VEZ Zevenaar Obstetric Ultrasonography Centre 2012-­‐2013 Annual Report Compiled by J. Snelder Ultrasonographer, registered member of the Royal Dutch Organisation of Midwives (KNOV, E7777), and member of the Dutch Association of Ultrasonography Professionals (BEN, membership number E1057312). Registered health-­‐care provider (BIG membership number 89032060603). VEZ AGB code: 08051182 Judith Snelder’s AGB code: 08000629 1 CONTENTS Foreword p. 2 Hoofdstuk 1 Introduction p. 4 Hoofdstuk 2 Objective p. 5 Hoofdstuk 3 Organisation and Protocols 3.1 Scans Showing Abnormalities 3.2 First-­‐Trimester Screening: The Procedure 3.3 Data Storage and Processing p. 7 Hoofdstuk 4 Safeguarding Quality p. 10 Hoofdstuk 5 Scans / Abnormalities and Referrals p. 12 p. 8 p. 8 p. 9 Hoofdstuk 6 Foetal Biometry p. 38 Afterword p. 42 2 FOREWORD In 2012 the Zevenaar branch of Rijnstate Hospital decided not to renew VEZ’s lease. As a result, VEZ moved into Sevenaer Physiotherapy’s Health Centre on 1 February 2013. The Centre is situated in the heart of Zevenaar and is easily accessible by both private and public transport. As with all other previous editions of this annual report, I owe a thank-­‐you to my colleagues Marja van Doesburg and Herma Veldhorst, who are perenially keen to improve health care and always happy to brainstorm with me about ‘problems’ and potential solutions. As always, I am grateful for their expertise and the pleasant way in which we all work together. As before, Corina Mateman proofread the document, and my father once again added the finishing touches. Thanks, Dad! Judith Snelder, December 2014 3 Chapter 1 Introduction Compared to 2011, the number of 20-­‐week ultrasound scans performed at VEZ has somewhat decreased: from 820 scans performed in 2011 and 755 scans performed in 2012, down to 689 in 2013. This reduction is largely due to the fact that Zevenaar gynaecologists no longer refer patients to VEZ, as the VEZ annexe at Slingeland Hospital was closed in 2013. There has not been a similar reduction in first-­‐trimester screenings: 213 such screenings were performed in 2013, as opposed to 215 in 2011, and 191 in 2012. However, it should be noted that the rest of the Netherlands presents a slight increase in the number of first-­‐trimester screenings performed. Due to the relocation of VEZ in 2013, small changes were made to the centre’s organisation, which are described elsewhere in this document. Number of referrals for advanced scans following 20-­‐week scan 20-­‐week Scans scans performed Referrals Percentage 2010 889 62 7.0% 2011 820 82 10.0% 2012 755 46 6.1% 2013 689 40 5.8% Duizenden Tot. Aant. Verw. Aant. 20-­‐week scans 1 0,8 0,6 0,4 0,2 0 2010 2011 2012 2013 100 80 60 40 20 0 Referrals for advanced scans 2010 2011 2012 2013 Verw. Aant. 4 Chapter 2 Objective VEZ’s objective is to deliver the best possible care to pregnant women and their partners, particularly with regard to 20-­‐week ultrasounds and first-­‐trimester screenings. In addition, VEZ considers the availability of this type of care in a relatively small town like Zevenaar a priority, and is committed to doing everything in its power to ensure that such care continue to be delivered in future. VEZ considers both the quality of its ultrasound scans and its customer satisfaction rating of paramount importance, and records and evaluates both of these aspects of its work. To measure customer satisfaction, every ultrasound scan performed at VEZ is followed up with a brief survey e-­‐mail. The results of these surveys are published on the VEZ website, under the heading of ‘Quality’. They cannot be altered in any way by our sonographers. We are proud to announce that we have a very high customer satisfaction rating. Please find below a copy of the VEZ website presenting an overview of our clients’ feedback. ………………………………………………………………………………………………………………………………………………………. Client feedback Please find below the results of the surveys completed by our clients.
