Volume 124, Issue S2 p. 17-49
Free Access

Fetal Medicine Poster Abstracts

First published: 28 March 2017
Citations: 2


Two dimensional echocardiography estimates of fetal ventricular mass and volumes throughout gestation

Aye, CYL; Lewandowski, AJ; Ohuma, EO; Upton, R; Packham, A; Kenworthy, Y; Roseman, F; Norris, T; Molloholli, M; Wanyonyi, S; Papageorghiou, AT; Leeson, P

University of Oxford, Oxford, UK

Introduction 2D ultrasound image quality and automated quantification methods have improved in recent years. Quantification of cardiac dimensions is important to screen and monitor cardiac and extra-cardiac fetal conditions. We assessed feasibility and reproducibility for fetal ventricular measures using 2D echocardiography and compared measures to reports using other modalities.

Methods Fetal hearts were scanned using an apical or basal four-chamber view. Left and right ventricular (LV and RV) mass and end-diastolic volumes (EDV) were measured by manual contouring of endo and epicardium using TomTec Image Arena 4.6 in end-diastole. Intraclass Correlation Coefficients (ICC) were used to estimate intra- and inter-observer agreement. Nomograms were created from smoothed centiles of mass and volume measurements, constructed using fractional polynomials after log-transformation. Results were compared to those from previous studies using other modalities identified from literature review.

Results 294 scans from 146 fetuses were included from 15 + 0 to 41 + 6 weeks of gestation. 7% of scans were unanalysable and intraobserver variability was good (ICC for LV and RV mass 0.97 (0.87–0.99) and 0.99 (0.95–1.0) respectively). There was good agreement with 3D estimates of mass up to 28 weeks of gestation, after which 2D measurements were in better agreement with previous results from neonatal cardiac MRI. There was good agreement with 4D volume estimates for the LV.

Conclusion Current state-of-the-art 2D echocardiography platforms appear to provide accurate, feasible and reproducible ventricular mass and volume measures across a wide range of gestations. In certain circumstances, such as extremes of gestation, 2D ultrasound may be the modality of choice.


Surveillance of pregnant women exposed to Zika virus areas

Spiliopoulos, D; Wooton, G; Economides, DL; Wright, A

Royal Free London NHS Foundation Trust, London, UK

Introduction The aim of this study was to assess prenatally the fetuses of pregnant women exposed to Zika virus (ZIKV) areas for microcephaly, intracranial and other abnormalities and monitor their head circumference size at birth.

Methods All pregnant women (symptomatic or not) that reported history of travel to Zika affected areas during their pregnancy were referred to the Fetal Medicine Unit at Royal Free Hospital for surveillance. They had serial growth scans every 4 weeks from the date of first referral for assessment, to assess head circumference (HC) measurement and evaluate fetal brain and limb anatomy. Blood samples were taken for ZIKV only in those symptomatic. Postnatally, the HC of the babies was measured to identify those with possible microcephaly. A total of 49 pregnant women were included in the study. 23 women are still pregnant and the fetuses have not been assessed postnatally yet.

Results The final number of women assessed was 22 (four miscarriages). The most common travel destination was Mexico (33.3%, 7 women). Three women were symptomatic. Only one woman tested positive for ZIKV infection. Only one fetus presented with microcephaly prenatally but was negative for ZIKV IgM. Four newborns had a HC below the 5th centile at birth.

Conclusion We have identified only one positive ZIKV case and no fetal abnormalities have been identified postnatally in those women that delivered. The four newborns that were born with HC measurements below the 5th centile appear to be healthy postnatally.


Improving the antenatal detection of fetal growth restriction: An audit of missed opportunities

Morgan, L1; Cartmill, J2

1Ulster Hospital, Belfast, UK; 2Altnagelvin Hospital, Londonderry, UK

Introduction Despite falling to 4.7 per 1000 total births in 2013, the stillbirth rates in the UK are amongst the highest in developed countries. The NHS has made it a priority to reduce stillbirth rates and has developed ‘Saving Babies’ Lives’: a care bundle of four elements designed to reduce stillbirth and early neonatal deaths.

Growth restricted babies are the single largest preventable group, however, most cases of fetal growth restriction (FGR) are late onset for which no early screening tests are available. Antenatal detection of FGR significantly reduces risk as it prompts further investigation, fetal surveillance and timely delivery.

Standards One of the intervetions recommended in ‘Saving babies' lives’ is to conduct case-note audit of selected cases of FGR that were not detected antenatally, to identify learning and improve future detection.

Methods A retrospective casenote analysis of a sample of 10 cases where FGR was undetected prior to delivery was undertaken using the ‘Saving Babies Lives’ audit tool, and the results presented at a multidisciplinary departmental meeting. The audit was subsequently repeated.

Key themes Three main problems were identified in both audits:

1 Failure to identify antenatal risk factors for FGR

2 Inaccurate symphysiofundal height (SFH) plotting

3 Inaccurate measurement and plotting of ultrasound estimated fetal weight.

Strategies for improvement We plan to implement three quality improvement initiatives to improve antenatal detection of FGR:

1 Antenatal risk assessment – Introduction of the ‘Saving Babies Lives’ algorithm.

2 Online GAP training package.

3 Ultrasound skills training simulator.


Renal vein thrombosis: A cryptic cause of stillbirth autopsy cases from 2010–2015 selected to illustrate the spectrum of disease

Kelehan, P

National Maternity Hospital, Dublin, Ireland

Introduction To demonstrate that renal vein thrombosis is a not uncommon finding at autopsy examination of late intra uterine foetal death.

It may be overt, with haemorrhagic infarction and propagation of thrombus into the vena cava or may not be found on careful gross examination but be clearly identified on microscopic histological examination. It is associated with chorionic vein and chorionic artery thrombosis. It is a cause of thromboembolism to the foetal circulation and with chorionic vessel thrombosis can be associated with cerebral infarction and occlusive limb ischaemia.

Results Four of the infants were stillborn with varying degrees of maceration, one was an early neonatal death. Two babies had external manifestations of thromboembolism: One had gangrene of the right forearm, another (the neonate) of the head and face. Two babies had bilateral thrombosis with hemorrhagic infarction of one kidney. Three had histological evidence of disease only, not seen on gross examination. Four had chorionic artery thrombosis and three vein thrombosis identified on histological examination of the placenta.

Conclusions A hypercoagulable state is a disease association of mother and fetus. In the foetal circulation, polycythaemia and vascular stasis associated with IUGR, maternal diabetes or chromosomal aneuploidy, can predispose to thrombosis within the foetal and placental compartments. Foetal death, perinatal stroke or cerebral palsy may be the result. The pathophysiology of renal vein thrombosis is complex and may present at different stages. Fibrinolysis is the mechanism of resolution, detachment of thrombus, the origin of thromboembolism. Postmortem lysis may also obscure the embolic event.


The Peninsula Pre/Perinatal Twins Research Bank (PTRB): Facilitating research into epigenetic and transcriptional variation in twins

Knight, B1; Taylor, MT2; Mill, J3

1NIHR Exeter Clinical Research Facility, Exeter, UK; 2Royal Devon and Exeter NHS Foundation Trust, Exeter, UK; 3University of Exeter Medical School, Exeter, UK

Introduction Monozygous twins share a common DNA sequence but are often discordant for disease. They are ideal for studying the potential role of the intrauterine environment in development, and its influence on genomic variation. The Peninsula Pre/Perinatal Twins Research Bank (PTRB) was set up to provide a secure, ethically approved infra-structure to collect and store biological samples from Twin pregnancies to enable genomic research.

We aim to test the potential of the Peninsula Pre/Perinatal Twins Research Bank (PTRB) to facilitate studies on the role and consequences of (epi)genomic variation arising during fetal development from a variety of tissues.

Methods Women with planned LSCS delivery for twin pregnancies were recruited at pre-op visit. Blood samples were obtained from both parents for DNA analysis and serum/plasma storage. Cord/placenta tissue and cord blood for DNA extraction was obtained from each twin at delivery. Additional meconium samples/buccal swabs/heel prick blood spots were obtained during routine post-natal care and stored. Associated routinely collected obstetric data was recorded.

Results 20/21 (95%) women and 18/20 (90%) fathers were recruited and provided blood samples over a 12 month period. Post-delivery twin tissue for genomic analysis was obtained from all 40 twins.

Conclusion This inaugural project enabled assessment of the PTRB infrastructure and feasibility of recruitment and sample collection during routine clinical care. We established an initial cohort of twin pregnancies specifically designed for molecular epidemiology. This together with our ability to store and manage samples/data transferred from other relevant projects will allow us to facilitate future epigenetic study.


A hemizygous mutation in FOXP3 gene (responsible for IPEX syndrome) resulting in recurrent X-linked fetal hydrops – a case report

Ho, A1; Ellard, S1; Yau, M1; Irving, M1; Jansson, M1; Hoyle, J1; Ahn, JW1; Yan, S1; Holder-Espinasse, M1; Pasupathy, D1,2

1Guy's and St Thomas’ NHS Foundation Trust, London, UK; 2Women's Health Academic Centre, King's College London, London, UK

Background Fetal hydrops carries a wide differential of underlying pathology with a reported 18% of unknown origin, leaving a guarded prognosis for future pregnancies. IPEX (immune dysregulation, polyendocrinopathy, enteropathy, X-linked) syndrome is a monogenic primary immunodeficiency syndrome of X-linked recessive inheritance due to FOXP3 gene mutations resulting in diabetes, hypothyroidism, diarrhoea and dermatitis with neonatal and childhood mortality. We present a rare cause of fetal hydrops in the context of IPEX syndrome.

Case A 28-year-old in her first pregnancy underwent a 20 + 6/40 anomaly ultrasound revealing fetal hydrops and an increased MCA peak systolic velocity. Fetal blood sampling confirmed anaemia, however demise occurred following an intra-uterine transfusion. Routine postmortem, array CGH, infection and antibody screening were normal.

In her second pregnancy with a different partner, serial ultrasounds following dating scan were normal. The 20 + 3/40 anomaly ultrasound detected fetal hydrops with no evidence of fetal anaemia. Invasive testing was declined and the patient opted for medical interruption of pregnancy at 25 + 3/40 due to rapid fetal hydrops progression and poor prognosis.

Linkage analysis showed both male babies had inherited the same maternal X chromosome supporting an X-linked pattern of inheritance. Subsequent whole exome sequencing demonstrated a hemizygous mutation within the FOXP3 gene in the patient and both babies.

Conclusion In the context of male fetal hydrops, FOXP3 gene mutations are a differential for currently ‘unexplained’ cases. Counselling regarding this X-linked inheritance pattern involves strategies such as fetal sexing on maternal blood, invasive testing, pre implantation genetic diagnosis and free fetal DNA testing in future pregnancies.


Spina bifida: Our experience over 15 years in the Royal London Hospital

Vaikousi, E1; Spaan, J1; Aquilina, J1; Gupta, M2

1Royal London Hospital, London, UK; 2Whipps Cross Hospital, London, UK

Introduction Spina bifida remains the commonest neural tube defect (NTD), with prevalence in the United Kingdom of 0.2 per 1000 live births. Folic acid has reduced incidence significantly, but its multifactorial nature means that it still occurs; it may persist in a folate-replete population.

Methods We present our experience of 53 cases of spina bifida diagnosed antenatally in our hospital over the last 15 years. We examined ultrasound and MRI reports as well as records of post-repair complications and long term disability. Of the 53 couples, 20 decided to continue with the pregnancy. MRI was requested in 11/20.

Results Nineteen babies were born alive, with 1 neonatal death due to extreme prematurity. Two were stillbirth due to additional congenital defects, 3 had late miscarriages and the rest underwent termination of pregnancy.

MRI was implemented since 2010 (in 11/20 cases) and its findings agreed with level of defect and severity of ventriculomegaly on ultrasound. MRI also detected additional defects including talipes, agenesis of corpus callosum and absence of cerebellum.

5/18 live babies had defects not detected prenatally, including two with imperforate anus and one with exomphalos.

All had surgical repair and shunt for hydrocephalus postnatally. Recorded long-term follow-up showed ongoing problems in 8, including bladder and lower limb sensory and motor dysfunction.

Conclusion In our experience ultrasound proved accurate in diagnosis of the level of defect but the introduction of MRI in the investigative work-up proved a useful adjunct in terms of prognostic assessment of the lesions.


Closing the gap between process-driven medicine and patient-driven medicine

Wilkins, S1; Fairclough, S1; Cunningham, S2

1Keele University Medical School, Keele, UK; 2University Hospitals of North Midlands, North Midlands, UK

Moving the NHS to a more patient-centred care is one of the targets of the NHS Five Year Plan. Engaging and empowering patients to improve their experience and outcomes was emphasised in the Berwick response to the Francis report into Mid-Staffs as a way of balancing the compassionate and technical aspects of care. Providing detailed patient information can be challenging, however we sought to empower patients with fetal medicine concerns by involving them in this process. Information for patients by patients giving them a stronger role in their own health experiences. We created information leaflets focused on frequently asked questions relevant to conditions and published these alongside patient experience videos discussing how they managed the practicalities and stress throughout pregnancy and after. This has been done with the aim of using multiple media to close the information gap and provide advice for patients in different modalities. We audited the information in the video by using feedback forms given to relevant patients to confirm if they adequately addressed their concerns. Empowering patients with knowledge about their own medical conditions, allowing them to be more involved in their own care is seen as a cornerstone of patient centred care and been shown to improve outcomes. The use of hospital websites can be a key area to demonstrate patient engagement. It is important to embrace this change in culture and engage with patients in ways they would best respond to, such as information leaflets, online videos and potentially the possibility of mobile apps.


Predictors of good outcome in cystic hygroma

Schaler, L; Doddy, F; Wallis, L; Kennelly, M; Lynch, C; Martin, A; Regan, C; Daly, S

Coombe Women and Infants University Hospital, Dublin, Ireland

The objective of this study was to predict factors associated with good outcome among cases of Cystic Hygroma (CH).

This was a prospective cohort study of all cases diagnosed from July 2014 to July 2016.

There were 59 cases of CH examined giving an incidence of approximately 1:288. There were 46 karyotypes obtained mostly by CVS (76%). The karyotype was Trisomy 21 in 19 cases (41%), 45X in 5 cases (10.8%), Trisomy 18 in 5 cases (10.8%), Trisomy 13 in 4 cases (8.8%), Triploidy in 1 case and normal in 12 cases (26%). The outcomes were termination of pregnancy in 28 cases (47%), IUD 11 cases (18.6%), early pregnancy loss 3 (5%) and one NND. There were 5 cases of a normal baby being delivered (8.4%) and there are 7 cases ongoing of which 5 are presumed normal with one Trisomy 21 and one hypoplastic right heart syndrome. An evaluation of the diagnostic scan revealed a CH confined to the head and neck in 16 cases (27%). The mean transverse measurement was 6.29 SD (4.0) mm. The mean value for the transverse measurement in the normal group was 4.0 mm SD (1.6), compared to a mean value of 6.29 mm in the overall population P < 0.0001. Using a normal outcome as the dependent variable the extent of the cystic hygroma was more important than the transverse measurement (P = 0.02).

Overall the outcomes for CH in our population were similar to published reports. We identified the extent of the CH as an additional outcome variable.


Congenital solitary functioning kidney, hypertrophy or hyperplasia? A fetal ultrasound study

Snoek, R1; de Heus, R1; de Mooij, KL2; Pistorius, LR3,4; Bekker, MN1; de Jong, TPVM1,5

1Obstetrics, University Utrecht Medical Center, Utrecht, The Netherlands; 2Pediatric Urology, University Utrecht Medical Center, Utrecht, The Netherlands; 3Obstetrics, Tygerberg Hospital, Capetown, South Africa; 4Obstetrics, Stellenbosch University, Stellenbosch, South Africa; 5Pediatric Urology, Academic Medical Center, Amsterdam, The Netherlands

Introduction Congenital solitary functioning kidney (CSFK) is due to unilateral renal agenesis and multicystic dysplastic kidney. The ‘hyperfiltration hypothesis’ states that the theoretical 50% loss of nephrons leads to hyperfiltration, with subsequent nephron hypertrophy and risk of renal injury. However, animal studies report signs of hyperplasia (increase in the actual number of functioning nephrons) and an increase in the number of renal papilla. We aim to assess renal papilla number (RPN) with fetal ultrasound (US) to assess the role of hyperplasia in CSFK.

Methods A case-control study was performed on two and three dimensional fetal US images of fetuses with CSFK and fetuses with two healthy kidneys. ‘Renal papilla’ was defined as a hyperechogenic focus near the renal pelvis. All imaging was assessed twice by two independent observers.

Results Sixty CSFK fetuses and 60 controls were included. Mean RPN is higher (P < 0.001) in CSFK (8.00 ± 1.14) than in controls (6.05 ± 1.23). RPN increases (P > 0.001–0.001) with 0.11 and 0.09 papillae per gestational week in cases and controls respectively. This does not differ between groups (P = 0.48). Conventional and three dimensional US are comparable (P = 0.39) and moderately reliable in assessing RPN, with 0.90 (95% CI 0.85–0.94) and 0.68 (95% CI 0.44–0.81) interclass correlation coefficients in intra- and inter-observer measurements respectively.

Conclusion We pose that the higher RPN in CSFK supports our hypothesis of nephron hyperplasia and not (only) hyperfiltration resulting in hypertrophy, challenging the hyperfiltration hypothesis. RPN might serve as a predictor for risk of developing renal injury, as a higher nephron number would lower risks of renal injury.


Arabin pessary for the prevention of preterm birth in twin pregnancies: A systematic review and meta-analysis

Mackie, FL1,2; Hodgetts, VA1,2; Norman, JE3; Morris, RK1,2; Kilby, MD1,2

1Centre for Women's and Newborn's Health, University of Birmingham, Birmingham, UK; 2West Midlands Fetal Medicine Centre, Birmingham, UK; 3MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK

Introduction Twin pregnancies are high-risk for preterm birth (PTB) which is associated with neonatal death and long-term health problems with substantial financial consequences. At present there is no effective intervention to prevent PTB in twins and approximately 12% deliver before 32 weeks of gestation. The PTB rate increases to 40% in pregnancies complicated by TTTS.

We aim to assess efficacy of Arabin pessary (AP) in PTB prevention in uncomplicated, and complicated twin pregnancies.

Methods Electronic searches up to July 2016 using MeSH terms and keywords for ‘preterm birth’ ‘twin’ ‘pessary’ ‘cervical’ ‘cerclage’ to ensure maximum inclusion. Data were extracted to compare the AP with control.

Results The systematic search revealed 2539 papers of which 8 studies were included which equated to 2522 pregnancies. In uncomplicated twin pregnancies, irrespective of cervical length (CL) at AP insertion, there was a significant decrease in the PTB rate <34 weeks in the AP group versus control (OR 0.66 [95% CI 0.50, 0.87], I2 = 91%, 4 studies, 1475 pregnancies). No difference was seen in PTB at <28 weeks or <37 weeks. In uncomplicated twin pregnancies with a CL ≤38 mm, there was a significant decrease in the AP group PTB rate at <28 weeks (OR 0.50 [95% CI 0.26, 0.99], I= 52%, 3 studies, 381 pregnancies), <34 weeks (OR 0.48 [95% CI 0.33, 0.69], I= 90%, 4 studies, 512 pregnancies), <37 weeks (OR 0.61 [95% CI 0.40, 0.92], I2 = 54%, 4 studies, 461 pregnancies). Only 1 study evaluated the AP in TTTS pregnancies.

Conclusion High heterogeneity is a significant problem in this review, therefore a large RCT is required to assess AP in uncomplicated twin pregnancies, and TTTS pregnancies.


