An innovative virtual reality technique for automated human embryonic volume measurements

Periconceptional maternal supplement intake and human embryonic growth, development, and birth outcomes: the Rotterdam Periconception Cohort

STUDY QUESTION

Is periconceptional multiple-micronutrient supplement (MMS) use including folic acid (FA) compared to FA use only associated with increased embryonic growth, development, and birth weight in a high-risk population?

SUMMARY ANSWER

Women with MMS intake show no significant differences in first-trimester morphological embryo development, but increased first-trimester embryonic growth trajectories and fewer neonates born small for gestational age (SGA), less than the 3rd percentile (

WHAT IS KNOWN ALREADY

Periconceptional maternal FA intake in the general population is associated with increased embryonic and fetal growth, and reduced risks of neural tube defects, other congenital malformations, low birth weight, and neonates born SGA.

STUDY DESIGN, SIZE, DURATION

A prospective tertiary hospital-based cohort study (the Rotterdam Periconceptional Cohort) was conducted from January 2010 to December 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included 1076 women from the Rotterdam Periconceptional Cohort, before 10 weeks of pregnancy with follow-up until delivery. Embryonic growth was assessed by measurement of crown-rump length (CRL) and embryonic volume (EV), and embryonic morphology was described by Carnegie stages using longitudinal three-dimensional ultrasound scans and virtual reality techniques. Birth outcomes were extracted from medical records. General characteristics and supplement use were extracted from research questionnaires.

MAIN RESULTS AND THE ROLE OF CHANCE

This study showed increased embryonic growth trajectories (adjusted models, CRL: β = 0.052, 95% CI 0.012-0.090, EV: β = 0.022, 95% CI 0.002-0.042) in women using MMS compared to those using only FA. Moreover, a 45% reduced risk of a neonate-born SGA (

LIMITATIONS, REASONS FOR CAUTION

Following the heterogeneity of the composition and dose of MMS preparations, it is unclear which specific micronutrient, combination, or dose explains the increased embryonic growth trajectory and reduction in risk for SGA. This also hampers the possibility of differentiating between the effects of FA alone or as a component of MMS.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings emphasize the importance of periconceptional maternal MMS use as a potential preventative intervention against reduced embryonic growth and neonates born SGA. Therefore, we recommend the periconceptional use of MMS in women at risk of inadequate micronutrient intake. However, awareness of potentially harmful side effects of high doses and combinations of micronutrients is essential, therefore the optimal composition and dose need to be investigated, and careful surveillance is recommended.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by the Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands, and the ZonMw grant Open Competition 2018 (09120011910046). The authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

NTR4356.

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Key Words

• birth weight
• embryo
• maternal supplement intake
• multivitamins
• pregnancy

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MESH Headings Collapse

Grants

• 09120011910046 Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center

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Affiliation(s)

N Schenkelaars Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
S Schoenmakers Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
M Rousian Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
S P Willemsen Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
M M Faas Department of Pathology and Medical Biology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
R P M Steegers-Theunissen Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands

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First trimester maternal tryptophan metabolism and embryonic and fetal growth: the Rotterdam Periconceptional Cohort (Predict Study)

STUDY QUESTION

What is the association between first trimester maternal tryptophan (TRP) metabolites and embryonic and fetal growth?

SUMMARY ANSWER

Higher 5-hydroxytryptophan (5-HTP) concentrations are associated with reduced embryonic growth and fetal growth and with an increased risk of small-for-gestational age (SGA), while higher kynurenine (KYN) concentrations are associated with a reduced risk of SGA.

WHAT IS KNOWN ALREADY

The maternal TRP metabolism is involved in many critical processes for embryonic and fetal growth, including immune modulation and regulation of vascular tone. Disturbances in TRP metabolism are associated with adverse maternal and fetal outcomes.

STUDY DESIGN, SIZE, DURATION

This study was embedded within the Rotterdam Periconceptional Cohort (Predict Study), an ongoing prospective observational cohort conducted at a tertiary hospital from November 2010 onwards.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 1115 women were included before 11 weeks of gestation between November 2010 and December 2020. Maternal serum samples were collected between 7 and 11 weeks of gestation, and TRP metabolites (TRP, KYN, 5-HTP, 5-hydroxytryptamine, and 5-hydroxyindoleacetic acid) were determined using a validated liquid chromatography (tandem) mass spectrometry method. Serial 3D ultrasound scans were performed at 7, 9, and 11 weeks of gestation to accurately assess features of embryonic growth, including crown-rump length (CRL) and embryonic volume (EV) offline using virtual reality systems. Fetal growth parameters were retrieved from medical records and standardized according to Dutch reference curves. Mixed models were used to assess associations between maternal TRP metabolites and CRL and EV trajectories. Linear and logistic regression models were utilized to investigate associations with estimated fetal weight (EFW) and birthweight, and with SGA, respectively. All analyses were adjusted for potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

Maternal 5-HTP concentrations and the maternal 5-HTP/TRP ratio were inversely associated with embryonic growth (5-HTP, √CRL: β = -0.015, 95% CI = -0.028 to -0.001; 5-HTP 3√EV: β = -0.009, 95% CI = -0.016 to -0.003). An increased maternal 5-HTP/TRP ratio was also associated with lower EFW and birthweight, and with an increased risk of SGA (odds ratio (OR) = 1.006, 95% CI = 1.00-1.013). In contrast, higher maternal KYN concentrations were associated with a reduced risk of SGA in the unadjusted models (OR = 0.548, 95% CI = 0.320-0.921).

LIMITATIONS, REASONS FOR CAUTION

Residual confounding cannot be ruled out because of the observational design of this study. Moreover, this study was conducted in a single tertiary hospital, which assures high internal validity but may limit external validity.

WIDER IMPLICATIONS OF THE FINDINGS

The novel finding that maternal 5-HTP concentrations are associated with a smaller embryo and fetus implies that disturbances of the maternal serotonin pathway in the first trimester of pregnancy are potentially involved in the pathophysiology of fetal growth restriction. The association between higher maternal KYN concentrations and a reduced risk of SGA substantiate the evidence that the KYN pathway has an important role in fetal growth. More research is needed to delve deeper into the potential role of the maternal TRP metabolism during the periconception period and pregnancy outcome for mother and offspring.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Department of Obstetrics and Gynecology and the Department of Clinical Chemistry of the Erasmus MC, University Medical Center, Rotterdam, the Netherlands. The authors have no competing interests to disclose.

TRIAL REGISTRATION NUMBER

N/A.

Discrepancies in Embryonic Staging: Towards a Gold Standard

For over half a century, the Carnegie staging system has been used for the unification of chronology in human embryo development. Despite the system's establishment as a "universal" system, Carnegie staging reference charts display a high level of variation. To establish a clear understanding for embryologists and medical professionals, we aimed to answer the following question: does a gold standard of Carnegie staging exist, and if so, which set of proposed measures/characteristics would it include? We aimed to provide a clear overview of the variations in published Carnegie staging charts to compare and analyze these differences and propose potential explanatory factors. A review of the literature was performed, wherein 113 publications were identified and screened based on title and abstract. Twenty-six relevant titles and abstracts were assessed based on the full text. After exclusion, nine remaining publications were critically appraised. We observed consistent variations in data sets, especially regarding embryonic age, varying as large as 11 days between publications. Similarly, for embryonic length, large variations were present. These large variations are possibly attributable to sampling differences, developing technology, and differences in data collection. Based on the reviewed studies, we propose the Carnegie staging system of Prof. Hill as a gold standard amongst the available data sets in the literature.

Fetal Hands: A Comprehensive Review of Prenatal Assessment and Diagnosis Over the Past 40 Years

Fetal skeletal dysplasias involving limbs and hands are rare congenital malformations. Prenatal two-dimensional ultrasound diagnosis of fetal limb defects has a sensitivity of about 30%; however, an increased detection rate may be obtained using three-dimensional (3-D) ultrasound in the rendering mode. 3-D ultrasound may be used as a complementary method providing additional information. Currently, magnetic resonance imaging (MRI), with the emergence of ultrafast imaging techniques and new sequences, allows for better diagnosis of several fetal skeletal dysplasias such as limb reduction defects and neuromuscular disorders. 3-D volumetric images from ultrasound or MRI scan data allow 3-D ultrasound reconstructions of virtual/physical models, and virtual reality can help researchers to improve our understanding of both normal and abnormal fetal limb/hand anatomy. In this article, we review the embryological development of fetal hands and their main anomalies including prenatal diagnostic methods, genetic counseling, the role of orthopedic and plastic surgery reconstruction, and new perspectives in fetal surgery.

