70 cases of dichorionic twin pregnancies (14%), in two sets of quadruplets, in 7 out of 30 monochorionic twin pregnancies (23.3%). NT greater than 95th centile in both fetuses was found in one dichorionic twin pregnancy. Two cases of trisomy 21 and one 47, XXY were found. NT greater than 95th centile in 2/2 fetuses with

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trisomy 21 (one dichorionic twin pregnancy and one tetrachorionic pregnancy), and not enlarged in the 47, XXY (trichorionic triplet pregnancy). A case of skeletal dysplasia and one goldenhar syndrome were found among the 10 cases of increased NT in dichorionic pregnancies. Three intrauterine deaths of both fetuses, one congenital heart disease and a case of twin-to-twin transfusion occurred in 7 cases of increased NT in monochorionic pregnancies. Conclusions: An enlarged NT in multiple pregnancies indicates fetuses at risk for chromosomal abnormalities and fetal malformation, as well as monochorionic twin pregnancies at higher risk for an adverse outcome.

WS10-03 Down's syndrome screening by NT measurement: women's opinion C. M. Bilardo, M. A. MuÈller, G. Bonsel and O. P. Bleker Department of Prenatal Diagnosis and Obstet & Gynaec, Academic Medical Centre, Amsterdam, The Netherlands In the context of an implementation study of nuchal translucency (NT) screening for Down's syndrome special attention was devoided to the psycho-social aspects. The impact of age, parity, religion, education together with the reasons for opting in or out for the NT measurement were recorded in 5895 patients. On a sample of 800 patients more specific aspects were addressed such as the level of knowledge about prenatal diagnosis before and after screening, the reaction to the offer of NT screening and the general women's opinion on whether this form of screening should be offered to all pregnant women. Questionnaires devised to measure the anxiety and depression produced by screening (hads) were filled before screening, at 20 weeks' gestation and after delivery by the same group of patients and by 200 controls. Preliminary results are available. 80% of the asked women, with no differences in age, religion and parity choose for NT screening. Main reason for having the NT measured was the hope of avoiding invasive testing and the wish of having more information on their pregnancy. The majority of women experienced positively NT screening even in case of an increased measurement and irrespectively of whether they would terminate an affected pregnancy or not. A slight increase in anxiety level produced by the screening normalized by 20 weeks' gestation.

WS11: MEDIA WS11-01 The Croatian ultrasound safety law B. Breyer [email protected] Legal regulation of the safety of medical applications of ultrasound is important for protection of the patients and physicians. The matter of ultrasound safety has recently been regulated in Croatia within the framework of the law on nonionising radiation protection. The law as approved by the parliament regulates the general principles and material cornerstones while the details are defined by rules and regulations issued by the Ministry of Health. Apart from medical applications ultrasound is used in plastic and metal welding, food processing, cleaning, electroplating, drilling and metal flaw detection, to mention but some. The law had to be general and sufficiently cover the whole spectrum allowing for the special medical exception. Namely, the medical professional may breach the integrity of human body and even harm the patient if the expected net final result of the whole proceeding is expected to help the person who seeks help. The law in Croatia states that ultrasound may not increase the temperature of the human body to more than 38.5 8C and may not induce cavitation there. However medical applications of ultrasound are specifically excluded from this limitation. The requirement is the application of the ALARA principle.

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The specifics of the regulation of the total field of medical applications of ultrasound are now being prepared under consideration of the existing and the presently processed IEC from IEC committees TC 62 and TC 87 documents and taking into account the present regulation in the USA.

WS11-02 Collaborative management of three-dimensional ultrasound between medical centers, physicians and patients T. R. Nelson and D. H. Pretorius University of California, San Diego La Jolla, CA, USA To purpose of this project was to evaluate the feasibility of performing off-line sonographic examinations over the internet using 3DUS data. To accomplish this we performed complete OB, pelvic, cardiac and abdominal studies following AIUM guidelines in 100 patients with 2DUS/3DUS methods including multiple volumes. Physicians performed a `virtual re-scan' of the patient using 3DUS data that was compared retrospectively to the 2DUS diagnosis. Our overall results showed that both abnormal and normal findings were identified for both 2DUS and 3DUS studies. Outcome depended on sonographer training, image quality and patient motion. There were few false negative/positive results with either 2DUS or 3DUS studies. Proper


4±7 October 2000, Zagreb, Croatia training was essential to acquire sufficient volumes for a complete study and for complete patient evaluation. In conclusion, off-line virtual evaluation of patients is feasible using 3DUS data but has different technical requirements for acquisition and review than 2DUS studies. Proper training of sonographers, well defined scanning protocols and acquisition of sufficient volume data are essential to obtain diagnostic studies.

WS11-03 How to create multimedia ultrasound teaching programs G. R. DeVore Fetal Diagnostic Center of Pasadena, Pasadena, CA, USA For a number of years the teaching of ultrasound principles has relied on slides of static, nonreal-time images. Although ultrasound originally employed only still images, the development of real-time ultrasound ushered in a new imaging modality. Unfortunately, the

Workshops presentation of real-time images has not been incorporated into most presentations because of the difficulty of preparing and editing video tape recordings of the examination. With the advent of multimedia programs available for the laptop and desktop computer, it is now possible to display real-time motion sequences that duplicate the actual scanning environment. To accomplish this, however, requires the physician to become versed in the various techniques required to capture video and audio sequences from the ultrasound machine. In addition, the proper computer software must be used to optimize these images. The purpose of this presentation is to review the methodology required to (1) acquire the highest quality video images from the ultrasound machine, (2) convert the ultrasound images from a analogto-digital format, (3) review programs required to optimize the converted digital images, and (4) examine the software programs to optimally display these images for the Windows and Macintosh platforms. At the conclusion of the presentation, the physician should be able to accomplish these tasks.

WS12: SECOND AND THIRD TRIMESTER DOPPLER I WS12-01 Uterine artery velocimetry in the third trimester K. Marsal, E. Hernandez-Andrade, G. Lingman and S. Gudmundsson Departments of Obstetrics and Gynecology, University Hospitals Lund and MalmoÈ, University of Lund, Sweden Spectral Doppler velocimetry supported by directional color Doppler imaging became the method of choice for recording blood velocity signals from the maternal uterine arteries during the third trimester of gestation. Normally, the uterine artery waveforms show a high proportion of diastolic flow without any early diastolic notch and with a low resistance (RI) or pulsatility (PI) index. With increasing gestation, there is a slight decrease in the resistance to flow in the placental circulation. The placental side of the uterus shows lower values of the waveform indices than the nonplacental. In high-risk pregnancies, the abnormally high PI or the presence of notch is predictive of the adverse outcome of pregnancy. Recently, a Uterine Artery Score (UAS) has been presented based on a combined evaluation of RI and notch (Sekizuka et al., J Mat Fet Invest 1997; 7: 197). We have modified this approach, using PI and a uniform cutoff value for definition of the abnormal PI, disregarding the placenta location. The modified UAS in combination with the umbilical artery Blood Flow Classes possess a high predictive value with regard to the perinatal outcome in high-risk pregnancies, especially in those with placental hemodynamic dysfunction. In cases of intrauterine growth restriction, the combined examination of the uterine and umbilical circulation improves the clinical value of the third trimester Doppler velocimetry.

WS12-02 Systematic screening with a uterine Doppler in low-risk pregnant women followed by low-dose aspirin in cases with abnormal results: results of the two French multicenter randomised controlled trial F. Goffinet²³, D. Aboulker*, D. Subtil¶, Uzan§, G. BreÂart² and S. Uzan** *Conseil geÂneÂral de Seine Saint-Denis, Bobigny, ²Epidemiological Research Unit on women and children's health, INSERM U 149, Paris, ³Department of Obstetrics and Gynecology, Maternity PortRoyal, Cochin-Saint Vincent-de-Paul Hospital, Paris, §Department of Obstetrics and Gynecology, Jean Verdier Hospital, Bondy, ¶Department of Obstetrics and Gynecology, Jeanne de Flandres, Lille, **Department of Obstetrics and Gynecology, Tenon Hospital, Paris, France Objectives: Two large multicenter randomised trials were performed


in France to assess whether systematic screening with an artery uteroplacental Doppler (AUD) in low-risk pregnant women followed by the prescription of low-dose aspirin in cases with abnormal results reduced the incidence of intrauterine growth restriction (IUGR) and of preeclampsia. Study design and population: The first trial `Seine Saint-Denis' (SSD) trial included 3317 low-risk pregnant women (multi and primigravidae) in 17 French maternity Hospitals and the second Èrasme' trial included 1869 primigravidae in 12 centres. In the Doppler group, the AUD was performed between 20 and 24 weeks, and women with abnormal results received 100 mg of aspirin daily until the 35th week. Results: In the Doppler group, 232 patients (15.7%) had an abnormal result in the SSD trial and 20% in the ERASME trial. The predictive value of the AUD was comparable to that reported in the studies of low-risk populations, but with a low sensitivity. Finally, IUGR, whether defined by the third or tenth percentile, and preeclampsia did not differ significantly between the treatment groups in both trials. Conclusions: There is no proof justifying the recommendation of a systematic AUD in a low-risk population, even if abnormal results are followed by aspirin treatment and increase in prenatal surveillance. Future studies must assess predictive tests that can be performed early in pregnancy and can identify populations at very high risk of preeclampsia and IUGR. Only when all of these conditions are fulfilled can aspirin prove its efficacy.

WS12-03 Uteroplacental resistances and maternal cardiac function in normal and hypertensive pregnancy: a Doppler and echocardiographic study H. Valensise*, B. Vasapollo*, G. P. Novelli², G. Larciprete*, D. Arduini*, A. Galante² and C. Romanini* *Department of Obstetrics and Gynaecology-Tor Vergata UniversityRome; ²School of Cardiology-Tor Vergata University-Rome, Italy Objective: To verify the existence of a relationship between maternal cardiac function and peripheral hemodynamic parameters in normal and gestational hypertensive women. Methods: 43 normotensive primigravidae were evaluated at 12 ^ 1, 21 ^ 1, and 33 ^ 1 weeks of gestation with uterine artery color Doppler and maternal echocardiographic examination comparing data of the third trimester with those of 21 gestational hypertensive women. Results: The 43 healthy women showed a decrease in Uterine Resistance Index (RI) from I8 to II8 trimester (0.72 ^ 0.10 vs. 0.54 ^ 0.09, P , 0.001) and modifications in Diastolic function parameters: E wave velocity and E/A ratio decreased; A wave velocity

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10th World Congress on Ultrasound in Obstetrics and Gynecology and deceleration time of the E wave increased; the left ventricular isovolumetric relaxation time (IVRT) decreased significantly (88.7 ^ 6.7, 75.6 ^ 7.7, 71.1 ^ 5.0 msec, P , 0.001) showing a correlation with left atrial dimensions and RI (r 20.38, r 0.47, P , 0.001). In the third trimester the comparison between normal and hypertensive women showed a significant reduction in (TVR) total vascular resistances (1006 ^ 212 vs. 1620 ^ 469, P 0.000) and IVRT (71 ^ 5.0 vs. 92.0 ^ 7.6 msec, P 0.000). Regression analysis showed a linear correlation between IVRT and TVR (r 0.68; P , 0.01), Uterine RI and TVR were directly related (r 0.59, P , 0.001). Conclusions: Maternal diastolic function analysis may be useful to identify women who fully adapt to pregnancy and at risk for development of gestational hypertension.