Average rating (based on 261 completed surveys) Filter the survey results and recalculate the average ratings. Select feedback left between 15 April 2013 and 31 December 2013 – marks out of 10 Ease of making an appointment: 8.5
Hygiene: Time spent in waiting room: 7.9
Ease of finding the centre: Explanations received during examination: 8.7
Accessibility of centre: Questions answered to client’s satisfaction: 8.8
Ease of finding centre on the Internet: Customer-­‐friendliness: 8.9
Help received following referral: 8.7
8.5
8.6
8.1
8.8
Overall mark for ultrasound scans: 8.4
8.7
Overall mark for centre as a whole: ………………………………………………………………………………………………………………………………………………………. It is self-­‐evident that clients must not only be satisfied with the services they receive at VEZ, but that the centre must run very smoothly in general. It is vital that the administrative side of things, for instance, is dealt with as professionally as the scans. Since VEZ is a small organisation, it is able to communicate directly with both clients and referring physicians. This ease of communication is valued by all parties involved, and is considered a priority by VEZ. Thanks to our close co-­‐operation with other ultrasound centres, we need not worry about the potential for vulnerability which so often comes with being a small organisation. 5 6 Chapter 3 Organisation and Protocols In the first instance, the VEZ ultrasonography centre is run by Judith Snelder (VEZ owner-­‐manager). VEZ has a contract with SPN, i.e. the Nijmegen Foundation for Prenatal Diagnostics. VEZ itself does not counsel for 20-­‐week scans and first-­‐trimester screenings. Clients are advised to undergo these examinations by their own referring physicians. They are given a referral by their doctor. The referral contains all the information necessary for booking a 20-­‐week scan or first-­‐
trimester screening. Clients can find additional information on the VEZ website: www.v-­‐e-­‐z.nl. In addition, referring doctors may provide their clients with VEZ brochures. Neither the website nor the brochure provides additional information on the nature of 20-­‐week scans and first-­‐trimester screenings. They mainly provide the client with practical information on our ultrasonography centre, and are in no way intended to replace the government’s brochures regarding first-­‐trimester screening and 20-­‐week scans. Appointments may be scheduled directly by the referring doctor, but also by the client herself, who can ring the VEZ secretary on weekdays from 9am to 12 noon. VEZ Zevenaar also has drop-­‐in consultation hours on Tuesday evenings and Wednesdays (all day). If necessary, additional drop-­‐in consultations can be scheduled on Mondays and Thursday evenings. In the event that no appointments can be booked in the short term, VAZ refers clients to Slingeland Hospital’s ultrasonography centre in Doetinchem (VES). VEZ works closely with the following referring organisations: -­‐ Zevenaar/Rijnwaarden Obstetric Practice -­‐ Duiven/Westervoort Obstetric Practice -­‐ Doesburg/Dieren Midwifery Practice -­‐ Montferland/Wehl Obstetric Practice However, any pregnant woman who has been advised to undergo first-­‐trimester screening or a 20-­‐
week test is welcome at VEZ, regardless of who wrote the referral. At the start of an ultrasound session the sonographer will ask for the referral form. In addition, she will ask whether the client received sufficiently clear information regarding the scan from her counsellor, and will then proceed to provide a little more information. Furthermore, she will ask whether the client consents to her scan data being used for annual figures, to the exchange of patient data through the Peridos database, and to the use of her scan for education and examination purposes. The following people are employed by VEZ: -­‐ Administrative tasks and phone calls are fielded by an external company, called Carins Care Center BV. -­‐ Sonographers: Judith Snelder and, as of January 2013, Herma Veldhorst (Zevenaar branch). Marja van Doesburg of VES acts as our substitute and holiday-­‐time sonographer. 