Periconceptional Maternal Protein Intake from Animal and Plant Sources and the Impact on Early and Late Prenatal Growth and Birthweight: The Rotterdam Periconceptional Cohort

Plant-based diets continue to rise in popularity, including among women of reproductive age, while consequences for pregnancy outcomes have hardly been studied. During pregnancy, maternal diet is the only source of proteins for the developing fetus. Hence, we investigated the effects of periconceptional maternal animal and plant protein intake on prenatal growth and birthweight. 501 pregnancies were included from the prospective Rotterdam Periconceptional Cohort. Embryonic growth was depicted by crown-rump length (CRL) and embryonic volume (EV) at 7, 9 and 11 weeks using 3D ultrasound scans. Estimated fetal weight (EFW) at 20 weeks and birthweight were retrieved from medical records and standardized. Multivariable mixed models were used for CRL and EV trajectories, and linear regression for EFW and birthweight. A 10 g/day higher maternal animal protein intake was positively associated with increased embryonic growth (CRL: β = 0.023 √mm, p = 0.052; EV: β = 0.015 ∛cm, p = 0.012). A positive association, albeit non-significant, was found between maternal animal protein intake and EFW, and birthweight. No clear associations emerged between maternal plant protein intake and prenatal growth and birthweight, with effect estimates close to zero. In conclusion, maternal animal protein intake during the periconception period was positively associated with early and late prenatal growth and birthweight, while no associations were found between maternal plant protein intake and prenatal growth and birthweight.

Innovative approach for first‐trimester fetal organ volume measurements using a Virtual Reality system: The Generation R Next Study

Introduction

To investigate the reproducibility of first‐trimester fetal organ volume measurements using three‐dimensional (3D) ultrasound and a Virtual Reality system.

Methods

Within a population‐based prospective cohort study, 3D ultrasound datasets of 25 first‐trimester fetuses were collected by three sonographers. We used the V‐scope application to perform Virtual Reality volume assessments of the fetal heart, lungs, and kidneys. All measurements were performed by two independent researchers.

Results

Intraobserver analyses for volume measurements of the fetal heart, lungs, and kidneys showed intraclass correlation coefficients ≥0.86, mean differences ≤8.3%, and coefficients of variation ≤22.8%. Interobserver analyses showed sufficient agreement for right lung volume measurements, but consistent measurement differences between observers for left lung, heart, and kidney volume measurements (p‐values <0.05).

Conclusion

We observed sufficient intraobserver reproducibility, but overall suboptimal interobserver reproducibility for first‐trimester fetal heart, lung, and kidney volume measurements using an innovative Virtual Reality approach. In the current stage, these measurements might be promising for the use in research settings. The reproducibility of the measurements might be further improved by novel post‐processing algorithms.

Periconceptional maternal body mass index and the impact on post-implantation (sex-specific) embryonic growth and morphological development

OBJECTIVE

Women with obesity have an increased risk of pregnancy complications. Although complications generally present in the second and third trimester of pregnancy, most of them develop in the periconception period. Moreover, fetal sex also impacts pregnancy course and outcome. Therefore, our aim is to study (sex-specific) associations between periconceptional maternal body mass index (BMI) and embryonic growth and morphological development.

METHODS

A total of 884 women with singleton pregnancies were selected from the Rotterdam Periconception Cohort, comprising 15 women with underweight, 483 with normal weight, 231 with overweight and 155 with obesity. Longitudinal three-dimensional ultrasound examinations were performed at 7, 9, and 11 weeks of gestation for offline measurements of crown-rump length (CRL), embryonic volume (EV), and Carnegie stages. Analyses were adjusted for maternal age, parity, ethnicity, education, and periconceptional lifestyle.

RESULTS

A negative trend was observed for embryos of women with obesity (β_EV -0.03, p = 0.086), whereas embryonic growth and developmental trajectories in women with overweight were comparable to those with normal weight. Maternal underweight was associated with faster morphological development (β_Carnegie 0.78, p = 0.004). After stratification for fetal sex, it was demonstrated that female embryos of underweight women grow and morphologically develop faster than those of normal weight women (β_EV 0.13, p = 0.008; β_Carnegie 1.39, p < 0.001), whereas female embryos of women with obesity grow slower (β_EV -0.05, p = 0.027).

CONCLUSION

We found that periconceptional maternal underweight is associated with faster embryonic growth, especially in females. In contrast, female embryos of women with obesity grow slower than female embryos of women with normal weight. This may be the result of altered female adaptation to the postnatal environment. Future research should focus on strategies for optimizing preconceptional maternal weight, to reduce BMI-related pregnancy complications and improve the health of future generations.

First-trimester maternal haemodynamic adaptation to pregnancy and placental, embryonic and fetal development: the prospective observational Rotterdam Periconception cohort

Objective

To investigate whether first‐trimester maternal haemodynamic adaptation impacts placental, embryonic and fetal development as well as birth outcomes in pregnancies with and without placenta‐related complications.

Design

Prospective observational cohort.

Setting

A Dutch tertiary hospital.

Population

Two hundred and fourteen ongoing pregnancies.

Methods

At 7, 9 and 11 weeks of gestation, we assessed maternal haemodynamic adaptation (mean arterial blood pressure [MAP], uterine artery [UtA] blood flow) and placental development (placental volume [PV], uteroplacental vascular volume [uPVV]) using three‐dimensional power Doppler ultrasound volumes, and embryonic development (crown–rump length, embryonic volume). At 22 and 32 weeks of gestation, fetal development was assessed by estimated fetal weight. Birth outcomes (birthweight, placental weight) were extracted from medical records. Linear mixed modelling and linear regression analyses were applied.

Main outcome measures

Birthweight centile and placental weight.

Results

In placenta‐related complications (n= 55, 25.7%), reduced haemodynamic adaptation, i.e. higher UtA pulsatility index (PI) and resistance index (RI) trajectories, was associated with smaller increase in PV (β = −0.559, 95% CI −0.841 to −0.278, P< 0.001; β = −0.579, 95% CI −0.878 to −0.280, P< 0.001) and uPVV trajectories (UtA PI: β = −0.301, 95% CI −0.578 to −0.023, P= 0.034). At birth, reduced haemodynamic adaptation was associated with lower placental weight (UtA PI: β = −0.502, 95% CI −0.922 to −0.082, P= 0.022; UtA RI: β = −0.435, 95% CI −0.839 to −0.032, P= 0.036). In pregnancies without placenta‐related complications, higher MAP trajectories were positively associated with birthweight centile (β = 0.398, 95% CI 0.049–0.748, P= 0.025).

Conclusions

Reduced first‐trimester maternal haemodynamic adaptation impacts both placental size and vascularisation and birthweight centile, in particular in pregnancies with placenta‐related complications.

Tweetable abstract

Reduced first‐trimester maternal haemodynamic adaptation to pregnancy impairs early placental development.

First trimester fetal proportion volumetric measurements using a Virtual Reality approach

OBJECTIVE

To establish feasibility and reproducibility of fetal proportion volumetric measurements, using three-dimensional (3D) ultrasound and a Virtual Reality (VR) system.

METHODS

Within a population-based prospective birth cohort, 3D ultrasound datasets of 50 fetuses in the late first trimester were collected by three ultrasonographers in a single research center. V-scope software was used for volumetric measurements of total fetus, extremities, head-trunk, head, trunk, thorax, and abdomen. All measurements were performed independently by two researchers. Intraobserver and interobserver reproducibility were analyzed using Bland and Altman methods.