WS12-04 Fetal hemodynamics and growth restriction G. Clerici and G. C. Di Renzo Centre of Reproductive and Perinatal Medicine, Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy Intrauterine growth restriction (IUGR) is a common symptom of many possible maternal-fetal pathologies and/or the expression of a genetic alteration; by far, the most common etiology is related to chronic fetal hypoxemia. Fetal hypoxemia may be the result of different feto-maternal pathophysiological processes which can produce completely different fetal hemodynamic modifications, not only in relation to the quality but particularly in relation to the chronology of the hemodynamic events. However, fetal hypoxia is mostly due to placental vascular insufficiency and it is important to point-out that fetal hypoxemia-acidemia is part of the terminal pathway starting from placental functional and structural alterations, through fetal IUGR, leading to intrauterine fetal death. Doppler evaluation of fetal arterial districts is important for the diagnosis of the fetal hemodynamic adaptation to the hypoxemia. Our observations suggest that, in the evaluation of fetal hemodynamics, it is important to consider also the intracardiac and the venous hemodynamics, focusing the study on the evaluation of the output tracts, the atrio-ventricular flow and on vessels like the ductus venosus, inferior vena cava, umbilical vein. Keeping the time of the hemodynamic alterations in these vessels and/or districts, which are characteristic signs of the incipient heart failure, may be one of the key for the solution for one of the main obstetrical problem: the diagnosis of fetal decompensation phase.

WS12-05 Umbilical and fetal cerebral circulation and fetal growth O. PetrovicÂ and B. Rukavina Clinical Hospital Center RIJEKA, Medical Faculty of Rijeka, Croatia Background: Fetal growth is determined by its genetic potential and growth support. The aim of our prospective study was to find out does the growth support (placental factor and blood flow) or genetic potential play a primary role in fetal growth. Method: From 27 to 41 gestational weeks an umbilical artery (RI1), a middle cerebral artery resistance index (RI2) and umbilical-cerebral (U/C) ratio were measured. Several US measurements in 3±4 week intervals of the same pregnancy were done. After delivery, fetuses were divided into the three groups (AGA, LGA, SGA) according to their birth-weights. Pregnancies with gestational diabetes were excluded from the study. Results: There were not statistically significant differences between the average values of RI1 (age related) in the groups of AGA and LGA fetuses. However, the mean values of RI1 (according to gestational age) in the mentioned two groups of fetuses were significantly lower than in the group of SGA fetuses, as well as their mean values of U/C ratios. Conclusion: Placental factor is equally and efficiently functioning in the both groups of AGA and LGA fetuses. The genetic regulating factor of fetal growth can be adequately expressed in conditions of

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appropriate uteroplacental and umbilical blood supply. In other words, in identical or at least similar conditions of umbilical blood supply, fetal growth is exclusively influenced by its genetic potential.

WS12-06 Doppler evaluation of IUGR fetuses G. P. Mandruzzato, Y. J. Meir, R. Natale and G. P. Maso Department of Ob/Gyn, IRCCS `Burlo Garofolo' Hospital, Trieste, Italy Intrauterine growth restriction (IUGR) is now defined as a condition in which the fetus does not reach the optimal condition of his growth. In this situation the birthweight can be reduced below the 10th percentile or can be superior to that threshold especially when the restriction took first place in late part of the pregnancy. Therefore it is possible to identify two groups of IUGR according to the intrauterine observation and the birthweight assessment: SGA and AGA IUGR. The most important complication of IUGR is represented by the hypoxaemia caused by placental vasculopathy. Hypoxaemia is present in about 30% of IUGR fetuses with not significant difference between SGA and AGA IUGR cases, and is the major cause of the poor perinatal outcome. After recognition of the growth restriction it is necessary to apply second level tests in order to assess the presence or absence of hypoxaemia. When hypoxaemia is present the first mechanism of fetal adaptation is represented by the redistribution of the circulation. This phenomenon is easily observable by using Doppler technology. When applying the same technique on the umbilical arteries it is possible to detect an increase in the peripheral resistance proportional to the obliteration of the placental vascular bed that is the cause of the fetal hypoxaemia. By using the information offered by Doppler study on fetal and umbilical vessels it is therefore possible to optimize the clinical management of the IUGR fetuses.

WS12-07 Fetal venous and arterial circulation in hypoxic IUGR. From adaptation to decompensation Y. Ville UniversiteÂ Paris v. CHI Poissy-St Germain, Paris, France Objective: To evaluate the changes in flow velocity waveforms in the mid-cerebral artery and in the transverse cerebral sinus in growth restricted fetuses and to correlate these changes between them and with (1) flow velocity waveforms in the ductus venosus and (2) changes in computerized analysis of fetal cardiotocogram. Design: Fetuses between 22 and 37 weeks' gestation with an estimated fetal weight below the 5th centile were included in this prospective longitudinal study. Doppler measurements in the umbilical artery, descending aorta, middle cerebral artery, transverse cerebral sinus and ductus venosus were recorded. Fetal heart rate was analyzed by a computer system according to the Dawes-Redman criteria. Results: Blood flow within the midcerebral artery and that in the cerebral transverse sinus follow a mirror image distribution. Arterial redistribution is already present when alteration in the venous cerebral circulation develops. We measured a significant correlation between pulsatility index in the transverse cerebral sinus and in the ductus venosus over the study period and at delivery. There was a negative correlation between these indices and short and long-term variability of the fetal heart rate. There was a parallel increase in pulsatility in the ductus venosus and the transverse cerebral sinus. These changes were inversely correlated with fetal heart rate variability and preceded fetal distress. Conclusion: Cerebral venous blood flow in IUGR fetuses may be a useful additional investigation to (1) understand better the mechanism of cerebral redistribution in hypoxemic IUGR and (2) to discriminate between fetal adaptation and fetal decompensation in chronic hypoxemia.



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

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

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

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

Objective: To measure peripheral pulmonary artery (PPA) and pulmonary vein (PV) velocity waveforms in growth restricted fetuses (IUGR) and to relate them to different Doppler indices fetal circulation and to pregnancy outcome. Design and methods: 108 IUGR fetuses from singleton pregnancies (gestational age median 28.4 range 25±32) were prospectively considered for this study. Entry criteria were an ultrasonographic extimated fetal weight , 5th centile, the absence of structural and chromosomal abnormalities, and a Pulsatility Index (PI) in umbilical artery . 95th centile of our reference limits for gestation. Velocity waveforms were recorded from the PPA and in one of the PV in proximity of the inflow in the left atrium. The PI from PPA and the Pulsatility Index for the vein from PV (PIV [S 2 D]/m) were calculated. Values obtained were compared to our reference limits for gestation and related to other Doppler indices from arterial, cardiac and systemic venous circulation and to fetal outcome. Results: In IUGR fetuses both the PI from PPA (P , 0.001) and the PIV from the PV (P , 0.001) were increased when compared to control fetuses. An inverse relationship was found between PPA and middle cerebral artery PI. Changes in PV were present when abnormal velocity waveforms are present in the systemic venous circulation. Reverse flow during atrial contraction is present in pulmonary vein in the most severely compromised fetuses and are associated with fetal distress and imminent fetal death. Conclusions: Abnormalities in arterial and pulmonary flows are present in IUGR fetuses. Changes in arterial circulation occur at an early stage of the disease while modifications in venous flows occurs

G. P. Mandruzzato, Y. J. Meir, R. Natale and G. P. Maso Department of Ob/Gyn, IRCCS `Burlo Garofolo' Hospital, Trieste, Italy The acronym ared indicates two characteristic patterns of the Doppler Velocity Waveform (DVWF) namely the observation of absence (EDFA) or reverse (RF) blood flow in diastole. ARED flow are usually observed in fetuses presenting severe intrauterine growth restriction (IUGR) or sometime are concomitant to fetal abnormalities like hydrops. The fetal condition is always severely affected mainly by hypoxaemia and/or acidaemia but at different levels according to the two patterns that are observed. Usually in the literature ared cases are presented and discussed without making difference between the two possible conditions. This approach cannot be considered correct because large differences in many clinical aspects are evident when evaluating separately EDFA or RF in 94 cases observed in our Institute. Gestational age, mean birth weight are significantly lower while perinatal mortality rate and prevalence of handicaps among survivors are significantly higher in the group presenting RF as compared to EDFA cases. As a consequence the clinical management is also different. In case of EDFA the timing of the delivery should be taken into consideration but it is not always urgent. On the contrary when RF is observed intrauterine death has to be expected within few days. Therefore the delivery should be immediate at the first observation of RF. The critical point is that also applying this policy the prevalence of handicaps among survivors is very high (35%). As a consequence when facing those clinical condition a careful and complete information must be offered to the family before choosing, if no maternal indications are present, an aggressive management.

W S 1 3 : M U LT I P L E P R E G N A N C Y WS13-01 The effect of treatment of twin-to-twin transfusion syndrome on the diagnosis to delivery interval D. Skupski, K. Gurushanthaiah and S. Chasen New York Presbyterian Hospital-Weill Cornell Ctr & New York Hospital Med, Ctr. of Queens, USA Purpose: No randomized controlled trials of treatment of twin-to-twin transfusion syndrome (TTTS) exist. Since severely preterm neonatal survival has increased over time, survival as an outcome measure is confounded by calendar time. The diagnosis-to-delivery interval is a calendar year independent measure of success of treatment. We wished to evaluate whether treatment of TTTS is associated with a lengthening of the diagnosis-to-delivery interval. Methods: MEDLINE search supplemented by careful reference review. All TTTS series were included where the following information on each patient was available: survival, fetal demise, gestational age (GA) at diagnosis and diagnosis to delivery interval in days. Inclusion criteria: GA # 29 weeks and diagnosis by ultrasound in the absence of maternal symptoms. Cases undergoing multiple types of treatment were excluded. Data were evaluated by Kruskal±Wallis ANOVA, logistic regression & Wilcoxon rank sum testing. Results: The 8 publications used included the following cases: controls (n 16), amnioreduction (n 61), septostomy (n 12), and fetoscopic laser occlusion of chorioangiopagus vessels (FLOC) (n 51). FLOC therapy showed a significantly longer diagnosis-to-delivery interval compared to amnioreduction (median 75 vs. 56 days) (p 0.01). There was no difference in overall survival, at least one survivor, or number of fetal deaths between the 4 groups. Logistic


regression using at least one survivor as the dependent variable revealed a positive association with GA at diagnosis and with diagnosis to delivery interval, a negative correlation with fetal death, and no correlation with treatment group. Conclusions: FLOC therapy for TTTS is associated with a longer diagnosis-to-delivery interval compared to amnioreduction without a significant increase in survival. The lack of increase in survival appears to be due to a small sample size.