7 3.1. Scans Showing Abnormalities If an abnormality or suspected abnormality has been detected, the sonographer will refer the patient for an advanced scan. The referring sonographer will be notified of the results of said advanced scan on the day of the scan, so she can continue to monitor the client and her partner. Generally speaking, VEZ refers clients to the Prenatal Diagnostics departments of Radboud Hospital in Nijmegen or Rijnstate Hospital in Arnhem for advanced scans. Reports from the above-­‐mentioned departments are monitored by the referring sonographer and VEZ’s secretary. Approximately twice a year, the VEZ sonographers meet with Dagmar de Bruijn, a sonographer with Radboud Hospital’s Prenatal Diagnostics department who specialises in advanced diagnostic scans, to discuss all cases recently referred for advanced diagnostic sonography. Clients are notified of these discussions and their consent is sought. This report includes abnormalities which do not call for an advanced scan, e.g. slightly enlarged renal pelvises (less than 10mm in size) or increased risk following a first-­‐trimester screening which does not show nuchal translucency. If a follow-­‐up ultrasound scan is required, for instance to verify the results of the first scan, the VEZ sonographer herself schedules a new appointment. Referring physicians/obstetricians do not necessarily receive notification of this follow-­‐up appointment. They can read all about it in the scan reports they receive after the 20-­‐week test or first-­‐trimester screening has been carried out. 3.2. First-­‐Trimester Screening: The Procedure (2013) First-­‐trimester screening is carried out in co-­‐operation with the Clinical Chemistry and Haematology Laboratory of the Rijnstate Alysis Care Group. VEZ advises pregnant women to undergo the biochemical testing component of the first-­‐trimester screening approximately ten weeks into the pregnancy. The results of this test are known by the time the client undergoes the other component of the screening, the ultrasound scan. Following the scan, the results of the CRL and NT measurements are added to the biochemical test results and forwarded to the Clinical Chemistry and Haematology Lab in Arnhem, which calculates the risk for Down/Patau/Edwards Syndrome. The lab forwards the full results of the screening to Carins Care Center, while VEZ receives the original file in the post. The screening results are passed on to the client by the sonographer, generally on the day of the screening. If the client has not yet undergone biochemical testing, the sonographer will fill out a form for the lab, requesting first-­‐trimester screening. The results of this screening are generally known within two or three working days. The results are forwarded to the referring physician. If the client is likely to have a high-­‐risk pregnancy, the referring physician is notified at once, so that he or she can contact the client and make an appointment for urgent further counselling. If an accumulation of fluid is detected at the back of the baby’s neck, or if any other abnormalities are detected, the sonographer will refer the patient directly to the Prenatal Diagnostics department of either Rijnstate Hospital in Arnhem or Radboud Hospital in Nijmegen. In these cases, too, the referring doctor will be notified, so that he or she can continue to monitor the client. Before undergoing the advanced ultrasound scan, the client and her partner are informed of the procedure described above. We also ask explicitly whether the client is aware that she is likely to 8 have to pay for the procedure herself if she is under the age of 36 and there are no indications for an advanced scan. Upon completion of the procedure the client is presented with the bill. 3.3. Data Storage and Processing Upon completion of the scan, the images are stored in the Dicom system. A report of the scan is processed in Vrumun, a computer programme for ultrasonography centres and midwifery practices. The client receives a report of the scan and a return form and is asked to forward these to her referring doctor. Furthermore, the client is asked to complete a survey which is sent to her by e-­‐mail. The sonographer retains a print of the day’s time schedule, to be used for the annual report, feedback to SPN (the Nijmegen Foundation for Prenatal Diagnostics), and a financial report. The return form is ultimately returned to the centre by the client’s referring physician, preferably between one and six weeks after the baby’s birth. At the centre, the returned form is added to the previously stored ultrasound report, after which it is used for reports submitted to SPN as well as for annual reports. VEZ’s secretary monitors the reception of the return forms. If, after a client has given birth, no form is received, the referring physician is reminded once to submit one, which results in a high response rate. In 2012 there were 10 failures to return the form (= 1.3 per cent of forms) In 2013 there were 6 failures to return the form (= 0.9 per cent of forms) Many thanks to Carin Dannenberg, our assistant, for providing us with this great look into our feedback procedure. The responsibility of monitoring the annual