Pre-test counselling – an essential part of antenatal screening for fetal aneuploidy in an era of expanded testing choices

Malone, C1; Tully, E1,2; McSweeney, L1,2; Malone, F1,2

1Royal College of Surgeons in Ireland, Dublin, Ireland; 2Rotunda Hospital Dublin, Dublin, Ireland

Introduction Pre-test counselling for fetal aneuploidy screening is an essential prerequisite before an informed choice can be made by patients, in particular where increased testing options are available. Our objective was to evaluate the role of pre-test counselling when multiple options for fetal aneuploidy screening exist.

Methods A prospective cohort study of patients opting for fetal aneuploidy screening in the first trimester was performed over 3 months. All patients were questioned regarding motivating factors, preferences for screening, and limiting factors influencing patient choices.

Results A total of 242 patients received detailed pre-test counselling regarding different forms of screening, including FTS (first trimester screening using nuchal translucency with serum markers), Harmony (non-invasive prenatal testing of fetal DNA for aneuploidy) and Panorama (non-invasive prenatal testing of fetal DNA for aneuploidy and DiGeorge). Panorama NIPT was the most popular screening option, with 210 of 242 patients ultimately choosing this option. 56% (23/41) of patients originally scheduled for Harmony NIPT and 45% (5/11) of FTS patients switched to a different screening option following pre-test counselling. Reasons to switch from one test to another include cost of screening, detection rate, range of conditions being tested, wait time for results and gestational age.

Conclusion The vast majority of patients who decided to switch tests (78%) chose Panorama NIPT as the alternative, following pre-test counselling. These changes in patient choices highlight the critical importance of pre-test counselling in fetal aneuploidy screening and emphasise that appropriate resources must be provided for this aspect of the screening process.


Fetal telemedicine pilot – a study of clinical stakeholder acceptance of a tele-ultrasound innovation linking a rural district general hospital with a fetal medicine unit at a major teaching hospital in northern England

Bidmead, E1; Robson, S2; Snaith, V3; Marshall, A1

1University of Cumbria, Carlisle, UK; 2Newcastle University, Newcastle upon Tyne, UK; 3The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK

Introduction The pilot explored delivery of complex obstetric ultrasound services via videoconferencing. A video link enabled a fetal medicine specialist to synchronously examine ultrasound images captured by sonographers at the DGH and to conduct remote consultations with parents. The study was undertaken to understand the barriers and enablers of technology adoption from the perspectives of clinical stakeholders.

Methods Adopted from the Stakeholder Empowered Adoption Model developed by the University of Cumbria, commissioners and managers were involved in determining the evidence needed to assist decision making; semi-structured qualitative interviews were then undertaken with six key clinical stakeholders.

Results The study identified a range of tangible benefits to DGH staff. Sonographers were upskilled; more involved in women's pregnancies; and had better access to specialist support. Consultants felt better supported and less isolated professionally, resulting in improved management of high risk pregnancies. All clinicians recognised benefits for women of convenience and continuity of care. Potential barriers included: engagement of DGH executive/management; establishing the video-link; interruption of routine practise. Most challenges were overcome within the pilot

Conclusion Fetal ultrasound via telemedicine has enhanced maternity provision at the DGH. Whilst staff acceptance is an identified barrier to adoption of telehealth, tangible benefits are known enablers. In this instance the identification of tangible early benefits for patients and staff influenced staff acceptance.


Case study and review of the literature of selective reduction using radiofrequency interstitial thermal ablation (RITA), in monochorionic monoamniotic (MCMA) twin pregnancies

Sim, P1; Gibson, K2; Ledingham, M2; Gibson, J2

1University of Glasgow, Glasgow, UK; 2Queen Elizabeth University Hospital, Glasgow, UK

Introduction A MCMA twin pregnancy was identified at booking. At 16 weeks of gestation, twin 2 had severe selective intrauterine growth restriction (sIUGR) with reversed end diastolic flow velocity (REDFV). The cords were entangled including around twin 1.

Conservative management was undertaken for 4 weeks during which selective termination was considered by differing methods: RITA or fetoscopic laser cord occlusion and division, but each carried a high risk of adverse outcome. (RITA could have thermally damaged both twins, fetoscopic procedures on a small uterus carries a higher risk of rupture of membranes or loss.) Intra-fetal cord vessel occlusion using RITA was carried out at 20 + 4, and the surviving twin monitored weekly until delivery.

Pregnancy outcome Ultrasound monitoring of the surviving fetus demonstrated normal middle cerebral artery post reduction and normal umbilical artery Doppler velocities for the remainder of the pregnancy. A fetal MRI was carried out at 26 weeks showing a normal expected appearance for this gestation. The surviving twin continued to develop normally with no evidence of cord or limb accidents due to the remaining undivided cord of the reduced twin, and was delivered by section at 32 + 1 weighing 2380 g.

Conclusion In a complex MCMA pregnancy it is possible to perform a selective reduction by various means, which we review in our presentation. We report a case of a successful outcome with simple RITA reduction. By reporting this case we hope to contribute to a very limited literature base regarding MCMA twin pregnancy.


Umbilical artery Doppler assessment at term in healthy nulliparous patients – is it ever necessary? Results from the Multicenter Prospective Genesis Study

Cody, F1,2; Burke, N1; Burke, G3; Breathnach, F1,2; Auliffe, FM4,5; Morrison, J6; Turner, M7,8; Dornan, S9; higgins, J10; Cotter, A3; Geary, M1,2; Daly, S8; Mulcahy, C5; Dicker, P2; Tully, L2; Malone, F1,2

1Rotunda Hospital, Dublin, Ireland; 2Royal College of Surgeons in Ireland, Dublin, Ireland; 3University of Limerick Graduate Entry Medical School, Limerick, Ireland; 4UCD School of Medicine and Medical Science, Dublin, Ireland; 5National Maternity Hospital, Dublin, Ireland; 6National University of Ireland, Galway, Ireland; 7UCD Centre for Human Reproduction, Dublin, Ireland; 8Coombe Women and Infants University Hospital, Dublin, Ireland; 9Royal Jubilee Maternity Hospital, Belfast, Ireland; 10Cork University Maternity Hospital, Cork, Ireland

Introduction The GENESIS study investigated a range of clinical, demographic and fetal ultrasound parameters in the development of a risk evaluation tool for Caesarean Delivery (CD) in nulliparous women at term. We evaluated the role of examining umbilical artery Doppler (UA Doppler) and whether there is a correlation with non-reassuring fetal testing and mode of delivery in healthy nulliparous patients?

Methods The Genesis Study was a prospective multi-center, blinded observational study in which a total of 2336 women with a vertex presentation, were recruited across seven obstetric units in Ireland. Participants had an ultrasound scan and a clinical evaluation performed between 39+0 and 40+6 weeks of gestation. One centre elected to assess UA Doppler. Women and clinicians were blinded from all the ultrasound details to reduce bias from pre-existing knowledge. Information was disclosed to clinicians when the EFW >5000 g or there was a biophysical profile <8/8. All patients delivered within 10 days of the ultrasound scan. Abnormal UA Doppler was defined as AEDF or UA pulsatility index (PI) >95th centile.

Results The UA Doppler was recorded in 587 patients and no differences were noted in non reassuring fetal testing or mode of delivery when comparing patients whose UAPI >95th centile to those with a UAPI <95th centile. There was 1 case of AEDF in this group and the details were disclosed to the clinicians.

Conclusion In healthy nulliparous patients with appropriately grown fetuses there appears to be no role in evaluating UA Doppler at term.


Cerebroplacental ratio in recurrent reduced fetal movements: Evidence for worsening fetal hypoxemia

Binder, J1,2; Monaghan, C1,3; Thilaganathan, B1; Morales-Rosello, J4; Khalil, A1

1Fetal Medicine Unit, St George's Hospital, London, UK; 2Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria; 3Fetal Medicine Unit, Royal Maternity Hospital, Belfast, UK; 4Servicio de Obstetrica, Hospital Universitario y Politécnico, La Fe, Valencia, Spain

Introduction To investigate the association between reduced fetal movements (RFM) and the fetal cerebroplacental ratio (CPR).

Methods This was a case-control study including singleton pregnancies presenting with RFM at term. The control group consisted of low-risk pregnancies at similar gestation. The fetal biometry, umbilical artery (UA) and middle cerebral artery (MCA), Doppler parameters were recorded. These were converted into centiles and multiples of the median (MoM). Maternal and pregnancy characteristics were obtained from hospital records. Regression analysis was used to identify and adjust for potential confounders.

Results The study included 4500 women presenting with RFM and 1527 low-risk controls. The fetuses in the RFM group showed significantly lower MCA pulsatility index (PI) MoM (median 0.95; IQR 0.84–1.09 versus 0.97; 0.86–1.11, P < 0.001) and CPR MoM (median 0.97; IQR 0.83–1.15 versus 0.99; 0.85–1.16, P = 0.018) when compared to controls. The fetuses in the multiple episodes of RFM demonstrated significantly lower CPR MoM (median 0.90; IQR 0.81–1.12 versus 0.96; 0.84–1.08, P = 0.021) compared to those with a single episode of RFM. Logistic regression analysis demonstrated an independent association of maternal age (OR 0.96, 95% CI 0.93–0.99), non-Caucasian ethnicity (OR 0.72; 95% CI 0.53- 0.97), estimated fetal weight (OR 1.01; CI 1.00–1.02) and CPR MoM (OR 0.24; 95% CI 0.12–0.47) with the risk of recurrent RFM.

Conclusion Pregnancies complicated by recurrent episodes of RFM have significantly decreased CPR MoM and MCA PI MoM when compared to single episodes and controls. This is likely to represent evidence of worsening fetal hypoxaemia in pregnancies presenting with recurrent RFM.


Can a point-of-care haemoglobin device replace complete blood count for fetal blood sampling during intrauterine transfusion?

Monteith, C1; Jadauji, J1; Abu, H1; McHugh, A1; Donnelly, J1; Mooney, C2; Enright, S2; Hayes, N3; Malone, F1

1Department of Obstetrics and Gynaecology, RCSI, Rotunda Hospital, Dublin, Ireland; 2Department of Laboratory Medicine, Rotunda Hospital, Dublin, Ireland; 3Department of Anaesthesia, Rotunda Hospital, Dublin, Ireland

IntroductionOur objective was to prospectively validate a Point-of-Care (POC) haemoglobin device (Hemocue 201 DM system) as an alternative to a laboratory based full blood count (FBC) in the setting of haemoglobin evaluation during cordocentesis and intrauterine fetal transfusion.

Methods This prospective study was performed in a tertiary level maternity hospital. Ten consecutive cases of fetal anaemia attending the hospital for cordocentesis and intrauterine fetal transfusion over a 12 month period were included. At the time of cordocentesis all participants had at least two episodes of dual fetal blood sampling with both a POC Test and a laboratory-based FBC. Statistical analysis was performed via Pearson's test.

Results Ten cordocentesis procedures were performed during the 12 month period yielding a total of 24 paired samples. There was strong correlation between the POC haemoglobin and a FBC haemoglobin with r = 0.988 (95% CI 0.972–0.995) and a P value <0.0001. This study demonstrated a linear fit between both methods of haemoglobin quantification enabling the prediction of the anticipated FBC haemoglobin from FBC haemoglobin via the equation Hemocue Hemoglobin = 4.925 + 0.9287 Laboratory Hemoglobin.

Conclusion Overall there is good agreement between the POC fetal haemoglobin and the FBC fetal haemoglobin. This suggests that the Hemocue 201 DM system is a viable and reproducible alternative form of measurement of fetal haemoglobin, with the important advantage of providing expedited results at the bedside. This ultimately may reduce fetal morbidity associated with cordocentesis and intrauterine transfusion, minimizing the time required to complete the procedure.


Changing trends in prenatal screening: An Irish consumer's experience

Monteith, C1; Donnelly, J1; Tully, E1; Dicker, P2; Malone, F1

1Department of Obstetrics and Gynaecology, RCSI, Dublin, Ireland; 2Department of Epidemiology, RCSI, Dublin, Ireland

Introduction Screening for Down syndrome in Ireland is currently a personally funded opt-in service. First trimester screening (FTS) has been the gold standard method of Down syndrome screening (DSS) for almost 10 years. Non-invasive prenatal testing (NIPT) for DSS was introduced in our unit in May 2014. This advance in technology is accompanied with an increase in cost which we hypothesize has an impact on patient decision making despite the benefits.

Methods A unicentre prospective study spanning 14 months was conducted in a tertiary-referral obstetric hospital. All women attending for a method of DSS were invited to participate in the patient questionnaire.

Results Of 537 women attending for DSS, 300 women completed the questionnaire, patient uptake of 56%. The test of choice was FTS for 13.6% (n = 41), NIPT for 66.3% (n = 199) and not disclosed in 20% (n = 60). Patient demographics attending for trisomy DSS 73% (n = 220) were white Irish; mean age of participants was 36.5 years; 85% (n = 255) of women had a tertiary education; 60% (n = 181) of women classed themselves as religious with 77% (n = 145) predominance Catholic faith. If cost were equivocal 81% (n = 243) would have the same test, 1.3% (n = 4) would opt for the alternative test and 17.7% (n = 53) did not respond.

Conclusion The reasons for attending for DSS were similar in both the FTS and NIPT groups. Contrary to our hypothesis cost was not a major contributor in patient choice. However, the majority of our patients were from a higher socioeconomic group which may have influenced their perception of cost.


Brain metabolism in fetuses at high risk of preterm birth

Story, L; Shennan, A; Rutherford, M

King's College, London, UK

Introduction Up to 10% of births <32 weeks of gestation develop cerebral palsy and 50% have other neurodevelopmental sequelae. Infection/inflammation is implicated in the aetiology of preterm birth (PTB) and in the pathophysiology of associated brain injury. This study aimed to see if alterations in brain development begin prior to delivery using magnetic resonance spectroscopy (MRS), a noninvasive way of assessing the metabolic profile of tissue in vivo.

Methods Six patients at high risk of PTB <32 weeks: preterm rupture of membranes or >50% risk of delivery derived from an algorithm based on cervical length and fetal fibronectin were recruited between 20 and 32 weeks gestation and underwent a fetal MRI on a 1.5T scanner. 24 control cases were used who had undergone an MRS <32 weeks. Conventional images were obtained followed by MRS at an echo time of 136 ms. Spectroscopy data was post-processed using the Jmrui software package to generate NAA:Cho, NAA:Cr and Cho:Cr ratios. ANCOVA statistical analysis was performed using SPSS.

Results Gestational age at MRI for the preterm group was median 25 + 0 (range 20 + 6–31 + 1) and median 27 + 3 (range 21 + 4–31 + 6) for the control group. There was no difference in metabolite ratios between control and preterm groups (NAA:Cho P = 0.83 NAA:Cr P = 0.72 Cho:Cr P = 0.853). All women at high risk of PTB delivered <32 weeks. All control fetuses delivered >37 weeks.

Conclusion Although the process of brain injury may begin antenatally in fetuses at high risk of PTB preliminary data suggests the metabolic profile of the brain is unaltered.


Magnetic resonance imaging assessment of lung volumes in fetuses at high risk of preterm birth

Story, L; Zhang, T; Aljabar, P; Hajnal, J; Shennan, A; Rutherford, M

King's College London, London, UK

Introduction Infants born preterm are at increased risk of pulmonary complications which result in both morbidity and mortality. The exact mechanism of this insult is not fully understood.

Methods Women at high risk of preterm birth 23–32 weeks of gestation (preterm prelabour rupture of membranes or a >50% risk of delivery <32 weeks derived from an algorithm utilising fetal fibronectin and cervical length) were recruited. A control group was obtained from the iFIND study (n = 42). A fetal MRI was performed: 3D MR trunk images were obtained from 6 to 8 motion corrupted T2 MRI stacks using slice-to-volume reconstruction method. Segmentations were estimated using multi-atlas approaches relying on 17 manually delineated lung images. Patient demographics, administration of antenatal steroids and outcome data were recorded. ANCOVA statistical analysis was performed using SPSS.

Results Six women at high risk of preterm birth were recruited. Median gestation at MRI was 25+3 (range 20+4–31+3). All delivered preterm: median gestation 28+6 weeks (range 20+4–31+6). Median gestation at MRI of the control group was 24+0 (range 21–30+5). Lung volumes were substantially and significantly smaller in fetuses that subsequently delivered preterm (P = 0.005), irrespective of whether the membranes had ruptured pre-labour.

Conclusion Fetuses that deliver preterm have a reduction in lung volume, irrespective of pre-labour rupture of membranes. This a novel finding and needs further investigation. Reduced amniotic fluid can result in fetal lung hypoplasia, however, this can also occur secondary to an absence of fetal breathing movements. The latter has previously been reported to occur in fetuses that subsequently deliver preterm.


Managing complicated monochorionic multiple pregnancies in Scotland

Gibson, K; Ledingham, MA; Anderson, L; Gibson, J; Whitelaw, S

The Ian Donald Centre for Fetal Medicine, The Queen Elizabeth University Hospital, Glasgow, UK

Complex monochorionic multiple pregnancies requiring invasive intervention are referred to a single centre for assessment and management in Scotland. From April 2015 to March 2016 twenty-two cases of monochorionic multiple pregnancies required evaluation. There were thirteen cases of twin to twin transfusion syndrome (TTTS)(stage 2–4), five cases of severe selective intrauterine growth restriction, two cases of twin reversed arterial perfusion (TRAP) sequence and two cases of severe fetal anomaly affecting one twin. Nineteen of these cases went on to require invasive interventional fetal therapy.

Ten of the thirteen TTTS cases underwent intervention. Nine had successful fetoscopic laser ablation therapy with a survival of at least one fetus in all cases and 60% achieving survival of both twins. One case was abandoned due to inability to visualise the angio-architecture (previous haemorrhage). The three pregnancies that did not undergo intervention included a termination of pregnancy, a case in spontaneous preterm labour at referral and a pregnancy presenting at 29 weeks of gestation.

Five cases of severe selective growth restriction underwent radiofrequency interstitial thermal ablation (RITA) with survival of the co-twin(s) in all cases. One of these pregnancies included a monochorionic pair within triplets.

RITA was also performed in two TRAP sequence cases and two cases of discordant fetal anomaly. All pregnancies resulted in a live birth but one suffered early neonatal demise due to extreme prematurity.

These data demonstrate the incidence, management and outcomes of complicated monochorionic multiple pregnancies in a specialist national centre over a 12 month period.


Fetal intrapericardial teratoma requiring in-utero pericardiocentesis

Gibson, K; Ledingham, MA; Hunter, L

The Ian Donald Centre for Fetal Medicine, The Queen Elizabeth University Hospital, Glasgow, UK

Fetal intrapericaridal teratomas are rare and often lethal in-utero secondary to cardiac tamponade or hydrops. The optimal management of this condition is yet to be established.

We review the literature on fetal intrapericadial teratomas and report a case of a large fetal intrapericardial teratoma diagnosed on ultrasound scan and its subsequent management.

A pericardial mass was identified on routine fetal anomaly scan at 20 weeks gestation and referred into a tertiary fetal medicine centre for evaluation where an intrapericardial teratoma was diagnosed. The fetus underwent serial ultrasound assessments and subsequently developed non-immune hydrops, large pericardial effusion and superior vena cava compression. Management included needle pericardiocentesis at 24 + 1 weeks of gestation in order to optimise survival chances to a gestation where neonatal surgical intervention would be feasible. However, despite successful drainage of 23 ml of pericardial fluid, fetal hydrops persisted with development of ascites. Intrauterine death was diagnosed at 25 + 6 weeks.

Our literature review considers the use of serial pericardiocentesis, thoracoamniotic shunts, ex utero intrapartum delivery with surgical resection under placental support and open fetal surgery as alternative management options for fetal intrapericardial teratomas.