WS12-02 Anticipating twin-to-twin transfusion syndrome: the putative role of venous return evaluation in the first trimester A. Matias and N. Montenegro Dep. Obstetrics/Gynecology, University Hospital of S. Joao, Porto, Portugal Background: Twin-to-twin transfusion syndrome (TTTS) complicates 10±15% of monochorionic (MC) and is associated with high perinatal mortality and morbidity. Method: Sixteen MC twin pairs were evaluated between 10±14 weeks for delta nuchal translucency (DNT) and Doppler blood flow in ductus venosus (DV). Sequential scans were performed to identify TTTS. Results: Neither the 12 cases with DNT,0.7 mm/normal flow, nor the two cases with DNT.0.7 mm/normal flow in DV, developed TTTS. The two cases that combined DNT.0.7 mm and abnormal flow in DV eventually developed TTTS. Conclusion: The presence of abnormal blood flow in the DV in MC twins, at 10±14 weeks, may be a precocious anticipatory sign of TTTS.

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10th World Congress on Ultrasound in Obstetrics and Gynecology WS13-03 Dynamics and clinical significance of placental shunt flow in monochorionic diamniotic twins K. Maeda, M. Utsu, T. Hirai, M. Sakata, N. Yamamoto and S. Ohki* Departments of Obstetrics & Gynecology and *Pediatrics, Seirei Mikatahara Hospital, Hamamatsu, Japan Background: The aim is to clarify placental shunt flow patterns in monochorionic diamniotic (MD) twins and their clinical outcome after the intervention under unique criteria. Method: Thirteen (13) MD twin pregnancies were studied from early pregnancy with 2D and 3D B-mode, color Doppler, power-angio mode, Doppler flow velocimetry, cardio-thoraxarea ratio (CTAR) and preload index (PLI) under tocolysis. Results: Artery to artery shunt flow was detected by fetalbeat-to-beat Doppler color change and cyclic bidirectionalflow at placental surface in 8 MD twin cases but not in 5. Shunt was more clear with 3D color Doppler and power-angio. Umbilical vein flow pulsation, variable FHR deceleration andcord complications were more in placental shunt flow casesthan its absence. Deep shunt flow was prenatally detected in 2 cases and small anastomses in all postnatal placenta. Pregnancy was terminated by emergency C-section in cases of uncontrollable contractions, unidirectional shunt flow, large CTAR and PLI (. 0.4) which were frequent in large twins after 30 weeks. Neonatal cardiac failure was more in shunt flow cases than its absence but the outcome was normal. Neonatal PVL and perinatal deaths were less than the MD twins in the past.

WS13-04 Doppler velocimetry determined brain sparing effect: correlations with neonatal outcome in diamniotic monochorionic and diamniotic dichorionic twins E. P. Gaziano, C. Gaziano, R. Hoesktra and C. Terrell Abbott North-western Hospital and Children's Healthcare, University of Minnesota, Minneapolis, Minnesota, USA Objective: Neonatal outcome was studied in 169 infants from diamniotic monochorionic (DAMC) and diamniotic dichorionic (DADC) twin pregnancies in relation to a measure of blood flow redistribution, the cerebroplacental ratio (CPR). Study design: Two groups were assessed, 50 infants from DAMC, and 119 infants from DADC twin pregnancies. Targeted ultrasound and Doppler recordings of umbilical artery (UA) and middle cerebral artery (MCA) were obtained. The resistance index (RI) and CPR were calculated for each fetus. Results: DAMC twins had lower birth weight (1979 vs. 2223 g for DADC, p#.01) and prolonged lengths of nicu stay (8.5 days vs. 3.5 days for DADC, p#.05). For total group, DAMC compared with DADC twins spent greater numbers of days on a ventilator. SGA infants were significantly more frequent in DAMC twins compared to DADC twins. Among antenatal Doppler variables only the CPR demonstrated a significant difference between twin types. For DAMC twins CPR was 1.15 vs. 1.21 for DADC twins, p#.05. Conclusions: Monochorionic twins from the lower birth weight groups demonstrate a greater number of growth restricted infants and prolonged hospitalizations compared to DADC twins. Among Doppler measures, the CPR is superior to UA-RI, and/or MCA-RI for the prediction of adverse events.

WS13-05 Selective photocoagulation of communicating vessels in the treatment of selective growth retardation in monochorionic twins: a functional dichorionization procedure R. A. Quintero, P. W. Bornick, W. J. Morales, M. H. Allen and P. K. Johnson Florida Institute for Fetal Diagnosis and Therapy, St. Joseph's Women's Hospital, Tampa, FL, USA Background: Intrauterine fetal demise (IUFD) of a selectively growthretarded (IUGR) monochorionic (MC) twin is associated with high

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morbidity/mortality in the appropriately grown (AGA) twin. Selective laser photocoagulation (SLPCV) allows precise separation of the circulations of both twins. The aim of this study was to assess SLPCV in the treatment of MC-IUGR. Methods: Patients with previable MC-IUGR were offered SLPCV. Absent or reverse end-diastolic velocity in the umbilical artery of the IUGR twin was also required for entry. Communicating vessels were identified endoscopically as deep artery-to-vein or superficial artery-to-artery or vein-to-vein as previously described. The communications were photocoagulated with Nd:YAG laser. Results: SLPCV was performed in 11 patients (GA mean 20.9 weeks). Survival of both fetuses was n 5 (45%), IUFD of the IUGR twin alone was n 4 (36%) and IUFD of the AGA twin alone was n 2 (18%). There were no dual losses, or adverse effects of an IUFD on the surviving twin. Previously undescribed superficial arteryto-vein anastomosis occurred in three patients. Conclusions: SLPCV can effectively create a `functionally dichorionic' placenta. SLPCV allows the AGA twin to avoid the adverse effects associated with IUFD of the IUGR twin. Unexpected IUFD of the AGA twin may reflect more complex placentation. A new type of vascular communication, superficial artery-to-vein, may have important pathophysiologic implications.

WS13-06 Multiple pregnancy-considerations of antenatal diagnostics B. Hodek, V. KosÏec and N. TucÏkar Department of Gynaecology and Obstetrics, University of Hospital `Sestre Milosrdnice', Zagreb, Croatia The aim of this study is to retrospectively evaluate the complications, safety and accuracy of midtrimester amniocentesis (MTAcz) in multiple pregnancy (MP). The indications and complications of MTAcz are the same for singleton pregnancies (SP) and MP, but what's different is the technique of the procedure and frequency of complications. Various techniques are here quoted, the purpose of which is to prove that samples have been taken from separate sacs. In general, the efficacy in amniotic fluid collection is 92±98%, and 95.6% in autors' cases. The number of insertion needles may have the influence on the abortion rate, but the opposite opinion also exists. The rate of spontaneous abortions has been analysed retrospectively in a group of SP with and without amniocentesis. The same parameters were also evaluated for MP. The risk of spontaneous abortions following MTAcz is nearly 2.5 times higher in MP (1.7% vs. 3.89%) than in SP, but is still within the range of normally elevated biological risk (4.5%) of this group of subjects.

WS13-07 The dilemma of selective termination of a malformed fetus in multifetal pregnancy S. Lipitz Sheba Medical Center, Tel-Hashomer, Israel The incidence of fetal malformation is higher in multifetal pregnancies than in singletons. In a dizygotic twin gestation there is slightly more than twice the risk per pregnancy of a fetal malformation. In a monozygotic twin gestation the rates of chromosomal and mendelian abnormalities are identical to those of a singleton pregnancy. However, there is an increased risk of structural malformations. Selective termination in a bichorionic biamniotic twin pregnancy is done with intracardiac injection of potassium chloride. The international experience show that it can be performed in all 3 trimesters with good outcomes in . 90% of cases and the loss rate is approximately 7%. In monochorionic twin gestation the aim is to arrest the umbilical cord flow completely and permanently. Several methods to achieve this goal are embolization, ligation (fetoscope of U/S guidance), laser coagulation, monopolar and bipolar thermocoagulation. The latter technique became more popular, with estimated loss rate of 20%. The techniques and results will be presented (including video), and the ethical issue will be discussed.


4±7 October 2000, Zagreb, Croatia WS13-08 Multifetal pregnancy reduction: clinical and pathophisiological aspects A. Mikhailov and A. Koroteev Ott Institute of Obstetrics and Gynecology of Russian Academe of Medical Sciences, St. Petersburg, Russia Background: To decrease perinatal mortality and morbidity rate in case of multifetal pregnancy fetal reduction (MFPR) in the first trimester was introduced. Methods: Combine ultrasound and Doppler evaluation of fetal chromosomal abnormality markers, fetal structure and biometry,

Workshops chorionicity and amnionicity, arterial and venous circulation in fetalplacental-maternal functional system were introduced as an algorithm before MFPR. Results: 355 fetuses in 112 women were examined before 141 MFPR. NT thickness was above 2.5 mm in 1,7% of fetuses and one fetus had reverse DV flow. But no fetal chromosomal defects were detected after CVS. No specific severe complications for multifetal pregnancy were registered in completed pregnancies. Average gestational age at birth was 35,5 w that was less then in essential twins but perinatal mortality rate was 5.8½ and 12.8½ correspondingly. Conclusion: MFPR with combine fetal examination seems to be the way to improve multifetal pregnancy outcome.