RESULTS

Intraobserver and interobserver analyses of volumetric measurements of total fetus, head-trunk, head, trunk, thorax and abdomen showed intraclass correlation coefficients above 0.979, coefficients of variation below 7.51% and mean difference below 3.44%. The interobserver limits of agreement were within the ±10% range for volumetric measurements of total fetus, head-trunk, head and trunk. The interobserver limits of agreement for extremities, thorax and abdomen were -26.09% to 4.77%, -14.14% to 10.00% and -14.47% to 8.83%, respectively.

CONCLUSION

First trimester fetal proportion volumetric measurements using 3D ultrasound and VR are feasible and reproducible, except volumetric measurements of the fetal extremities. These novel volumetric measurements may be used in future research to enable detailed studies on first trimester fetal development and growth.

IVF with or without ICSI and the impact on human embryonic brain development: the Rotterdam Periconceptional Cohort

STUDY QUESTION

Does IVF with or without ICSI (IVF/ICSI) treatment impact the development of embryonic brain structures?

SUMMARY ANSWER

Our results show associations between IVF/ICSI treatment, smoking and slightly increased sizes of early human embryonic brain structures.

WHAT IS KNOWN ALREADY

The number of IVF/ICSI procedures is increasing worldwide and is associated with higher risks of obstetric and perinatal complications in pregnancies.

STUDY DESIGN, SIZE, DURATION

One hundred seventy-five women with a singleton pregnancy were included in the Rotterdam Periconceptional Cohort (Predict study).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Self-reported questionnaires, verified by a research assistant at enrollment, provided information on periconceptional maternal characteristics and mode of conception. Three-dimensional ultrasound (3D-US) examinations were performed at 9 and 11 weeks of gestational age (GA). Diencephalon total diameter (DTD), mesencephalon total diameter (MTD) and telencephalon thickness on the left and right site (TTL/TTR) were measured offline in standardized planes using 4D View software. Linear regression models with adjustment for GA, maternal age, body mass index, moment of initiation of folic acid supplement use and smoking were used to study associations between mode of conception and embryonic brain measurements at 9 and 11 weeks of GA.

MAIN RESULTS AND ROLE OF CHANCE

A total of 276 3D-US scans of 166 participants, of which 50 conceived through IVF/ICSI, were included for embryonic brain measurements. Success rates of the DTD and MTD measurements were between 67% and 73% and of the TTL/TTR between 52% and 57%. In the fully adjusted model, we found that at 11 weeks of GA, the MTD (ß = 0.264, 95% CI = 0.101; 0.427, P < 0.01) and TTR (ß = 0.075, 95% CI = 0.001; 0.149, P < 0.05) sizes were larger in IVF/ICSI pregnancies. In addition, smoking also resulted in larger TTL measurements at 11 weeks of GA (ß = 0.095, 95% CI= 0.005; 0.186, P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

The implications of these small deviations on brain functioning need further investigation.

WIDER IMPLICATIONS OF THE FINDINGS

Enlargement of attention for prenatal brain development and postnatal neurodevelopmental outcome after IVF/ICSI treatment.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by the Department of Obstetrics and Gynecology, Erasmus MC, and Sophia research foundation for Medical Research, Rotterdam, the Netherlands (SSWO grant number 644). No competing interests are declared.

TRIAL REGISTRATION NUMBER

N/A

Prenatal growth trajectories and birth outcomes after frozen-thawed extended culture embryo transfer and fresh embryo transfer: the Rotterdam Periconception Cohort

RESEARCH QUESTION

Are there differences in prenatal growth trajectories and birth outcomes between singleton pregnancies conceived after IVF treatment with frozen-thawed extended culture embryo transfer at day 5, fresh embryo transfer at day 3 or naturally conceived pregnancies?

DESIGN

From a prospective hospital-based cohort, 859 singleton pregnancies were selected, including 133 conceived after IVF with frozen-thawed embryo transfer, 276 after fresh embryo transfer, and 450 naturally conceived pregnancies. Longitudinal 3D ultrasound scans were performed at 7, 9 and 11 weeks of gestation for offline crown-rump length (CRL) and embryonic volume measurements. Second trimester estimated fetal weight was based on growth parameters obtained during the routine fetal anomaly scan at 20 weeks of gestation. Birth outcome data were collected from medical records.

RESULTS

No differences regarding embryonic growth trajectories were observed between frozen-thawed and fresh embryo transfer. Birthweight percentiles after fresh embryo transfer were lower than after frozen-thawed embryo transfer (38.0 versus 48.0; P = 0.046, respectively). The prevalence of non-iatrogenic preterm birth (PTB) was significantly lower in pregnancies resulting from fresh embryo transfer compared with frozen-thawed embryo transfer (4.7% versus 10.9%; P = 0.026, respectively). Compared with naturally conceived pregnancies, birthweight percentiles and percentage of non-iatrogenic PTB were significantly lower in pregnancies after fresh embryo transfer and gestational age at birth was significantly higher.

CONCLUSIONS

This study shows that embryonic growth is comparable between singleton pregnancies conceived after fresh and frozen-thawed embryo transfer. The lower relative birthweight and PTB rate in pregnancies after fresh embryo transfer than after frozen-thawed embryo transfer and naturally conceived pregnancies warrants further investigation.

First-trimester utero-placental (vascular) development and embryonic and fetal growth: The Rotterdam periconception cohort

INTRODUCTION

Impaired placental development is a major cause of fetal growth restriction (FGR) and early detection will therefore improve antenatal care and birth outcomes. Here we aim to investigate serial first-trimester ultrasound markers of utero-placental (vascular) development in association with embryonic and fetal growth.

METHODS

In a prospective cohort, we periconceptionally included 214 pregnant women. Three-dimensional power Doppler ultrasonography at 7, 9 and 11 weeks gestational age (GA) was used to measure placental volumes (PV) and basal plate surface area by Virtual Organ Computer-aided AnaLysis™, and utero-placental vascular volume (uPVV), crown-rump length (CRL) and embryonic volume (EV) by a V-scope volume rendering application. Estimated fetal weight (EFW) was measured by ultrasound at 22 and 32 weeks GA and birth weight percentile (BW) was recorded. Linear mixed models and regression analyses were applied and appropriately adjusted. All analyses were stratified for fetal sex.

RESULTS

PV trajectories were positively associated with CRL (β_adj = 0.416, 95%CI:0.255; 0.576, p < 0.001), EV (β_adj = 0.220, 95%CI:0.058; 0.381, p = 0.008) and EFW (β_adj = 0.182, 95%CI:0.012; 0.352, p = 0.037). uPVV trajectories were positively associated with CRL (β_adj = 0.203, 95%CI 0.021; 0.384, p = 0.029). In girls, PV trajectories were positively associated with CRL (p < 0.001), EV (p = 0.018), EFW (p = 0.026), and uPVV trajectories were positively associated with BW (p = 0.040). In boys, positive associations were shown between PV trajectories and CRL (p = 0.002), and between uPVV trajectories and CRL (p = 0.046).

DISCUSSION

First-trimester utero-placental (vascular) development is associated with embryonic and fetal growth, with fetal sex specific modifications. This underlines the opportunity to monitor first-trimester placental development and supports the associations with embryonic and fetal growth.

The impact of the origin of surgical sperm retrieval on placental and embryonic development: The Rotterdam Periconception cohort

BACKGROUND

In patients with azoospermia, pregnancy can be achieved after surgical techniques using sperm retrieved from the testis or epididymis, which can impact on DNA integrity and epigenetics. DNA of the fetus and placenta is equally derived from both parents; however, genes important for placental development are expressed from the paternal alleles. Therefore, the origin of sperm may affect fetal and placental development.

OBJECTIVES

To investigate whether first-trimester trajectories of embryonic and placental development of pregnancies conceived after intracytoplasmic sperm injection (ICSI) with testicular sperm extraction (TESE) or microsurgical epididymal sperm aspiration (MESA), are different from pregnancies after ICSI with ejaculated sperm or natural conceptions.

MATERIALS AND METHODS

A total of 147 singleton ICSI pregnancies, including pregnancies conceived after TESE (n = 23), MESA (n = 25) and ejaculated sperm (n = 99), and 380 naturally conceived and 140 after IVF treatment without ICSI were selected from the prospective Rotterdam periconception cohort. Crown-rump length (CRL), embryonic volume (EV), Carnegie stages, and placental volume (PV) at 7, 9, and 11 weeks of gestation were measured using 3D ultrasound and virtual reality technology.