statistics has been assigned to Carin Dannenberg, while the annual report and reporting to SPN are the responsibilities of the centre’s manager, Judith Snelder. VEZ processes most of its data in Excel. In addition, Vrumun* automatically processes data for the Peridos database. *Vrumun: computer program for the sector 9 CHAPTER 4 Safeguarding Quality The quality of the care we deliver is evaluated in several ways: -­‐ We use surveys to obtain customer feedback. -­‐ Once every six months, all three of our sonographers meet with VES and Dagmar de Bruijn for an extensive evaluation of the past half year. -­‐ The sonographers are encouraged to improve the quality of their scans through refresher courses and hands-­‐on training seminars taught once or twice a year by Dagmar de Bruijn. -­‐ Judith Snelder has obtained Fetal Medicine Foundation certification to carry out the following tests: NT measurements, ductus venosus flow assessment, tricuspid flow assessment, nasal bone detection, uterine and umbilical artery Doppler assessments, facial angle measurement. -­‐ Every year SPN requires us to send them images of 20-­‐week scans and NT measurements carried out at VEZ for assessment purposes. Our sonographers are only allowed to perform 20-­‐week scans and NT measurements if they pass this annual SPN assessment. -­‐ Our sonographers are all registered and certified members of the Royal Dutch Organisation of Midwives (KNOV) and the Dutch Association of Ultrasonography Professionals (BEN). To keep their certification up to date, they have to attend a certain number of refresher courses, conferences, assemblies and meetings each year. In 2012-­‐2013 Herma Veldhorst attended the following refresher courses and conferences: January 2012: Foetal monitoring course at UMCU (Utrecht Academic Medical Centre) January 2012: Foetal ultrasonography working group anniversary conference March 2012: Prenatal Screening: SPN anniversary conference March 2012: Audit by SPN, including an interview April 2012: Discussion of progress with VES May 2012: Hands-­‐on training seminar presented bij Dagmar de Bruijn, tertiary sonographer and lecturer July 2012: Discussion of progress with VES September 2012: Case study and theoretical seminar presented by Dagmar de Bruijn, tertiary sonographer and lecturer October 2012: Scientific presentation on the detection of foetal growth restriction by KNOV October 2012: Discussion of progress with VES October 2012: Organised and attended VES’ anniversary conference: Prenatal Screening: On Whose Say-­‐So? November 2012: BEN conference: The First-­‐Trimester Scan: Are We Prepared for the Future? December 2012: Hands-­‐on training seminar presented by Dagmar de Bruijn, tertiary sonographer and lecturer January 2013: Conference: The Foetal Skeleton from Ultrasound to Diagnosis and Prognosis January 2013: Hands-­‐on training seminar presented by Dagmar de Bruijn, tertiary sonographer January 2013: Discussion of progress with VES February 2013: Internship at Prenatal Diagnostics and Therapy department of Radboud Academic Medical Centre (including hands-­‐on component) June 2013: Heart conditions practical at Amsterdam Medical Centre 10 June 2013: 12th World Congress in Fetal Medicine in Marbella, Spain (hosted by FMF) September 2013: Case study seminar presented by Dagmar de Bruijn, tertiary sonographer October 2013: Regional meeting on Prenatal Screening, hosted by SPN November 2013: Training at Prenatal Diagnostics and Therapy department of Radboud Academic Medical Centre November 2013: Foetal Echocardiography: From Four-­‐Chamber View to Corrected Transposition In 2012-­‐2013 Judith Snelder attended the following refresher courses and conferences: January 2012: Foetal Ultrasonography Working Group anniversary conference April 2012: Discussion of progress with VES April 2012: Conference: Small Foetus or Growth Restriction? May 2012: Hands-­‐on training seminar presented by Dagmar de Bruijn, tertiary sonographer and lecturer May 2012: Scientific component of the BEN 24th Annual General Meeting June 2012: FMF World Congress in Kos Island, Greece July 2012: Discussion of progress with VES August 2012: Passed FMF theoretical course on the 11-­‐13-­‐week scan September 2012: Case study and theoretical seminar presented by Dagmar de Bruijn, tertiary sonographer and lecturer October 2012: Discussion of progress with VES October 2012: Organised and attended VES anniversary conference: Prenatal Screening: At Whose Say-­‐So? November 2012: BEN anniversary conference: The First-­‐Trimester Scan: Are We Prepared for the Future? December 2012: FMF Advances in Foetal Medicine course December 2012: Hands-­‐on training