WS14: THREE-DIMENSIONAL POWER DOPPLER IN OBSTETRICS AND GYNECOLOGY WS14-01 3-D ultrasound in routine check-up of infertility patients E. RadoncÂicÂ, B. Funduk-Kurjak, Sanja KupesÏicÂ and A. Kurjak Objective: The aim of this study was to determine whether threedimensional ultrasound (3-D US) can improve the diagnostic ability in a routine check-up of patients undergoing in vitro fertilisation (IVF) in an office practice. Methods: Three-dimensional and power Doppler ultrasound were performed on 267 patients undergoing IVF on the first visit, during ovulation induction and aspiration of the oocytes. Patients with suspected uterine anomalies and/or abnormalities of the endometrium (N 108) were treated by operative hysteroscopy. On the day of oocyte collection, multiplanar imaging and 3-D reconstruction demonstrated cumuli in follicles greater than 15 mm. Cumulus assessment inside the ovarian follicles was correlated to the number of mature oocytes. Power Doppler reconstruction was performed in the cases when superponing vessels did not allow correct placing of the puncture needle. Results: Of 108 patients with suspected uterine abnormality, the diagnosis was correct in all cases of endometrial polyp, submucous myoma, arcuate uteri and septate uteri, as confirmed by an office hysteroscopy. Intrauterine synechiae was correctly diagnosed preoperatively in one out of the four cases. The mean (^ SD) number of follicles . 18 mm was 8.2 ^ 5.8, and total number of follicles demonstrating cumulus in all three planes was 6.4 ^ 5.1. The ratio cumuli/retrieved oocytes, cumuli/fertilised oocytes and cumuli/mature oocytes was 6.2 ^ 4.2, 5.4 ^ 2.8 and 5.9 ^ 2.6, respectively. Conclusions: Three dimensional ultrasound can become a standard of routine check-up of infertility patients allowing improved recognition of the uterine anatomy, characterisation of the surface features, and precise depiction of the ovaries during stimulation cycles. It can enhance and facilitate the morphologic and functional evaluation of the anatomic structures of the inner reproductive organs, thus avoiding the need of invasive diagnostic procedures. Various puncturing procedures can be more precisely performed. The built-in application of live 3-D mode may be very helpful in performing invasive procedures, such as oocyte collection.

WS14-02 3D color histogram: principles and practice in transvaginal and abdominal sonography H. Pairleitner and H. Steiner Objective: The 3D Color Histogram gives quantitative informations about (changes) of perfusion and vascularisation packed in indices. Aim of the presentation is to illustrate the information gained by the vascularisation and perfusion indices. In addition, to show the reproducibility of the indices according to published studies,


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

WS14-03 Fetal extremities ± three-dimentional approach M. Kos Department of Obstetrics and Gynecology, Sveti Duh General Hospital, Zagreb, Croatia Background: To assess particular features of fetal extremities evaluation using three-dimensional ultrasound. Methods: Total of 276 patients were selected from our routine outpatient clinic or sent for supervision from other clinics because of a suspected fetal anomaly. Patients were examined during a three year period (Jan1997-Dec1999). Pre-selected patients were examined with standard 2-D ultasonic devices, and their gestation age ranged between 12 and 40 weeks. 3-D ultrasound devices were Combison 530D and Voluson 530D MT (Kretztechnik, Zipf, Austria) with a 3± 5 MHz annular array transducer for three dimensional volume scanning. Results: In 28/276 patients the initial diagnosis was suspected by 2-D sonography at entry in the study. In 18/28 suspected cases diagnosis was determined after examination by 3-D sonography (15/28 clubfoot, 3/28 other limb anomalies). The diagnosis of clubfoot was confirmed In 17/28 cases after delivery or termination of pregnancy, meaning that 2/18 cases of clubfoot were not detected using ultrasonography. In all of 3 other cases the sonographic diagnoses of hand contractures and micromelia were confirmed after termination of pregnancy. Conclusion: 3-D sonography accurately visualized angular and structural limb anomalies. In two cases of severe oligohydramnios we missed clubfoot by 3-D sonography.

WS14-04 Improved fetal weight estimation by three-dimensional ultrasound R. L. Schild and M. Hansmann Department of Obstetrics and Gynaecology, University Hospital Bonn, Germany

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10th World Congress on Ultrasound in Obstetrics and Gynecology Aim: To investigate the value of 3D-ultrasound in predicting fetal weight at delivery. Patients and methods: The study group consisted of 251 pregnant women (formula-finding group: n 125; evaluation group: n 126) with a singleton pregnancy and an ultrasound examination within seven days of delivery. Pregnancies with major structural or chromosomal anomalies were excluded. Ultrasound examinations included standard biometry as well as three-dimensional volumetry of the upper arm, the thigh and the abdomen of the fetus. All examinations were performed with a Voluson 530D MT system (Kretztechnik, Zipf, Austria). The results were compared with commonly used weight formulas. Results: All measurements were completed successfully. Polynomial regression analysis with standard biometric parameters and volumes of the upper arm, the thigh and the abdomen was employed to yield the best-fit formula for prediction of fetal weight at birth. The new 3D formula (Estimated fetal weight (EFW) ± 1478.557 1 7.242 * thigh volume 1 13.309 * upper arm volume 1 852.998 * lg abdominal volume 1 0.526 * BIP3) proved to be superior to established two-dimensional equations with the lowest mean error (25.8 ^ 194.4 g), the lowest mean absolute error (155.2 ^ 118.2 g) and the lowest mean absolute percentage error (6.1 ^ 5.0%) when studied prospectively in the evaluation group. Conclusion: Fetal weight estimation by 3D±ultrasound compares favourably with conventional 2D±formulas.

WS14-05 Technique of `three-dimensional' volume mode sectional planar imaging D. N. Jackson, L. Aptekar and K. K. Thompson St. Vincent's Health Center, Department of Fetal Imaging, Billings, Montana, USA Background: Three-dimensional imaging of superficial fetal abnormalities is well established. We prospectively evaluated if a technique of sectional planar imaging could interrogate nonsurface fetal abnormalities without changing transducers or requiring postrendering software. Method: Patients referred for perinatal consultation received traditional 2-D scanning and simultaneous volume mode imaging. Fetal abnormalities were visualized with a sectional technique similar to `tomogram' slices. No post image rendering manipulation was required. Twelve patients had correlative MRI scanning. Neonatal images were obtained when possible. Results: Structural fetal abnormalities amenable to volume rendering were found in 192 of 600 referral patients. Of these, 49% (94/192) benefited from 3-D planar imaging. Consistently improved counseling occurred with abdominal wall defect (11/11), cystic hygroma (8/8), neural tube defect (8/8), skeletal dysplasia (5/5), hydrops (5/5), ovarian mass (4/4), myoma (9/11), and fetal chest mass (2/3). Moderate image concordance was seen for nuchal thickness (4/8), renal dysgenesis (27/50), and placental mass or separation (7/12). Lowest concordance was seen for echogenic bowel (0/17), isolated SUA (0/9), and CPC (4/41). Conclusion: Complex syndromes with superficial and deep architecture are accessible with a simple volume mode planar scanning technique. The additional information is immediately available and useful in counseling of these syndromes.

WS14-06 Implemented three-dimensional power Doppler for evaluation of fetal and placental circulation: implications for clinical management Jin-Chung Shih, Hsi-Yao Chen and Fon-Jou Hsieh Department of Obstet/Gynecol, National Taiwan University Hospital, Taipei, Taiwan Background: The study of fetal and placental circulation has focused on the interaction betweens fetal hypoxia and abnormal flow regulation. The assessed methods including spectral and color Doppler

26

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US. However, their uses in the depiction of angioarchitecture to make the specific diagnosis are limited. Methods: We use three-dimensional (3D) power Doppler sonography (Voluson 530D, Medison; and HDI 3000, ATL) a to detect and visualize the fetal vasculature since 8 weeks gestation. We also use the same method to render the angioarchitecture of placenta as early as 5 weeks gestation. The scanning methods were using either freehanded or built-in mechanical probe. We also assess its application in decision making for difficult cases. Results: Power Doppler provides excellent visualization of fetal circulation (including umbilical vein, portal vein systems, ductus venosus, hepatic veins, etc.). Furthermore, these data can be rendered in 3D perspectives, which is more comprehensive for understanding the complicated vasculature of fetus. It can correlates the embryonic findings in vivo, therefore can confirm the normalcy and also contribute in the diagnosis of pathological state. Conclusion: Our results indicate 3D power Doppler is a promising tool in evaluation of complicated fetal and placental anatomy, and might help to make decision in clinical dilemmas.

WS14-07 Volume sonography of the female pelvic floor after childbirth J. Wisser Department of Obstetrics, University Hospital Zurich, Switzerland Objective: To evaluate the sonomorphologic changes of the female pelvic floor after childbirth. Furthermore the timing of the appearance of these defects labor are examined. Methods: We examined three groups of patients. 104 primiparae after vaginal delivery, 26 primiparae after elective cesarean section and 77 primiparae after secondary cesarean section within 3±7 days after delivery. To assess the morphology of the pelvic floor we used to examine the anal morphology, whereas the transrectal route was used to assess the paraurethral fixation of the lateral vaginal edges. Paravaginal defect was defined as descent of the lateral vaginal edges below the suburethral portion of the vagina and defects of the internal anal sphincter is defined by anterior vs. posterior thickness-ratio below 0.5. Clinical symptoms were documented using a standardized questionnaire. Results: Primiparae after elective cesarean section served as control group. After vaginal delivery 7.3% of women showed urinary and 17.7% anal incontinence. Mode of delivery is significantly associated with anal and urinary incontinence. Paraurethral defect is predictive for urinary incontinence. Morphological defects of the pelvic floor could be documented after dilatation of the cervix to more than 7 cm. Conclusions: Volume sonography after childbirth allows to document trauma to the pelvic floor due to vaginal delivery. Defects of the anterior compartment are predictive for the development of urinary incontinence. To study the timing of the appearance of pelvic floor defects during the course of vaginal delivery may be helpful for obstetrical decision making.

WS14-08 Three dimensions in neonatal period M. Stanojevic Department of Obstetrics and Gynecology, Medical School University of Zagreb, Sveti Duh Hospital, Zagreb, Croatia Background: The aim of this study was to compare the application of 2D neurosonography (USG) and 3D USG in newborns with respect to the time required to obtain the data for analysis. Method: All newborns in whom neurosonography was indicated underwent 2D USG and 3D USG by the same investigator. The Voluson 530 D Color System was used with vaginal 5±8 MHz 3D probe for 3D imaging. 2D real-time imaging was performed with Aloka SSD 121 device using 5 MHz sector probe. The time needed to perform the examination was determined. Non-parametric Kruskal± Wallis rank sum test was used in statistical analysis. Results: A total of 30 newborn infants of different gestational ages (ranging from 25 to 40 weeks) underwent USG after delivery at


4±7 October 2000, Zagreb, Croatia different postnatal ages (ranging from 2 to 60 days). The median time required to perform the 2D USG was 14 min (10±21). The median time required to perform the investigation by 3D USG was 5 min (ranging from 3 to 10). The difference was statistically significant (H 24.88; P 0.0031). The median time of data interpretation for 2D USG was 25 min (15±35), and for 3D USG it was 45 min (30±63). The difference was not statistically significant (H 13.22; P 0.1531).