Fetal haemangioendothelioma presenting at 27 weeks: Antenatal, postnatal effects and outcome

Hale, J1; Stedman, F2; Parasuraman, R1; Jones, C2; Keys, C2; Davenport, M3; Howe, D1

1Wessex Fetal Medicine Unit, Princess Anne Hospital, Southampton, UK; 2Department of Paediatric Surgery, University Hospitals Southampton, Southampton, UK; 3Department of Paediatric Surgery, King's College Hospital London, London, UK

Case A primigravid presented with reduced fetal movements at 27 + 2 weeks. Ultrasound scan (USS) demonstrated a right sided intra-abdominal mass in the fetus measuring 9 × 6 × 6 cm. There was moderate pleural effusion and middle cerebral artery peak systolic velocity (MCA-PSV) was above 1.5MoMs, suggesting fetal anaemia. An intrauterine transfusion of 60mls of red cells was performed (fetal haemoglobin 3.1 g/dl).

Two days later, MCA-PSV remained high, suggesting further bleeding and thrombocytopenia, with scalp oedema and reduced fetal movements. Further transfusion was thought unlikely to be beneficial and delivery was performed by caesarean section.

The baby was delivered with no respiratory effort or heart rate. Clamping of the cord was delayed in view of the anaemia and he was intubated at 2 minutes of life. Packed red cells and platelets were transfused. Ventilation was difficult due to the mass and emergency laparotomy revealed a non-resectable mass in the right lobe of the liver. Abdominal tension was reduced by closing with a goretex patch and ventilation immediately improved.

The baby required intensive care and multiple transfusions of blood and platelets. Initial MRI scan was inconclusive but a subsequent USS identified a large vessel feeding the mass, consistent with haemangioendothelioma, confirmed by later CT. At 37 weeks he underwent hepatic artery ligation as the mass remained unresectable. Non-invasive ventilation was weaned and breast feeding was established. He was discharged home 44 + 3 weeks of gestation.

Conclusion Liver tumours presenting antenatally are extremely rare. This is the first report of survival of an extremely preterm neonate with hepatic haemangioendothelioma.


A retrospective study examining the outcomes from antenatal trisomy screening in 46 twin pregnancies in a UK teaching hospital

Ewington, L1; Fern, E2; Vanes, N1; Mukherjee, S1

1University Hospital Coventry and Warwickshire, Coventry, UK; 2University of Warwick, Coventry, UK

Introduction The risk of chromosomal abnormalities is higher in multiple pregnancies than singletons. Therefore the National Institute for Health and Care Excellence (NICE) recommends that all twin pregnancies undergo the combined screening test. The aim of this study was to review our screening uptake and results.

Methods A retrospective analysis was undertaken of 46 twin pregnancies from a twin antenatal clinic at University Hospital Coventry and Warwickshire (UHCW).

Results There were 13 monochorionic diamniotic (MCDA) twin and 33 dichorionic diamniotic (DCDA) twin pairs, average maternal age was 31 (19–47). 10 women declined trisomy screening. 1 woman underwent non-invasive prenatal testing (NIPT) which was low risk. Of the remaining 35 pregnancies only one results was characterised as high risk. This was a DCDA pregnancy in which the risk for twin 1 was 1 in 232 and twin 2 was 1 in less than 5. This patient went on to have amniocentesis, confirming trisomy 21 and subsequent selective reduction of twin 2. Another fetal abnormality was identified at 15 weeks of gestation in which twin 1 had a left sided arachnoid cyst. The pregnancy is still ongoing. The average PAPP-A was 2.28 (0.89–6.41) MoMs.

Conclusion Studies have shown approximately 3% of DCDA pregnancies are screen positive for trisomy 21 and this is in accordance with the data collected at UHCW. In the literature approximately 3% of MCDA twin pregnancies are screen positive, this study had no MCDA screen positive results but did have low MCDA twin numbers.


Safety and acceptability of surgical termination of pregnancy for fetal anomaly within an independent sector termination of pregnancy service

Callaby, H1; Lohr, P2; Fisher, J3

1Ninewells Hospital, Dundee, UK; 2BPAS, London, UK; 3ARC, London, UK

Introduction To describe the safety and acceptability of surgical termination of pregnancy for fetal anomaly (TOPFA) within an independent sector termination of pregnancy service in Britain.

Methods Non-identifiable demographic, treatment, and complications data for women undergoing TOPFA at British Pregnancy Advisory Service (BPAS) between 1 Jan 2015 and 31 Mar 2016 were extracted from existing databases. Anonymous feedback was obtained using a structured questionnaire. Descriptive data were generated using Excel.

Results In total, 389 women were treated along a specialised care pathway within routine surgical termination of pregnancy lists. Average age was 38 years (range 17–48), 61% were parous; 20% had a prior termination of pregnancy, 31% a prior miscarriage or ectopic. Median gestational age was 14 weeks + 6 days (range 10 + 2–23 + 5). Indications for TOPFA were diagnosed chromosomal/genetic anomaly (64%), structural anomaly (31%), suspected chromosomal and/or structural anomaly (4%), and not recorded (1%). Time from referral to treatment averaged 6 days (range 1–22). TOPFA method was vacuum aspiration (42%) or dilation and evacuation (58%); 92% under general anaesthesia. No complications were reported. Feedback was obtained from 173 women and 122 partners; response rates varied by question. Women indicated care received during treatment was sensitive (100%), supportive (100%), knowledgeable (99%), and helpful (100%). Most (92%) reported their partner was included the right amount during treatment; 98% of partners felt included the right amount. All respondents were likely or very likely to recommend BPAS to someone needing similar care.

Conclusion A cross-sector approach to TOPFA service delivery can safely and satisfactorily increase choice of termination methods available to women.


Is prenatal appearance of the atrial septum predictive of the need for atrial septostomy in transposition of great arteries?

Vanherwijnen, I1; Stocker, L1,2; Black, D1; Parasuraman, R1; Howe, D1

1Universtity Hospitals Southampton, NHS Foundation Trust, Southampton, UK; 2University of Southampton, Southampton, UK

Introduction To ascertain whether prenatal mobility of the atrial septum in babies with transposition of the great arteries (TGA) is associated with need for emergency atrial septostomy.

Methods An eight-year retrospective cohort of pregnancies with prenatally diagnosed TGA from the Wessex Fetal Medicine unit. The appearance of the atrial septum during third trimester echocardiography was classified as normal or redundant: bulging >50% of the way across to the left atrial free wall, flat: the angle between the septum primum and the rest of the septum <30% and fixed: little movement of septum, as previously described (Wilson et al, Journal of the American Society of Echocardiography 1990). This was correlated with need for emergency septostomy.

Results 33 babies had an antenatal diagnosis of simple TGA. We had complete data in 24 babies. The atrial septum was classified as normal in 50.0% (n = 12). The abnormal septal morphology group (n = 12) was equally distributed between the three categories described.

17 (70.8%) babies had septostomies; 13 (76.4%) within 24 hours of birth. In emergency septostomy subgroup, the septum was normal in 30.7% (n = 4), flat in 30.7% (n = 4), fixed in 23.0% (n = 3) and redundant in 15.3% (n = 2).

Three babies with a fixed (75.0%), two babies with a redundant (50.0%) and all babies with a flat septum required an emergency septostomy.

Conclusion There is a good correlation with an abnormal atrial septum and the need for emergency septostomy in our cohort. However further research into improving the positive predictive value of antenatal assessment is needed.


Should all newborn with antenatal diagnosis of polyhydramnios have nasogasteric tube patency testing after delivery? A service review of approach to diagnose tracheo-oesophageal fistula in neonates born to mothers with polyhydramnios

Singh, N1; Grahame, E1; Broomes, N1; Djemai, H1; Mousa, H2; Mittal, S1; Anzar, S1; Behrsin, J1

1Neonatal Service, University Hospitals of Leicester NHS Trust, Leicester, UK; 2Fetal Medicine Service, University Hospitals of Leicester NHS Trust, Leicester, UK

Introduction To evaluate if a policy of passage of Nasogastric tube (NGT) in infants born with antenatal diagnosis of polyhydramnios has improved the detection rate of tracheo-oesophageal fistula ± oesophageal atresia (TOF ± OA).

Methods In this retrospective study we identified all cases of antenatally diagnosed polyhydramnios between January 2009 – December 2014. As per policy, NGT patency test should have been performed after delivery in all cases. We identified the infants operated on for TOF ± OA from computerised discharge summary and theatre operating list. For the purpose of the study we have only included cases which had maternity scans and delivered in our tertiary centre.

Results Out of 551 antenatal polyhydramnios, 427 (77%) infants underwent NGT patency test. NGT was passed successfully in (425/427) 99.5% infants. In 2/427 (0.5%), it was unsuccessful and false positive. Out of 59 operated cases of TOF ± OA, 41 infants were excluded due to external referral and lack of access to maternity data. Out of 18 included, 7 (39%) had polyhydramnios on antenatal scan. The NGT patency test was false negative in 2/18 (11%). Ultrasound features of small or absent stomach correctly predicted TOF ± OA in 5/18 (27%). All undiagnosed cases were identified within 8 hours of delivery.

Conclusion We propose that NGT patency test adds very little value in the identifying TOF ± OA. Careful assessment of the fetus and size of stomach were helpful in identifying 5/18 (27%) cases of TOF ± OA. We have modified our departmental guidelines to reflect this. Larger studies are required to assess the current observation.


Abnormal placental cord insertion and risk of adverse pregnancy outcomes: A systematic review and meta-analysis

Ismail, KI1; Hannigan, A1; O'Donoghue, K2; Cotter, A1

1Graduate Entry Medical School, University of Limerick, Limerick, Ireland; 2Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland

Introduction Abnormal placental cord insertions (PCI) including velamentous cord insertion (VCI) and marginal cord insertion (MCI) have been associated with adverse pregnancy outcomes including small-for-gestational-age (SGA) infants. We systematically reviewed and meta-analysed studies of abnormal PCI and the associated adverse outcomes.

Methods Embase, Medline, CINAHL, Scopus, Web of Science and Cochrane Databases were searched in September 2016 (from inception to September 2016). Potentially eligible studies were reviewed by two authors independently. The quality of included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Summary risk ratios with 95% confidence intervals were calculated.

Results Meta-analysis of two studies showed a statistically significant increased risk of SGA infants with VCI (pooled RR, 2.38; 95% CI, 2.25–2.52, P < 0.00001) and MCI (pooled RR, 1.63; 95% CI, 1.57–1.69, P < 0.00001) compared to normal PCI. Four studies were meta-analysed for the outcome emergency caesarean section (CS) and showed a statistically significant increased risk with VCI (pooled RR, 2.86; 95% CI, 1.56–5.22, P = 0.0006) and MCI (pooled RR, 1.39; 95% CI, 1.35–1.44, P < 0.00001). MCI and VCI were combined as abnormal PCI, showing similar findings. Meta-analysis of two and four studies respectively, showed a statistically significant increased risk of SGA (pooled RR, 1.78; 95% CI, 1.72–1.83, P < 0.00001) and emergency CS (pooled RR, 1.48; 95% CI, 1.44–1.52, P < 0.00001) for abnormal PCI compared to normal PCI with no evidence of significant heterogeneity (I2 < 50%, P > 0.05).

Conclusion The available evidence suggests an association between abnormal PCI and adverse pregnancy outcomes, with VCI having higher risk compared to MCI.


Placental and umbilical cord morphometry of pregnancies with small-for-gestational-age infants

Ismail, KI1; Hannigan, A1; Fitzgerald, B2; Kelehan, P3; O'Donoghue, K4; Cotter, A1

1Graduate Entry Medical School, University of Limerick, Limerick, Ireland; 2Department of Pathology, Cork University Hospital, Cork, Ireland; 3Department of Pathology, National Maternity Hospital, Dublin, Ireland; 4Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland

Multiple factors contribute to infants being small-for-gestational-age (SGA), including placental and umbilical cord (UC) abnormalities. Research focuses on timely antenatal detection of SGA, to reduce associated risks of perinatal mortality and morbidity. We aimed to examine different morphological characteristics of the placenta and UC, focussing on pregnancies with SGA infants.

This prospective cohort study examined 1005 placentas from consecutively-delivered singleton pregnancies in a tertiary centre. Standardised images of each placenta were taken. Measurements on gross examination included placental weight and thickness; umbilical cord length, diameter and handedness. Distance from placental cord insertion site to placental margin, length and breadth of the placenta and placental chorionic surface area were measured digitally using ImageJ software. Birthweight and gestational age were recorded. Classification and regression models were used to identify the best subset of measurements to correctly classify infants as SGA (<10th centile).

Overall, 141 (14%) infants were SGA. A regression model with maternal age, placental weight, surface area and birthweight to placenta weight ratio correctly classified 98% of infants >10th centile and 47% of infants <10th centile. Of the potential antenatal measurements, diameter of UC (placental and fetal ends), and distance from placental cord insertion to placental margin were statistically significant (P < 0.05) predictors after adjusting for maternal age, with smaller diameters and shorter distances associated with increased odds of SGA.

SGA infants can be identified using placental and UC morphometry. Further research on antenatal detection may improve our understanding of the pathophysiology and contribute as predictors for SGA.


Prolapsed patent urachus found at 13 weeks of pregnancy

Stedman, F1; Keys, C1; Henrik, S1; Hale, J2; Parasuraman, R2; Howe, D2

1Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK; 2Wessex Fetal Medicine Unit, Princess Anne Hospital, Southampton, UK

A multigravida was referred after an umbilical cord cyst was seen during her 12 week nuchal translucency scan. Repeat scan at 13 + 1 weeks confirmed presence of an 11 × 12 mm cystic structure at the base of the umbilical cord connecting to the enlarged fetal bladder. The fetus was male and NIPT was negative. At 16 + 1 weeks the cyst had enlarged further with normal liquor and normal kidneys. At 20 weeks of gestation, the bladder remained large but there was no obvious keyhole sign and kidneys remained normal. The cyst was larger than the fetal head at this point. However, at 32 + 6 weeks, the cyst had collapsed. The infant was delivered following induction of labour at 38 + 1 weeks. A red mucosal mass with a visible lumen protruded from an abdominal wall defect, similar to an exomphalos. Clear fluid could be expressed from the lumen. The appearances suggested rupture of the cord cyst with prolapsed bladder mucosa. Cystoscopy revealed a tubular bladder with normal mucosa, and normally sited ureteric orifices. The scope passed into an inflamed region at the dome and then through the lumen at the umbilicus. Following excision of the sac, the prolapsed mucosa was excised and bladder closed in layers. An umbilicus was reconstructed and following excellent postoperative recovery the neonate was discharged home at 6 days with normal bladder function. The final diagnosis was of a prolapsed, persistent urachus with leakage of urine into the umbilical cord causing cystic appearance and resultant failure of closure of the abdominal wall.


Late karyotyping during pregnancy: What should we tell our patients regarding success rate and pregnancy complications?

Shakeel, F; Mousa, T; Cresswell, L

University Hospital of Leicester, Leicester, UK

Introduction To examine the success rate and pregnancy complications among pregnant women who had late karyotyping.

Methods We carried out a retrospective analysis of all pregnant women who had karyotyping after 32 weeks of gestation between 2006 and 2016. Data were collected from the ultrasound, cytogenetic and maternity databases.

Results We reviewed 100 pregnancies that underwent amniocentesis and chorionic villus sampling after 32 weeks during the study time period. The median gestational age was 32 weeks. Overall, 14 CVS and 86 amniocentesis procedures were performed. Indications for invasive testing were single system fetal abnormality in 68% of cases, multisystem fetal abnormalities in 20% of cases, 12% of cases had other indications. Premature rupture of membranes were reported in 3% of cases, preterm labour within two weeks in 14% of cases. There was no case of chorioamnionitis. The FISH results were reported in all 100 cases (100%). Culture failure rate was 0.07%. There was 100% concordance between the FISH and culture results. Fetal karyotype was abnormal in 13 cases (13%).

Conclusion Third-trimester invasive testing is a good option for late karyotyping and should be considered for pregnant women who would like to avoid miscarriage. Patients should be counselled about risk of preterm labour and premature rupture of membranes. We propose that steroid injection for foetal lung maturity should be considered for all cases. Future work will be required to evaluate the success rate of micro-array in this cases.


Antenatal vitamin D supplementation does not affect fetal femur volume: Secondary outcome of a randomised controlled trial

Ioannou, C1; Cavallaro, A1; D'Angelo, S2; Javaid, MK2; Cooper, C2; Harvey, NC2; Papageorghiou, AT1,3

1Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital, Oxford, UK; 2MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; 3Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK

Introduction Observational studies demonstrate a possible effect of maternal vitamin D on fetal bone indices but randomised controlled trials are few.

Methods This is a secondary outcome analysis in a randomised controlled trial of vitamin D supplementation in pregnancy (MAVIDOS trial) whose primary outcome were neonatal bone indices using dual energy x-ray absorptiometry (DXA). Maternal 25(OH) cholecalciferol was measured at 14 and 34 weeks of gestation. Participants with levels between 25 and 100 mmol/l were randomised prior to 17 weeks to either placebo or oral daily cholecalciferol 1000 IU. 3D ultrasound scans were performed at 20 and 34 weeks, where fetal femur volume (FV) was measured according to a previously validated method. Linear regression analysis between 25(OH) cholecalciferol and FV was performed in the study cohort irrespective of trial allocation. FV was compared between the placebo and intervention arms.

Results 367 women had FV data at 34 weeks of gestation. There was no significant correlation between 25(OH) cholecalciferol and FV. 188 women were randomised to placebo and had a mean FV = 4.7 ml; whereas 179 were assigned to daily cholecalciferol and had a mean FV = 4.6 ml (t-test, P = 0.18). There was no difference between the two groups in any of the constituent femoral measurements used to calculate FV.

Conclusion Antenatal supplementation with 1000 IU cholecalciferol daily does not affect FV measurement in late gestation. These findings are consistent with the study's primary DXA outcome results, where a possible effect was demonstrated on bone mineralisation but not on bone size.


Ultrasound markers predicting complex gastroschisis and adverse outcome: A longitudinal prospective nationwide cohort study

Lap, CCMM1; Pistorius, LR2; Mulder, EJ1; Aliasi, M1; Kramer, WL1; Visser, GH1; Manten, GT1; FLAMINGO Working Group2

1University Medical Center Utrecht, Utrecht, The Netherlands; 2University of Stellenbosch, Stellenbosch, South Africa

Introduction The objectives were to identify antenatal ultrasound markers differentiating between complex and simple gastroschisis.

Methods Longitudinal ultrasound examinations at four-weekly intervals were performed in isolated gastroschisis cases. Primary outcome was simple or complex gastroschisis. Biometry, polyhydramnios, intra- and extra-abdominal boweldiameters and the PI of the sma (superior mesenteric artery) were assed. The last measurements before delivery of the intra- and extra-abdominal boweldiameters were used to compare mortality, time to full enteral feeding (TFEF) and length of hospital stay (LOS).

Results Seventy-nine liveborns had simple and 19 had complex gastroschisis. Three intra uterine deaths occurred. There were 2 neonatal deaths in the complex and one in the simple group. TFEF and LOS were significantly longer in the complex group (P < 0.001, and P < 0.001, respectively). There was no correlation between biometry and the sma PI between both groups. In both groups the PI was significantly lower than in controls. Both intra- and extra-abdominal boweldiameter were larger in complex cases and multilevel analysis showed a significant group main effect for both variables (P < 0.001 and P < 0.05, respectively). Identification of complex cases based on boweldiameter, remains, however, difficult. TFEF and LOS were significantly longer in cases with an intra-abdominal diameter >15 mm at the last measurement before birth (P = 0.009 and P = 0.013, respectively).

Conclusion In both simple and complex groups the PI of the intra- and extra-abdominal sma is substantially lower than in controls, but this measurement does not differentiate between both groups. Only the intra-abdominal bowel diameter differentiates between simple and complex cases, although its predictive value is relatively low.