seminar presented by Dagmar de Bruijn, tertiary sonographer and lecturer January 2013: Conference: The Foetal Skeleton from Ultrasonography to Diagnosis and Prognosis January 2013: Hands-­‐on training seminar presented by Dagmar de Bruijn, tertiary sonographer January 2013: Discussion of progress with VES March 2013: Obtained FMF certificate of attendance for Cervical Assessment course May 2013: Obtained FMF certificate of attendance for Antenatal Surveillance, Doppler in Ultrasound theoretical course June 2013: Obtained FMF certificate of competence for Doppler in Ultrasound course June 2013: 12th FMF World Congress in Fetal Medicine in Marbella, Spain August 2013: Passed FMF Assessment of Ductus Venosus Flow course September 2013: Passed FMF Measurement of Nuchal Translucency course September 2013: Case study seminar presented by Dagmar de Bruijn, tertiary sonographer October 2013: Obtained FMF certificate of attendance for Basic Foetal Echocardiography course October 2013: Regional meeting on Prenatal Screening, hosted by SPN November 2013: Heart conditions practical at Amsterdam Medical Centre December 2013: Completed e-­‐learning course on Normal Foetal Anatomy of the Kidneys December 2013: FMF Advances in Fetal Medicine course 11 CHAPTER 5 Scans/Abnormalities and Referrals A total number of 755 20-­‐week scans were performed at VEZ in 2012, as well as 689 20-­‐week scans in 2013. Furthermore, VEZ performed 191 NT measurements and first-­‐trimester screenings in 2012, and another 185 in 2013. FIRST-­‐TRIMESTER SCREENINGS PERFORMED IN 2012 A total of 191 clients made an appointment for first-­‐trimester screening at VEZ in 2012. Two clients decided not to undergo the screening – one because there was no longer any foetal heart action and another because of the out-­‐of-­‐pocket expenses associated with the screening. In the end, VEZ performed 189 first-­‐trimester screenings, nine of which showed the pregnancy to be high risk. This equals 4.8 per cent of the total number of screenings, down from 6 per cent in 2011. Thirty-­‐seven out of 189 clients were over the age of 36. The youngest client was 19 years old; the oldest was 47. If we consider the number of 20-­‐week scans performed (755) as the total population (nearly 100 per cent of clients undergo 20-­‐week scans; however, the number of clients who had an advanced scan is unknown), less than 25 per cent of the population underwent first-­‐trimester screening. High-­‐risk pregnancies identified in the first quarter of 2012 February Performed first-­‐trimester screening on a client who had not menstruated for 11 weeks and 5 days (client born 27 September 1976, a priori risk score of 1:180). The client is pregnant with twins. Lab unknown to us. Foetus A has a CRL of 50mm and an NT of 2.5mm. Foetus B has a CRL of 52mm and an NT of 2.3mm. Foetus A is at increased risk of having three trisomies (T21 1:45/ T18 1:170 / T13 1:180). Foetus B is only at increased risk for Down syndrome (1:85). The client chooses to undergo an amniotic fluid test. Outcome: Both foetuses present a normal feminine DNA profile. Performed first-­‐trimester screening on a client who had not menstruated for 12 weeks and 2 days (client born 13 June 1978, a priori risk score of 1:320). The foetus has a CRL of 60mm and an NT of 1.9mm. The ultrasound does not show any abnormalities. Low PAPP-­‐A and HCGB. Increased risk for Edwards syndrome: 1:75. CVS outcome: Foetus has Edwards syndrome => Termination of pregnancy High-­‐risk pregnancies identified in second quarter of 2012 April Performed first-­‐trimester screening on a client who had not menstruated for 11 weeks and 4 days (client born 18 April 1976, a priori risk score of 1:190). The foetus has a CRL of 50mm and an NT of 1.8mm. Low PAPP-­‐A, high HCGB. Increased risk for Down syndrome (1:20). Neither CVS nor the 20-­‐
week scan reveals any abnormalities. No abnormalities reported post partum. May 12 Performed first-­‐trimester screening on a client who had not menstruated for 11 weeks and 6 days (client born 12 August 1977, a priori risk score unknown). The foetus has a CRL of 58.0mm and an NT of 4.2mm. The client chooses to undergo CVS, which shows that the foetus has Down syndrome. The pregnancy is terminated. Performed first-­‐trimester screening on a client who had not menstruated for 12 weeks and 2 days (client born 28 May 1974, a priori risk score of 1:120). The foetus has a CRL of 55.0mm and an NT of 2.6mm. Low PAPP-­‐A, slightly elevated HCGB. Increased risk for Down syndrome: 1:20. CVS comes back normal. No abnormalities detected in 20-­‐week scan. No abnormalities reported post partum. High-­‐risk pregnancies