Abnormal Obstetrical Numbers: A Case Based Approach - HD

Introduction

Hello, my name is Dr. Dolores Pretorius. I'm a professor of radiology at the University of California San Diego.

And I'm gonna talk to you about abnormal obstetrical numbers and what you should think about.

First Case: Symmetrical IUGR

The first case is a 34 week, one day pregnancy.

And look at these numbers and I'll just give you a minute or so to look glance at this 30 seconds maybe and look down at all of them.

First we see the bial diameter, then the OFD, which is the occipital frontal diameter, which I hardly use.

The head circumference, abdominal circumference, femur length.

This one has a tibia and a fibula and a humerus and a radius.

And that's because things were small.

We don't routinely take all those. And then the ulna.

Now you know what they are and you see the percentiles at the far right.

What do you think? First you notice that they're four weeks off from the ultrasound dates to the menstrual dates.

And then we notice that everything else is down.

And we're thinking it's not just one parameter that's down, but all of 'em are down and they're pretty close.

Although the, that radius looks a bit smaller.

And we're thinking, ah, this is likely symmetrical IUGR.

Now she could be off dates a month if you haven't ever done a study before.

But if you've done previous studies, that's really helpful.

And this is what happens the symmetrical IUGR patients, the differential diagnosis includes maternal factors like nutrition, drugs, underlying medical conditions, placental factors like preeclampsia, multiple gestations, uterine anomalies, and fetal factors like chromosomal anomalies and congenital anomalies.

Now this was a 25-year-old G five P four referred for IUGR with multiple abnormalities.

She had a quad screen negative and gestational diabetes at 34 weeks.

Her ultrasound by her menstrual period gave her this dating of 31 weeks.

She had bilateral ventricular magaly and absent cafa septum, lucin and abnormal posterior fossa, she had micrognathia and abnormal nose.

She had an absent stomach bubble, bilateral hydro nephrosis, short right forearm and clenched fists, right club foot and a possible atrial ventricular canal of the heart.

And just for those of you who may not know, micrognathia is a small chin.

So here's the pictures showing the ventricular magaly with those dilated ventricles.

You can see that the ventricle itself measured 22 millimeters.

A normal ventricle is up to 10.

And the choroidal separation from the medial wall to the choroid, which here is measured 10 millimeters and we use a normal of up to about four in our practice.

She has ambiguous genitalia that you can see in the upper left.

She has an overlapping digit on the hand in the upper right and then she has a clubfoot in the lower image.

When we looked at the heart pictures, her three vessel view is abnormal because the pulmonary artery is just a little too big compared to the aorta.

It's supposed to be a little big.

But this one is just too much.

And then she has bilateral hydronephrosis on the images on the right.

And then, a short radius on the image at the bottom.

The neonatal course was that she was born, the fetus was born at 39 weeks with the weight of five pounds 15 ounces.

She was in the ICU for two weeks for respiratory support and feeding difficulties.

She had absence of the corpus callosum.

She had an atrial septal defect and she had bilateral hydro nephrosis.

Her genetic evaluation showed a growth, retarded, infant ous respiration with tongue-based obstruction, a micrognathia small chin ambiguous genitalia with labial hypoplasia and prominent PHAs, a left rock or bottom foot and a pattern of anomalies not typical for trisomy 18.

And it was unclear exactly what syndrome it would be.

Basically our bottom line is it was symmetric IUGR with anomalies.

Now that's much more typical to have IUGR in the second trimester with anomalies in the third trimester.

It's less frequent to be some symmetric, but you can see that it is true in this patient.

Second Case: Asymmetrical IUGR

Now contrast to this patient who came in at 31 weeks, four days and look at these numbers for just a few seconds while I give you a couple minutes.

Now that you know what you're looking at, Notice that the overall growth is only one week behind.

That's not that bad.

But if you look at the specific parameters, the abdominal circumference is less than the second percentile and the other numbers are much more reasonable.

So this is a patient with a differential for a small abdomen, which we would think first might be asymmetrical IUGR.

And secondarily, maybe there's something going on in the belly.

The bowel contents are out and therefore you have a small belly.

So look carefully to make sure nothing's out.

So she was a 29-year-old G two P zero at 26 weeks with renal insufficiency and high blood pressure, admitted for worsening hypertension on her ultrasound at 27 weeks, she had size equal to dates.

She had a weight at the 32 percentile, an estimated fetal weight.

She had an amniotic fluid index of 26 centimeters, which is increased.

She had bilateral uterine artery lodging and she had normal umbilical artery and middle cerebral artery doppler.