The natural history of prenatally diagnosed fetal aneuploidy: A ten year series of expectantly managed cases in a large tertiary referral centre

Dunne, H1; Flood, K2

1Royal College of Surgeons in Ireland, Dublin, Ireland; 2Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland

Prenatal diagnosis of chromosomal anomaly is associated with a high rate of termination and therefore many details regarding the expected antenatal course of those who chose to continue the pregnancy are relatively unknown. This study analysed the complications and outcomes associated with fetal aneuploidies in a single large tertiary centre. 500 prenatally diagnosed cases were identified between 2005 and 2015 from prospectively collected data in the Fetal Medicine Department, Rotunda Hospital. Chromosomal abnormalities included cases of Trisomy 21 (45.4%), Trisomy 18 (27.6%), Trisomy 13 (8%), Monosomy X (7.4%), Triploidy (3.8%) and others (7.8%). Of the 49.8% (n = 249) who were expectantly managed 59 (11.8%) miscarried, 43 (8.6%) suffered an intrauterine death and 118 (15.4%) achieved a live birth. There was a 38.14% Caesarean section rate with the indications attributed to maternal complications, maternal request and fetal distress (mostly in cases of Trisomy 21). Antenatal complications were recorded in 70 pregnancies, such as gross polyhydramnios (41), pre-eclampsia (5) and preterm prelabour rupture of membranes (3). The mean gestational age at time of delivery was 36 + 4 weeks (ranging from 26 to 42 + 2 weeks) and there were 29 neonatal deaths (24.6% of live births). The information gathered in this study gives insight into the natural history of common prenatally diagnosed aneuploidies and can be used to help guide counselling of patients regarding the prognosis and advise clinicians about the associated complications.


How high is the risk of congenital toxoplasmosis in women with positive IgG and IgM antibodies at the first test in pregnancy?

Donadono, V1; Agangi, A1; Cavallaro, A2; Mazzarelli, LL1; Quaglia, F1; Sarno, L1; Saccone, G1; Sirico, A1; Tagliaferri, S1; Maruotti, GM1; Martinelli, P1

1Department of Neuroscience, Reproductive Sciences, and Dentistry, University of Naples Federico II, Naples, Italy; 2Nuffield Department of Obstetrics and Gynecology and Oxford Maternal and Perinatal Health Institute, University of Oxford, Oxford, UK

Introduction The objectives were to determine incidence of congenital toxoplasmosis (CT) in women with suspect of primary infection in pregnancy, other than seroconversion, with respect to the first IgG avidity result in pregnancy.

Methods This is a retrospective cohort study of women referred to our clinic for suspected toxoplasmosis during pregnancy between January 2000 and December 2012 at the University Federico II of Naples in Italy. Women with documented seroconversion were excluded and only women with positive IgM and IgG at first test in pregnancy were included. All women had a repeated blood test at a reference laboratory for IgG, IgM, and IgG avidity. Specific pharmacological therapy was started as soon as the infection was suspected. Babies were followed for at least one year of age. Incidence of CT was calculated in the groups of women with low, intermediate, and high avidity.

Results Seven hundred thirty women were included in the study. 27.40% (200/730) of women had low avidity, 19.18% (140/730) had intermediate avidity, 53.43% (390/730) had high avidity. CT was detected in only 1% (2/200) of children whose mother had low avidity but none among children whose mother had intermediate or high avidity.

Conclusion Our study showed that incidence of CT in women that at the first test in pregnancy have positive IgM and IgG antibodies is extremely low and accounts for only 1% of cases with low avidity. No case of CT was identified in women with intermediate or high avidity.


Impaired uteroplacental circulation in pregnancies complicated by fetal congenital heart defects

Binder, J1,2; Carta, S1; Thilaganathan, B1; Papageorghiou, A1; Bhide, A1; Khalil, A1

1Fetal Medicine Unit, St George's Hospital, University of London, London, UK; 2Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienns, Vienn, UK

Introduction Recent studies have reported an angiogenic imbalance in the maternal and fetal circulations in pregnancies complicated by fetal congenital heart defects (CHD), suggestive of impaired placentation. The aim of this study was to investigate uterine artery (UtA) and fetal Doppler in these pregnancies.

Methods This was a case-control study including 218 singleton pregnancies with confirmed CHD and 729 normal pregnancies. The UtA mean pulsatility index (PI) was recorded at 20–24 weeks of gestation and the umbilical artery (UA) PI and middle cerebral artery (MCA) PI after 20 weeks of gestation. The head circumference (HC), abdominal circumference (AC) and estimated fetal weight (EFW) values were converted into z scores and centiles, and Doppler parameters into multiples of the median (MoM), adjusting for gestational age.

Results The UtA mean PI z scores were significantly different in the CHD group compared to controls (median −0.67; IQR −1.36 to 0.09 versus −0.98; −1.63 to 0.12, P = 0.009). The UA PI was significantly higher, while the MCA PI was significantly lower, in the CHD group compared to the control group (P < 0.001 for both). The fetal biometry, including HC z scores (median −0.20; IQR −0.82 to 0.36 versus 0.19; −0.35 to 0.64, P < 0.001), AC z scores (median −0.10; IQR −0.91 to 0.47 versus 0.12; −0.31 to 0.61, P < 0.001) and EFW centile (median 21.9; IQR 0.9−53.1 versus 51.3; 28.6–70.1, P < 0.001), were significantly lower in the CHD group compared to controls.

Conclusion CHD is associated with impaired placentation and changes in fetal biometry and Doppler, which are similar to those seen in fetal growth restriction secondary to placental insufficiency.


Outcome of mother and neonates with Rhesus and other blood group antibodies

Experton, L1; Kirkham, C2; Monteith, C2; Holohan, M2; Murphy, D3; Donnelly, JC2

1Royal College of Surgeons in Ireland, Dublin, Ireland; 2Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland; 3Department of Laboratory Medicine, Rotunda Hospital, Dublin, Ireland

Introduction To review the prevalence of clinically significant red blood cell antibodies among a cohort of pregnant women attending a tertiary maternity hospital and to assess their obstetric and neonatal outcomes.

Methods A five year retrospective review of all pregnant women (including miscarriage, hydatidiform moles and ectopic pregnancy) who had an antibody screen in a tertiary referral centre between January 1 2011 and December 31 2015. Haematological, obstetric and neonatal data were identified from hospital databases. Ethical approval was obtained. Statistical analysis was carried out using SPSS v22.

Results The prevalence of clinically significant antibodies among pregnant women screened was 0.53% (279/52 150). Anti-M (n = 77, 22.7%), anti-E (n = 70, 20.6%) and anti-D (n = 60, 17.7%) were the most common. Of the thirty four percent liveborn neonates (79/229) with a positive direct Coombs test (DCT), those associated with anti-D or anti-c had a lower mean gestational age (37.1 and 38.4 weeks) and haemoglobin level (123.8 and 146.2 g/L) at delivery compared to other antibodies. They were also more frequently admitted to the neonatal intensive care unit (22/33, 65% and 7/12, 58%) for phototherapy (23/34, 72% and 6/12, 50%) and exchange transfusion (11/34, 32% and 1/12, 8%).

Conclusion In our population, the frequency of clinically significant antibodies was 1 in 187 pregnancies. As expected, the presence of rhesus (Rh) antibodies D or c was associated with worse perinatal outcomes requiring greater antenatal and postnatal care and treatment. Results support current practices for antibody screening and RhD prophylaxis.


Intrauterine transfusion after single fetal demise in monochorionic twins?

Tedjawirja, VN; van Klink, JM; Haak, MC; Klumper, FJ; Middeldorp, JM; Lopriore, E; Oepkes, D

Leiden University Medical Centre, Leiden, The Netherlands

Introduction Our aim was to evaluate the effectiveness of intrauterine blood transfusion (IUT) to treat anemia in the surviving co-twin after single intrauterine fetal demise (sIUFD) in monochorionic diamniotic (MCDA) twin pregnancies.

Methods A retrospective cohort study of MCDA twins with sIUFD and anemia in the surviving co-twin was conducted. Data was used from the national fetal therapy referral centre, the Leiden University Medical Center between 2005 and 2016. The outcomes of pregnancies treated with IUT were compared to expectantly managed pregnancies.

Results In the study period, 247 pregnancies were seen with sIUFD. In 17 cases the surviving fetus appeared anemic based on middle cerebral artery Doppler examination. IUT was given in 6/17 surviving co-twins. We found no difference in co-twin mortality (3/6 (50%) versus 4/11 (36%)). Neonatal survivors in the IUT group all had normal imaging or an expected normal neurodevelopmental outcome. In the expectantly managed group, 2/7 survivors had severe cerebral injuries and 1 other neonate had non-severe anomalies on imaging.

Conclusion IUT may improve neurodevelopmental outcome in anemic surviving co-twins after sIUFD. International multicentre collaboration is needed to obtain more data and preferably prospectively study this as yet unanswered clinical question.


Spontaneous twin anaemia-polycythaemia sequence (TAPS) in monochorionic diamniotic twin complicated by selective intra-uterine growth restriction: A case report

Dieh, A; Rana, N

The Royal Oldham Hospital, Oldham, UK

Twin to twin transfusion syndrome (TTTS) and Twin Anaemia-Polycythaemia Sequence (TAPS) can complicate monochorionic (MC) twin pregnancies. TAPS is less well-known of the two and is characterized by a marked difference in inter-twin haemoglobin without the discordant in liquor volume as in TTTS.

We present a case of a set of monochorionic diamniotic twins complicated by selective intra-uterine growth restriction (sIUGR) and TAPS. Stage 1 TAPS were suspected at 33-week of gestation during a growth scan when middle cerebral artery MCA) doppler interrogation was performed. The fetuses were delivered by caesarean section at 34-week of gestation after corticosteroids cover. They have significantly discrepant haemoglobin levels at birth with the polycythaemia twin appeared plethoric as expected.

It is unusual for TAPS to occur spontaneously. It is more common after laser ablation for TTTS (1–16%). A review of the literature shows that TAPS can occur spontaneously in 1–5% of MC twins. In most district general maternity units, monochorionic twins are scanned by sonographers who do not perform MCA doppler and current NICE guideline does not include the routine monitoring of MCA doppler. Therefore, TAPS may remain undetected during pregnancy. In cases where it is undetected and untreated, TAPS may lead to intrauterine fetal demise. In this case, increased surveillance was instigated due sIUGR which led to the suspicion of TAPS. Perhaps MCA dopplers should form part of the routine ultrasound assessments in all monochorionic twin pregnancy.


The usefulness of fetal MRI for prenatal evaluation of fetal anomalies

Doherty, E; Wyness, V; Fullerton, G; Crichton, L

Aberdeen Maternity Hospital, Aberdeen, UK

Introduction Evaluation of fetal anomalies by US can be limited. MRI is believed to provide greater accuracy and detail. It's usefulness in prenatal diagnosis was evaluated in this study.

Methods Over a 36 month period August 2012 to August 2016, 47 patients received MRI to evaluate ultrasound diagnoses of fetal anomalies. US diagnoses included CNS anomalies, CDH, lung masses, limb, abdominal and urinary tract anomalies. Gestation at which MRIs were performed ranged from 21 to 35 weeks. Correlation between MRI findings and USS findings and postnatal diagnoses were examined to assess the value of each imaging modality.

Results MRI changed the US diagnosis in 16 cases. 2 of the 5 cases of CDH diagnosed by MRI, the primary US diagnosis was CCAM. MRI refuted the US diagnoses of 5 brain abnormalities and 3 spinal abnormalities detected by ultrasound. MRI confirmed the US diagnosis of all 3 cases of spina bifida but provided more detailed information. MR provided more accurate assessment of urinary tract abnormalities than US. In 8 cases, the MRI was normal where ultrasound was not. MRIs consistent with US diagnoses provided clarity and additional detail.

Conclusion Ultrasound is a cost-effective and safe screening tool however the information can be limited and doubtful. We suggest that fetal MRI is more informative than ultrasonography for the evaluation of suspected fetal anomalies which is particularly useful for prenatal counselling and postnatal treatment planning.


Bonding during termination for fetal anomaly – is the fetus named?

Fullerton, K1; Unger, H2,3; Clegg, I2; Tydeman, G2

1University of Edinburgh Medical School, Edinburgh, UK; 2Department of Obstetrics and Gynaecology, Victoria Hospital Kirkcaldy, Kirkcaldy, UK; 3Department of Medicine, The University of Melbourne, Australia

Many women grieve for a pregnancy terminated for anomaly equivalent to stillbirth.1 As a proxy for how many women made a close emotional connection, we investigated whether the terminated fetus was named and whether this was dependent on maternal history, gestation or type of termination.

In our hospital, 128 pregnancies over six years were terminated using section E of the Abortion Act. Anomaly was suspected because of ultrasound findings (75, 58.6%), an abnormal screening test result (51, 39.8%), or medical history (known carrier) (2, 1.6%). Amniocentesis and CVS were performed for 28 (21.9%) and 19 (14.8%) pregnancies, respectively. Most terminations were medical (115, 89.8%), and five were preceded by feticide.

Nearly half of parents named the fetus (62, 48.4%). There was no significant association of naming with gravidity, parity, or presence of a scan-detectable abnormality (all P > 0.10).

Naming was more likely if termination was medical than surgical (61/115 versus 1/13, P = 0.002) and when diagnosis was by amniocentesis rather than CVS (P < 0.001). Six surgical terminations were following CVS. Named pregnancies were at a more advanced gestational age (median 130 days versus 90 days, P < 0.001). There was no association between naming a pregnancy and interval between suspicion of anomaly and termination.

We believe that this adds useful information for those providing fetal medicine services in terms of the support women may require during the grieving process after termination for abnormality.

1. Maguire M, et al. Grief after second-trimester termination for fetal anomaly: a qualitative study. Contraception 2015;91:234–9.


Case series: Discordant growth in MCDA pregnancies in a District general hospital

Kumar, SA1; Hill, C1; Rich, D2

1Royal Gwent Hospital (ABUHB), Newport, UK; 2Nevill Hall Hospital (ABUHB), Abergevanny, UK

Background We present a case series of 3 monochorionic diamniotic (MCDA) twin pregnancies with discordant growth managed in a secondary care within a dedicated fetal medicine unit.

Case Case 1 – Natural conception MCDA pregnancy. Discordant growth identified at 25 + 4 weeks. Twin 2 – reduced growth, oligohydramnios, increased umbilical artery resistances. Delivery by lower segment caesarean section at 30 + 5 weeks for absent end diastolic flow (EDF) and IUGR of twin 2. Twin 1 – 1198 g Twin 2 – 882 g. Good outcome for both babies. Case 2 – Natural conception MCDA pregnancy. Discordant growth identified at 18 + 5 weeks. Opinion from the team in St Michael's, Bristol confirmed significant growth restriction, oligohydramnios and absent EDF of twin 2 at 20/40 secondary to placental insufficiency. Selective feticide of twin 2 by cord ablation. Twin 1 normal growth. Delivered by LSCS at 36 weeks with steroid cover. Alive and well. Case 3 – IVF MCDA pregnancy. Discordant growth identified at 19 weeks and TTTS confirmed. Laser ablation in Bristol at 19 weeks +5 days. Delivery by caesarean at 34 weeks secondary to fulminating pre-eclampsia. Twin 1 – 1910 g, Twin 2 – 2580 g.

Conclusion Management of complicated MCDA twins in secondary care is possible within the setting of a local fetal medicine unit. However, it is essential that there is close liaison and good communication conduits with a Tertiary team.


Fetal abdominal circumference growth velocity and cerebroplacental ratio as predictors of perinatal outcome in small-for-gestational-age fetuses

Cavallaro, A1,2; Veglia, M3; Svirko, E4; Black, R2; Impey, L2

1Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital, Oxford, UK; 2Oxford Fetal Medicine Unit, Women's Centre, John Radcliffe Hospital, Oxford, UK; 3Department of Obstetrics and Gynaecology, Cristo Re Hospital, Rome, Italy; 4Department of Experimental Psychology, Oxford Group for Children's Potential, University of Oxford, Oxford, UK

Introduction The objective was to investigate the relationship between fetal abdominal circumference (AC) growth velocity and cerebroplacental ratio (CPR) to predict perinatal outcome in small-for-gestational-age (SGA) fetuses.

Methods 150 growth scans on SGA singleton fetuses at 36–38 weeks of gestation were performed. The CPR and the percentage change of the AC centile from the anomaly scan were calculated. A composite perinatal outcome (CPO) was defined as 1+ of: umbilical artery pH <7.10, 5 min Apgar score <7, admission to neonatal intensive care unit, hypoglycaemia, intrapartum fetal distress requiring expedited delivery, and stillbirth. Pearson χ² tests were used to test for associative relationships between AC centile drop ≥40%, CPR <10th centile and CPO. Backwards entry multivariate logistic regression (MLR) was performed to investigate the influence of AC centile drop and CPR on the outcome.

Results An AC centile drop ≥40% (OR = 0.39, P = 0.023; 95% CI 0.17–0.88) and the CPR <10th centile (OR = 0.29, P = 0.002; 95% CI 0.13–0.63) were significant predictors of adverse outcome. AC centile drop and CPR centile were weakly correlated (r = −0.23, P = 0.006), indicating some shared variance. MLR showed that both AC centile drop ≥40% (0.41, P = 0.037; 95% CI 0.18–0.95) and the CPR <10th centile (0.31, P = 0.005; 95% CI 0.14–0.70) were independent predictors of adverse outcome (χ2 = 13.4, P = 0.001), and removing either from the model caused a significant drop in fit.

Conclusion Analysis of both AC growth velocity and CPR could be used to better identify which SGA fetuses that are at increased risk of morbidity. If confirmed with larger numbers intervention could be better targeted.


The ‘dynamic’ cervix – is it simply dynamic or truly incompetent?

Thompson, MO; Opemuyi, I; Coker, A

Barking, Havering and Redbridge University Teaching Hospital, Essex, UK

The rate of preterm birth (PTB), especially iatrogenic has increased in developed countries rather than reduced over time. The evidence suggests that spontaneous PTB rates may be reduced by prophylactic progesterone in women with a history of previous preterm delivery and in those with a short cervical length identified by transvaginal sonography. However avoiding unnecessary medication during pregnancy is also desirable and although a dynamic cervix is reported to increase the risk of PTB, there is insufficient evidence.

A dynamic cervix has been defined as one showing significant sporadic changes in length and appearance during a trans-vaginal ultrasound scan with shortening, funnelling or dilatation. Earlier studies report no changes in uterine contour or myometrial contractions that would indicate rapid increases in intra-uterine pressure as being responsible, therefore cervical weakness was implicated. This has however not been firmly substantiated although this may be expected because cervical remodelling is a dynamic process that involves complex biochemical and anatomical interplays, which ultrasound scanning as a test of competence does not allow for.

We present two illustrative cases. The cases presented instigated a search for an evidence based approach to counselling and subsequent care. We sought to determine whether there is any clinical importance to be attached to dynamic change and therefore determine need for disclosure. The questions posed were; Is the dynamic cervix truly incompetent? What is the associated likelihood ration of spontaneous preterm delivery based on its occurrence? Should prophylactic therapy be instituted? Clinical evidence is currently limited. National guidance is needed.


Case report of a prenatally diagnosed case of copy number loss for chromosome 5 long arm

Gajree, S; Dumplacal, M

Newham University Hospital, London, UK

Introduction A 33-year-old nulliparous lady booked her pregnancy at 12 + 5 weeks. An exomphalos was noted at her dating scan. Her combined screening test indicated a 1:1800 risk of trisomy 21.

Methods She underwent a Fetal Medicine Unit scan at 15 + 1 weeks. This confirmed the presence of an omphalocele containing liver and bowel. She was referred to Great Ormond Street Hospital for a fetal echocardiogram (performed at 17 + 5 weeks) in view of the association with cardiac anomalies. This demonstrated a univentricular heart with single atrioventricular connection. The parents were advised the defect was not correctable. The patient underwent amniocentesis with fluid being sent for PCR and karyotyping. Whilst the PCR was normal, the microarray revealed a copy number loss on the long arm of chromosome 5.