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

WS15: SECOND AND THIRD TRIMESTER DOPPLER II WS15-01 High pathological Doppler flow findings (absent or reverse enddiastolic flow) and fetal outcome W. Schmidt and A. K. Ertan Department of Ob & Gyn, University of Saarland, Homburg/Saar, Germany Background: Reversed enddiastolic Doppler flow velocity waveforms on umbilical velocimetry is regarded to be associated with catastrophical perinatal outcome with a high perinatal mortality ranging from 35% to 100%. This study focused on the differences of fetal morbidity and mortality between the cases with reverse flow and other Doppler flow velocity waveforms. Method: During a 10-year period we found 30 cases with reverse flow in the umbilical artery or fetal aorta (gr. I), we selected 30 cases with absent end diastolic velocities (gr. II), 30 cases with high A/B-ratio (gr. III) and 30 cases with normal A/B-ratio (gr. IV). All cases in this study were patients with similar para, gravida, maternal age and gestational ages by delivery (# 36 weeks). Results: The fetuses with reverse flow showed the highest perinatal mortality of 27% (7% in the gr. II, 10% in the gr. III and 0% in the gr. IV). In the gr. I the neonatal morbidity of 78% was also the highest (59% in the gr. II, 36% in the gr. III and 30% in the gr. IV). 80% of intrauterine fetal death (IUFD) were within this group, while no IUFD has been found in the gr. IV. Furthermore, the incidence of cerebral haemorrhage by the neonates in the gr. I (28%) was also much higher than those in the gr. III (4%) and IV (0%). Conclusions: Our study suggests that reverse flow represents severe fetal condition with the highest perinatal mortalities. The fetal outcome in cases with reverse flow is further worse than those with absent end diastolic flow velocity waveforms. A highest morbidity was also observed by those fetuses, especially high incidences of cerebral haemorrhage. Colour Doppler-sonography is a very useful tool to identify high risk pregnancy leading worse perinatal outcome and allows to select worst perinatal prognosis if reverse end diastolic flow is detected.

WS15-02 Fetal biophysical profile and kinetic measurement: Doppler contribution J. M. Troyano Ultrasound Division, University Hospital of Canary Islands, Tenerife, Spain Background: Two methods are presented for the assessment of fetal behaviours under the application of Doppler effects: (a) Measurement of the velocity wave of fetal limb by vibroacustic stimulating. (b) Hydrodynamic evaluation of the transnasal amniotic velocity wave and its relation to gastric peristalsis. Method: A Doppler device was employed to assess the velocimetry wave from the `FEMORAL BONE' in motion, following vibroacoustic stimulation in 138 phisiological pregnancy and Doppleraided evaluation of transnasal amniotic hydrodynamics. Results and conclusion: Assessment of normal fetal behaviour. Quantification of patterns of reactivity of any body structure. Reduction in the duration of explorations for biophysical profiles.


(3±4 min). Fetal reflex responses slow down and become increasingly complex as maturation carries on. Both mean velocity and acceleration of fetal reactive responses experience a gradual decline throughout gestation. The time a fetus takes to respond to a stimulus increases directly with gestational age. Simultaneousness between fetal respiration episodes and phases of gastric distention and activity. (physiological conditions). Fetal active respiration can be unequivocally accounted for by Doppler assessment of the activity of intake/release of amniotic fluid along the high respiratory branches of the pulmonary tree. Amniotic respiratory dynamics are always transnasal in physiological conditions. Velocities of transnasal, decreasing steadily from the 32nd gestational age to the end of gestation.

WS15-03 Fetal centralization C. A. B. Montenegro, M. L. A. Lima and J. Rezende-Filho ClõÂnica de Ultra-Sonografia Botafogo and Departamento de Ginecologia e ObstetrõÂcia da UFRJ, Rio de Janeiro, Brazil We have been studying fetal centralization in the toxemic/IUGR model since 1992, by means of Doppler of the umbilical and middle cerebral arteries and ductus venosus, computerized CTG and cordocentesis. The natural history of fetal centralization may be divided into 3 phases: normoxemic centralization, hypoxemic centralization and decompensation. The natural history of fetal hypoxemia in these models and the patterns of computerized CTG were also described. Having analysed 105 cases of very high-risk pregnancies in the toxemic/IUGR model with fetal centralization, we tried to define the best parameter to indicate the ideal timing for delivery, and the presence of centralization after 28 weeks gestation appears to seems to indicate it.

WS15-04 The value of evaluation of adrenal circulation in predicting hypoxia of the fetus G. H. Breborowicz and M. Dubiel Department of Perinatology and Gynecology, University School of Medical Sciences, Poznan, Poland From animal studies it is known that fetus during hypoxia redistributes it's blood flow preferentially to the brain, heart and adrenal glands. In animal studies, a three-fold increase in adrenal blood flow has been demonstrated during hypoxia. The adrenals are relatively large organs in the fetus. Compared to fetal body weight, they are 20 times bigger than in the adult. The fetal adrenals respond to stress, such as hypoxemia by increased production of dihydroandrostendion (DHA), DHA sulfate and their metabolites. The adrenal gland is supplied by three arteries: the superior, coming from the inferior phrenic artery; the middle, from the abdominal aorta and inferior, arising from the renal artery. In the recent studies the Doppler signals were obtained from fetal middle adrenal artery. The normal adrenal PI shows decreasing values with the gestational age, which might suggest lower vascular resistance and high blood flow to the adrenals. From our observations the adrenal Doppler velocimetry is easier to record in fetuses from high-risk pregnancies than in normals,

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10th World Congress on Ultrasound in Obstetrics and Gynecology probably due to the adrenal sparing effect. Recent results suggest that the adrenal artery velocimetry might be useful in fetal assessment and predicting outcome. The àdrenal-sparing' effect might be maintained at the same time the brain-sparing signs disappear.

WS15-05 Fetal venous Doppler: is it helpful in timing of delivery of hypoxic fetus? V. Latin and T. Hafner Department of obstetrics and Gynecology, `Sveti Duh' Hospital, University of Zagreb, Zagreb, Croatia Background: The aim of this study was to investigate the potential of fetal venous Doppler in detection of fetal hypoxia and timing of the delivery. Methods: The study group consisted of patients with increased risk for developing fetal hypoxia. These were patients with diagnosed fetal intrauterine growth retardation (IUGR) and patients with pregnancy induced hypertension (PIH), or a combination of both problems. All patients had Doppler assessment of fetal arterial (umbilical artery, aorta, middle cerebral artery) and venous circulation (ductus venosus and umbilical vein), and cardiotocography 24 h before delivery. Collection of postnatal data included pH of umbilical chord blood, admission in neonatal intensive care unit, and perinatal death. Results: A total of 360 patients were included in the study (IUGR 48%, PIH 20%, IUGR 1 PIH 32%). Deterioration in fetal venous return developed after fetal arterial circulation had been severely compromised. The decrease in end-diastolic flow in ductus venosus anticipated development of umbilical vein pulsatile flow. Patients with pulsations in umbilical vein blood flow had high incidence of perinatal acidosis, morbidity, and mortality. Conclusion: Delivery should be performed before umbilical vein pulsations develop. Careful monitoring of ductus venosus blood flow is helpful predictor of this event.

WS15-06 Doppler ultrasonography of the human fetal pulmonary circulation and its role in the prediction of pulmonary hypoplasia J. A. M. Laudy, D. Tibboel, S. G. F. Robben, R. R. De Krijger, M. A. J. De Ridder and J. W. Wladimiroff Department of Ob. & Gyn, University Hospital Rotterdam-Sophia/ Dijkzigt, The Netherlands Objectives: To determine the value of Doppler flow velocity waveforms from the fetal arterial pulmonary branches relative to fetal biometric indices and clinical correlates in the prenatal prediction of lethal lung hypoplasia (LH) in prolonged oligohydramnios. Study design: 42 singleton pregnancies with oligohydramnios associated with premature rupture of membranes (PROM, n 31) or bilateral renal pathology (n 11) were examined using a combined color coded Doppler and 2d real-time ultrasound system. Thoracic (TC), cardiac (CC) and abdominal circumference (AC) and the largest vertical amniotic fluid pocket were measured. Pulsed Doppler measurements of the arterial pulmonary branches were made at the level of the cardiac four-chamber view after visualization with color Doppler. Diagnosis of LH was based on pathological, clinical and radiological criteria.

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Results: The prevalence of lethal LH was 43%. In the PROM-subset, combination of onset of PROM 20 weeks; duration of oligohydramnios 8 weeks and degree of oligohydramnios 1 cm, presented the highest clinical prediction rate for lethal LH. For both the total group and the PROM-subset, the highest prediction rate for lethal LH from biometric and Doppler parameters was presented by TC/AC ratio, peak systolic velocity in the proximal branch and timeaveraged and end-diastolic velocity in the middle branch of the pulmonary artery. In the prom subset, combination of all three clinical, biometric and Doppler parameters revealed the most favorable combination to predict lethal LH (PPV 100%, accuracy 93%, and sensitivity 71%). Conclusion: Doppler velocimetry may detect changes in blood velocity waveforms from the arterial branches of the fetal pulmonary circulation in the presence of LH, but fails to be the ultimate test for the prenatal prediction of lethal LH. The best prediction can be achieved by combining clinical, biometric and Doppler parameters.

WS15-07 Assessment of a formula using Doppler velocimetry to calculate fetal hemoglobin (Hb) L. S. Voto, O. B. Mulki, J. L. Zapaterio, A. Falco, E. R. Mathet, R. L. Lede and M. Margulies Maternal Fetal Department, j.A. FernaÂndez Hospital, University of Buenos Aires, Argentina Aim: To assess agreement between fetal cord blood Hb concentration by Doppler velocimetry and a formula (Oepkes et al, Br J Obstet Gynaecol 1994; 101:680±4), and the actual Hb concentration by cord blood sampling. Material and methods: A prospective cohort of 31 Rh isoimmunised fetuses undergoing Doppler cord blood velocity measurements within the 24 hs previous to cordocentesis or delivery was included. Mean aortic velocity at descent fetal aorta and maximum umbilical vein flow at intrahepatic portion were measured blindly by a single operator with pulsed Doppler and a 3.5 Mhz transducer. Cord Hb was the gold standard. Abnormality and normality were defined as a Hb level lower and higher, respectively, than the cut-off point (,7, ,8, ,9, ,10, ,11 and ,12 g/dL were tested). Likelihood ratio was also calculated. Results: Interval between Doppler study and cordocentesis/delivery was 24±48 hs. Fetal blood sampling was performed by cordocentesis in 4 cases, following a C-section in 24, and following vaginal delivery in 3. Conclusion: An acceptable agreement was found. Further populationbased studies are required to corroborate its clinical significance.