So here she was at 27 weeks and you can see that the numbers looked pretty good at 27 weeks.

Everything you know is measuring out fine in the right hand column there.

And she had normal umbilical artery dopplers and middle cerebral artery doppler at that time.

Those the one on the left is the umbilical artery.

One on the right is the middle cerebral artery.

Those are both normal when she, but she did have abnormal uterine artery doppler and she has notching right there where you can see it coming down, where the arrows are.

And that's in comparison to the image on the right, which is a normal, umbilical, I mean a uterine artery doppler.

There's no notching there at all.

There's also a little bit more diastolic flow in the normal one well, so at 31 weeks when she comes back, that's the one that I showed you the pictures for already.

And you see that her estimated fetal weight is at the third 3.8 percentile and her abdomen was little less than the 2.3.

So what happens to her, she's dictated a size less than dates by seven days, but an estimated fetal weight at the fourth percentile.

And now her amniotic fluid index is up to 41, which is markedly elevated for poly hydrous.

Her other doppler were normal, and she had this ultrasound and her, she was 1.5 weeks behind and her abdominal circumference was at 29 weeks.

And then her a FI went up to 48 centimeters and now she gets a mildly elevated umbilical artery doppler and a normal ductus osis waveform and they weren't able to get the middle cerebral artery on this exam.

So here we are at 33 weeks now two weeks later and often we'll follow these patients at about every two weeks when we're worried about them.

So here you see that, the abdomen, the femur and the humerus are all now down below the fifth percentile.

And we look at her umbilical artery doppler and her SD ratio is 4.1, which is a little too high.

I usually remember three at 32.

So someplace around that they should be less than three.

So hers is four.

Now we do her again at 34 weeks and now her a FI is, my gosh, she must have a really big belly.

It's 59 centimeters and her umbilical artery doppler is elevated finally now to an SD ratio of 5.2 to 5.6.

And she has a very hyper coiled umbilical cord.

She was delivered at 34 weeks for super imposed severe preeclampsia via a C-section, 4% of previa.

And she ended up with a male at the ninth percentile weight with a right ear abnormally shaped and they got a dysmorphology genetics consult, because there was a normal karyotype.

Her placenta was small and immature and the cord was inserting at the edge there, a marginal cord insertion and there were lots of twists in the cord.

We usually think of a normal cord as having three or less in a 10 centimeter length of cord.

And this one had six. So it's hyper coiled.

Summary: Symmetric vs. Asymmetric IUGR

This is a nice just summary slide, showing you IUGR growth, intrauterine growth restriction with symmetric versus asymmetric and just summarizing the head size, the abdominal circumference and the skeletal will all be impaired and shorter on the symmetric, whereas in the asymmetric the head will usually be spared and it's the abdomen and the limbs that make it short.

And the symmetric is often from a intrinsic insult like chromosomal anomalies or congenital malformations infection, maternal chemical or drug exposure, whereas the asymmetric ones are often from an external consult, like maternal vascular disease or decreased utero.

Placental perfusion often called placental insufficiency.

Symmetric usually occurs in the second trimester earlier and asymmetric is often in the third trimester.

And as I said before, these can be fetal placental or maternal causes.

Third Case: Macrosomia in Type 1 Diabetes

Okay, the next case is here.

So look at these numbers for just a moment and see what you think.

I want you to notice that the head and the abdomen here are both a little bit big beyond the 97th percentile and the estimated fetal weight is above the 97th percentile.

When you look at the expected dates dating, it's only two weeks.

Big, so it's not that much and it makes us want to go look at the head abdomen circumference, which measures 0.0, 0.91 and normal is from 0.93 to 1.1.

So it's a little small.

I want you to look at the calipers of where we put them on fetal abdomen.

So lots of times I find that sonographers put the calipers too far inside along the ribs.

But really the calipers for the abdominal circumference are meant to measure the soft tissues on the outside.

So we have an idea how much fat there is around this little fetus.

Because when they don't have enough fat, that's when they get growth restricted and when they have too big, they get more fat.

So we always wanna measure on the outside.

So this is a diagnosis of macrosomian.

The history is type one diabetes.

The sonogram was done at 35 weeks, three days and we do most of our diabetics at both 30 and 36 weeks.

At UCSD, This wasn't the abdomen and the estimated fetal weight were greater than the 97th percentile.

She was delivered by C-section at 39 weeks and the neonatal weight was 10 pounds four ounces or 4,600 grams.

So that's a lot we counsel about macrosomian.