Results The guarded prognosis was discussed with the parents. They opted for medical termination of pregnancy. They declined post mortem examination but did agree for a tissue sample to be sent for cytogenetics and karyotyping of parental blood.

Conclusion A literature search using the terms ‘long arm’ ‘chromosome 5’ and ‘prenatal’ on the EMBASE and Medline databases revealed a number of case reports. These included cases of chromosomal translocations (hydrops fetalis), duplications (IUGR & VSD or short stature and learning disabilities and chracteristic facial profile), interstitial deletions (dysmorphic features, thin limbs, renal abnormalities) and partial deletions (membranous ventricular septal aneurysms). However, we could not find any reported cases of a copy number loss for chromosome 5.


Is fetal Doppler assessment at term related to fetal heart rate short-term variation and adverse pregnancy outcome?

Khalil, A; Morales-Roselló, J; Papageorghiou, A; Bhide, A; Thilaganathan, B

St George's University of London, London, UK

Introduction The aim of this study was to investigate the relation between fetal Doppler, EFW, FHR short-term variation (STV) at Term and adverse pregnancy outcome.

Methods This was a cohort study of singleton pregnancies undergoing ultrasound and computerised FHR monitoring at Term. Ultrasound assessed EFW, and umbilical artery (UA) and MCA Doppler. Regression analysis was performed to identify and adjust for potential confounders.

Results The study included 3745 pregnancies. Fetuses with low cerebroplacental ratio (CPR) MoM were more likely to have low STV (25.6% versus 15.4%; OR 1.89, 95% CI 1.25–2.85; P = 0.002). Even after adjusting for EFW centile, low STV was significantly associated with the MCA PI MoM (adjusted OR 0.29, 95% CI 0.12–0.70; P = 0.006). When pregnancies with SGA fetuses were excluded, MCA PI MoM remained significantly associated with low STV (OR 0.32, 95% CI 0.13–0.76; P = 0.010), while EFW centile was not (P = 0.116). Low CPR MoM was an independent predictor of emergency CS (adjusted OR 1.47, 95% CI 1.01–2.08; P = 0.029), even after adjusting for low STV and SGA. These findings were the same even after excluding pregnancies with an SGA fetus (adjusted OR of low CPR MoM for emergency CS 1.48, 95% CI 1.04–2.17; P = 0.043). Low CPR, SGA and low STV recorded at Term were significantly associated with NNU admission (OR 2.04, 95% CI 1.17–3.57; P = 0.012; OR 4.55, 95% CI 2.06–10.03; P < 0.001; OR 3.08, 95% CI 1.57–6.07; P = 0.001, respectively).

Conclusion Fetal Doppler assessment at Term, regardless of fetal size, is an independent predictor of low STV and the need for emergency CS.


Worsening of the uterine artery Doppler is associated with the development of hypertensive disorders of pregnancy

Binder, J1,2; Monaghan, C1,3; Thilaganathan, B1; Carta, S1; Khalil, A1

1Fetal Medicine Unit, St. George's Hospital, University of London, London, UK; 2Department of Obstetrics and Feto-maternal Medicine, Medical University of Vienna, Vienna, Austria; 3Fetal Medicine Unit, Royal Maternity Hospital, Belfast, UK

Introduction Hypertensive disorders of pregnancy (HDP) are associated with impaired placentation, as evidenced by abnormal uterine artery (UtA) Doppler. UtA mean pulsatility index (PI) shows a progressive decline with gestational age (GA). However, previous studies have reported that a proportion of pregnancies demonstrate worsening of the UtA Doppler. The aim of this study was to investigate the incidence of HDP according to the change in the UtA mean PI between the second and third trimester.

Methods This cohort study included singleton pregnancies undergoing longitudinal UtA Doppler assessment in the second and third trimester. All the parameters were converted into centiles and multiples of the median (MoM) adjusting for GA. The study cohort was divided into 2 groups according to the change in the UtA Doppler between the second and third trimesters (decline or no change versus increase in the mean PI MoM). HDP included women who developed pre-eclampsia and gestational hypertension. Regression analysis was used to adjust for potential confounders.

Results The analysis included 5887 pregnancies. The incidence of HDP was significantly higher in the group with worsening of the UtA mean PI compared to those without (7.9% versus 5.8%; P < 0.002). Logistic regression analysis demonstrated that both the second trimester UtA PI MoM (OR 8.12, 95% CI 5.07–13.00; P < 0.001) and the difference between the 2 trimesters (OR 3.41, 95% CI 2.434–4.768; P < 0.001) were significant independent predictors for the development of HDP.

Conclusion Worsening of the UtA Doppler, independent of the value recorded in the second trimester, is associated with HDP.


Fetal genetics impacts on risk of macrosomia independently of maternal hyperglycaemia

Hughes, AE1; Beaumont, RN1; Knight, BA2,3; Shields, B1; Freathy, RM1; Hattersley, AT1,3

1Institute of Biomedical and Clinical Science, Exeter, UK; 2National Institute for Health Research (NIHR), Exeter, UK; 3Research and Development, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK

Introduction Maternal hyperglycaemia is associated with a higher prevalence of macrosomia, but it is not known how much fetal genetics moderates this and through what mechanisms.

Aim To investigate the extent fetal genetics modifies the relationship between maternal glucose and birthweight and the underlying mechanism.

Methods Subjects from the Exeter Family Study of Childhood Health with maternal fasting plasma glucose (FPG) at 28 weeks of gestation, and fetal DNA from cord blood were studied. A fetal genetic risk score (GRS) for birth weight was calculated using 58 SNPs. The outcomes were corrected birthweight and rates of macrosomia (birthweight >90th centile).

Results Maternal FPG and fetal GRS data were available for 679 maternal-offspring pairs. Both maternal FPG and fetal GRS independently predicted birthweight (P < 0.0001 and P = 0.0001, respectively). Fetal GRS did not correlate with maternal FPG (P = 0.83). In the highest tertile for FPG (>4.76 mmol/L), macrosomia rate was higher in the highest fetal GRS tertile (28.6%) than in the lowest GRS tertile (9.3%), P = 0.003. Maternal FPG was positively correlated with cord insulin levels, whilst fetal GRS was not (P < 0.0001 and P = 0.72, respectively).

Conclusion Maternal FPG is an accurate predictor of birthweight, but fetal genetics has an independent modifying effect on birth weight and hence macrosomia risk. The impact of fetal genetics is mediated through different mechanisms to maternal glucose, as it does not influence fetal insulin levels. Fetal growth reflects both considerable contributions from maternal glycaemia and fetal genetics, thus reducing the accuracy of prediction of macrosomia based solely on maternal glycaemia.


Histological and microbiological findings of placentas in early and late preterm births: A case-control study

Kornete, A1,2; Blazuka, S3; Vedmedovska, N1,4; Sneiders, K2

1Department of Obstetrics and Gynecology, Riga Stradins University, Riga, Latvia; 2Department of Obstetrics and Gynecology, Vidzemes Hospital, Valmiera, Latvia; 3Department of Pathology, Vidzemes Hospital, Valmiera, Latvia; 4Department of Prenatal Diagnostic, Riga Maternity Hospital, Riga, Latvia

Introduction Preterm births occur in approximately 12% of pregnancies worldwide and in 5.6% of pregnancies in Latvia, and the incidence has increased. In almost 30% of cases the clinical cause is not identified. The placenta is a unique and valuable organ in explaining the incomprehensible pathogenesis of prematurity.

Methods The retrospective case-control study was conducted to determine placental histological and microbiological findings according to prematurity. Seventy-two placentas, including 17 of early preterm births (22–27 weeks of gestation) and 55 of late preterm births (28–36 weeks of gestation), and 20 placentas of term births (37–41 weeks of gestation) as control group were included in the study.

Results Histologic chorioamnionitis was detected more frequently among early preterm births compared with late preterm and term births (P = 0.004). Funisitis and deciduitis were significantly associated with early preterm births (P = 0.001). The most common pathogens included Streptococcus agalactiae, Streptococcus viridans, Staphylococcus epidermidis. Among preterm births maternal placental infarction characterised by massive perivillous fibrin deposition was observed predominantly in early preterm births (P = 0.005). Placental and cord hemorrhagic and thrombotic vasculopathy were more prevalent in late preterm births than early preterm and term births (P = 0.008). Late preterm births placentas revealed degenerative changes and calcification in chorionic villi more often than in early preterm and term births (P = 0.012).

Conclusion Comprehension of the pathogenic mechanisms of preterm births, prematurity of the placenta and the impact of placental prematurity on fetal wellbeing may lead to improved early prenatal diagnostic and enhanced preventive care for both the mother and her child.


Placental histological findings in association with gestational age and neonatal morbidity: A case-control study

Kornete, A1,2; Blazuka, S3; Vedmedovska, N1,4

1Department of Obstetrics and Gynecology, Riga Stradins University, Riga, Latvia; 2Department of Obstetrics and Gynecology, Vidzemes Hospital, Valmiera, Latvia; 3Department of Pathology, Vidzemes Hospital, Valmiera, Latvia; 4Department of Prenatal Diagnostic, Riga Maternity Hospital, Riga, Latvia

Introduction Annually one in 10 neonates is born prematurely, and preterm births rates are increasing. Prematurity poses the major challenge for perinatology, accounting for 75% of perinatal mortalities and for 50% of long-term complications. Placental pathology has been implicated in the pathogenesis of adverse fetal outcomes.

Methods Placental histological findings were reviewed in the retrospective case-control study aiming to define correlation between gestational age and neonatal morbidity. Preterm births cohort (N = 72) was subcategorised according to gestational age at the time of birth: extremely (22–27 weeks of gestation), very (28–31 weeks of gestation), moderate to late (32–36 weeks of gestation) preterm. Twenty term births (37–41 weeks of gestation) was selected as controls.

Results Deciduitis was found with a higher frequency among placentas at extremely preterm neonates (P = 0.014). Placentas at very preterm births category more often revealed chorioamnionitis (P = 0.027), chorion-decidual hemorrhage (P = 0.063) and decidual necrosis (P = 0.035). Placental lesions reflecting disturbances of fetal-placental blood flow (villous fibrosis, hyalinisation, calcifications, necrosis, placental thrombotic vasculopathy, cord vessels’ thrombosis) were predominantly seen in moderate to late preterm births category (P = 0.014). Funisitis was identified as predictor for the development of intraventricular hemorrhage (P = 0.063). Chorion-decidual hemorrhage and deciduitis were significantly associated with respiratory distress syndrome (P = 0.015). Intrauterine growth restriction was linked to villous edema (P = 0.007). Chorion-decidual hemorrhage was the main predisposing factor for cerebral ischemia (P = 0.016).

Conclusion The placental histological examination may provide a significant impact on care of the premature neonate and insights into future investigations to determine which neonate could be at relatively greater risk for developing long-term complications.


Outcome of prenatally-diagnosed echogenic fetal lung lesions in the North of England: A review of 228 cases to aid in prenatal counselling

Walker, L1; Cohen, K1; Crabbe, D1; Rankin, J2

1Leeds Teaching Hospitals Trusts, Leeds, UK; 2Regional Maternity Survey Office, Newcastle upon Tyne, UK

Introduction Fetal echogenic lung lesions usually have a good outcome, with a small risk of hydrops and death. Previous reported series have shown a high rate of antenatal intervention for hydropic fetuses and a high rate of postnatal surgery. We present the largest case series to date.

Methods 25 year retrospective observational study of fetal ELL ascertained from NORCAS (Northern Congenital Abnormality Survey) and Yorkshire Fetal Medicine Unit datasets. Postnatal follow-up was from 6 months to 20 years.

Results 228 antenatally diagnosed cases, with 82% diagnosed at anomaly scan. 88% CCAMs, 10% sequestrations, 2% undefined. 7% of cases had chromosome testing. 3 (1%) patients had a chromosome abnormality. (2 cases of T18 and 1 T21.) Mediastinal shift was present in 114 (50%) and hydrops in 21 (9%). Overall survival was 181/187 (97%). 8/21 (38%) of hydropic babies survived, of which 5 underwent antenatal intervention and the remainder regressed spontaneously. Antenatal intervention was performed in 11 (5%). 28/228 (12%) of all babies had postnatal surgery. 4/28 (14%) of the surgical cases were sequestrations and 24/28 (86%) were CCAMs. 18/28 (64%) of children were alive and asymptomatic at most recent follow up. 2/28 (7%) of babies died, following emergency surgery on day 1 of life.

Conclusion The risk of poor outcome in echogenic lung lesions is low. In this series the rate of antenatal and postnatal intervention is lower than is previously reported. Prenatal counselling should reflect this.


Alternatives to microarrays: Evaluating fetal structural abnormalities using copy number variation by sequencing (CNV-Seq)

Walker, L; Cohen, K; Hewitt, S

Leeds Teaching Hospitals Trust, Leeds, UK

Introduction Prenatal microarray CGH is now widely used to investigate fetal abnormality in centres across the UK. Newer techniques to assess chromosomal variation are based on Next Generation Sequencing and may offer additional benefits. CNV-seq is able to detect submicroscopic variants with a similar resolution to array CGH. We present a prospective anonymised cohort study of the comparison of CNV-seq against array CGH for 40 cases of fetal structural abnormality.

Methods All fetuses were assessed using 8x 60K oligoarray CGH (BlueGnome) and also by CNV-seq using a ten sample multiplex run on the Illumina HISeq 2500. Array analysis was by BlueFuse software and sequencing bioinformatics were performed by the regional genomic translational unit.

Results 40 fetuses were analysed following normal qfPCR. Average resolution in the array group was 80Kb, compared to a mean calculated resolution of 29Kb in the CNV-Seq group. Despite the improved resolution, no additional variants of uncertain significance were identified. 4 significant copy number imbalances were identified with 100% concordance in both groups. Genomic break points were more accurately defined in the CNV-Seq group. Fewer poor quality control scores were obtained in the CNV-Seq group. CNV Seq performed well, even in the presence of low concentration DNA, assessed by Qubit Assay.

Conclusion The detection of pathogenic variants is similar between array CGH and CNV-Seq. Poor quantities of prenatal DNA appear to perform better on CNV-seq. There are also improvements in quality control parameters and assessment of genomic breakpoints.


The introduction of a fetal ultrasound telemedicine service: Quality outcomes and family costs

Snaith, VJ1; Lie, M2; Marshall, A3; Bidmead, E3; Robson, SC2

1The Newcastle upon Tyne Hosptials NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK; 2Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK; 3University of Cumbria, Carlisle, Cumbria, UK

Introduction The complexity of fetal medicine (FM) referrals that can be managed in a district general hospital (DGH) is dependent on the availability of specialist ultrasound expertise. Telemedicine can effectively transfer real-time ultrasound images via video-conferencing. We report the successful introduction of a fetal ultrasound telemedicine service.

Methods All women referred for FM consultation from the linked DGH were seen via a weekly telemedicine service, excluding cases where invasive testing was anticipated. Image and audio quality were rated (using a 5 point scale) following each consultation. Women referred for their first appointment were asked to complete a questionnaire following the consultation. Figures presented are median [range].

Results 80 women had a telemedicine consultation between October 2015 and September 2016. 37 cases were new referrals because of fetal anomaly (n = 17), exclusion of abnormal placental invasion (n = 11), small-for-gestational-age (n = 7) and prior history of fetal anomaly (n = 2) and 43 cases were follow-up consultations. Median gestation was 29 [13–36] weeks. Image quality was of sufficient quality to achieve the aims of the consultation in 79 cases with an image score of 4 [3–5] and audio score of 5 [3–5]. Journey to the telemedicine consultation was 20 [4–150] minutes in comparison to an estimated journey time of 238 [120–450] minutes to the FM centre. Estimated family costs for attendance at the FM centre were £95 [20–555].

Conclusion We have demonstrated that a fetal ultrasound telemedicine service can be successfully introduced and used to provide high quality consultations.


An offline 3D-ultrasonography intra- and interobserver agreement study of fetal cerebral structures

Buisman, ET1,2; Albers, ME1; Onland-Moret, NC1; Kahn, RS1; Franx, A1; de Heus, R1

1UMC Utrecht, Utrecht, The Netherlands; 2Radboudumc, Nijmegen, The Netherlands

Introduction This study aimed to assess intra- and interobserver agreement for various measurement techniques of the fetal cerebrum, cerebellum and each thalamus in 3D-ultrasonography volumes.

Methods 3D-ultrasound volumes were acquired of 78 fetuses at 19–24 weeks of gestational age for a large Dutch cohort study. Measurements were performed offline and independently by two observers using Virtual Organ Computer-Aided AnaLysis in 4D View for volumetry. The intraclass correlation coefficient (ICC) was used for analysis of agreement.

Results Intra- and interobserver agreement was excellent for cerebral distance measurement in the form of the occipitofrontal diameter (ICC: 0.881 and 0.912, respectively), as well as total intracranial volume (ICC: 0.961 and 0.866) and the transcerebellar diameter (ICC: 0.909 and 0.842). The rate of agreement was good for cerebellar volumetry (ICC 0837 and 0.721). Agreement for thalamic dimensions varied from poor to fair, scoring lowest in measurement of the anteroposterior diameter (ICC: 0.294 and 0.176) and width (ICC: 0.516 and 0.470), followed by area measurement (ICC 0.460 and 0.543) and with the highest scores in volume calculations (ICC 0.584 and 0.529).

Conclusion Agreement for most of the studied fetal cerebral measurements was good to excellent, while some measurements scored poor to fair. Volumetric measurements had higher agreement rates compared to distance measurements of the same structures in all cases, with the exception of the cerebellum. Based on this study, measurements of the intracranial and cerebellar volume in 3D-ultrasonography are feasible for assessment of fetal brain development, while reliability of fetal thalamic measurements remains questionable.


Reproducibility of a new three-dimensional ultrasound method for the measurement of fetal frontal lobe volume

Albers, ME1; Buisman, ET1,2; Onland-Moret, NC1; Kahn, RS1; Franx, A1; de Heus, R1

1UMC Utrecht, Utrecht, The Netherlands; 2Radboudumc, Nijmegen, The Netherlands

Introduction This study aimed to evaluate intra- and interobserver reproducibility of a new way of measuring frontal lobe volume in three-dimensional ultrasound images of the fetal brain, using virtual organ computer-aided analysis (VOCAL).

Methods 3D-ultrasound images of 60 fetuses at 20–24 weeks of gestational age, were randomly selected. Fetal frontal lobe volume was measured offline with the VOCAL method, using the manual mode. Two observers independently measured frontal lobe volume three times per ultrasound. Intra- and interobserver agreement were determined for the first measurement and the average of three measurements, using intraclass correlation coefficients (ICC) and the Bland-Altman method.

Results Measurement of the frontal lobe volume was possible in 57 (95%) of the ultrasound volumes. Agreement of the frontal volume measurements was excellent with an intraobserver ICC of 0.78 (95% CI 0.655–0.864) and an interobserver ICC of 0.78 (95% CI 0.582–0.876) for the average of three measurements and an intraobserver ICC of 0.77 (95% CI 0.638–0.858) and an interobserver ICC of 0.77 (95% CI 0.539–0.878) for each observer's first measurement. Bland-Altman analysis shows a mean difference of 672 cm3 (95% Limits of Agreement (LoA) −5027 to 6370) for intraobserver agreement and of 1338 cm3 (95% LoA −3880 to 6555) for interobserver agreement.

Conclusion The reproducibility of a new way of measuring fetal frontal lobe volume was shown to be excellent. Since agreement is excellent for both the first measurement and the average of three measurements, it is sufficient to measure the frontal lobe volume once.


Understanding women's experiences of having a small-for-gestational-age fetus

Dhillon, S1,2; Kennedy, S1; Ryan, S3; Kelly, B1

1Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, UK; 2DeGroote School of Medicine, McMaster University, Hamilton, Canada; 3Department of Primary Health Sciences, Oxford University, Oxford, UK

Introduction The patient experience literature in perinatal research centres on the detection and management of structural and/or chromosomal abnormalities (e.g. Down Syndrome, neural tube defects). More common conditions/phenotypes associated with sub-optimal fetal size are not currently explored from the patient's perspective. Small-for-Gestational-Age (SGA), for instance, by definition affects 10% of all pregnancies and has not yet been researched from a patient perspective. Our study addresses this gap and explores women's experiences of carrying an SGA fetus.