identified in fourth quarter of 2012 October Performed first-­‐trimester screening on a client who had not menstruated for 13 weeks and 2 days (client born 29 September 1974, a priori risk score of 1:120). The foetus has a CRL of 62.4mm and an NT of 1.6mm. Low PAPP-­‐A, high HCGB. Increased risk for Down syndrome: 1:30. CVS does not show any trisomy anomalies. QF-­‐PCR detects a 22q13 deletion. The pregnancy is terminated. November Performed first-­‐trimester screening on a client who had not menstruated for 12 weeks and 1 day (client born 4 January 1970, a priori risk score of 1:35). The foetus has a CRL of 67.0mm and an NT of 2.4mm. High PAPP-­‐A, normal HCGB. Increased risk for Down syndrome: 1:120. The client does not wish to undergo any invasive diagnostic procedures. The 20-­‐week scan does not pick up any anomalies. A healthy baby is born at term. December Performed first-­‐trimester screening on a client who had not menstruated for 12 weeks and 1 day (client born 7 August 1968, a priori risk score of 1:20). The foetus has a CRL of 54.8mm and an NT of 1.0mm. Low PAPP-­‐A, high HCGB. Increased risk for Down syndrome: 1:75. CVS presents a normal masculine DNA profile. QF-­‐PCR does not detect any anomalies, either. A healthy baby is born at term. Performed first-­‐trimester screening on a client who had not menstruated for 12 weeks and 1 day (client born 7 March 1974, a priori risk score of 1:100). The foetus has a CRL of 59.0mm and an NT of 2.1mm. Low PAPP-­‐A, slightly elevated HCGB. Increased risk for Down syndrome: 1:100. The client does not wish to undergo any invasive diagnostic procedures. The 20-­‐week scan comes back normal; no abnormalities reported post partum. Out of nine first-­‐trimester screenings that showed an increased risk for congenital disorders, -­‐ Seven clients were over the age of 36 -­‐ Three foetuses were found to have abnormalities. This equals 33.3 per cent of foetuses with a high risk score, and 1.6 per cent of the total number of clients undergoing first-­‐trimester screening. o 1x nuchal translucency (4.2mm), client >36 of age => T21 o 1x no nuchal translucency, client 33 years of age, severe anomalies detected in biochemical testing =>T18 o 1x no nuchal translucency, client 38 years of age, severe anomalies detected in biochemical testing => 22Q13 deletion All three of the above-­‐mentioned pregnancies were terminated. 13 Of the first-­‐trimester screenings that did not detect an increased risk for congenital disorders, no neonates were found to have abnormalities afterwards, neither in the 20-­‐week scan nor post partum. FIRST-­‐TRIMESTER SCREENINGS PERFORMED IN 2013 213 first-­‐trimester screenings were performed in 2013, nine of which showed the pregnancy to be high risk. This equals 4.2 per cent of the screenings performed (as opposed to 6 per cent in 2011, and 4.8 per cent in 2012). Forty out of 213 clients were over the age of 36. The youngest client was 19 years old; the oldest was 42. If we consider the number of 20-­‐week scans performed (698) as the total population (nearly 100 per cent of clients undergo 20-­‐week scans; however, the number of clients who had an advanced scan is unknown), 30.5 per cent of the population underwent first-­‐
trimester screening. High-­‐risk pregnancies identified in first quarter of 2013 January Performed first-­‐trimester screening on a client who had not menstruated for 12 weeks and 1 day (client born 9 September 1976, a priori risk score of 1:570). The foetus has a CRL of 52.2mm and an NT of 3.8mm. Elevated PAPP-­‐A and HCGB. Increased risk of Down syndrome: 1:5. The client does not wish to undergo an invasive diagnostic procedure. The advanced scan comes back normal. No abnormalities reported post partum. February Performed first-­‐trimester screening on a client who had not menstruated for 13 weeks and 2 days (client born 29 September 1974, unknown a priori risk score). The foetus has a CRL of 56.5mm and an immeasurable NT. Low PAPP-­‐A, high HCGB. Multiple abnormalities are identified: hygroma colli, omphalocoele, legs and feet growing at abnormal angles. The abnormalities are such that the client is immediately referred to Radboud Hospital in Nijmegen, which confirms the ultrasound findings. CVS detects a T21 abnormality. The pregnancy is terminated. March Performed first-­‐trimester screening on a client who had probably not menstruated for 11 weeks and 0 days (client born 2 June 1979, a priori risk score of 1:300). The foetus has a CRL of 49.8mm and an NT of 2.3mm. No nasal bone discerned. Low PAPP-­‐A, high HCGB. Increased risk for Down syndrome: 1:10. The client does not wish to undergo an invasive diagnostic