Table 1 Distribution of cases according to results obtained (n cases) Cut-off point True1 False1 True± False±

,7g

,8g

,9g

,10g

,11g

,12g

1 1 29 0

5 1 25 0

7 7 15 2

14 7 7 3

23 6 2 0

26 5 0 0

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

,7

,8

,9

,10

,11

,12

Abn. Norm. LR

50(5±100) 97(81±100) 30(2.3±129.8)

83(36±99) 96(78±100) 26(4.2±132.4)

43(21±69) 62(41±80) 2.7(1.2±5.9)

58(37±77) 41(17±67) 1.6(1±3)

79(60±91) 25(4±64) 1.3(1±2.4)

84(66±94) 0(0±54) 1(0.9±2)

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

WS15-09 Three-dimensional ultrasound examination of fetal and placental vessels

R. Matijevic Department of obstetrics and Gynecology, University of School Medicine and Sveti Duh Hospital, Zagreb, Croatia

J. Wisser Department of Obstetrics, University Hospital Zurich, Switzerland

Physiologic change of spiral arteries is important adaptation of maternal vascular network for ongoing pregnancy. It is characterised by destruction of muscular layer of these vessels changing them to a low resistance vascular channels. Physiologic change was found to be incomplete in pregnancies complicated by pregnancy induced hypertension (PIH) and intrauterine growth retardation (IUGR). These changes were detected in vitro in histrologic studies but recently were investigated in vivo using Doppler ultrasound. In normal pregnancy the impedance to blood flow in spiral arteries measured by resistance (RI) and pulsatility (PI) indices significantly decrease toward the mid trimester (P , 0.05) and then remains stable. Similar observation was found in pregnancies complicated by PIH and IUGR. Both of these represent the second wave of trophoblastic invasion of spiral arteries. In pregnancies complicated by PIH and IUGR measured impedance indices were significantly higher compared to the matched normotensive women with normal fetal growth (P , 0.05), representing ht failure of the complete physiologic change of the spiral arteries. This is in concordance with histologic studies. Comparing the significance levels of blood flow in proximal and distal parts of uteroplacental circulation between investigated groups, the higher significance levels were obtained in terminal parts. This can have serious implication in designing further research protocols of the screening programmes for the PIH and IUGR based on the blood flow in uteroplacental circulation.

Objective: Since August 1998 we used the integrated 3-D software with the Siemens Elegra in order to evaluate fetoplacental vessels in the 3-D mode. Aim of the evaluation was to examine the feasibility of the application and to demonstrated potential clinical advantages. Methods: In our antenatal clinic we recruited pregnant women between 12 and 38 weeks of gestation to take part in a feasibility study in order to evaluate the free-hand 3-D application using the 5.0 MHz transducer for routine antenatal scanning. We examined vasculatore within the placenta, intrathoracoabdominal and intracranial fetal vessels with the integrated powermode. Acquisition time for a volume date set is between 3 and 20 s depending on the resolution selected. Results: Three-dimensional examination of the fetoplacental vessels is easily available using the Siemens Elegra, because no change in transducer is necessary. Our preliminary data show that we are able to demonstrate the complexity of intraplacental vasculature, which may be clinically helpful in the evaluation of twin placentas. Within the fetus the spatial arrangement of the vessels and their relation to each other can be depicted. This allows to study the fetal vascular tree and clearly discloses vascular anomalies. Conclusions: Application of the integrated 3-D software within the Siemens Elegra for the first time allows the examination of the complex fetoplacental vascular tree in vivo. This may be clinically helpful in the differential diagnosis of fetal anomalies.

W S 1 6 : E A R LY P R E G N A N C Y WS16-01 The value of first trimester sonography for the diagnosis of structural and chromosomal abnormalities

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

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

WS16-02 Sonoembryology using intrauterine sonography

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


T. Hata Department of Perinatology, Kagawa Medical University, Kagawa, Japan Our first purpose was to describe embryonic anatomic structures by use of IUS with a 20-MHz flexible catheter-based, high resolutions, real-time miniature transducer. The number and the clarity of structures increased from 7 to 8 weeks of gestation; however, the image quality was degenerated because of the increasing fetal size at 9 weeks. At 8 weeks secondary brain vesicles, spine, midgut herniation, liver, upper and lower limb buds, and sacral tail were visualized in all fetuses. The four-chamber view was first identified at 8 weeks, as were fingers or toes. The stomach was first noted at 9 weeks. Second purpose was to compare the ultrasound visualization of the early first-trimester embryo using TVS and IUS as 6±8 weeks of gestation. The ability to view most organs was better with IUS compared to TVS, and this was especially true for the brain, spine, heart, liver, midgut herniation, extremities, and sacral tail. Moreover, it was possible to obtain finer image quality of very small embryonic structures with IUS than with TVS. Third purpose was to evaluate embryonic organ growth (liver, heart, and brain vesicles) using IUS in the early first trimester of pregnancy. The significant good correlation between each parameter and gestational age was obtained. Fourth purpose was to visualize normal embryonal surface anatomic structures using 3D-IUS at 7±9.9 weeks gestational age. At week 8, prominent forehead was evident, and upper and lower limbs and midgut herniation were clearly depicted. At week 9, fingers

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10th World Congress on Ultrasound in Obstetrics and Gynecology and toes were depicted as small digital rays, and the sacral tail protruded caudally. At week 10, embryonic face and fingers were clearly shown.

WS16-03 Three-dimensional-ultrasound in the assessment of embryonic anatomy H.-G. K. Blaas National Center for Fetal Medicine, Norwegian University of Science and Technology, Trondheim, Norway Diagnostic ultrasound in the early pregnancy deals with the recognition of normal anatomy and/or the detection of anomalies in very early viable pregnancies. There are clinical situations where the position of the embryo does not allow imaging of the optimal section of a certain organ. This is often the case with the transvaginal approach, where movements of the transducer are limited. Deriving new 2D images by anyplane slicing is an important presentation mode of embryonic 3D ultrasound. Geometric 3D reconstructions can also be helpful for the understanding of the embryonic anatomy. High quality 2D tomograms are the prerequisite of 3D imaging of the tiny embryo and its organs. Such ultrasound tomograms can be achieved by using annular array transducers, which have a thin elevation plane due to symmetric focussing. Examples of multiplane imaging and geometric volume reconstructions in the assessment of the embryonic anatomy will be presented, and the limitations will be discussed.

WS16-04 Doppler ultrasound: potential in early pregnancy I. Zalud Division of Maternal Fetal Medicine, Kapiolani Medical Center for Women & Children, University of Hawaii John Burns School of Medicine, Honolulu, HI, USA Remarkable changes and continuous growth and development of the early maternal-fetal circulation could be studied by Doppler ultrasound. This approach seems to give more light in understanding of the early pregnancy development. Doppler ultrasound was reported accurate to separate different segments of uterine blood flow during pregnancy. Color flow is used to anatomically locate arcuate, radial and spiral arteries. Pulsed Doppler is then used to study different flow patterns of visualized vessels. Studies of maternal-fetal circulation in early pregnancy may help for better understanding of physiological and pathophysiological hemodynamic changes in the circulation. Investigation of maternal (main uterine, arcuate, radial and spiral) arteries; placental (umbilical, chorionic arterioles) vessels and embryonic/fetal (heart, aorta and intracranial circulation) arteries flow patterns may help to diagnose abnormal implantation and embryonic development. More studies are necessary in order the Doppler technique to be used for clinical assessment in early pregnancy. Safety aspects should also be considered. However, potentials of this technique are promising in study of early pregnancy failure, chromosomal abnormalities, development of pre-eclampsia and IUGR.

WS16-05 Doppler assessment of early pregnancy M. Ruiz-Flores Medical School, University of Chile Doppler velocimetry give possibility of making noninvasive evaluation of the vascular modifications from the beginning of pregnancy. We have studied following vessels: Retrocorial arteries: The flow increases since sixth to twelfth weeks, progressively which is explained by the increment of the conductancy and the reduction of resistance. Trophoblastic invasion of spirals arteries in the coral bed, and hormones produced during the gestation affect both values.

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Uterine arteries: The resistance of the uterine arteries diminish since sixth to twelfth weeks, in normal pregnancy. The low increment depends on the modifications in the coral bed and of hormonal vasodilator effect. OVF Luteum gravidicus: When ovary flow is greater in first stage of pregnancy suggest a favorable early gestation, and vice versa, a regress in those measures had a negative character. We could evaluate the role of Doppler examinations in the following situations: X Abortion in any stage and variations X Blighted ovum X Ectopic pregnancy In all these conditions, Doppler showed to be a trusty, predictive, prognostical and diagnostical instrument of great utility. Clinical application of Doppler Uterus Corial could be used in a preventive way when the increment of the resistance in the uterine arteries appears before clinical abortion symptoms. We also applied Doppler exploration in AVF patients confirming that the deficit in uterine perfusion is significantly related with the failures in embryonary implantation. Recently, we are performing endovaginal color Doppler in the diagnoses of early ectopic gestation and trophoblastic disease with very satisfactory results.

WS16-06 Three-dimensional ultrasound assessment of the first trimester fetus ± a òne step' approach A. D. Hull, G. James, T. R. Nelson and D. H. Pretorius University of California San Diego, La Jolla, California, USA Background: The optimal time at which to perform obstetric ultrasound remains controversial. Late first trimester imaging offers the possibility for early diagnosis of structural and genetic abnormalities. Three-dimensional ultrasound (3DUS) allows the entire first trimester conceptus to be contained within one or two volumes of data. Subsequent processing of this data allows optimized views of the fetus, placenta and cord to be obtained. Method: Late first trimester (,12 week) pregnancies were imaged with transvaginal 3DUS. A fetal structural survey was performed, standard biometry obtained and nuchal translucency thickness (NTT) measured. The time taken to perform and assess the scans was recorded. Results: A comprehensive fetal survey was obtained, fetal measurements made and NTT measured in most fetuses with average scan times of less than one minute and average volume assessment times of less than 10 min in all cases. There were no abnormal findings in this series. Conclusion: 3DUS appears to be a useful tool in the ultrasound evaluation of the 12 week fetus. A detailed examination of the fetus may be performed with minimal scan time offering exciting possibilities for the use of transvaginal 3DUS as a òne step' screening examination.