Methods A longitudinal qualitative study was conducted to elicit patient experiences of SGA at the John Radcliffe Hospital, Oxford. Participants were purposively selected based on clinical and socio-demographic variables determined a priori. Thirteen women were interviewed during and after pregnancy. The semi-structured interviews were transcribed verbatim. Thematic analysis was undertaken using the one-sheet-of-paper method (developed at Oxford University).

Results and conclusion An SGA diagnosis can be a very distressing and confusing experience for a mother. Information provided by the healthcare system is viewed as inadequate and inconsistent by women and so they often turn to the Internet for information and support. Women report that continuity of care is limited, and the relationship with the community midwife is affected once the management of the fetus moves to tertiary level care. Postnatal interviews reveal that women feel ill-prepared to care for an SGA neonate. Better information and resources are required to support women with an SGA fetus during the antenatal and postnatal periods.


Does a dedicated twin antenatal clinic improve the management of twin pregnancies in accordance with the International Society of Ultrasound in Obstetrics and Gynaecology (ISUOG) guidance? A retrospective analysis of mono- and dichorionic pregnancies at a teaching hospital in the UK

Ewington, L1; Fern, E2; Vanes, N1; Mukherjee, S1

1University Hospital Coventry and Warwickshire, Coventry, UK; 2University of Warwick, Coventry, UK

Introduction In February 2016 the International Society of Ultrasound in Obstetrics and Gynaecology (ISUOG) released guidance surrounding ultrasound in twin pregnancy. In April 2016 a dedicated twin pregnancy antenatal clinic was introduced to a teaching hospital in the Midlands. This project audited the compliance with the guidance before and after the introduction of this dedicated clinic.

Methods A retrospective analysis was undertaken of 11 patients prior to the introduction of a dedicated twin antenatal clinic and 36 patients from the twin clinic at University Hospital Coventry and Warwickshire (UHCW).

Results There were 35 dichorionic diamniotic (DCDA) twins and 12 monochorionic diamniotic (MCDA) twins. 82% of patients had a booking scan between 11 + 0 and 13 + 6 weeks. Following the introduction of the clinic this increased to 86%. 90% of patients had the gestational age determined by the larger crown rump length, this did not change from April 2016. All patients had chorionicity determined at booking and had a completed anatomy scan. For the DCDA twins pre-April 2016 62.5% had 24-week, 87.5% had 28-week, 100% had 32-week and 80% had 36-week growth scans. In comparison after April 2016, 80.8% had 24-week, 87.5% had 28-week, 90.5% had 32-week and 92.3% had a 36-week growth scans. 88.9% of MCDA twins had 16 and 18 week growth scans from April 2016 in comparison to 33.3% and 66.7% of 16 and 18 week scans pre April 2016.

Conclusion A dedicated twin antenatal clinic improves antenatal care for twin pregnancies in concordance with the ISUOG twin ultrasound guidance.


Cytogenetic testing by PCR and multiplex ligation-dependent probe amplification (MLPA) in the investigation of pregnancy loss

Younis, M; O'Donoghue, K

Cork University Maternity Hospital, Cork, Ireland

Cytogenetic evaluation of products of conception (POC) for chromosomal abnormalities can determine the cause of pregnancy loss and estbalish risks for future pregnancies. Traditionally, cytogenetic investigation was performed by karyotyping after culture of chorionic villi. Testing by PCR and MLPA has higher success rates and faster reporting times than karyotyping.

We aimed to review our numbers of samples, indications for testing, sample failure rates, laboratory reporting times, and cytogenetic results.

All samples sent for PCR/MLPA testing from 2013 to 2015 were recorded. Data were collected from laboratory reports and sample tracking books, supplemented by chart reviews.

A total of 735 samples were sent for cytogenetic analysis during the three years audited.

Of these samples, 677 were successfully processed, giving a 92% success rate. Overall, 49% of processed samples revealed abnormal cytogenetics. Further analysis of the failed samples showed that in 42/58 (72%) only maternal tissue was sent to the laboratory, in 13/58 (22%) the tissue was of insufficient quality for analysis and in only 3 cases did testing fail. The most common indications for testing were recurrent miscarriage (224/735; 30%), and second-trimester miscarriage (136/735; 18%), however some cases were incorrectly recorded and others sent for inappropriate clinical indications.

These data confirm high success rates with the PCR/MLPA technique, and we recommend its continued use as the cytogenetic investigation of choice in pregnancy loss. Local protocols for testing and documentation need to be followed and education may be needed to improve clinical sample collection and processing.


Antenatal findings and management in a prospective national population cohort of infants presenting with meconium ileus in association with cystic fibrosis

Long, A-M1; McNally, J2; Knight, M1

1National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK; 2Department of Paediatric Surgery, Bristol Royal Hospital for Children, Bristol, UK

Introduction Meconium ileus (MI), neonatal small-bowel obstruction with inspissated meconium most commonly occurs in infants with Cystic Fibrosis (CF). The bowel may be intact, so-called ‘simple’ MI, or may be compromised in ‘complicated’ MI. Infants with complicated MI always require surgery. This rare condition has never before been studied on a population basis in the UK.

Methods Paediatric surgeons in 26 centres in the UK and Ireland reported cases of MI with CF using an established surveillance system. Data were collected on early management and outcomes prospectively over a two-year period.

Results 56 infants with CF presenting with MI were identified during the data collection period. In 14, there was a suspicion of MI antenatally (25%). The most common feature noted was echogenic bowel, present in 10 (71%) of those identified before birth. Six had bowel dilatation (43%), four had ascites (29%) and one had intra-abdominal calcification (7%). Polyhydramnios was present in 6/54 (11%) of pregnancies. Where the diagnosis was suspected antenatally, parental testing was performed in six, (43% of pregnancies) and fetal DNA testing in three (21%). Antenatal diagnosis was significantly associated with the postnatal finding of complicated MI (P = 0.01). 71% of fetuses suspected antenatally had complicated MI (10/14), and only 31% of those not detected antenatally were complicated (13/42).

Conclusion One quarter of cases of MI associated with CF are antentally suspected. These infants are more likely to be complicated and require urgent surgical attention. Close liaison between fetal medicine specialists, neonatologists and paediatric surgeons in such cases is warranted.


Establishing NIPT as a first choice screening test for Down's syndrome

Ajmal-Ali, R; Allen, K; Anderson, P; Jackson, N

The Hillingdon Hospital Foundation Trust, London, UK

Non Invasive prenatal testing (NIPT) is a new screening test analysing fetal DNA present in maternal circulation, identifying more than 99% of fetuses with T21 (Downs syndrome) 97% with T18 (Edwards syndrome) and 87% with T13 (Patau syndrome).

All pregnant women in England are offered screening for Down's Syndrome. Call back groups consist of screen positive results of 1:150 and below, who are then offered diagnostic testing. Currently this comprises of Amniocentesis or Chorionic Venous Sampling which carries an associated risk of 1–2% of miscarriage.

Our aim at The Hillingdon hospital was to explore the option of offering NIPT privately whilst awaiting the decision of the national screening programme. Thus pump priming a fund to allow us to offer NIPT as a second line test free of charge rather than invasive diagnostic testing.

Not only has this been a successful introduction to NIPT within our trust, but it has provided a source of income to the maternity department, enabling the test to be offered to all our high risk NHS patients free of charge. This will reduce the amount of invasive testing and associated risk to the unborn child. When this service is commissioned nationally, we will already be up and running and able to provide it immediately, whilst any funds from private testing can be used to invest in other services.


Neonatal outcome after thoracoamniotic shunting for fetal hydrothorax

Witlox, R; Klumper, F; te Pas, A; Oepkes, D; Lopriore, E

Leiden University Medical Centre, Leiden, The Netherlands

Introduction To evaluate the short-term neonatal outcome after thoracoamniotic shunt placement for fetal hydrothorax.

Methods Retrospective evaluation of infants with isolated hydrothorax treated with thoracoamniotic shunt placement at our fetal therapy centre between 2001 and 2016.

Results 48 fetuses were treated with a thoracoamniotic shunt. All fetuses had signs of hydrops at the time of intervention. Median (interquartile range (IQR)) gestational age at shunting was 28.7 (24.4–31.3) weeks. Forty-one of 48 (85%) fetuses were born alive at a median (IQR) gestational age of 34.4 (31.1–36.7) weeks. In one child the course of disease after birth was unknown (this child was excluded from further analyses). After birth, 24/40 (60%) children had signs of pleural effusion and 12/40 (30%) needed a thoracic shunt for continuous pleural drainage. Twenty-one (53%) children required mechanical ventilation of which 13 (33%) needed high frequency ventilation as rescue therapy. Overall 30/40 (75%) infants survived the neonatal period. Neonatal survival rate was significantly higher when infants were born ≥ 32 weeks of gestation as compared to <32 weeks, 93% (26/28) versus 33% (4/12); P < 0.01).

Conclusion The postnatal course of hydropic fetuses treated with thoracoamniotic shunt for isolated hydrothorax is often complicated by respiratory failure and persistent pleural effusions. Neonatal survival is good provided delivery occurs at or after 32 weeks of gestation.


Evaluation of array comparative genomic hybridisation (aCGH) in prenatal diagnosis

Gajewska-Knapik, K1; Staines, J2; Cramer, E3; Sutton-Cole, A1

1Department of Fetal Medicine, Cambridge University Hospitals, Cambridge, UK; 2Department of Genetics, Cambridge University Hospitals, Cambridge, UK; 3Anglia Ruskin University, Cambridge, UK

Introduction The advantage of array comparative genomic hybridisation (aCGH) is to detect genomic imbalances, including submicroscopic changes. We report our experience after implementing aCGH on samples from invasive procedures performed for fetal abnormalities including nuchal translucency (NT) >3.5 mm.

Methods Evaluation of aCGH as a diagnostic tool in a Fetal Medicine Department between October 2014 and August 2016.

Results There were 220 aCGH requests for the following indications: high NT (n = 108); structural abnormalities (n = 105, including 3 at feticide); family history of genetic syndrome (n = 5); monochorionic diamniotic twins with high aneuploidy risk (n = 1) and maternal request (n = 1). There were 125 chorionic villus samples (CVS), 92 amniotic fluid (AF), and 3 blood.

Subsequently 76 samples were excluded from testing due to: abnormal quantitative fluorescence polymerase chain reaction (QFPCR) result indicating trisomy 13, 18 or 21, Monosomy X or triploidies (n = 72); cystic fibrosis (n = 1); insufficient DNA to process after normal QFPCR result (n = 1); unsuitable DNA (n = 2 blood samples).

Array was performed on 144 samples including 6 (4.2%) which required culturing (5 AF and 1 CVS). There were 14 (9.7%) abnormal results. 7 abnormalities classified as microscopically visible and 7 (4.9%) as submicroscopic. 1 submicroscopic abnormality was a parentally derived copy number variation (CNV) of no clinical significance.

5/6 cases of clinically significant submicroscopic abnormalities occurred de novo and 1 CNV was paternally inherited.

Conclusion We found aCGH a very efficient and powerful tool in our routine practice. 4.2% of tests enabled identification of clinically relevant submicroscopic abnormalities and 95.8% were successfully performed on uncultured samples.


Evaluation of twin-twin transfusion syndrome (TTTS) services: A comparison of patient and clinician feedback

Hall, M1; Mackie, FL1,2; Pattison, H3; Katie Morris, R1,2; Kilby, MD1,2

1Centre for Women's and Newborn's Health, University of Birmingham, Birmingham, UK; 2West Midlands Fetal Medicine Centre, Birmingham, UK; 3School of Life and Health Sciences, Aston University, Birmingham, UK

Introduction TTTS is a complication of monochorionic diamniotic twins with option for treatment via fetoscopic laser ablation (FLA). In the UK, FLA is provided through national referral centres including the service of West Midlands Fetal Medicine Unit (FMU). No national service evaluation exists regarding FLA or other fetal therapy.

Aim A qualitative study assessing patient and clinician experience of the service, to determine how to improve care and support.

Methods Focus groups with TTTS parents were performed to design the patient questionnaire which was piloted, amended and given in hard copy to every couple attending the FMU for FLA for TTTS from 28/01/16–28/10/16. The clinician questionnaire was piloted locally, amended, and disseminated electronically to clinicians working at FMUs across the UK.

Results 13/13 eligible women completed the questionnaire, with median maternal age 28 years (range 20–38), gestational age 20 + 0 weeks (range 16 + 5–23 + 1) and Quintero Stage I n = 2, Stage II n = 3 and Stage III n = 8 at treatment. 32/35 clinician responses were received. Mean service score was 4.900/5 and 4.387/5 by patients and clinicians respectively. Important themes arising were the need for written information regarding TTTS and support groups, difficulty of provision of childcare/accommodation for family members and the importance for referring centres to emphasise that there may be discrepancies between the potential diagnosis made at the Local Hospital and the FMU.

Conclusion This was a small service evaluation and whilst it seems the service is generally well received there are aspects that could be improved. Further evaluation work needs to continue.


Counselling of triplets: Are we up to date?

Spaan, J; Vaikousi, E; Gupta, M; Greco, E; Aquilina, J

Royal London Hospital, London, UK

Introduction To assess the risk of preterm delivery and perinatal mortality in triplet pregnancies.

Methods Retrospective study of triplet pregnancies over a 10-year period (June 2006–June 2016) in a tertiary referral hospital in East London.

Results Forty-five triplet pregnancies were reviewed. Median maternal age was 33.2 (±6.8) years. Eighteen (40%) pregnancies were conceived by in vitro fertilization. 11 (24%) had spontaneous miscarriage and 2 (2%) social termination of pregnancy. Spontaneous reduction to twins or singleton occurred in 8 (18%) cases. Two (2%) women opted for embryo reduction to twins. One pregnancy was lost-to-follow-up.

Of the 21 ongoing pregnancies after 12 weeks, 11 were trichorionic triplets and 10 monochorionic twins plus singleton. There were 3 (14%) spontaneous reductions to singleton and 2 (10%) pregnancy losses before 24 weeks of gestation. The median gestational age at delivery was 32 + 5 (IQR 30 + 1–34 + 2) weeks. Early preterm delivery before 32 weeks occurred in 6 (29%) cases, 2 (10%) of which delivered before 28 weeks. Mean birthweight was 1628 g (IQR 1045–1948). There was 1 (5%) neonatal death. The live birth rate of at least one baby was 90%. The live birth rate of all three babies was 81%. Overall, the ‘take home’ rate of three babies was 76%.

Conclusion The rate of preterm delivery in triplets remained unchanged in the last 10-years.

Future directives Advances in neonatal medicine have significantly improved the outcome of preterm babies. This raises the question of whether embryo-reduction carries the same benefits as it may have 10 years ago.


Routine third trimester ultrasound scans – can Ireland buck the trend?

Smyth, S; Imcha, M

University Maternity Hospital Limerick, Limerick, Ireland

Internationally there are conflicting reports on the merits of routine third trimester ultrasound scans (USS) in low risk pregnancies.

This study aimed to assess whether routine USS during the third trimester of pregnancy is a valuable resource in low risk pregnancies in Ireland.

The routine 31 week USS appointments for January–March 2016 were acquired from the Viewpoint Booking System data. Parameters of fetal growth, anomaly and wellbeing were reviewed.

Of the initial 507 records reviewed, 491 were included in the final draft. The USS were at a mean of 31.1 weeks of gestation. The mean estimated fetal weight at the time of the scan was 1.8 kg. This resulted in 46 (9.3%) diagnoses of small-for-gestational-age and 89 (18.1%) diagnoses of large for gestational age. Repeat scans were performed on 260 women who did not originally meet requirements for re-scan. Assessment of growth (n = 150) was the most common reason documented in these cases.

In addition to estimating fetal weight, useful parameters such as presentation and markers of fetal wellbeing can be assessed at 31 weeks of gestation. In this low risk population while the prevalence of abnormalities is expectedly low, offering a routine third trimester ultrasound scan allows for identification of evolving high risk pregnancies. This can lead to increased intervention rates and underlines the importance of appropriate interpretation of scan findings by qualified ultrasonographers and fetal medicine specialists. This much debated question of validity of third trimester USS requires more robust studies in Ireland and internationally.


Patients’ views of a fetal ultrasound telemedicine service: A mixed methods evaluation study

Lie, M1; Snaith, V2; Bidmead, E3; Marshall, A3; Robson, SC1

1Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK; 2The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK; 3University of Cumbria, Carlisle, Cumbria, UK

Introduction The aim of this study was to evaluate from the patient's perspective, a new fetal ultrasound telemedicine service to improve prenatal diagnosis and management at a rural district general hospital.

Methods Eligible patients requiring a specialist fetal medicine consultation were referred to a tertiary care centre for inclusion in the study. Women who underwent a telemedicine examination with a consultant guiding an ultra-sonographer and providing specialist counselling via video-conferencing link were approached to complete a structured questionnaire with the option of participating in a semi-structured telephone interview. The questionnaire included a 5-point scale to evaluate patient satisfaction with the consultation. The mixed methods analysis employed SPSS and Atlas.ti software packages.

Results Of the 80 consultations undertaken during the study, 38 new referrals having their first telemedicine consultation were approached; 31 returned survey questionnaires, and 16 interviewed. Survey and interview participants expressed very high satisfaction with the timely service (93.5 percent highly satisfied with quality of care overall), particularly as a result of the reduced travel times and costs. Analysis of the interviews revealed other advantages such as familiarity and continuity of care from staying local and increased confidence through the sharing of expertise, particularly during an anxious time in their pregnancies.

Conclusion A fetal ultrasound telemedicine service was highly acceptable to patients in this rural community, offering them a range of personal benefits as a result of easier access to specialist healthcare.


Predicting preterm birth in high-risk women with prophylactic intervention in situ: A large prospective series

Ross, G; Ridout, A; Seed, P; Shennan, A

King's College London, London, UK

Introduction Quantitative fetal fibronectin (qfFN) and cervical length (CL) are reliable predictors of spontaneous preterm birth (sPTB), and can work in synergy. The objective of this study was to establish the extent to which prophylactic intervention (cerclage/progesterone) impacts on the ability of these predictive markers.

Methods This was a planned analysis of a prospectively collected cohort of high-risk asymptomatic women (EQUIPP, Evaluation of Fetal Fibronectin for the Prediction of Preterm Birth) (n = 2141). Women were grouped according to intervention, and qfFN and CL measurements from the first visit between 22+0 to 27+6 selected.

Our primary outcome was sPTB <34 weeks of gestation; ROC curves were generated and AUC calculated to assess the accuracy of tests with cerclage and/or progesterone.

Results Predictive accuracy of CL and qfFN for the whole cohort was comparable to published data (0.81 (0.76–0.87) and 0.72 (0.64–0.80), respectively).

Test performance was maintained with cerclage (0.79 (0.71–0.86) and 0.72 (0.63–0.80) for CL and qfFN respectively). Similarly predictive statistics were similar if not better for women with both interventions (0.91 (0.81–1.00) for CL and 0.72 (0.54–0.89) for qfFN).

Conclusion qfFN and CL appear to be reliable predictors of sPTB <34 weeks with prophylactic intervention. In fact, CL may be even better in this group. This new evidence should reassure clinicians these markers can be used to reliably target management in women with intervention in situ.


Diagnosis, management and complications of large placental chorioangioma – a case series

Down, C1; Bills, V1; Gradhand, E2; Lee, A3

1Department of Obstetrics and Gynaecology, St Michaels’ Hospital, University Hospitals Bristol, Bristol, UK; 2Department of Cellular Pathology, North Bristol NHS trust, Southmead Hospital, Bristol, UK; 3Anatomical Pathology, St Michaels’ Hospital, University Hospitals Bristol, Bristol, UK

Background Chorioangiomas are benign hamartomas of the chorionic plate. Large tumours (>4 cm) are rare, but often associated with adverse perinatal outcome.