RESULTS

Linear mixed model analysis showed no differences in trajectories of CRL, EV, and Carnegie stages between pregnancies conceived after ICSI with testicular, epididymal, and ejaculated sperm. A significantly positive association was demonstrated for PV between pregnancies conceived after TESE-ICSI (adjusted beta: 0.28(95%CI: 0.05-0.50)) versus ICSI with ejaculated sperm. Retransformation to original values showed that the PV of pregnancies after TESE-ICSI is 14.6% (95%CI: 1.4%-25.5%) larger at 11 weeks of gestation compared to ICSI pregnancies conceived with ejaculated sperm.

DISCUSSION AND CONCLUSION

Here we demonstrate that the first-trimester growth trajectory of the placenta is increased in pregnancies conceived after TESE-ICSI compared to those conceived after ICSI with ejaculated sperm. Findings are discussed in the light of known differences in sperm DNA integrity, epigenetics, and placental gene expression.

The Impact of Neighbourhood Deprivation on Embryonic Growth Trajectories: Rotterdam Periconception Cohort

Background: Neighbourhood deprivation is a risk factor for impaired health and adverse pregnancy outcomes. We investigated whether living in a deprived neighbourhood is associated with embryonic growth. Methods: From the Predict cohort, we studied 566 women who underwent repeated first trimester ultrasound examinations. Crown rump length (CRL; n = 1707) and embryonic volume (EV; n = 1462) were measured using three-dimensional techniques. Neighbourhood deprivation was assessed using the neighbourhood status scores (NSS) of the Dutch Social Cultural Planning office. A high NSS represents a non-deprived neighbourhood. Associations between the NSS and embryonic growth were investigated using linear mixed models. Adjustment was performed for individual-level factors: maternal age, geographic origin, educational level, BMI, folic acid supplement use, fruit and vegetable intake, alcohol use and smoking habits. Results: The NSS was negatively associated with embryonic growth: a higher score (a less deprived neighbourhood) was associated with a smaller CRL and EV; adjusted β: −0.025 (95% CI −0.046, −0.003) and adjusted β: −0.015 (95% CI −0.026, −0.003). At 11 weeks of pregnancy, we observed a 0.55 cm³ smaller EV (7.65 cm³ vs. 7.10 cm³) and 1.08 mm smaller CRL (43.14 mm vs. 42.06 mm) in the highest compared to the lowest category. Conclusion: In deprived neighbourhoods, embryos are larger than in non-deprived neighbourhoods.

Does the father matter? The association between the periconceptional paternal folate status and embryonic growth

OBJECTIVE

To study the association between periconceptional paternal folate status and embryonic growth trajectories in early pregnancy.

DESIGN

Prospective periconceptional cohort study.

SETTING

Single tertiary hospital.

PATIENT(S)

A total of 511 singleton pregnancies, with 303 conceived spontaneously and 208 after in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Crown-rump length (CRL) and embryonic volume (EV) at 7, 9, and 11 weeks of gestation measured offline using three-dimensional ultrasound data and a virtual reality system.

RESULT(S)

Using the third quartile of paternal red blood cell (RBC) folate levels as reference values, we found statistically significantly negative associations between RBC folate and longitudinal CRL measurements in the second quartile (beta: -0.14 √mm [95% confidence interval (CI), -0.28 to -0.006]) and fourth quartile (beta: -0.19 √mm [95% CI, -0.33 to -0.04]) in spontaneously conceived pregnancies. Comparable results were found for longitudinal EV measurements in the fourth quartile (beta: -0.12 ∛cm³ [95% CI, -0.20 to -0.05]). No statistically significant associations were observed between RBC folate levels and embryonic growth trajectories in IVF-ICSI pregnancies.

CONCLUSION(S)

These data demonstrate for the first time that low and high periconceptional paternal RBC folate levels are associated with reduced embryonic growth trajectories in spontaneously conceived pregnancies. These data underline the importance of paternal folate status during the periconception period.

The impact of maternal lifestyle factors on periconception outcomes: a systematic review of observational studies

The main risk factors for important reproductive health issues such as subfertility and perinatal mortality largely originate in the periconception period. To evaluate associations between modifiable maternal lifestyle factors and periconception outcomes, a systematic search was conducted for relevant studies published from 1990 to February 2017 on Embase, Medline, Web of Science, Cochrane database, PubMed and Google Scholar. The initial search identified 6166 articles, of which 49 studies were eligible for inclusion. Fecundity (the capacity to have a live birth) showed significant inverse associations with smoking, alcohol use and poor diet. Studies regarding time to pregnancy showed a decline in fecundity ratios (the monthly conception rate among exposed relative to unexposed couples) with increasing body mass index (BMI). Furthermore, risk of first-trimester miscarriage was found to be increased in smokers, alcohol and caffeine consumers, and with increasing BMI. Vitamin supplement use showed a decrease in this risk. This review demonstrates that maternal modifiable lifestyle factors affect periconception outcomes. If couples planning a pregnancy are more aware and supported to adopt healthy lifestyles during the periconceptional 'window of opportunity', short-term reproductive health as well as health in later life and even of future generations can be further improved.

No independent associations between preconception paternal dietary patterns and embryonic growth; the Predict Study

BACKGROUND & AIM

Several studies show the importance of periconceptional maternal dietary patterns on human embryonic growth. Healthy paternal nutrition has been associated with better semen quality and fecundability, however, evidence on the impact on pregnancy outcome is limited. Therefore, the aim of this study was to investigate the association between preconception paternal dietary patterns and first trimester embryonic growth using the parameters longitudinal crown-rump length (CRL) and embryonic volume (EV).

METHODS

A total of 638 couples were enrolled in the Rotterdam Periconceptional Cohort and received longitudinal three dimensional transvaginal ultrasound scans from 7⁺⁰ up to 12⁺⁰ weeks of gestation. Virtual reality software was used to perform offline measurements of the embryonic CRL and EV. Food frequency questionnaires (FFQ) were used to estimate habitual food intake in couples. Principal component analysis (PCA) was performed to identify paternal and maternal dietary patterns. Linear mixed models adjusted for potential confounders were applied to analyze associations between paternal and maternal dietary patterns and embryonic growth parameters.

RESULTS

The paternal dietary patterns retrieved were identified as "Whole wheat grains and Vegetables", "Sauces and Snacks Refined Grains", "Fish and Legumes" and explained 27.5% of the total variance of the dietary intake. No significant additional effects, independent of maternal dietary patters and other maternal and paternal potential confounders, were shown of these paternal dietary patterns on embryonic growth in spontaneous or IVF/ICSI pregnancies.

CONCLUSION

No significant effects of paternal dietary patterns independent of maternal dietary patters and other parental potential confounders on embryonic growth parameters could be established in spontaneous or IVF/ICSI pregnancies. The biological importance of paternal nutrition on semen quality, however, supports the need of periconceptional tailored nutritional counselling of couples trying to conceive.

Gestation-Specific Changes in the Anatomy and Physiology of Healthy Pregnant Women: An Extended Repository of Model Parameters for Physiologically Based Pharmacokinetic Modeling in Pregnancy

BACKGROUND

In the past years, several repositories for anatomical and physiological parameters required for physiologically based pharmacokinetic modeling in pregnant women have been published. While providing a good basis, some important aspects can be further detailed. For example, they did not account for the variability associated with parameters or were lacking key parameters necessary for developing more detailed mechanistic pregnancy physiologically based pharmacokinetic models, such as the composition of pregnancy-specific tissues.

OBJECTIVES

The aim of this meta-analysis was to provide an updated and extended database of anatomical and physiological parameters in healthy pregnant women that also accounts for changes in the variability of a parameter throughout gestation and for the composition of pregnancy-specific tissues.

METHODS

A systematic literature search was carried out to collect study data on pregnancy-related changes of anatomical and physiological parameters. For each parameter, a set of mathematical functions was fitted to the data and to the standard deviation observed among the data. The best performing functions were selected based on numerical and visual diagnostics as well as based on physiological plausibility.

