Management of fetal goiters: 6-year retrospective observational study in three prenatal diagnosis and treatment centers of the Pays De Loire Perinatal Network

Introduction: The incidence of fetal goiters is reported to be around 1 per 40,000 births. The risk of complications is first of all obstetric, directly related to goiter size, but it may also affect longer term fetal and child development, depending on whether the goiter is due to hypo- or hyperthyroidism. Management is multidisciplinary, but not yet consensual and not always optimal by either endocrinologists or obstetricians.Objectives: The principal objective of this retrospective study was to analyze the data that enabled the physicians to assess whether the goiter was hypo- or hyperthyroid and then to analyze the obstetric practices used in the Pays de Loire network to describe in detail the tools used to diagnose and characterize the goiters and the management chosen in these cases. The secondary objectives are to assess, in our small cohort, the effectiveness of the in utero treatments provided, based on the examination of the children at birth and their outcome at 6 months of life, and to suggest a strategy for monitoring these women at risk that takes current guidelines into consideration.Materials and methods: This multicenter retrospective study covers a 6-year period and focused on the prenatal diagnosis centers (CPDPN) of the Pays de Loire perinatal network: in Nantes, Angers, and Le Mans. The network is responsible for around 42,000 births a year, and the study included 17 women, for a prevalence of 1 per 15,000 births.Results: Ten of the 17 fetuses had a hypothyroid goiter, 4 a hyperthyroid goiter, and 3 normal thyroid findings on fetal blood sample (FBS). For four women, these goiters were secondary to fetal dyshormonogenesis, for 9 more to Graves disease with TSH receptor antibodies (TRAb), and for four women to thyrotoxicosis at the start of pregnancy, managed by synthetic antithyroid drugs. Two newborns had severe complications associated with maternal transmission of Graves disease (TRAb positive at birth): one with exophthalmos and one with neonatal tachycardia. The other 14 had normal psychomotor development at 6 months, based on a clinical examination by a pediatric endocrinologist; only one child was lost to follow-up.Conclusion: Together, ultrasound and multidisciplinary expertise (of an endocrinologist and an obstetrician experienced with this disease) remain the best means for avoiding, or otherwise for accurately characterizing fetal goiter. An ultrasound diagnostic score, of the type proposed by Luton et al. in 2009, may make it possible to homogenize practices and thus to defer or delay the - currently too common - performance of invasive FBS procedures, which must remain rare in this management to limit comorbidities. A threshold TRAb value (>5 IU/l) makes it possible to define this group of women as at risk of fetal and neonatal hyperthyroidism and thus requiring close monitoring. The value of prenatal intra-amniotic thyroxine treatment for hypothyroid goiters (including dyshormonogenesis) remains to be demonstrated.

Computed tomographic study of anatomical relationship between pubic symphysis and ischial spines to improve interpretation of intrapartum translabial ultrasound

OBJECTIVE

To analyze the anatomical relationship between the pubic symphysis and the ischial spines to determine reliable landmarks for the assessment of fetal head descent by intrapartum translabial ultrasound (ITU).

METHODS

All computed tomography (CT) scans performed for breech presentation and for twin delivery between 2006 and 2014 in a tertiary university hospital were obtained for measurement and analysis by two operators. The symphysis-left ischial spine angle (SIA) and the symphysis-left ischial spine distance (SID) were measured on three-dimensional reconstructions from the CT volume dataset. We calculated intra- and interobserver agreements for SIA and SID with 95% prediction intervals, created Bland-Altman plots with 95% limits of agreement and estimated the intraclass correlation coefficient (ICC). A sagittal plane projection from the SIA enabled calculation of a sagittal angle, corresponding to the angle of progression (AoP) on ITU.

RESULTS

SIA and SID were obtained from CT images from 458 women. Reproducibility was good for both SIA (intraobserver ICC, 0.94 (95% CI, 0.88-0.97) and interobserver ICC, 0.81 (95% CI, 0.66-0.92)) and SID (intraobserver ICC, 0.92 (95% CI, 0.82-0.97) and interobserver ICC, 0.83 (95% CI, 0.73-0.92)). The median SIA was 106° (interquartile range (IQR), 105-109°) and median SID was 26.1 (IQR, 23.4-29.5) mm. SIA and SID were not correlated with pelvic diameter or height. The 50^th percentile of AoP was 110°.