We present three histologically confirmed cases, highlighting the different complications that can arise.

Case Case 1: Ultrasound at 21 + 5 reveals a mildly dilated fetal heart, polyhydramnios (AFI 30 cm) and a vascular placental chorioangioma 80 × 50 × 75 mm. At 27 + 5 multiple infarcts are seen within the tumour and there is resolution of the polyhydramnios. The pregnancy progressed to term without further complication.

Case 2: Severe polyhydramnios (AFI 40.6 cm) and a 40x38x38 mm placental chorioangioma are demonstrated on ultrasound at 28 + 0. Amnioreduction is performed, but spontaneous rupture of membranes and preterm delivery occurs at 31 + 5.

Case 3: A 57 × 43 × 51 mm placental chorioangioma is noted incidentally on ultrasound at 32 + 4. The pregnancy progressed to term without complication. Histological examination demonstrated large areas of infarction.

Conclusion Complications of large placental chorioangioma include polyhydramnios, preterm labour, fetal haemolytic anaemia, thrombocytopaenia, cardiomegaly, non-immune hydrops, growth restriction, pre-eclampsia and intra-uterine death.

The pathophysiology is likely three-fold. (1) arteriovenous shunts causing vascular steal and transudative polyhydramnios (2) mass effect causing cord compression (3) consumptive coagulopathy with microangiopathic haemolysis.

Prognosis of chorioangiomas are therefore related not only to size, but also vascularity. This is evident in the above case series, where tumour infarction is likely to have influenced outcome, leading to the spontaneous resolution of symptoms in one case, and no symptoms in another in spite of large tumour size.

This knowledge could drive future therapies in the management of this condition.


Risk factors for coarctation of the aorta on prenatal ultrasound: A systematic review and meta-analysis

D'Antonio, F1,2; Khalil, A3; Acharya, G1,2; Rizzo, G4; Sonesson, S-E5

1Department of Clinical Medicine, Faculty of Health Sciences, UiT – The Arctic University of Norway, Tromso, Norway; 2Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø Norway; 3Fetal Medicine Unit, Saint George's Hospital, London, UK; 4Department of Obstetrics and Gynaecology, University of Rome, Rome, Italy; 5Pediatric Cardiology Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden

Introduction The objective was to ascertain the strength of association and to quantify the diagnostic accuracy of different ultrasound signs in predicting CoA prenatally.

Methods Medline, Embase, CINAHL and Cochrane databases were searched. We explored the strength of association and the diagnostic accuracy of different prenatal ultrasound parameters in fetuses at risk for CoA.

Results 794 articles were identified and 12 (922 fetuses at risk for CoA) were included. Mean mitral valve diameter z-score was lower (P < 0.001) and the mean tricuspid valve diameter z-score was higher in fetuses with CoA compared to those without CoA (P = 0.01). Mean Aortic valve diameter z-score was lower in fetuses with CoA compared to normal fetuses (P =< 0.001). Mean aortic isthmus diameter z-scores measured either in sagittal (P = 0.02) or in three-vessel trachea view (P < 0.001) were lower in fetuses with CoA. Mean pulmonary artery diameter z-score, the right/left ventricular and pulmonary artery/ascending aorta diameter ratios were higher (P < 0.001, P = 0.02 and P = 0.02) in fetuses with CoA, while aortic isthmus/arterial duct diameter ratio was lower in fetuses with CoA compared to those without (P < 0.001). The presence of coarctation shelf and aortic arch hypoplasia were more common in fetuses with CoA compared to controls (OR: 26.0, 95% CI 4.42–153, P < 0.001 and OR: 38.2, 95% CI 3.01–486, P = 0.005), while persistent left superior vena cava (P = 0.85), ventricular septal defect (P = 0.12) and bicuspid aortic valve (P = 0.14) did not carry an increased risk for this anomaly.

Conclusion The detection rate of CoA may improve when a multiple criteria-prediction model is adopted.


Two year outcome of pregnancies complicated by low PAPP-A (<0.3 MoM) at a tertiary fetal medicine unit

Sharp, A1,2; Denton-Cardew, L2; Agarwal, U2; Alfirevic, Z1,2

1University of Liverpool, Liverpool, UK; 2Liverpool Women's Hospital, Liverpool, UK

Introduction Low first trimester serum PAPP-A is associated with adverse obstetric outcomes, including being small-for-gestational-age (SGA) (birthweight <10th centile), preterm labour, stillbirth, pre-eclampsia and miscarriage. At present there is no dedicated protocol on how to manage these pregnancies and wide variations exist between units. At Liverpool Women's NHS Foundation Trust, we introduced a dedicated protocol for such cases in 2012 that included giving low dose aspirin, 20 week uterine artery (UtA) Doppler (mean PI >1.45 MoM deemed significant), serial 3rd trimester growth scans and delivery by 40 weeks of gestation.

Methods Retrospective case notes review of all cases with PAPP-A < 0.3 MoM's from Jan 2013-Dec 2014. Data was available for 76 women with pregnancies >24 weeks.

Results 25/76 babies (33%) were SGA at birth, with only 9/25 (36%) recognised as SGA antenatally. 9/76 (12%) women had mean UtA PI >1.45 MoM, of these 4 (44%) were SGA. 67/76 (88%) women had a mean UtA PI <1.45 MoM, of which 21 were SGA (31%). Six women delivered <37 weeks. A single woman developed hypertension. There were no still births in the study cohort.

Conclusion Pregnancies with low PAPP-A remain high risk, in particular for SGA. Even with a policy of UtA Doppler and serial growth scans in the third trimester we were only able to detect 31–44% of those who subsequently had an SGA fetus. We suggest that a consistent low PAPP-A policy has benefits but further biomarker based strategies are urgently required to improve detection.


Correlation between total uterine artery volume flow and umbilical vein blood flow

Falco, ML1,2; Bhide, A1

1Fetal Medicine Unit, St George's Hospital, London, UK; 2Universita’ degli Studi di Napoli Federico II, Napoli, Italy

Introduction The objectives were to determine the relationship between Uterine Artery PI (UtAPI) and Uterine artery volume flow (UtAVF), and also between the maternal Uterine artery volume flow and fetal Umbilical vein volume flow (UVVF).

Methods This was a prospective study of 59 low-risk singleton pregnancies between 20 and 24 weeks of gestation. We evaluated fetal venous and arterial Doppler, and Doppler study of the maternal uterine arteries, and the study of calculated UtAVF and UVVF. Diameters of the uterine arteries and umbilical vein were measured. Fetal biometry was measured to calculate estimated fetal weight.

Results The mean gestational age was 22.4 weeks. UtAVF was negatively correlated with the ipsilateral UtAPI (r = −0.489, P < 0.01 and, r = −0.411, P < 0.01 for the right and left uterine artery respectively). Total uterine artery volume flow was negatively correlated with sum of the right and the left uterine artery PI. No significant correlation was seen between the total uterine artery flow volume and Umbilical vein volume flow.

Conclusion Significant correlation was seen between uterine artery PI and volume flow. Despite the variation in uterine artery volume flow, no significant correlation was seen between the umbilical vein volume flow and uterine artery volume flow. Compensatory mechanisms must exist to allow enough oxygen delivery to the fetus despite a variation in uterine artery volume flow.


The influence of gestational age at single fetal loss on the risk of preterm birth in twin pregnancies: Analysis of the STORK multiple pregnancy cohort

D'Antonio, F; Thilaganathan, B; Dias, T; Khalil, A

Fetal Medicine Unit, Division of Developmental Sciences, St. George's University of London, London, UK

Introduction The aim of this study is explore the risk of PTB according to the gestational age at the diagnosis of sIUD.

Methods A cohort study of all twin pregnancies from a large regional network of 9 hospitals over a ten-year period. Ultrasound data was matched to hospital delivery records and a mandatory national register for perinatal losses (CMACE). The risk of PTB was stratified according to the gestational age at the diagnosis of sIUD.

Results The analysis included 3035 twin pregnancies (2469 dichorionic and 566 MC). The risk of PTB, either before 34 weeks (OR: 10.4, 95% CI 6.4–16.8), before 32 weeks (OR: 8.4, 95% CI 5.2–13.4) or before 28 weeks (OR: 14.0, 95% CI 7.3–26.7) was significantly higher in the pregnancies with sIUD compared to those which were not complicated by any fetal loss. There was a significant trend towards a higher risk of PTB in the pregnancies with sIUD compared to those without (Hazard Ratio 6.50 (95% CI 3.3–12.0). This trend of higher risk of PTB was seen in both MC and DC twins (P < 0.001 for both). The risk of PTB before 34 weeks was significantly higher (Chi-square test for trend, P < 0.0001) if the sIUD occurred at 20–25 weeks (OR 4.5, 95% CI 1.1–18.9) and 26–32 weeks (OR 37.1, 95% CI 5.9–232.9), when compared to 14–19 weeks of gestation.

Conclusion Twin pregnancies complicated by sIUD, regardless of the chorionicity, have a significantly higher risk of PTB before 34, 32 and 28 weeks of gestation.


Is folic acid supplementation or fortification in pregnancy associated with an increase in multiple births? A systematic review and meta-analysis

Lee, A; Hodgetts-Morton, V; Katie Morris, R

Institute of Metabolism and Systems Research, Birmingham, UK

Introduction To determine whether folic acid (FA) supplementation or fortification is associated with an increased risk of multiple births.

Methods Electronic searches of Medline and EMBASE were conducted in September 2016 using MeSH terms and keywords related to the PICO. Population: pregnant women, Intervention: folic acid, Comparator: no folic acid, Outcome: multiple births. Studies were selected on the basis of this and data extracted with meta-analysis performed.

Results 11 053 citations were identified and 465 selected for detailed evaluation. 11 studies were included; 7 related to FA supplementation (1 099 717 women, of which 200 055 had FA supplementation), and 4 related to fortification (3 903 136 women). Assessing all studies, women who received FA supplementation had an increased risk of multiple births (OR 1.15 [95% CI 1.08–1.22]). However, when dose and time were assessed, evidence was conflicting. Post-conceptual supplementation showed an increased risk (OR 1.46 [95% CI 1.23–1.73]), but no significant effect with pre-conceptual supplementation (OR 0.91 [95% CI 0.79–1.05]). There was a decreased risk of twinning with 0.4 mg pre-conceptual FA supplementation (OR 0.75 [95% CI 0.64–0.89], n = 2 studies) and after initiation of FA fortification (OR 0.97 [95% CI 0.94–0.99], n = 4 studies).

Conclusion There is no consistent effect between FA supplementation and risk of multiple births. Furthermore, the introduction of mandatory FA fortification does not appear to show an increased risk of multiple births. Currently, there is no evidence of a dose-temporal relationship and as biological plausibility is unclear, a causal relationship cannot be definitively established at this time.


Does folic acid supplementation or fortification in pregnancy reduce the rate of Down syndrome and other chromosomal abnormalities? A systematic review and meta-analysis

Agrawal, M; Hodgetts-Morton, V; Katie Morris, R

Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK

Introduction The objectives were to conduct a systematic review and meta-analysis to determine if folic acid (FA) has an effect on the rate of Down Syndrome (DS) and other chromosomal abnormalities (CAs).

Methods Systematic searches of Medline and EMBASE were performed. No language restrictions were applied. Studies selected either compared FA supplemented groups to non-supplemented women or detailed prevalence data for CAs before and after mandatory FA fortification. Data was extracted and quality assessed. Statistical analysis and meta-analysis were conducted.

Results 1011 citations were identified, 87 studies were eligible for detailed review and 7 papers (3 supplementation and 4 fortification) were finally included (6 676 879 participants; 47 713 in the supplementation and 6 629 166 in the fortification cohort). There was a significant relationship between periconceptional FA supplementation and decreased number of DS pregnancies (summary odds ratio [OR] 0.71, [95% confidence interval [CI] 0.52–0.96]) when compared to no/other (non-FA) supplementation in countries with no mandatory FA fortification at the time of study. This significance was maintained when considering the matched control subgroup (OR 0.47, [95% CI 0.29–0.77]) and the general population subgroup (OR 0.68, [95% CI 0.49–0.95]) separately. There was no significant relationship between mandatory FA fortification policy and DS pregnancies (Prevalence OR 1.04, [95% CI 0.99–1.09]).

Conclusion Current evidence, though minimal, suggests that periconceptional FA supplementation is associated with lower odds of a DS pregnancy. However, mandatory FA fortification does not show a significant effect. This suggests that a targeted approach for FA supplementation is more suitable and that there may be a temporal dose-response relationship.


Outcomes of monoamniotic twin pregnancies: A 12 year cohort from a specialist twin clinic and tertiary fetal medicine unit

Tang, J1,2; Swain, A2; Cohen, K2; Breeze, A2

1York Teaching Hospitals NHS Foundation Trust, York, UK; 2Leeds Teaching Hospital NHS Trust, Leeds, UK

Introduction Monochorionic monoamniotic twins are a rare type of multiple pregnancy, with a reported high rate of fetal loss. The reported poor outcomes can lead to considerable obstetric and parental anxiety.

Aim To determine the outcomes of monochorionic monoamniotic (MCMA) twin pregnancies assessed in our specialist twins clinic and fetal medicine unit.

Methods A Viewpoint database search was performed for MCMA twin pregnancies assessed in the period 2005–2016. Information about structural and chromosomal disorders, pregnancy outcome and delivery gestation were sought.

Results 26 monoamniotic twin pregnancies were identified in the study period. Of these, 5 were conjoined twin pregnancies, but only 1 ended with livebirths, with the remaining pregnancies being terminated.

Outcome data were available on 21 of the remaining MCMA pregnancies. In these pregnancies, there were 26 liveborn babies. 15 fetuses (15/42, 35%) were miscarried, and in six pregnancies there were double fetal losses.

In the 14 pregnancies with two fetuses alive at 24 weeks, there was only one subsequent fetal loss – a late termination of pregnancy for major brain abnormality (1/28 ‘potentially viable’ fetuses ˜3.5%). 12 of these pregnancies reached 31 weeks or more before delivery.

Conclusion While MCMA pregnancies carry a high risk of fetal loss prior to viability, in pregnancies reaching 24 weeks of gestation, many MCMA twins will have a good pregnancy outcome with appropriate surveillance, and planned preterm delivery. Such data may be helpful in counselling couples after a diagnosis of confirmed monoamniotic twins.


Automatic detection of bidimensional fetal head planes from ultrasound 3D volumes using the ‘Fetal Brain Plane Finding Prototype’ tool

Cavallaro, A1; Donadono, V1; Salim, I1; Waechter-Stehle, I2; Klinder, T2; Rouet, J-M3; Roundhill, D4; Lorenz, C2; Papageorghiou, AT1,5

1Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital, Oxford, UK; 2Philips GmbH Innovative Technologies, Research Laboratories Hamburg, Hamburg, Germany; 3Philips GmbH Innovative Technologies, Research Laboratories Paris, Paris, France; 4Philips Ultrasound, Bothell, USA; 5Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK

Introduction To develop a tool able to automatically extract bidimensional (2D) fetal head planes from ultrasound tridimensional (3D) volumes.

Methods Ultrasound volumes of the fetal brain were acquired at 18–24 weeks of gestation using Philips EPIQ 7G ultrasound system. Acquisition settings included volume box adjustment; single sweep 3D mode; maximum resolution; and 60° acquisition angle. The ‘Fetal Brain Plane Finding Prototype’ tool (Philips Healthcare) was used to automatically extract 2D transventricular (TV), transthalamic (TT) and transcerebellar (TC) planes. The automatically extracted planes were then assessed and scored for quality by a skilled observer in a blinded fashion. Agreement of the type of plane extracted was assessed between the automated tool and the observer. The image quality was evaluated as ‘acceptable’ or not for clinical purposes; and scored using predefined criteria (0–5).

Results Of the 170 brain volumes acquired, automatic extraction of all three planes was successful in 143 (84%) volumes, giving a total of 429 planes. Of these, 92% were correctly identified as TV, TT or TC and 85% were deemed to be acceptable for clinical purposes. The average score was 4.7. In only 17 planes was the score ≤ 3.

Conclusion Automatic extraction of 2D fetal head planes from 3D ultrasound volumes showed good results. This could be used to facilitate and speed up the exam process, while maintaining high specificity and accuracy of the exam. Larger numbers of 3D volumes are needed in order to improve the accuracy of the tool and to validate the technique in clinical practice.


Ethical issues of non-invasive prenatal testing: Opinions of Dutch healthcare professionals

Kater-Kuipers, A; Bunnik, EM

Erasmus MC, Rotterdam, The Netherlands

Healthcare professionals play a leading role in the implementation of the non-invasive prenatal test (NIPT) in the Netherlands. In contrast to many other countries, the uptake of prenatal screening for Down syndrome is low in the Netherlands: only 25% of pregnant women opt for a prenatal test. It is suggested that NIPT will affect this situation and potentially increase the test uptake. Besides, it is suggested that because of its test characteristics, NIPT will negatively affect the informed decision-making processes of pregnant women. The possibility to expand the scope of NIPT enforces this fear. What do Dutch professionals in the field of prenatal screening think about the possible consequences of NIPT? What do they perceive to be important areas of concern in the implementation of NIPT?

In this qualitative study gynaecologists, clinical geneticists, midwives, lab specialists, test developers and policy makers (n = 15) are interviewed about ethical issues surrounding the introduction of NIPT and the expansion of the scope of prenatal screening. In the interviews four ethical themes are discussed: reproductive autonomy, proportionality of NIPT, justice and social aspects. Professionals underlined the importance of reproductive autonomy as the goal of prenatal screening but differed in their opinions on what is considered to be an informed choice. Some professionals focused more on information about the test and medical aspects. Others underlined the importance of personal values and the impact of choice. Opinions also differ about the adequate scope of NIPT, especially when the test is offered as a first-tier prenatal screening test.


Long-term neurodevelopmental outcome after fetal therapy for congenital lung lesions

Witlox, R; Lopriore, E; Klumper, F; Rijken, M; Oepkes, D; van Klink, J

Leiden University Medical Center, Leiden, The Netherlands

Introduction To evaluate the long-term neurodevelopmental, behavioral and respiratory outcome after fetal therapy for fetal pleural effusion (FPE), congenital cystic adenomatoid malformation (CCAM) and bronchopulmonary sequestration (BPS).

Methods Assessment with standardized tests of the long-term outcome in children with primary hydrothorax, CCAM or BPS treated with either thoraco-amniotic shunt placement or laser ablation of the feeding vessel in BPS at our fetal treatment center (Leiden University Medical Center) between January 2001 and May 2016. The primary outcome was a composite outcome termed severe neurodevelopmental impairment (NDI) including cerebral palsy, cognitive or motor test score <70, bilateral blindness and/or deafness. An ‘overall adverse outcome’ was calculated including perinatal mortality or severe NDI.

Results The long-term neurodevelopmental, behavioral and respiratory outcome of long-term survivors treated with fetal therapy for congenital lung lesions at our center between 2001 and 2016 will be presented.

Conclusion Overall adverse outcome, including perinatal mortality or severe NDI appears high but is mainly due to a high risk of perinatal death. The risk of severe NDI in long-term survivors is within the range of the incidence of NDI reported in case series treated with other fetal therapies (5–10%). Results are however limited by the relatively small sample size which is inherent with the rarity of the disease and the fetal intervention. To reach reliable conclusions, large multicentre studies including an international web-based registry are warranted to prospectively gather outcome data in this high-risk group of children. Only then, parents can be accurately counselled using not only information on survival, but most importantly also information on long-term development in case of survival.