RESULTS

The literature search yielded 473 studies, 302 of which met the criteria to be further analyzed and compiled in a database. In total, the database encompassed 7729 data. Although the availability of quantitative data for some parameters remained limited, mathematical functions could be generated for many important parameters. Gaps were filled based on qualitative knowledge and based on physiologically plausible assumptions.

CONCLUSION

The presented results facilitate the integration of pregnancy-dependent changes in anatomy and physiology into mechanistic population physiologically based pharmacokinetic models. Such models can ultimately provide a valuable tool to investigate the pharmacokinetics during pregnancy in silico and support informed decision making regarding optimal dosing regimens in this vulnerable special population.

Accuracy of fetal sex determination in the first trimester of pregnancy using 3D virtual reality ultrasound

PURPOSE

Early detection of fetal sex is becoming more popular. The aim of this study was to evaluate the accuracy of fetal sex determination in the first trimester, using 3D virtual reality.

METHODS

Three-dimensional (3D) US volumes were obtained in 112 pregnancies between 9 and 13 weeks of gestational age. They were offline projected as a hologram in the BARCO I-Space and subsequently the genital tubercle angle was measured. Separately, the 3D US aspect of the genitalia was examined for having a male or female appearance.

RESULTS

Although a significant difference in genital tubercle angles was found between male and female fetuses, it did not result in a reliable prediction of fetal gender. Correct sex prediction based on first trimester genital appearance was at best 56%.

CONCLUSION

Our results indicate that accurate determination of the fetal sex in the first trimester of pregnancy is not possible, even using an advanced 3D US technique.

Early first trimester maternal 'high fish and olive oil and low meat' dietary pattern is associated with accelerated human embryonic development

BACKGROUND/OBJECTIVES

Maternal dietary patterns were associated with embryonic growth and congenital anomalies. We aim to evaluate associations between early first trimester maternal dietary patterns and embryonic morphological development among pregnancies with non-malformed outcome.

SUBJECTS/METHODS

A total of 228 strictly dated, singleton pregnancies without congenital malformations were enrolled in a periconceptional hospital-based cohort. Principal component analysis was performed to extract early first trimester maternal dietary patterns from food frequency questionnaires. Serial transvaginal three-dimensional ultrasound (3D US) scans were performed between 6⁺⁰ and 10⁺² gestational weeks and internal and external morphological criteria were used to define Carnegie stages in a virtual reality system. Associations between dietary patterns and Carnegie stages were investigated using linear mixed models.

RESULTS

A total of 726 3D US scans were included (median: three scans per pregnancy). The 'high fish and olive oil and low meat' dietary pattern was associated with accelerated embryonic development in the study population (β = 0.12 (95%CI: 0.00; 0.24), p < 0.05). Weak adherence to this dietary pattern delayed embryonic development by 2.1 days (95%CI: 1.6; 2.6) compared to strong adherence. The 'high vegetables, fruit and grain' dietary pattern accelerated embryonic development in the strictly dated spontaneous pregnancy subgroup without adjustment for energy intake.

CONCLUSIONS

Early first trimester maternal dietary patterns impacts human embryonic morphological development among pregnancies without congenital malformations. The clinical meaning of delayed embryonic development needs further investigation.

Periconceptional maternal one-carbon biomarkers are associated with embryonic development according to the Carnegie stages

STUDY QUESTION

Is periconceptional maternal one-carbon (I-C) metabolism associated with embryonic morphological development in non-malformed ongoing pregnancies?

SUMMARY ANSWER

Serum vitamin B12, red blood cell (RBC) folate and plasma total homocysteine (tHcy) are associated with embryonic development according to the Carnegie stages.

WHAT IS KNOWN ALREADY

Derangements in maternal I-C metabolism affect reproductive and pregnancy outcomes, as well as future health of the offspring.

STUDY DESIGN, SIZE, DURATION

Between 2010 and 2014, women with singleton ongoing pregnancies were enrolled in a prospective periconceptional cohort study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 234 pregnancies, including 138 spontaneous or IUI pregnancies with strict pregnancy dating and 96 pregnancies derived from IVF, ICSI or cryopreserved embryo transfer (IVF/ICSI pregnancies), underwent longitudinal transvaginal three-dimensional ultrasound (3D US) scans from 6+0 up to 10+2 weeks of gestation. Carnegie stages were defined using internal and external morphologic criteria in a virtual reality system. Maternal venous blood samples were collected at enrollment for serum vitamin B12, RBC folate and plasma tHcy assessment. Associations between biomarker concentrations and longitudinal Carnegie stages were investigated using linear mixed models.

MAIN RESULTS AND THE ROLE OF CHANCE

We performed a median of three 3D US scans per pregnancy (range 1-5) resulting in 600 good quality data sets for the Carnegie stage annotation (80.5%). Vitamin B12 was positively associated with embryonic development in the total study population (β = 0.001 (95% CI: 0.000; 0.002), P < 0.05) and in the subgroup of strictly dated spontaneous pregnancies (β = 0.002 (95% CI: 0.001; 0.003), P < 0.05). Low vitamin B12 concentrations (-2SD, 73.4 pmol/l) were associated with delayed embryonic development by 1.4 days (95% CI: 1.3-1.4) compared with high concentrations (+2SD, 563.1 pmol/l). RBC folate was positively associated with Carnegie stages only in IVF/ICSI pregnancies (β = 0.001 (95% CI: 0.0005; 0.0015), P < 0.05). In this group, low RBC folate concentrations (-2SD, 875.4 nmol/l) were associated with a 1.8-day delay (95% CI: 1.7-1.8) in development compared with high concentrations (+2SD, 2119.9 nmol/l). tHcy was negatively associated with embryonic development in the total study population (β = -0.08 (95% CI: -0.14; -0.02), P < 0.01), as well as in the IVF/ICSI subgroup (β = -0.08 (95% CI: -0.15; -0.01), P < 0.05). High tHcy concentrations (+2SD, 10.4 µmol/l) were associated with a delay of 1.6 days (95% CI: 1.5-1.7) in embryonic development compared with low concentrations (-2SD, 3.0 µmol/l).

LIMITATIONS, REASONS FOR CAUTION

The study was performed in a tertiary care center, resulting in high rates of folic acid supplement use and comorbidity that may reduce the external validity of our findings.

WIDER IMPLICATIONS OF THE FINDINGS

In periconceptional care, maternal I-C biomarkers should be taken into account as predictors of embryonic morphological development. Combining embryonic size measurements with morphological assessment could better define normal embryonic development.

STUDY FUNDING/COMPETING INTEREST(S)

The work was funded by the Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. RPMST is CSO of the startup company Slimmere Zorg and CEO of eHealth Care Solutions. The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Virtual reality imaging techniques in the study of embryonic and early placental health

Embryonic and placental growth and development in the first trimester of pregnancy have impact on the health of the fetus, newborn, child and even the adult. This emphasizes the importance of this often neglected period in life. The development of three-dimensional transvaginal ultrasonography in combination with virtual reality (VR) opens the possibility of accurate and reliable visualization of embryonic and placental structures with real depth perception. These techniques enable new biometry and volumetry measurements that contribute to the knowledge of the (patho)physiology of embryonic and early placental health. Examples of such measurements are the length of complex structures like the umbilical cord, vitelline duct, limbs and cerebellum or the volume of the whole embryo and brain cavities. Moreover, for the first time, embryos can now be staged in vivo (Carnegie stages) and vasculature volumes of both the embryo and the early placenta can be measured when VR is combined with power Doppler signals. These innovative developments have already been used to study associations between periconceptional maternal factors, such as age, smoking, alcohol use, diet and vitamin status, and embryonic and early placental growth and development. Future studies will also focus on the identification of abnormal embryonic and early placental development already in the earliest weeks of pregnancy, which provides opportunities for early prevention of pregnancy complications.

Periconceptional maternal 'high fish and olive oil, low meat' dietary pattern is associated with increased embryonic growth: The Rotterdam Periconceptional Cohort (Predict) Study

OBJECTIVE

To investigate the association between periconceptional maternal dietary pattern and first-trimester embryonic growth.