procedure. The 20-­‐week scan comes back normal (no soft markers for Down syndrome detected). No abnormalities reported post partum. Performed first-­‐trimester screening on a client who had not menstruated for 12 weeks and 3 days (client born 19 March 1981, a priori risk score of 1:430). The foetus has a CRL of 59.4mm and an NT of 3.5mm. High PAPP-­‐A and HCGB. Increased risk of Down syndrome: 1:45. The client does not wish to undergo an invasive diagnostic procedure or advanced scan. The 20-­‐week scan comes back normal (no soft markers for Down syndrome detected). No abnormalities reported post partum. High-­‐risk pregnancies identified in second quarter of 2013 14 May Performed first-­‐trimester screening on a client who had not menstruated for 11 weeks and 4 days (client born 3 November 1984, a priori risk score of 1:640). The foetus has a CRL of 48.9mm and an NT of 1.9mm. Low PAPP-­‐A and HCGB. Increased risk for Down syndrome: 1:170. The client does not wish to undergo an invasive diagnostic procedure but consents to an advanced scan, which comes back normal (no soft markers for Down syndrome detected). A healthy baby boy is born at term. June Performed first-­‐trimester screening on a client who had not menstruated for 12 weeks and 6 days (client born 23 October 1974, a priori risk score of 1:100). The foetus has a CRL of 65.5mm and an NT of 3.2mm. Low PAPP-­‐A, high HCGB. Increased risk for Down syndrome: 1:15. CVS detects a T21 anomaly. The pregnancy is terminated. A client is referred to VEZ by a primary midwife who suspects a nuchal translucency. First-­‐trimester screening performed on a client who had not menstruated for 11 weeks and 5 days (client born 26 February 1978, a priori risk score of 1:220). The foetus has a CRL of 50.4mm and an NT of 2.7mm. High PAPP-­‐A, low HCGB. Increased risk for Down syndrome: 1:80. The client does not wish to undergo an invasive diagnostic procedure. The 20-­‐week scan raises some suspicion about the third ventricle, which is visible. The advanced scan shows a somewhat extended cavum vergae, which does not result in further steps being taken. No abnormalities reported post partum. High-­‐risk pregnancies identified in fourth quarter of 2013 October Performed first-­‐trimester screening on a client who had not menstruated for 13 weeks and 0 days (client born 18 September 1976, a priori risk score of 1:150). The foetus has a CRL of 68.1mm and an NT of 3.8mm. Low PAPP-­‐A, high HCGB. In view of the detected nuchal translucency, the client is immediately referred to Radboud Hospital in Nijmegen. Risk for T21: 1:170/ T18 1:85/ T13 1:35. CVS and advanced scan do not show any anomalies. No abnormalities reported post partum. November Performed first-­‐trimester screening on a client who had not menstruated for 12 weeks and 6 days (client born 5 July 1986, a priori risk score of 1:770). The foetus has a CRL of 69.2mm and an NT of 2.4mm. Low PAPP-­‐A and HCGB. Increased risk for Edwards syndrome: 1:200. CVS does not detect any anomalies. The 20-­‐week scan comes back normal, too. A baby boy weighing 1700 grams is born at 31 weeks + 1 day’s gestation (P70). Apart from the preterm birth, no abnormalities are reported. Out of nine first-­‐trimester screenings that showed an increased risk for congenital disorders, -­‐ Three clients were over the age of 36 -­‐ Two foetuses were found to have anomalies, which equals 22.2 per cent of foetuses with a high risk score, and 0.9 per cent of the total number of clients undergoing first-­‐trimester screening, down from 33.6 and 1.6 per cent, respectively, in 2012) o 1x multiple anomalies found in scan, client 36 years of age, anomalies detected in biochemical testing => T21 o 1x large, 3.2mm nuchal translucency, anomalies detected in biochemical testing, client over 36 years of age =>T21 Both pregnancies were terminated. 15 Of the first-­‐trimester screenings that did not detect an increased risk for congenital disorders, no neonates were found to have abnormalities afterwards, neither in the 20-­‐week scan nor post partum. Number First-­‐trimester screenings that detected high-­‐
risk pregnancies from 2010 onwards 14 12 10 8 6 4 2 0 Totaal 1e kwart. 2e kwart. 3e kwart. 4e kwart. Verh.risc. 12 4 5 1 2 tr.21,13,18 6 2 2 1 1 Verh.risc. 13 7 3 2 1 tr.21,13,18 3 3 0 0 0 Verh.risc. 9 2 3 1 3 tr.21,13,18 3 1 1 1 0 Verh.risc. 9 4 3 0 2 tr.21,13,18 2 1 1 0 0 2010 2011 2012 2013 First-­‐trimester screenings from 2009 onwards 250 Number 200 150 100 50 0 2009 2010 2011 2012 2013 202 224 215 191 213 Verh.risc. 7 12 13 9 9 Tris 3 2 3 3 2 Totaal 16 Trisomy disorders from 2010 onwards 14 12 10 Aantal 8 6 4 2 0 2010 tr.
tr.
tr.
tr.