WS16-07 Stem cell therapy in the first trimester: the role of ultrasound vs. embryoscopy D. V. Surbek Department of Obstetrics and Gynecology, University of Basel, Basel, Switzerland Intrauterine allogeneic hematopoietic stem cell transplantation has been successfully used for the prenatal treatment of severe combined immunodefiency syndrome. However, this treatment has not been successful in other conditions in which the fetus is immunologically competent. The main obstacles to success are lack of competitive advantage of donor vs. host stem cells preventing stable engraftment and graft rejection by the host immune system. Strategies to overcome these hurdles include, among others, early transplantation before 12 weeks of gestation, and increase of cells dose in the target organs (fetal liver and fetal bone marrow) which might be best achieved by the intravascular administration route. However, whilst ultrasoundguided intraperitoneal administration of the graft in the first trimester is feasible, access to the fetal circulation in the first trimester is more


4±7 October 2000, Zagreb, Croatia difficult. Combined ultrasound-guided/embryofetoscopic approach is a promising technique to achieve this goal. Thin-gauge embryofetoscopes allow the exact visualization of the optimal funipuncture site

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

WS17: NEWCOMERS WS17-01 Hormone replacement therapy reduces impedance to flow in different vascular beds W. M. Van Baal, P. Kenemans, C. D. A. Stehouwer, J. M. G. Van Vugt and M. J. Van Der Mooren Project Àgeing Women', Institute for Cardiovascular Research-Vrije Universiteit (ICaR-VU), Departments of Obstetrics & Gynecology and Internal Medicine, University Hospital Vrije Universiteit, Amsterdam, The Netherlands An HRT-associated reduction of the pulsatility index (PI) has been reported in the literature, although cross-sectional studies have shown conflicting data. In a prospective, controlled study we randomized 30 healthy postmenopausal women (mean age 52 ^ 3 years) into two groups. Women in the HRT group (N 15) received 1 mg micronized 17b-estradiol daily (E2) sequentially combined with 5 or 10 mg dydrogesterone for 14 days of each 28-day cycle during 12 months, and, thereafter, 2 mg E2 combined with 10 mg dydrogesterone for a period of 3 months. The control group (N 15) received no treatment. Color Doppler ultrasound was used to measure the impedance to flow (pulsatility index [PI]) within the uterine, central retinal and ophthalmic arteries in the E2-phase at baseline and after 3, 12 and 15 months. Compared to controls, 12 months of HRT was associated with a significant decrease in the mean PI of the uterine artery of 239% (HRT 225%, controls 114%) and in that of the central retinal artery of 229% (HRT 29%, controls 120%). After 3 months this effect was already evident. During HRT, the reductions in mean PI of the uterine and central retinal arteries vs. baseline were larger (both P 0.002) in the women with high pretreatment PI values when compared to those with low pretreatment values. The baseline PI of the uterine artery correlated positively with age and with duration of amenorrhoea (r 0.42, P 0.01 and r 0.48, P 0.008, respectively). Our 12-month study expanded on earlier reports of a reduced PI of the uterine artery. We used a combined regimen containing a low-dose of oestrogens. These results are important because the recent trend is to recommend combined HRT that contain lower dosages of oestrogens than before. Furthermore, a 29% reduction of the PI of the central retinal artery was observed, which suggests that HRT has a positive influence on the impedance of the cerebral circulation. From the point of view of atherothrombotic risk these observations are beneficial and possibly helpful in understanding the decreased risk of cardiovascular disease, and of the impairment of cognitive functions associated with oestrogens in epidemiological data.

WS17-02 Utero-ovarian arterial blood flow and hormonal profile in patients with polycystic ovaries E. VrtacÏnik-Bokal Department of Ob/Gyn, University Medical Centre Ljubljana, Slovenia Background: To review the literature of utero-ovarian arterial blood flow and serum hormonal profile in the patients with polycystic ovaries (PCO) compared to the patients with normal menstrual cycles undergoing in-vitro fertilization treatment. Method: Pertinent studies were identified through a computer MEDLINE search. References of selected articles were hand-searched for additional citations. Results: The vascular impedance to uterine artery blood flow is higher during the luteal phase of PCO patients compared to the normally


cycling patients and it does not show any dynamics throughout the menstrual cycle. In the normally cycling patients the active ovary shows dramatic hemodynamic changes during the cycle, therefore the vascular impedance to ovarian artery blood flow is almost constant throughout the menstrual cycle in the inactive ovary. In PCO patients the ovarian arterial blood flow in both ovaries is about the same as in inactive ovaries in the normally cycling patients. High vascular impedance to utero-ovarian arterial blood flow is associated with typical low vascular impedance of stromal ovary vascularization in PCO patients. In stimulated cycles a strong negative correlation between the vascular impedance to the uterine artery blood flow and the serum E2 concentration is found on the day of HCG administration. Taking only anovulatory PCO cycles into consideration, the above correlation is not confirmed. Conclusion: Doppler analysis can be a valuable method for the assessment of utero-ovarian arterial blood flow in spontaneous and in stimulated cycles.

WS17-03 Relationship between ultrasound-determined follicular size and DNA ploidy of human granulosa cells K. Gersak, J. Lavrencak, M. Us-Krasovec and T. Tomazevic Department of Obstetrics and Gynaecology, University Medical Centre Ljubljana and Department of Cytopathology, Institute of Oncology Ljubljana, Slovenia Background: The possibility that the hyperstimulatory effect of gonadotropins may be important etiologically in the genesis of some cases of ovarian cancer is still under discussion. Few flow and image cytometric studies report on DNA aneuploid granulosa cells in follicular fluid from women undergoing in vitro fertilization (IVF). The reports are very controversial. The aim of the study was to analyse relationship between ultrasound-determined follicular size and DNA ploidy of granulosa cells from gonadotropin-stimulated follicles. Method: The granulosa-luteal cells were obtained from women undergoing an IVF-ET program at the University Department of obstetrics and Gynecology Ljubljana. Seventy aspirates of individual follicles (transvaginal determined size, range 15 mm ± 30 mm in diameter) from gonadotropin-stimulated cycles were analysed. Cytospins were prepared and fixed in delaunay fixative. All the slides were stained by the feulgen thionin method. Image DNA analyses was performed on automated high-resolution image cytometer. The DNA index was calculated to define DNA ploidy. Results: All granulosa cell samples were found to be diploid. Conclusion: Regardless of different ultrasound-determined size of follicles, all analysed granulosa cells have diploid DNA content. Acknowledgements: Supported by grants from ministry of Research and technology republic of Slovenia (No. j3-0428±032±98).

WS17-04 Operative histeroscopy in treating intrauterine abnormalities as a factor in marital infertility S. IzetbegovcÂ Department of Obstetrics and Gynecology, University Medical Center, Sarajevo We have researched operative histeroscopy in treating endometrial abnormalities as a cause of marital infertility. A group of 320 infertile patients was included in the study. Color Doppler examination

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10th World Congress on Ultrasound in Obstetrics and Gynecology detected endometrial abnormalities (subseptus, polyp, synechiae, myoma, uterus bicornuate, and uterus arcuate). The controlling group consisted of 100 patients suffering endometrial abnormalities, who have not underwent the operation. In research group, there were 9 pregnancies following operative histeroscopy over a period of 18 months. That is 34.6%, out of which 89 (27.8%) have been carried out and delivered. We have also studied the surgical risk of operative histeroscopy. According to the results, operative histeroscopy is minimally invasive, surgically comfortable, economically acceptable. The influence of histeroscopy on the endometrium during pregnancy and delivery is such that there is no significant difference in comparison to the patients that were not operated. The pregnancy following operative histeroscopy is phsysiological. The delivery has no implication of pathological nature, nor difference in duration, type, or any other component. The enonathological parameters do not differ from physiological

WS17-05 Placentation studied by three dimensional power Doppler sonography T. Hafner Department of Ob/Gyn, `Sveti Duh' Hospital, University of Zagreb, Zagreb, Croatia Objective: The aim of this study is to investigate processes of placentation by the use of three-dimensional sonography. Methods: A group of 25 pregnant women in gestational age ranging six to 10 weeks underwent a detailed assessment. The ultrasound device was Voluson 530D MT, by Kretztechnik, Zipf, Austria. Measurements in three-dimensional B-mode were gestational sac volume, chorion volume, and embryonic volume. Volumes were measured by the use of an integrated software. Structures were outlined manually in multiple parallel sections. The machine integrated and calculated the volume. The hemodynamical changes correlated to the process of placentation were assessed by the use of three-dimensional power Doppler (angio mode). Three-dimensional imaging of vascular changes was expressed and quantified by the use of volume flow index (VFI). The analysis of the results included correlation of morphological and hemodynamical parameters obtained by measurements. Results: The volume of gestational sac, chorion and embryo increases during the weeks of gestation under investigation. The amount of vascular spaces in the chorion and surrounding myometrium increase with gestational age and correlates with the gestational sac and chorion volume. Conclusion: 3D power Doppler sonography is a valuable tool for assessment and quantification of hemodynamic changes involved in placentation.

WS17-06 Three-dimensional power Doppler ultrasound as a second line screening tool in ovarian cancer screening ± preliminary results T. Zodan, M. Gregov, V. Sparac, A. Kurjak, S. Kupesic and M. Ilijas Sveti Duh General Hospital, Zagreb, Croatia Introduction: In this screening program, 2D color Doppler (2D CD) was used as the first, and CA-125 and 3D power Doppler (3D PD) were used as second-line screening tools when 2D scoring system indicated possible malignancy. The study was designed to show whether early stages of ovarian cancer can be correctly diagnosed by 3D PD and whether 3D would perform better than CA-125. Methods: All patients were either postmenopausal, or premenopausal with positive family history, or they had a persistent ovarian cyst. They were all examined by 2D CD and if values of scoring system were over cut-off point, 3D PD analysis was performed and CA-125 was tested. Results: A total of 108 patients (97 postmenopausal and 11 premenopausal with family history) had a 2D scan. In 5 cases 2D scoring indicated possible malignancy after which 3D analysis was

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done as well as test for CA-125. In 2 cases 3D PD scoring was negative, as well as CA-125 and the lesions were simple cyst surrounded by chronic inflammatory process in the first patient and ovarian fibroma in the second. In 3 cases 3D PD scoring was positive while CA-125 measurement showed increased values only in 1 case. PHD analysis confirmed the diagnosis of ovarian carcinoma in all three lesions. 3D PD correctly predicted benign or malignant nature of the lesion, while CA-125 failed to do so in two stage 1 ovarian cancers. Conclusion: Although now expensive and in most hospitals unavailable, 3D power Doppler is a future screening tool in ovarian cancer screening programs. However, a lot more women should be screened before proper statistical analysis could be done.

WS17-07 Fetal and neonatal echocardiographic features in twin-to-twin transfusion syndrome T. Murakoshi, Seguchi*, H. Naruse, Y. Torii and K. Maeda Obstetrics and Pediatric Cardiology*, Maternal and Perinatal Care Center, Seirei Hamamatsu Hospital, Hamamatsu, Japan Background: Twin-to-Twin transfusion syndrome (TTTS) is a severe complication in monochorionic twin pregnancies. Particularly severe fetal and neonatal cardiac dysfunction is complicated in recipient twin and attended with high perinatal morbidity and mortality. The aim of this study was to evaluate the abnormal echocardiographic features and clinical complications of cardiac disease in TTTS. Method: We studied 20 pregnancies complicated with TTTS. Serial fetal and neonatal echocardiography were carried out and evaluated the following parameters: cardiothoracic area ratio, aortic and pulmonary artery Doppler peak velocities, umbilical arterial resistance index, preload index of inferior vena cava, ventricular valve regurgitation and structural heart abnormalities. Result: In recipients, all features had cardiomegaly, tricuspid valve regurgitation and high preload condition with increased preload index of inferior vena cava. Aortic and pulmonary artery peak velocities were increased in the recipients than those in the donors. Three cases of recipients had pulmonary valve stenosis and received balloon pulmonary valvuloplasty. Furthermore, three cases of donors had coarctation of aorta and also received surgical repair. Conclusion: In addition to the severity of cardiac dysfunction, pulmonary stenosis and coarctation of aorta would be the important factors to evaluate perinatal prognosis of TTTS.