METHODS

This was a prospective cohort study of 228 women with a singleton ongoing pregnancy, of which 135 were strictly dated spontaneous pregnancies and 93 were pregnancies achieved after in-vitro fertilization or intracytoplasmatic sperm injection (IVF/ICSI). All women underwent serial transvaginal three-dimensional ultrasound (3D-US) examinations from 6 + 0 to 13 + 0 weeks' gestation. Crown-rump length (CRL) and embryonic volume (EV) measurements were performed using a virtual reality system. Information on periconceptional maternal dietary intake was collected via food frequency questionnaires. Principal component analysis was performed to identify dietary patterns. Associations between dietary patterns and CRL and EV trajectories were investigated using linear mixed models adjusted for potential confounders.

RESULTS

A median of five (range, one to seven) 3D-US scans per pregnancy were performed. Of 1162 datasets, quality was sufficient to perform CRL measurements in 991 (85.3%) and EV measurements in 899 (77.4%). A dietary pattern comprising high intake of fish and olive oil and a very low intake of meat was identified as beneficial for embryonic growth. In strictly dated spontaneous pregnancies, strong adherence to the 'high fish and olive oil, low meat' dietary pattern was associated with a 1.9 mm (95% CI, 0.1-3.63 mm) increase in CRL (+14.6%) at 7 weeks and a 3.4 mm (95% CI, 0.2-7.81 mm) increase (+6.9%) at 11 weeks, whereas EV increased by 0.06 cm³ (95% CI, 0.01-0.13 cm³ ) (+20.4%) at 7 weeks and 1.43 cm³ (95% CI, 0.99-1.87 cm³ ) (+14.4%) at 11 weeks. No significant association was observed in the total study population or in the IVF/ICSI subgroup.

CONCLUSION

Periconceptional maternal adherence to a high fish and olive oil, low meat dietary pattern is positively associated with embryonic growth in spontaneously conceived pregnancies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

A preliminary prediction model for potentially guiding patient choices between breast conserving surgery and mastectomy in early breast cancer patients; a Dutch experience

Purpose

To guide early stage breast cancer patients to choose between breast conserving surgery (BCS) and mastectomy (MST) considering the predicted cosmetic result and quality of life (QoL).

Methods

A decision model was built to compare QoL after BCS and MST. Treatment could result in BCS with good cosmesis, BCS with poor cosmesis, MST only, and MST with breast reconstruction. QoL for these treatment outcomes were obtained from a previous study and the literature and translated into EuroQoL-5D derived utilities. Chance of good cosmesis after BCS was predicted based on tumor location and tumor/breast volume ratio. The decision model determined whether the expected QoL was superior after BCS or MST based on chance of good cosmesis.

Results

The mean utility for the treatments such as BCS with good cosmesis, BCS with poor cosmesis, MST only, and MST with breast reconstruction were 0.908, 0.843, 0.859, and 0.876, respectively. BCS resulted in superior QoL compared to MST in patients with a chance of good cosmesis above 36%. This 36% threshold is reached in case the tumor is located in the upper lateral, lower lateral, upper medial, lower medial, and central quadrant of the breast with a tumor/breast volume ratio below 21.6, 4.1, 15.1, 3.2, and 14.7, respectively.

Conclusions

BCS results in superior QoL in patients with tumors in the upper breast quadrants or centrally and a tumor/breast volume ratio below 15. MST results in superior QoL in patients with tumors in the lower breast quadrants and a tumor/breast volume ratio above 4.

Electronic supplementary material

The online version of this article (10.1007/s11136-017-1740-0) contains supplementary material, which is available to authorized users.

First-Trimester Crown-Rump Length and Embryonic Volume of Fetuses with Structural Congenital Abnormalities Measured in Virtual Reality: An Observational Study

Background. With the introduction of three-dimensional (3D) ultrasound it has become possible to measure volumes. The relative increase in embryonic volume (EV) is much larger than that of the crown-rump length (CRL) over the same time period. We examined whether EV is a better parameter to determine growth restriction in fetuses with structural congenital abnormalities. Study Design, Subjects, and Outcome Measures. CRL and EV were measured using a Virtual Reality (VR) system in prospectively collected 3D ultrasound volumes of 56 fetuses diagnosed with structural congenital abnormalities in the first trimester of pregnancy (gestational age 7⁺⁵ to 14⁺⁵ weeks). Measured CRL and EV were converted to z-scores and to percentages of the expected mean using previously published reference curves of euploid fetuses. The one-sample t-test was performed to test significance. Results. The EV was smaller than expected for GA in fetuses with structural congenital abnormalities (−35%  p < 0.001, z-score −1.44  p < 0.001), whereas CRL was not (−6.43%  p = 0.118, z-score −0.43  p = 0.605). Conclusions. CRL is a less reliable parameter to determine growth restriction in fetuses with structural congenital abnormalities as compared with EV. By measuring EV, growth restriction in first-trimester fetuses with structural congenital abnormalities becomes more evident and enables an earlier detection of these cases.

Agreement and reliability of pelvic floor measurements during rest and on maximum Valsalva maneuver using three-dimensional translabial ultrasound and virtual reality imaging

OBJECTIVES

Imaging of the levator ani hiatus provides valuable information for the diagnosis and follow-up of patients with pelvic organ prolapse (POP). This study compared measurements of levator ani hiatal volume during rest and on maximum Valsalva, obtained using conventional three-dimensional (3D) translabial ultrasound and virtual reality imaging. Our objectives were to establish their agreement and reliability, and their relationship with prolapse symptoms and POP quantification (POP-Q) stage.

METHODS

One hundred women with an intact levator ani were selected from our tertiary clinic database. Information on clinical symptoms were obtained using standardized questionnaires. Ultrasound datasets were analyzed using a rendered volume with a slice thickness of 1.5 cm, at the level of minimal hiatal dimensions, during rest and on maximum Valsalva. The levator area (in cm(2) ) was measured and multiplied by 1.5 to obtain the levator ani hiatal volume (in cm(3) ) on conventional 3D ultrasound. Levator ani hiatal volume (in cm(3) ) was measured semi-automatically by virtual reality imaging using a segmentation algorithm. Twenty patients were chosen randomly to analyze intra- and interobserver agreement.

RESULTS

The mean difference between levator hiatal volume measurements on 3D ultrasound and by virtual reality was 1.52 cm(3) (95% CI, 1.00-2.04 cm(3) ) at rest and 1.16 cm(3) (95% CI, 0.56-1.76 cm(3) ) during maximum Valsalva (P < 0.001). Both intra- and interobserver intraclass correlation coefficients were ≥ 0.96 for conventional 3D ultrasound and > 0.99 for virtual reality. Patients with prolapse symptoms or POP-Q Stage ≥ 2 had significantly larger hiatal measurements than those without symptoms or POP-Q Stage < 2.

CONCLUSIONS

Levator ani hiatal volume at rest and on maximum Valsalva is significantly smaller when using virtual reality compared with conventional 3D ultrasound; however, this difference does not seem clinically important. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Growth trajectories of the human embryonic head and periconceptional maternal conditions

STUDY QUESTION

Can growth trajectories of the human embryonic head be created using 3D ultrasound (3D-US) and virtual reality (VR) technology, and be associated with second trimester fetal head size and periconceptional maternal conditions?

SUMMARY ANSWER

Serial first trimester head circumference (HC) and head volume (HV) measurements were used to create reliable growth trajectories of the embryonic head, which were significantly associated with fetal head size and periconceptional maternal smoking, age and ITALIC! in vitro fertilization (IVF)/intra-cytoplasmic sperm injection (ICSI) treatment.

WHAT IS KNOWN ALREADY

Fetal growth is influenced by periconceptional maternal conditions.

STUDY DESIGN, SIZE, DURATION

We selected 149 singleton pregnancies with a live born non-malformed fetus from the Rotterdam periconception cohort.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Bi-parietal diameter and occipital frontal diameter to calculate HC, HV and crown-rump length (CRL) were measured weekly between 9 + 0 and 12 + 6 weeks gestational age (GA) using 3D-US and VR. Fetal HC was obtained from second trimester structural anomaly scans. Growth trajectories of the embryonic head were created with general additive models and linear mixed models were used to estimate associations with maternal periconceptional conditions as a function of GA and CRL, respectively.