Shoulder dystocia risk.

With these types of numbers, if our estimates are that she's diabetic and she has a weight estimate between 4,040 2 49, we're gonna give her a 3% risk.

But if you go up above 5,000 grams, notice that the diabetic we're gonna give her risk of 63% whereas a non-diabetic of 10%.

So it makes a big difference as to whether they're diabetic or not.

We also use, abdominal circumference greater than 37 centimeters and a head abdomen ratio less than 0.91, as risk factors and we counsel them regarding that estimated fetal weight they have, which we know is a plus or minus 15%.

When we talk about whether they should have a C-section or not and whether they might have a risk for accreta, and previa and a VBAC in the future.

The risk for transient injury like an herbs palsy or a fracture of the clavicle is like 10% and a permanent injury about 2%.

And then also there's the injury to the mom of vaginal perineal or uterine rupture.

Fourth Case: Macrosomia and Beckwith-Wiedemann Syndrome

Okay, so the next case, look at this one and see what you think.

We notice that it's just a little bit big, not that much, not even a full week.

And yet the overall percentiles give us 96 percentile and we look at the abdominal circumference and it's a little bit big.

It's the thing definitely pulling up this estimated fetal weight I find in the second trimester that the percentiles aren't quite as good as they are in the third trimester and sometimes we'll follow people with abnormal percentiles but they have to be pretty abnormal for us to follow from the second trim trimester.

So this one shows I'm showing you these normal kidneys with no hydronephrosis and I'm showing you this normal abdominal cord insertion because at delivery this fetus is gonna have an EM falle and so it's pretty amazing that it looks so normal at this point.

There is a filamentous cord insertion on this cord coming in at the edge of the placenta at the bottom here, right there.

So she was referred for genetic screening and she had an ultrasound at 12 weeks that showed really good risk factors for her normal nuchal translucency with a trisomy 21 risk of one in 1002 and one in 2,600 and a trisomy 18 risk of one in 42,000.

She had a marginal cord insertion identified and she was otherwise screen negative at 20 weeks.

She has now that her cord insertion has progressed and evolved from a marginal to a mentis, but everything else looked great and she was size equal dates.

We scan her again at 30 weeks and we see that she's a little big greater than the 90th percentile here and two, almost three weeks ahead.

And then you look at her abdominal circumference and it's greater than 97th percentile, no hydro nephrosis vous cord insertion and then this macrosomic profile.

So we follow up at 30 weeks and we get this 97th percentile and we recommend a correlation with a diabetic screen and follow up in three weeks.

And her diabetic screening had been negative before so we recommend a follow up at 36 weeks and she has this persistent macrosomic growth profile and no hydronephrosis.

So here she is at that 36 weeks and notice that just a week ahead overall and yet her abdomen circumference is really greater than the 98th percentile as is her estimated fetal weight.

So she has a vaginal delivery at 37 weeks with mild shoulder dystocia.

Her weight is 46 10 grams with Apgars of five and nine.

She has a large protruding tongue and she has a fissure noted in her left ear, a shallow ear pit on the right and she has hepatomegaly with liver edge palpable at two centimeters below the embolus.

She has a large amount of Wharton's jelly, a small and falle and hypoglycemia and there's a picture of this tongue sticking out.

And this turns out to be beckworth wheatman syndrome with this very long cord with a knot in it and a development discord insertion.

And there you see it's right there at the edge of this placenta.

So she had an ultrasound after birth, showing mild left hydronephrosis with increased renal echogenicity bilaterally with mildly echogenic kidneys.

And she has, enlargement of all of her abdominal organs and she has no evidence of reflux on her reflux study her VCUG and she has an enlarged liver.

So here's her kidneys which are measuring 6.7 centimeters and normal kidneys at birth are four to five centimeters.

She's got mild hydro nephrosis on the left.

She has an increased spleen that's right there at the top.

It's 4.6 centimeters and normal it's up to 4.5 so it's just borderline.

And then her liver is measuring 5.8 at this, no it's measuring 7.1 and hers.

The normal length is 5.8.

So both of them just a little bit big.

She ends up with beckworth Weideman syndrome as I said, and she had a repair for an EM falle on day five and did well.

Now the incidence of Beckworth Weedman syndrome is one in 13,700.

It's an older overgrowth disorder with a preposition, a predeposition to umbral tumors.

It's caused by epigenetic and genetic alterations that affect expression of the imprinted genes on chromosome 11.

It's 85% of sporadic and 15% are familial and it's often associated with infertility.