WS17-08 Fetal biochemical markers in severe placental insufficiency ± comparison with fetal Doppler findings J. RaÈsaÈnen, K. MaÈkikallio, O. Vuolteenaho and P. Jouppila Departments of Obstetrics and Gynecology, and Physiology, University of Oulu, Oulu, Finland Background: The aims of this study were to assess the activity of the human fetal atrial natriuretic peptide system in hypertensive pregnancies with and without signs of increased fetal systemic venous pressure and to investigate the association between severe placental insufficiency and fetal myocardial cell destruction. Method: Control group consisted of 50 newborns with uncomplicated pregnancy and labor. In group 1, 22 newborns after hypertensive pregnancies were included. Doppler ultrasonography revealed abnormal umbilical artery (UA) blood velocity waveform in five cases, and normal nonpulsatile umbilical vein (UV) blood velocity profile in every case. Group 2 consisted of five newborns after pregnancies complicated by maternal hypertensive disorder. Atrial pulsations in the UV and retrograde diastolic blood velocity pattern in the UA were detected in every case. Immediately after birth blood samples were collected from the UA and plasma N-terminal peptide of proatrial natriuretic peptide (NT-proANP) and serum cardiac specific troponinT concentrations were measured. Results: In group 1, nt-proANP concentrations were higher (P , 0.001) than in the control group. In group 1, newborns with


4±7 October 2000, Zagreb, Croatia abnormal UA blood velocity pattern had higher (P , 0.006) NTproANP concentrations than newborns with normal UA Doppler findings. Troponin-T concentrations in group 1 did not differ from the control group. In group 2, NT-proANP (P , 0.002) and troponin-T (P , 0.0001) concentrations were higher than in the control group and study group 1. Conclusion: Maternal hypertensive disorder stimulates fetal atrial natriuretic peptide production, being greatest in fetuses with severe placental insufficiency and a rise in systemic venous pressure. These fetuses also have evidence of myocardial cell destruction.

WS17-09 Doppler flow measurements and neuromotoric morbidity A. K. Ertan and W. Schmidt Department of Ob & Gyn, University of Saarland, Homburg/Saar, Germany Background: Absent enddiastolic flow (AEDF) velocities are associated with fetal distress and adverse fetal outcome. The aim of this study was to evaluate perinatal findings of fetuses with an AEDF in fetal vessels and to investigate the neurological long-term-outcome. Method: The analytical program `Munich functional developmental diagnostics' (MFDD) was applied to the 90 children at different time intervals. The results of 40 children with an AEDF (Gr. I) and 20 children with pathological S/D-Ratio (Gr. II) were compared to the group of 30 children with normal Doppler-flow-findings (Gr. III) with the same pregnancy weeks at birth. Results: The rate of C-section (92% vs. 71% vs. 36%), birthweight (1140g vs. 1725g vs. 2570g), 5 0 min. APGAR-Score (31% vs. 5% both) were significantly different in three groups. Brain sparing effect in the middle cerebral arteries was found in 81% in Gr. I, in 21% Gr. II and only 8% in Gr. III. At the time of neurological assessment the age of children was between 12 and 36 months. The developmental age for each functional category was evaluated and the difference between corrected age and developmental age was calculated. In 33% of all infants with a AEDF had a pathological neuromotoric development vs. 22% in Gr. II and only 15.3% in Gr. III. Conclusions: The children with pathological Doppler-flow-measurements during pregnancy have not only very high risk of perinatal abnormality but also show a distinctly increased risk of impaired growth and neurodevelopmental disability comparing to the cases with a normal Doppler-flow-finding. Most of these fetuses showed brain-sparing effect. These aspects are very important to be discussed with the parents before the definitive perinatal decision is made.

WS17-10 Sonographic evaluation of the umbilical cord throughout gestation E. Di Naro, L. Raio, F. Ghezzi, Franchi, D. Bolla, V. D'Addario and H. Schneider Departments. Ob/Gyn, University of Bari, Italy; University of Bern, switzerland, University of Insubria, Varese, Italy Traditionally, the prenatal assessment of the umbilical cord (UC) is limited to the assessment of the number of vessels and to the evaluation of umbilical artery blood flow parameters. Morphologic

Workshops aspects of the UC have usually been studied by pathologists and retrospectively correlated with the perinatal outcome. The introduction of more sophisticated imaging techniques have offered the possibility to investigate the UC characteristics during fetal life from early to late gestation. A number of investigations have demonstrated that an altered structure of the UC can be associated with pathologic conditions (i.e. preeclampsia, fetal growth restriction, diabetes, fetal demise). Nomograms of the various UC components have been generated and allow the identification of lean or large umbilical cords, entities frequently associated with fetal growth abnormalities and diabetes, respectively. Of note, lean UC in the second and third trimester differs from normal UC not only from a structural point of view but also in the umbilical vein blood flow characteristics. On the other hand a thin UC in the first trimester seems to be a marker for identifying a subset of fetuses at risk for spontaneous abortion and pre-eclampsia. A Wharton's jelly reduction has also been invoked as a possible cause of fetal death in the presence of single umbilical artery. Prenatal morphometric and morphologic UC characteristics as well as UC arterial and venous blood flow parameters in normal and pathologic conditions will be presented and discussed.

WS17-11 Amniotic fluid erythropoietin concentration and cerebroumbilical Doppler flow ratio in diabetic pregnancies and pregnancies complicated by hypertension, pre-eclampsia or/and intrauterine growth restriction V. Stefanovic, H. Markkanen and K. Teramo Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Haartmaninkatu 2, 00290, Helsinki, Finland Subacute or chronic fetal hypoxia is associated with an increase in fetal erythropoietin (EPO) synthesis irrespective of the etiology of hypoxia. Amniotic fluid (AF) EPO level is often elevated in diabetic pregnancies (especially in macrosomic fetuses), and in pregnancies complicated by hypertension (HT), pre-eclampsia (PE) or/and intrauterine growth restriction (IUGR). It is shown that cerebroumbilical arterial flow ratio (RIC/RIU) is often abnormal (less than 1) in the case of fetal hypoxia. We studied AF EPO levels in 29 diabetic pregnancies, 18 pregnancies with HT, PE or/and IUGR and 19 healthy controls. The samples were obtained during the elective amniocenteses in the case of suspected fetal hypoxia or during caesarean sections. Doppler measurements were performed not more than 24 h before amniocenesis. AF EPO levels were significantly elevated in diabetics with abnormal fetal growth (either macrosomia or IUGR) and nondiabetics with HT, PE or/and IUGR as compared with healthy controls or diabetics with normal fetal growth. AF EPO levels of fetuses with normal fetal growth in diabetic mothers were not different from those of healthy controls. There was no correlation between AF EPO levels and RIC/RIU in any of the diabetic or nondiabetic group. However, 5 fetuses had either absent end-diastolic or reversed umbilical flow. All had elevated AF EPO levels (range 16± 15 800 mU/ml). We conclude that both fetal macrosomia and IUGR in diabetic pregnancies seem to cause chronic fetal hypoxia. Normal fetal growth in diabetic pregnancies is not associated with chronic fetal hypoxia. Single measurement of RIC/RIU is of little value in the diagnosis of chronic fetal hypoxia in abnormal pregnancies.

WS18: BREAST WS18-01 Ultrasounds of the breast ± the role of the gynecologist E. V. Cosmi, G. L. Cascialli, P. Nusiner, L. Meggiorini and A. Patella 2nd Institute of Gynecology and Obstetrics, University `La Sapienza' ± Rome, Italy Early detection of breast cancer is of paramount importance for its


management. Therefore, new diagnostic tools are continously searched, including 3D-US and 3D Power Doppler, and for later management, the study of the sentinel node. 3D ultrasonography (3-D US) may be of value in the differential diagnosis of the following conditions. Cysts: Not all cysts display a typical US appearance. Small cysts may lack the distal sound enhancement. Inflammatory cysts may exhibit a

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10th World Congress on Ultrasound in Obstetrics and Gynecology thickened wall. However, the major problem it the not so rare presence of intracystic echoes, which may be either real or artifactual. Fibroadenomas: A refraction artifact (edge shadowing) is often noted at each lateral margin of smooth-marginated fibroadenomas. Contours are irregular in about 25% of cases, and in about 5% shadowing makes it impossible to rule out malignancy. Carcinomas: Shadowing is associated only with those carcinomas that have a significant amount of fibrosis (, 50% of cases in our experience). Some partial shadowing seen with some carcinomas may also be caused by beam scattering by jagged margins, with 3D scan potentially useful for diagnosis. The sentinel node. Axillary lymph node status is the most important pathological determinant of prognosis in early breast cancer, whereas local axillary lynphadenectomy is the most reliable staging procedure. However, routine axillary dissection does not benefit the majority of patients with early breast cancer who are node-negative, thereby sustaining the potential morbidity of the procedure. Sentinel node is the first regional node to receive lymph from the breast and accurately represents the metastatic status of the primary cancer. Sentinel node biopsy appears to offer an alternative to routine axillary lymph node dissection for staging patients with breast cancer. (Supported in part my MURST and CNR, Italy)

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WS18-02 Modern breast ultrasound B.-Joackhim Hackeloer Hamburg, Germany Development during the past 5 years increased significantly the quality of ultrasound mammography. After trying to receive better image quality by using higher and higher frequencies up to 20 Mhz the todays breakthrough was reached by better scan converter and transducer technology. Broadband tranducers, harmonic imaging, Siescape, Angio-powerdoppler, SonoCT, 3-D imaging and the use of contrast agent improved not only image but diagnostic quality of the method. The better scin, nipple, ductal an microcalcification visualization in combination with better mass delineation allowed a diagnostic accuracy equally or better than X-ray mammography. Ultrasound mammography is the logical examination following breast palpation, can complement mammography in all patients, substitute too frequent mammography controls and save unnecessary MRIs. Unfortunately the method suffers from lack of qualified education & training, qualified users and qualified payment. Gynecologists, radiologists and surgeons should struggle together to establish the method in a appropriate way ± in the interest of all women.