MAIN RESULTS

A total of 303 3D-US images of 149 pregnancies were eligible for embryonic head measurements (intra-class correlation coefficients >0.99). Associations were found between embryonic HC and fetal HC ( ITALIC! ρ = 0.617, ITALIC! P < 0.001) and between embryonic HV and fetal HC ( ITALIC! ρ = 0.660, ITALIC! P < 0.001) in ITALIC! Z-scores. Maternal periconceptional smoking was associated with decreased, and maternal age and IVF/ICSI treatment with increased growth trajectories of the embryonic head measured by HC and HV (All ITALIC! P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

The consequences of the small effect sizes for neurodevelopmental outcome need further investigation. As the study population consists largely of tertiary hospital patients, external validity should be studied in the general population.

WIDER IMPLICATIONS OF THE FINDINGS

Assessment of growth trajectories of the embryonic head may be of benefit in future early antenatal care.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by the Department of Obstetrics and Gynaecology, Erasmus MC University Medical Centre and Sophia Foundation for Medical Research, Rotterdam, The Netherlands (SSWO grant number 644). No competing interests are declared.

A Preliminary Study of Three-dimensional Sonographic Measurements of the Fetus

OBJECTIVES

This study was aimed at establishing an ideal method for performing three-dimensional measurements of the fetus in order to improve the estimation of fetal weight.

METHODS

The study consisted of two phases. Phase I was a prospective cross-sectional study performed between 28 and 40 weeks' gestation. The study population (n=110) comprised low-risk singleton pregnancies who underwent a routine third-trimester sonographic estimation of fetal weight. The purpose of this phase was to establish normal values for the fetal abdominal and head volumes throughout the third trimester. Phase II was a prospective study that included patients admitted for an elective cesarean section or for induction of labor between 38 and 41 weeks' gestation (n=91). This phase of the study compared the actual birth weight to two- (2D) and three-dimensional (3D) measurements of the fetus. Conventional 2D ultrasound fetal biometry was performed measuring the biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur diaphysis length (FL). Volume estimates were computed utilizing Virtual Organ Computer-aided AnaLysis (VOCAL), and the correlation between measured volumes and actual neonatal weight was calculated.

RESULTS

Overall, this longitudinal study consisted of 110 patients between 28 and 41 weeks' gestation. Normal values were computed for the fetal abdomen and head volume throughout the third trimester. Ultrasound examination was performed within three days prior to delivery on 91 patients. A good correlation was found between birth weight and abdominal volume (r=0.77) and between birth weight and head volume (r=0.5). Correlation between bidimensional measurements and actual fetal weights was found to be comparable with previously published correlations.

CONCLUSION

Volume measurements of the fetus may improve the accuracy of estimating fetal size. Additional studies using different volume measurement of the fetus are necessary.

Design and validation of a 3D virtual reality desktop system for sonographic length and volume measurements in early pregnancy evaluation

PURPOSE

To design and validate a desktop virtual reality (VR) system, for presentation and assessment of volumetric data, based on commercially off-the-shelf hardware as an alternative to a fully immersive CAVE-like I-Space VR system.

METHODS

We designed a desktop VR system, using a three-dimensional (3D) monitor and a six degrees-of-freedom tracking system. A personal computer uses the V-Scope (Erasmus MC, Rotterdam, The Netherlands) volume-rendering application, developed for the I-Space, to create a hologram of volumetric data. Inter- and intraobserver reliability for crown-rump length and embryonic volume measurements are investigated using Bland-Altman plots and intraclass correlation coefficients. Time required for the measurements was recorded.

RESULTS

Comparing the I-Space and the desktop VR system, the mean difference for crown-rump length is -0.34% (limits of agreement -2.58-1.89, ±2.24%) and for embryonic volume -0.92% (limits of agreement -6.97-5.13, ±6.05%). Intra- and interobserver intraclass correlation coefficients of the desktop VR system were all >0.99. Measurement times were longer on the desktop VR system compared with the I-Space, but the differences were not statistically significant.

CONCLUSIONS

A user-friendly desktop VR system can be put together using commercially off-the-shelf hardware at an acceptable price. This system provides a valid and reliable method for embryonic length and volume measurements and can be used in clinical practice.

First trimester trophoblast and placental bed vascular volume measurements in IVF or IVF/ICSI pregnancies

STUDY QUESTION

Are first trimester trophoblast volume (TV) and placental bed vascular volume (PBVV) different in IVF or IVF/ICSI pregnancies in comparison with spontaneously conceived pregnancies?

SUMMARY ANSWER

Any possible abnormal placentation in IVF or IVF/ICSI pregnancies in comparison with spontaneously conceived pregnancies is not detected by a difference in PBVV or TV at an early gestational age (GA).

WHAT IS KNOWN ALREADY

Assisted reproductive technology pregnancies have been associated with an increased risk of placenta-related adverse pregnancy outcomes. It is unclear whether these effects originate from infertility or from the technique itself.

STUDY DESIGN, SIZE, DURATION

We performed a retrospective cohort study in which 154 pregnant patients qualified for participation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Out of 154 pregnant patients, 84 conceived spontaneously and 70 conceived after IVF or IVF/ICSI. We determined the TV at 10 weeks GA by Virtual Organ Computer-aided AnaLysis measuring application and the PBVV at 12 weeks GA by the virtual reality operating system of BARCO I-Space in both subgroups. The investigators were blinded to the mode of conception during the measurements. Analysis was limited to singleton pregnancies with only one sac ever detectable.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no differences in TV (mean 42.7, SD 15.9 versus mean 41.2, SD 13.9, P = 0.70) and PBVV (mean 27.6, SD 16.9 versus mean 24.8, SD 19.9, P = 0.20) between IVF or IVF/ICSI pregnancies and spontaneously conceived pregnancies. There was a significant correlation between TV and PBVV (rs = 0.283, P = 0.004).

LIMITATIONS, REASONS FOR CAUTION

The limitations of the present study concern the small size of the study groups.

WIDER IMPLICATIONS OF THE FINDINGS

IVF or IVF/ICSI does not seem to be associated with abnormal placentation.

STUDY FUNDING/COMPETING INTERESTS

This study was financially supported by the Erasmus Trustfonds, the Meindert de Hoop foundation and the Fonds NutsOhra. No competing interests are declared.

Preoperative prediction of cosmetic results in breast conserving surgery

BACKGROUND

Preoperative objective predictions of cosmetic result after breast conserving surgery (BCS) has the potential to aid in surgical treatment decision making. Our aim was to investigate the predictive value of tumor volume in relation to breast volume (TV/BV ratio) for cosmetic result.

METHODS

Sixty-nine invasive breast cancer women with preoperative MRI and treated by BCS and radiotherapy in 2007-2012 were prospectively included. Simple excision or basic oncoplastic techniques were used, but no volume displacement. TV/BV ratio was measured in the MRI while 3D-projected in virtual reality environment (I-Space). Cosmetic result was assessed by patient questionnaire, panel evaluation, and breast retraction assessment (BRA). Quality-of-life was assessed by EORTC QLQ-C30 and BR23.

RESULTS

Intraobserver and interobserver correlation coefficients for tumor and breast volume were all >0.95. Increasing TV/BV ratio correlated with decreasing cosmetic result as determined by patient, panel, and BRA. TV/BV ratio was a significant independent predictor for the panel evaluation (P=0.028), as was tumor location (P<0.05), and together they constituted a good prediction model (AUC 0.83).

CONCLUSIONS

TV/BV ratio was a precise and independent predictor for cosmetic result determined by a panel and can be used as preoperative prediction tool to enable more informed surgical treatment decision making.

The influence of IVF/ICSI treatment on human embryonic growth trajectories

STUDY QUESTION

Is in vitro fertilization treatment with or without intracytoplasmatic sperm injection (IVF/ICSI) associated with changes in first and second trimester embryonic and fetal growth trajectories and birthweight in singleton pregnancies?

SUMMARY ANSWER

Embryonic and fetal growth trajectories and birthweight are not significantly different between pregnancies conceived with IVF/ICSI treatment and spontaneously conceived pregnancies with reliable pregnancy dating.