CONCLUSION

Knowledge of the anatomical relationship between the pubic symphysis and ischial spines makes it possible to establish a sonographic method for assesssing fetal head descent by taking into account the level of the ischial spines. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Biparietal/transverse abdominal diameter ratio ≤ 1: potential marker for open spina bifida at 11-13-week scan

OBJECTIVE

In the first trimester of pregnancy, a biparietal diameter (BPD) below the 5(th) percentile is a simple marker that enables the prenatal detection of half of all cases of open spina bifida. We hypothesized that relating the BPD measurement to the transverse abdominal diameter (TAD) might be another simple and effective screening method. In this study we assessed the performance of using the BPD/TAD ratio during the first trimester of pregnancy in screening for open spina bifida.

METHODS

A total of 20,551 first-trimester ultrasound scans (11-13 weeks' gestation), performed between 2000 and 2013, were analyzed retrospectively; there were 26 cases of open spina bifida and 17,665 unaffected pregnancies with a crown-rump length of 45-84 mm and a record of both BPD and TAD measurements.

RESULTS

The mean (± SD) BPD/TAD ratio was 1.00 ± 0.06 for fetuses with spina bifida and 1.13 ± 0.06 for those without (P < 0.0001). A BPD ≤ 5(th) percentile enabled the prenatal detection of 46.2% of spina bifida cases, while a BPD/TAD ratio of ≤ 1.00 detected 69.2%. If we considered cases in which either BPD was ≤ 5(th) percentile or BPD/TAD ratio was ≤ 1, we identified 76.9% of cases. In the latter case, the false-positive rate was 5.1%, while that for using a combination of both BPD ≤ 5th percentile and BPD/TAD ratio ≤ 1 was 0.6%, with a sensitivity of 38.5%. The positive predictive value of using a combination of BPD ≤ 5th percentile and BPD/TAD ratio ≤ 1 for detecting spina bifida was 8.5%.

CONCLUSIONS

Between 11 and 13 weeks' gestation, relating BPD to TAD improves considerably the diagnostic performance of using BPD measurement alone in screening for open spina bifida. Screening using this marker is simple and applicable to a large population.

[How many ultrasound examinations for low-risk pregnancies monitoring?]

OBJECTIVES

To assess the average number of ultrasounds per low-risk pregnancy and estimate the proportion of ultrasound scans without morphological examination of the fetus (non-morphological ultrasounds).

RESEARCH DESIGN AND SETTING

Retrospective study conducted among patients who delivered at the University Hospital of Tours (France) between January 2012 and February 2012.

PARTICIPANTS

Women with a singleton pregnancy who delivered after 37weeks' gestation an eutrophic child.

DATA COLLECTION

Distinction was made between morphological and non-morphological ultrasound examinations. The type of non-morphological ultrasound examination was analyzed.

RESULTS AND DISCUSSION

Among the 300 patients of the study, the average number of scans per patient was five (SD=1.9), which is higher than the three recommended ultrasounds for these low-risk pregnancies. In this study, 77% of patients were receiving more than three ultrasounds. Moreover, 28.1% of all ultrasound examinations were non-morphological examinations. Among them, 42.2% of examinations were performed in the third trimester of pregnancy. Among these non-morphological ultrasounds performed in the third trimester, there were 51.9% of fetal biometric measurements and cervical length measurements in 18.5% of cases. We believe that resorting to non-morphological ultrasounds during low-risk pregnancies is not censurable in itself and should even be promoted. Nevertheless, we should improve the relevance of all these examinations.

New insights into uteroplacental perfusion: quantitative analysis using Doppler and contrast-enhanced ultrasound imaging

OBJECTIVE

To monitor and quantify uteroplacental perfusion in rat pregnancies by Doppler ultrasound (DUS) and contrast-enhanced ultrasound (CEUS).

METHODS

Fourteen rats were randomized in two groups (the CEUS group and the control group). On days 8, 11, 14, 17, 19 and 20 of gestation, we used DUS to measure the resistance index (RI), pulsatility index and blood velocity in the uterine, arcuate and umbilical arteries in both groups. On days 14, 17 and 20, one group was also examined by CEUS. Quantitative perfusion parameters were calculated in 4 compartments (mesometrial triangle, placenta, umbilical cord and fetus) and compared.

RESULTS

The DUS measurement showed that the RI of the uterine and arcuate arteries decreased (p < 0.01) from day 14 to day 17, while velocity increased each of these arteries (p < 0.01 and p < 0.05, respectively). Quantification of uteroplacental perfusion by CEUS in bolus mode revealed that blood volume and local blood flow increased from day 14 to day 20 in the mesometrial triangle (p < 0.01) and the placenta (p < 0.05). In the CEUS destruction-replenishment mode, the perfusion parameters showed trends similar to those observed in bolus mode. No microbubbles were detected in the umbilical vein or fetal compartments. The weights of pups in the two groups did not differ significantly.

CONCLUSIONS

CEUS estimates of placental perfusion complement the data provided by DUS.