The major findings here, you see abdominal wall defects, which we had in this patient, a large tongue macroglossia, macro somia, yes we got that big baby abnormal ears like this baby had and enlargement of the organs like we had the liver, spleen, kidneys, tumors in childhood, hemi hyperplasia, abnormal adrenal, we won't see that.

The renal abnormalities sometimes and a family history possible and cleft palate.

Fifth Case: Gastroschisis

Okay, next case. Look at this for a moment and you'll notice that the overall growth is not that delayed.

It's the estimated fetal weight is at the 15th percentile, but the abdomen is small.

So what do we do with a small abdominal circumference?

We think about asymmetric IUGR that I've already talked to you about.

We think about abdominal wall defects, amniotic band syndrome and limb body wall defect.

So this is a picture of the abdomen.

You can see the abdominal circumference, you don't see anything wrong on the top left picture and yet when you go down just a little bit to the abdominal cord insertion that we see going into this abdomen, with the color you can see bowel immediately adjacent to it and that is a case of gastroschisis.

This is, a little pericardial effusion adjacent to the heart.

This binds over to the left on this, it mentions a transverse of the four chamber view.

And this was an 18-year-old, which we do have more cases of gastric GEs in our teenagers.

We're not exactly sure why.

Some people think it's due to fast food.

The estimated fetal weight is often small on these because the bowel contents are out.

So calling IUGR is hard.

Her amniotic fluid index was normal.

Her dopplers were normal.

She had multiple gas, loops out with several other findings worrying US about possible limb body wall.

She had mildly shortened femurs and humerus and that pericardial effusion bothered us and her cord length was markedly reduced.

She did not do any screening for genetics, initially, but later she decided to do it and we got a normal karyotype and a positive acet cholinesterase, which is a test we often think of as specific for neural tube defects, but it's also positive in abdominal wall defects.

She had a normal fetal echo and an ultrasound at 32 weeks showed that she was three weeks behind her growth and worrisome for IUGR.

So here's that study where you look at this in her abdominal circumferences against mal and these are her, bowel loops that are dilated and have debris in them.

And here is some debris in the amniotic cavity as well.

She presented at 33 weeks with decreased fetal movement and she had a fetal demise with a stillborn in front of Gastroschisis.

There was a study that I was a part of from the University of California Fetal Consortium, which includes all of the University of California campuses and they had 191 cases of gastric GEs.

And you can see here that the neonates with adverse outcome was 14%.

And the most common things they can get into trouble with is intestinal atresia or, necrotizing enterocolitis and very rarely death of 1.6%.

Like in this case, This was another study of 80 cases.

And the only things that correlated with the IUGR were hyper peristalsis and IUGR, leading to, adverse outcomes that had statistical significance.

Sixth Case: Enlarged Abdominal Circumference and Posterior Urethral Valves

Okay, here's our next case.

Notice the abdominal circumference is enlarged.

So when you see a big abdominal circumference, what should you think about?

You should think about macrosomian.

You should think about abdominal pathology.

Is there ascites? Are the organs large in there?

Is there bowel obstruction? Is there renal obstruction?

So look at this. This patient has these pictures.

So the top left is a picture showing oligohydramnios with the head and the spine.

The picture on the right is a picture of a cystic fluid collection filling up nearly the entire abdomen.

The spine is over on the right in that cross-sectional picture.

And there are also two pictures showing, I mean two measurements, measuring 0.65 centimeters on the right and 0.48 on the left.

That's the, hydronephrosis of the kidneys.

We try to get the longitudinal through those kidneys in the bottom left and it's kind of hard to see them.

Then the bottom right is turning on color doppler and seeing the flow around the bladder.

Those are the hypogastric arteries that are equivalent to our uterine art, our umbilical arteries.

So that proves that this is the urinary bladder.

So this was a 26-year-old Ethiopian female who was referred for an elevated, maternal serum, a FP at 18 weeks.

She had this large cystic mass in the fetal abdomen that had a keyhole appearance.

She had no fluid around it and hydros, she had mild pelviectasis and a thoracic circumference at the seventh percentile.

So because of this we thought this is likely posterior urethral valves with a dilated bladder.

She was offered no intervention termination or scopic surgery and she elected no intervention.

Now the keyhole sign we talk about all the time as being associated with posterior urethra valves, but I just wanna point out to you this paper that shows that just because you have a keyhole doesn't mean it has to be the bladder, from valves.

And it really can be from many other things as well, like reflux, like, prune belly and primary mega ureter.

So think keyhole. Thank you very much.