WHAT IS KNOWN ALREADY

IVF/ICSI treatment has been associated with increased risks of preterm birth, fetal growth restriction and low birthweight. Decreased first-trimester crown-rump length (CRL) in the general population has been inversely associated with the same adverse pregnancy outcomes.

STUDY DESIGN, SIZE, DURATION

In a prospective periconception birth cohort study conducted in a tertiary centre, 146 singleton pregnancies with reliable pregnancy dating and nonmalformed live borns were investigated, comprised of 88 spontaneous and 58 IVF/ICSI pregnancies.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Serial 3D ultrasound scans were performed from 6 to 12 weeks of gestation. As estimates of embryonic growth, CRL and embryonic volume (EV) were measured using the I-Space virtual reality system. General characteristics were obtained from self-administered questionnaires at enrolment. Fetal growth parameters at 20 weeks and birthweight were obtained from medical records. To assess associations between IVF/ICSI and embryonic growth trajectories, estimated fetal weight and birthweight, stepwise linear mixed model analyses and linear regression analyses were performed using square root transformed CRL and fourth root transformed EV.

MAIN RESULTS AND THE ROLE OF CHANCE

In 146 pregnancies, 934 ultrasound scans were performed of which 849 (90.9%) CRLs and 549 (58.8%) EVs could be measured. Embryonic growth trajectories were comparable between IVF/ICSI pregnancies and spontaneously conceived pregnancies (CRL: βIVF/ICSI = 0.10√mm; P = 0.10; EV: βIVF/ICSI = 0.03(4)√cm³; P = 0.13). Estimated fetal weight and birthweight were also comparable between both groups (βIVF/ICSI = 6 g; P = 0.36 and βIVF/ICSI = 80 g; P = 0.24, respectively).

LIMITATIONS, REASONS FOR CAUTION

Variations in embryonic growth trajectories of spontaneously conceived pregnancies with reliable pregnancy dating may partially be a result of less precise pregnancy dating and differences in endometrium receptivity compared with IVF/ICSI pregnancies.

WIDER IMPLICATIONS OF THE FINDINGS

The absence of a significant difference in embryonic and fetal growth trajectories suggests safety of IVF/ICSI treatment with regard to early embryonic growth. However, further research is warranted to ascertain the influence of IVF/ICSI treatments in a larger study population, and to estimate the impact of the underlying causes of the subfertility and other periconceptional exposures on human embryonic and fetal growth trajectories.

FUNDING STATEMENT

This study was supported by the Department of Obstetrics and Gynaecology of the Erasmus MC, University Medical Centre.

CONFLICT OF INTEREST

No competing interests are declared.

Early pregnancy placental bed and fetal vascular volume measurements using 3-D virtual reality

In this study, a new 3-D Virtual Reality (3D VR) technique for examining placental and uterine vasculature was investigated. The validity of placental bed vascular volume (PBVV) and fetal vascular volume (FVV) measurements was assessed and associations of PBVV and FVV with embryonic volume, crown-rump length, fetal birth weight and maternal parity were investigated. One hundred thirty-two patients were included in this study, and measurements were performed in 100 patients. Using V-Scope software, 100 3-D Power Doppler data sets of 100 pregnancies at 12 wk of gestation were analyzed with 3D VR in the I-Space Virtual Reality system. Volume measurements were performed with semi-automatic, pre-defined parameters. The inter-observer and intra-observer agreement was excellent with all intra-class correlation coefficients >0.93. PBVVs of multiparous women were significantly larger than the PBVVs of primiparous women (p = 0.008). In this study, no other associations were found. In conclusion, V-Scope offers a reproducible method for measuring PBVV and FVV at 12 wk of gestation, although we are unsure whether the volume measured represents the true volume of the vasculature. Maternal parity influences PBVV.

First-Trimester Detection of Surface Abnormalities: A Comparison of 2- and 3-Dimensional Ultrasound and 3-Dimensional Virtual Reality Ultrasound

The aim was to determine the diagnostic performance of 3-dimensional virtual reality ultrasound (3D_VR_US) and conventional 2- and 3-dimensional ultrasound (2D/3D_US) for first-trimester detection of structural abnormalities. Forty-eight first trimester cases (gold standard available, 22 normal, 26 abnormal) were evaluated offline using both techniques by 5 experienced, blinded sonographers. In each case, we analyzed whether each organ category was correctly indicated as normal or abnormal and whether the specific diagnosis was correctly made. Sensitivity in terms of normal or abnormal was comparable for both techniques (P = .24). The general sensitivity for specific diagnoses was 62.6% using 3D_VR_US and 52.2% using 2D/3D_US (P = .075). The 3D_VR_US more often correctly diagnosed skeleton/limb malformations (36.7% vs 10%; P = .013). Mean evaluation time in 3D_VR_US was 4:24 minutes and in 2D/3D_US 2:53 minutes (P < .001). General diagnostic performance of 3D_VR_US and 2D/3D_US apparently is comparable. Malformations of skeleton and limbs are more often detected using 3D_VR_US. Evaluation time is longer in 3D_VR_US.

Periconception maternal characteristics and embryonic growth trajectories: the Rotterdam Predict study

STUDY QUESTION

Are maternal characteristics and lifestyle factors associated with human embryonic growth trajectories?

SUMMARY ANSWER

Periconception maternal age is associated with increased, and smoking and alcohol use with decreased embryonic growth trajectories, estimated with crown-rump length (CRL) measurements.

WHAT IS KNOWN ALREADY

Fetal weight is associated with health and disease in later life. Maternal characteristics and lifestyle factors affect fetal growth in the second and third trimesters of pregnancy and at birth; however, little is known about the association of these characteristics with first trimester embryonic growth.

STUDY DESIGN, SIZE, DURATION

In a tertiary centre, pregnant women were recruited and enrolled in a prospective periconception cohort study before 8 weeks of gestation. We selected 87 spontaneously conceived singleton pregnancies of women recruited in 2009 and 2010 that ended in non-malformed live births.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We performed weekly three-dimensional ultrasound scans from enrolment up to 13 weeks of gestation. At enrolment, a questionnaire was completed. Embryonic CRL measurements were performed using the V-Scope software in the BARCO I-Space. Associations between maternal characteristics and embryonic growth were assessed using square root transformed CRL as response in linear mixed model analyses, adjusted for potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

Four hundred and ninety-six scans from 87 pregnancies were included. In the multivariable analysis, maternal age was positively associated with first trimester CRL (difference per maternal year of age 0.024√mm (95% confidence interval (CI) 0.009, 0.040), P = 0.001). At 6 and 12 weeks of gestation, the CRL of an embryo from a 40-year-old mother was estimated 2.0 mm (61%) and 7.2 mm (14%) larger, respectively, compared with an embryo from a 20-year-old mother. Smoking of 10 or more cigarettes per day was negatively associated with CRL (difference -0.211√mm (95% CI -0.416, -0.006), P = 0.04), with embryos that were 0.9 mm (18.7%) and 3.1 mm (5.5%) smaller at 6 and 12 weeks, respectively, compared with non-smokers. Periconception alcohol use was negatively associated with CRL growth rate (difference -0.0025√mm (95% CI -0.0047, -0.0003)/day gestational age, P = 0.022), with embryos that were 0.2 mm (3%) and 1.1 mm (2%) smaller at 6 and 12 weeks, respectively, compared with non-alcohol users. Parity, BMI and moment of initiation of folic acid use were not significantly associated with embryonic CRL.

LIMITATIONS, REASONS FOR CAUTION

Due to the selection of pregnancies in a tertiary centre and the small number of pregnancies, the external validity of the results has to be confirmed using larger sample sizes and other population-based periconception cohort studies.

WIDER IMPLICATIONS OF THE FINDINGS

The association of maternal age and smoking with embryonic growth is in line with previous literature, whereas the association between embryonic growth and alcohol use is a new finding. However, concerning exposure to alcohol, the effect estimate was small and it is questionable whether this is of clinical value. More research is warranted to unravel underlying mechanisms and to assess the implications for preconception and early pregnancy care, such as the development and implementation of effective lifestyle interventions.

STUDY FUNDING/COMPETING INTEREST(S)

The work was funded by the Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. The authors declare no conflicts of interest.