Worsening of the uterine artery Doppler is independently associated with fetal cerebral redistribution

Monaghan, C1,2; Binder, J1,3; Thilaganathan, B1; Carta, S1; Khalil, A1

1Fetal Medicine Unit, St George's Hospital, London, UK; 2Fetal Medicine Unit, Royal Maternity Hospital, Belfast, UK; 3Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria

Introduction Uterine artery pulsatility index (UtA PI) decreases with advancing gestational age (GA). Previous studies have reported a proportion of pregnancies demonstrate worsening of the UtA Doppler. The aim of this study was to examine the change in the UtA mean PI between the second and third trimester on fetal cerebral redistribution.

Methods This cohort study included singleton pregnancies undergoing longitudinal UtA Doppler assessment. Fetal biometry and Dopplers including umbilical artery (UA) and middle cerebral artery (MCA) were recorded. The cerebroplacental ratio (CPR) was determined as the ratio MCA PI/UA PI. The study cohort was divided into two groups according to the change in the UtA Doppler between the two trimesters. Regression analysis was performed to adjust for potential confounders.

Results The analysis included 5887 pregnancies. Women who demonstrated a rise in UtA PI had significantly smaller babies (median BW centile 31.60; IQR 12.19–57.67 versus 40.60; IQR 19.25–66.09, P < 0.001), significantly higher UA mean PI MoM (median 1.10; IQR 0.98–1.22 versus 1.07; IQR 0.96–1.19, P < 0.001), significantly lower MCA PI MoM (median 0.93; IQR 0.84–1.06 versus 0.95; IQR 0.85–1.07; P < 0.001) and a significantly higher proportion of fetuses with low CPR (7.6% versus 4.2%, P < 0.001). Logistic regression analysis demonstrated that CPR MoM (OR 0.61, CI 0.47–0.79; P < 0.001) and BW centile (OR 0.99, CI 0.99–0.99; P < 0.001) were independently associated with the difference in UtA PI between the second and third trimester.

Conclusion Worsening of the UtA Doppler is associated with fetal cerebral redistribution regardless of fetal size.


Bridging the non-invasive prenatal testing gap? Accessing private screening in an NHS teaching hospital

Cohen, K1; Perry, A1; Zeolla, L2; Denman, W2

1Fetomaternal Medicine Unit, Leeds General Infirmary, Leeds, UK; 2Premaitha Health, Manchester, UK

Introduction NIPT is the most sensitive and specific screening test available for trisomies 13, 18 and 21, but is accessible only to those able to self-fund. In the private sector, especially in cases of self-referral, the quality of counselling is highly variable, and screen positive women are usually referred back to the NHS with little support. Women with fetal abnormalities can therefore access NIPT without referral into fetal medicine, losing opportunities for diagnostic testing and appropriate counselling.

Concerns regarding these issues led us to develop a midwife-led NIPT send-away service in partnership with Premaitha Health, providers of the IONA test. We offer a self-pay option on a not-for-profit basis, with all laboratory aspects of the service performed by Premaitha Health.

Methods We implemented a midwifery-led standard operating procedure for NIPT in March 2016. Region-wide educational events were arranged for doctors and midwives. Eligibility criteria and pre-test counselling are standardised. Fetal structural anomalies are referred directly to Fetal Medicine.

Results 189 IONA tests have been performed since March 2016. Mean result turnaround time 4 days. 5 women (2.6%) screened positive for trisomy 21, and 1 low fetal fraction (0.5%) required a redraw. 30/189 (16%) referrals are from outside LTHT catchment areas.

Conclusion Concerns regarding unethical provision of NIPT prompted this development as an alternative to the private sector. Until NIPT becomes available on the NHS for all, there is unavoidable inequality in access. An NHS send-away solution offers an acceptable and cheaper alternative for women who wish a private screening test.


Fetal biometry and estimated fetal weight in the second trimester: A comparison of intra- and inter- observer agreement and variability using ultrasound and magnetic resonance imaging with two-dimensional measurements and three-dimensional whole fetal volume techniques

Matthew, J1,2; Knight, C1,2; Malamateniou, C1; Pasupathy, D1,2; Rutherford, M1,2

1King's College London, London, UK; 2Guy's and St Thomas’ Hospital, London, UK

Ultrasound derived estimated fetal weight (EFW), can result in significant errors at the extremes of weight ranges, impacting the quality of antenatal care and clinical decision making. Previously, MRI volumetry has been used as a more reliable method of calculating EFW in the third trimester. However, there is a paucity of evidence about the validity of fetal MRI biometry and MRI-derived EFW, especially in mid-pregnancy.

25 fetal studies (mean gestational age, 23.5 weeks), with paired scans, were prospectively collected for common biometric measurements and weight estimation, EFWbiometry, obtained by 2 ultrasound and 2 MRI observers. Additionally, 10 cases had an MRI-derived whole fetal volume weight calculated, EFWvolume.

Between the modalities, there were systematic errors of the bi-parietal diameter, femur length (FL), and the MRI EFWvolume (P < 0.05). MRI was more precise than ultrasound for a number of intraobserver measures (head circumference, abdominal circumference, FL and EFWbiometry, P < 0.05), but less precise for some interobserver measures (FL and EFWbiometry, P < 0.05). The MRI volume demonstrated excellent intra- and interobserver agreement. Furthermore, the proportion of cases falling outside a ±5% error threshold was; 0% for MRI EFWvolume and 22% for US EFWbiometry.

This study suggests MRI specific growth charts are required, and that MRI has advantages over ultrasound with further gains likely through operator training. Volumetry is reproducible and precise, nonetheless, refinement of the EFWvolume equation is required. The findings have important implications for the assessment of fetuses at risk of morbidity and mortality due to early growth disturbances or preterm delivery.


Examining the relationship between Doppler ultrasound and HbA1c levels in diabetic pregnancies

McDonnell, B1; Sharkey, L1; Russell, N2; Mulcahy, C3; McAuliffe, F4,5; Higgins, M4,5

1UCD School of Medicine, Dublin, Ireland; 2Cork University Maternity Hospital, Cork, Ireland; 3Midwifery, National Maternity Hospital, Dublin, Ireland; 4UCD Obstetrics and Gynaecology, School of Medicine, Dublin, Ireland; 5The National Maternity Hospital, Dublin, Ireland

Pre-gestational diabetes mellitus (PGDM) is associated with an increased risk of fetal and neonatal morbidity and mortality. The aim of this study was to assess fetal vascular Doppler ultrasound measurements (measured at 30, 33 and 36 gestational weeks) based on glycaemic control in early pregnancy (booking HbA1c).

Serial third trimester ultrasound measurements of 231 pregnancies affected with maternal PGDM were analysed; clinical measurements were recorded including measures of glycaemic control (HbA1c). Umbilical Artery Pulsatility Index (UAPI), Middle Cerebral Artery Pulsatility Index (MCAPI) and Middle Cerebral Artery Peak Systolic Velocity (MCAPSV) measurements at 30, 33 and 36 weeks were studied and compared based on booking HbA1c (<6.5% as a marker of ‘good glycaemic control’ and ≥6.5% as ‘poorer control’). Subgroup analysis was performed based on type of PGDM (Type 1 diabetes (T1DM), n = 167; Type 2 diabetes (T2DM), n = 64).

There was no consistent pattern of significant differences in UAPI, MCAPI and MCAPSV between groups based on booking glycaemic control. Women with HbA1c >6.5% had a statistically significant increased 33 week MCAPI measurements (MCAPI ‘good control’ 1.87 ± 0.263; MCAPI ‘poorer control’ 1.86 ± 0.376; P = 0.02); this difference held in women with T1DM (P < 0.01) but not in T2DM.

No consistent pattern has yet been identified in Doppler ultrasound measurements based on booking glycaemic control in PGDM pregnancies. This study is ongoing.


Quantification of the proteomic signatures underlying human placental vascular maturation

Palmowski, P; Zhang, Z; Taggart, J; Robson, S; Treumann, A; Taggart, M

Newcastle University, Newcastle upon Tyne, UK

Fetal growth is dependent upon the appropriate maturation of the placental vasculature yet the molecular signatures underpinning this process in humans remain unresolved. In an effort to address this, we used a proteome-scale approach (LC-MS-based, label-free quantification of trypsin-treated homogenates using SWATH) to investigate the protein expression changes accompanying placental chorionic plate artery development between 1st (7–12 weeks, n = 9) and 3rd (39–40 weeks, n = 7) trimesters of normal pregnancy (LREC 10/H0906/71). 3586 distinct proteins were quantified on the basis of at least two unique peptides identified per protein. Dynamic regulation of the placental vascular proteome was evident with 1539 proteins differing significantly between 1st and 3rd trimester (t-test with multiple comparison correction, FDR <0.05) and 710 proteins being up-regulated at term. Pathway analysis revealed many notable features to be indicative of vascular maturation. Examples of these were: (1) The down-regulation of molecules key to gene splicing and protein synthesis. These included 41 spliceosome proteins (e.g. top-regulated, ACIN1), 68 ribosomal proteins (e.g. RPL10A) and 18 translation initiation/elongation factors (e.g. ELF4A3). (2) The up-regulation of components of myofilament/cytoskeletal integrity and metabolic-contraction coupling. These included 31 focal adhesion-related proteins (e.g. FLNA), 13 LIM domain proteins (e.g. PDLIM3) and all elements of the glycolytic cascade (e.g. GP1). Our study gives a comprehensive description of the major protein expression changes, and underlying biological processes, associated with human placental vascular maturation. This also provides a valuable resource to investigate if these features are altered in situations of compromised fetal growth.

Supported by a BMFMS bursary.


Can colour difference on the maternal side of the placenta help distinguish between acute peripartum twin-to-twin transfusion syndrome and twin anaemia polycythaemia sequence?

Tollenaar, LSA; Zhao, D; Middeldorp, JM; Slaghekke, F; Oepkes, D; Lopriore, E

Leiden University Medical Center, Leiden, The Netherlands

Introduction Monochorionic twins share a single placenta and are connected to each other trough vascular anastomoses. Unbalanced inter-twin blood transfusion can lead to various complications, including acute peripartum twin-to-twin transfusion syndrome (acute TTTS) and twin anaemia polycythaemia sequence (TAPS). Acute TTTS and TAPS twins have a similar presentation at birth, but require a different therapeutic approach. A quick and easy tool to distinguish between the two conditions is needed.

Objective The objective was to determine the colour intensity difference between two placental shares in monochorionic placentas with acute TTTS and TAPS.

Methods We evaluated all digital pictures of TAPS, acute TTTS and a control group of uncomplicated monochorionic placentas examined at our center. We determined the colour intensity of the individual placental share on the maternal side of each monochorionic placenta using an image-processing program and calculated the color difference ratio (CDR).

Results Digital pictures of 19 TAPS, 4 acute TTTS and 50 uncomplicated monochorionic placentas were included in this study. A CDR value >1.5 was found in all TAPS placentas and in none of the acute TTTS placentas and uncomplicated monochorionic placentas.

Conclusion TAPS placentas have a higher CDR compared to acute TTTS placentas. Examining colour difference between the two placental shares might help distinguish between acute TTTS and TAPS.


Polyhydramnios in isolated oral cleft pregnancies: Incidence and outcome in a retrospective study

Depla, AL1; Breugem, C1; van der Horst, C2; de Heus, R1; van den Boogaard, M-J1; Maas, S2; Pajkrt, E2; Bekker, M1

1University Medical Center Utrecht, Utrecht, The Netherlands; 2Academic Medical Center, Amsterdam, The Netherlands

Introduction Polyhydramnios is suggested to be associated with oral clefts (OC's) due to swallowing problems. In general pregnancies polyhydramnios occurs in 1–2%. This study assessed incidence and outcome of idiopathic polyhydramnios in isolated OC pregnancies.

Methods This was a retrospective cohort study of prenatally diagnosed OC. The incidence of idiopathic polyhydramnios in isolated OC pregnancies was determined. Pregnancy outcome, neonatal and pediatric follow-up were compared between polyhydramnios cases and normal amniotic fluid cases. Subgroup analysis of polyhydramnios incidence in fetuses classified isolated prenatally, with associated anomalies diagnosed after birth.

Results In 230 isolated OC cases, 15 polyhydramnios occurred (6.5%). In the polyhydramnios group, the palate was significantly more involved (87% to 58%, P = 0.03). No significant differences were seen in pregnancy outcome or neonatal and pediatric follow-up. In subgroup analysis, polyhydramnios incidence appeared not significantly different in associated cases that had appeared isolated prenatally (1/27; 3.7%), compared to the isolated cases (15/230; 6.5%).

Conclusion The incidence of idiopathic polyhydramnios in isolated OC pregnancies is 6.5%. Polyhydramnios in isolated OC indicates palate involvement. The presence of polyhydramnios is not associated with adverse perinatal or long-term outcome. If isolated at prenatal assessment, polyhydramnios does not increase the risk of associated anomalies postpartum.


Service evaluation to assess accuracy of identifying fetal cardiac abnormalities between 2010–2015 at Lancashire Women's and Newborn centre

Martindale, E; Torossian, L; Cox, S

Lancashire Women's and Newborn Centre, Burnley, UK

Introduction Antenatal screening for fetal cardiac abnormalities still remains a challenge, with overall detection rates remaining low. The importance of prenatal diagnosis is two fold in that there may be an improvement in postnatal care and outcome, as well as allowing parents time to consider various options as well as prepare for subsequent treatments. The majority of cases are detected by screening the low-risk population at the time of routine obstetric scanning. Standards for doing this are not uniform therefore significant variation exist. The aim of this study was to conduct a service evaluation to assess accuracy of identifying fetal cardiac abnormalities between 2010 and 2015 at Lancashire Women's and Newborn centre.

Methods All patients identified as having cardiac abnormalities antentally, and sent on for tertiary centre assessment, as well as those identified postnatally were reviewed and data collected on maternal age, gestation at diagnosis, risk factors, BMI and correlation of diagnosis.

Results and conclusion A total of 101 cases have been identified and data has been collected but final data analysis to be completed imminently. Analysis will help determine anomaly detection rates, false positives and false negative rates.


TAPS TRIAL: Fetoscopic laser surgery versus care as usual for twin anaemia polycythaemia sequence: An open-label randomized controlled trial

Tollenaar, LSA; Slaghekke, F; Middeldorp, JM; Lopriore, E; Oepkes, D

Leiden University Medical Center, Leiden, The Netherlands

Monochorionic twins share a single placenta and are connected to each other through inter-twin vascular anastomoses, allowing the blood to transfer bi-directionally between the two fetuses. Unbalanced net inter-twin blood transfusion can lead to twin anaemia polycythaemia sequence (TAPS). TAPS is a newly described form of chronic and slow inter-twin blood transfusion characterized by large inter-twin haemoglobin differences without signs of amniotic fluid discordances. TAPS can occur spontaneously or after laser surgery for twin-to-twin transfusion syndrome. Management options include fetoscopic laser surgery of the vascular equator at the placental surface, intra-uterine blood transfusion with or without partial exchange transfusion, selective feticide, delivery and expectant management. The optimal treatment for TAPS is not clear. Preliminary data are based on case reports and small cohort studies. We propose to conduct a multi-center open-label randomized controlled trial to assess if fetoscopic laser surgery improves the outcome of TAPS compared to care as usual. We will randomly assign 130 monochorionic twin pregnancies diagnosed with TAPS between 20 and 28 weeks of gestation to the fetoscopic laser surgery group or the care-as-usual group, using a web-based application with a computer-generated list with random permuted blocks, stratified by gestational age at inclusion (20–24 weeks versus 25–28 weeks) and TAPS type (spontaneous versus post-laser TAPS). The inclusion period will be 2.5–3 years. Primary outcome will be a composite of perinatal mortality and severe neonatal morbidity; secondary outcomes include haematological complications, placental characteristics and long-term neurodevelopmental outcome at a corrected age of 2 years.


‘NIPT for Down syndrome – should I do it?!’ Understanding women's support and information needs on Mumsnet

Budge, E; Samarendra, H; Dhillon, S; Wishlade, T; Kelly, B

Nuffield Department of Obstetrics & Gynaecology, Oxford University, Oxford, UK

Introduction NIPT for Down Syndrome will be available in the NHS by 2018. Improved understanding of women's experiences and expectations of NIPT/screening to address gaps in knowledge is a key part of implementation. The internet and social media are increasingly used by patients seeking information on health matters. In this study, we analysed discussion threads on Mumsnet to understand what women are discussing about NIPT and identify information and support needs.

Methods Consent to conduct this study was sought from the Mumsnet research team. Archived discussion posts from 01/01/2013 to 28/07/2016 were retrieved. A coding framework was developed. Two analyses were performed: (1) content analysis to understand what was discussed and how often; (2) thematic analysis for a richer exploration of information and support needs of women considering or having undergone NIPT. NVivo Version 11 was used for all analyses.

Results 109 discussions (1455 posts) were analysed. Most discussions sought factual information on NIPT, Down Syndrome, risk calculations, cost/access and role of invasive diagnostic testing. Thematic analysis revealed unmet information/support needs in several areas, including: experience of life with a child with Down Syndrome, uncertainty about limitations of NIPT, cost and what to do with a positive screen.

Conclusion Women's use of internet and social media provides useful insight into gaps in knowledge and understanding. Prior to widespread implementation of NIPT across the NHS, there is a need to develop appropriate patient-centred resources to address such gaps. In addition, providers should consider developing online/social media educational resources for accessible information and support.


Antenatal management in fetal and neonatal alloimmune thrombocytopenia: A systematic review

Winkelhorst, D1; Murphy, M2; Greinacher, A3; Bakchoul, T3,4; Massey, E5; Baker, J6; Lieberman, L7; Tanael, S8; Shehata, N9; Hume, H10; Arnold, D11; Baidya, S12; Bertrand, G13; Bussel, J14; Kjaer, M15; Kaplan, C16; Kjeldsen-Kragh, J17; Oepkes, D1; Ryan, G9

1LUMC, Leiden, The Netherlands; 2NHSBT, Oxford, UK; 3University Hospital Greifswald, Greifswald, Germany; 4University of Tuebingen, Tuebingen, Germany; 5NHS Blood and Transplant, London, UK; 6St Micheal's Hospital, Toronto, Canada; 7University of Toronto, Toronto, Canada; 8Canadian Blood Services, Toronto, Canada; 9Mount Sinai Hospital, Toronto, Canada; 10CHU Sainte-Justine, Montreal, Canada; 11McMaster University, Montreal, Canada; 12Australian Red Cross, Melbourne, Australia; 13EFS, Rennes, France; 14Weill Cornell Medical College, New York, USA; 15University Hospital of North Norway, Tromso, Norway; 16Formerly Institut National de la Transfusion Sanguine, Paris, France; 17Regional and University Laboratories Region Skane, Lund, Sweden

Several strategies can be used to manage fetal or neonatal alloimmune thrombocytopenia (FNAIT) in subsequent pregnancies. Serial fetal blood sampling (FBS) and intrauterine platelet transfusions (IUPT), and weekly maternal intravenous immunoglobulin infusion (IVIG), with or without additional corticosteroid therapy are common options, but the optimal management has not been determined. The aim of this systematic review was to assess antenatal treatment strategies for FNAIT. Four randomised controlled trials and twenty-three non-randomised studies were included. Pooling of results was not possible due to considerable heterogeneity. Most studies found comparable outcomes regarding the occurrence of intracranial haemorrhage, regardless of antenatal management strategy applied; FBS, IUPT or IVIG with/without corticosteroids. There is no consistent evidence for the value of adding steroids to IVIG. Fetal blood sampling or intrauterine platelet transfusion resulted in a relatively high complication rate, consisting mainly of preterm emergency caesarean section, 11% per treated pregnancy in all studies combined. Overall, non-invasive management in pregnant mothers who have had a previous neonate with FNAIT is effective without the relatively high rate of adverse outcomes seen with invasive strategies. This systematic review suggests that first line antenatal management in FNAIT is weekly IVIG administration, with or without the addition of corticosteroids.