Verh.
Verh.
Verh.
Verh.
21,13 2011 21,13 2012 21,13 2013 21,13
risc. risc. risc. risc. ,18 ,18 ,18 ,18 Totaal 12 6 13 3 9 3 9 2 1e kwart. 4 2 7 3 2 1 4 1 2e kwart. 5 2 3 0 3 1 3 1 3e kwart. 1 1 2 0 1 1 0 0 4e kwart. 2 1 1 0 3 0 2 0 First-­‐trimester screening by age group 250 Number 200 150 100 50 0 Totaal < 36 jaar > 36 jaar 2012 189 152 37 2013 213 173 40 20-­‐week scans performed in 2012-­‐2013 2012 Out of 755 20-­‐week scans performed in 2012, we referred 46 clients to Radboud Hospital in Nijmegen and Rijnstate Hospital in Arnhem for advanced diagnostic sonography. This equals 6.1 per cent of the population (down from 10.2 per cent in 2011). In eight cases we deliberately chose to perform a 20-­‐week scan despite the fact that there were indications for an advanced scan. In one 17 case we did not refer a client for an advanced scan because the 20-­‐week scan did not pick up any anomalies, apart from a relatively large amount of amniotic fluid. This was then spotted by a secondary gynaecologist, who referred the client for an advanced scan because of it. The advanced scan did not reveal any other anomalies, and no abnormalities were reported post partum. -­‐ In 13 cases we referred a client for an advanced scan because we had detected soft markers that warranted an advanced scan. -­‐ In 22 cases we referred a client for an advanced scan because we suspected an anomaly. -­‐ In 9 cases we were unsure whether to refer a client for an advanced scan as we were not sure whether we were really seeing an anomaly. -­‐ In 0 cases did it transpire afterwards that there were indications for an advanced scan. -­‐ In 8 cases we deliberately opted for a 20-­‐week scan rather than an advanced scan, despite the fact that there were indications for an advanced scan. -­‐ In 2 cases the 20-­‐week scan was incomplete, which was an indication for an advanced scan. In both cases the 20-­‐week scan was unclear due to maternal adiposity. Our scans looked normal, and the advanced scans did not pick up any anomalies, either. 2013 Out of 689 20-­‐week scans performed in 2013, we referred 40 clients for an advanced scan. This equals 5.8 per cent of the population (down from 10.2 per cent in 2011 and 6.1 per cent in 2012). -­‐ In 22 cases we deliberately chose to perform a 20-­‐week scan despite the fact that there were indications for an advanced scan. -­‐ In 19 cases we referred a client for an advanced scan because we had detected soft markers that warranted more testing. -­‐ In 14 cases we referred a client for an advanced scan because we suspected an anomaly. -­‐ In 4 cases we were unsure whether to refer a client for an advanced scan, as we were not sure whether we were really seeing an anomaly. -­‐ In 5 cases did it transpire afterwards that there were indications for an advanced scan. Three of these clients did end up undergoing advanced scans. -­‐ In 22 cases we deliberately opted for a 20-­‐week scan rather than an advanced scan, despite the fact that there were indications for an advanced scan. -­‐ In 1 case the 20-­‐week scan was incomplete, which was an indication for an advanced scan. Here, too, the 20-­‐week scan was unclear due to maternal adiposity. The scan looked normal, and the advanced scan did not reveal any anomalies, either. 2012 REFERRALS FOR ADVANCED DIAGNOSTIC SONOGRAPHY DUE TO THE PRESENCE OF SOFT MARKERS In 2012 we referred 13 clients who had undergone a 20-­‐week scan for an advanced scan due to the presence of soft markers. This equals 1.7 per cent of the total number of 20-­‐week scans carried out (down from 2.7 per cent in 2011) and 28.3 per cent of the total number of referrals for an advanced scan (up from 26.8 per cent in 2011). January Case 1: Gravida 1, age 33. No grounds for concern following first-­‐trimester screening. At 19 weeks + 1 day’s gestation, the foetus appears to have choroid plexus cysts at both sides, and both renal pelvises are >5mm dilated (5.5 and 5.7mm). Since more than one soft marker has been detected, we 18 advise the client to undergo an advanced scan, which confirms our findings. In the repeat scan performed at 32 weeks’ gestation, the choroid plexus cysts and pyelectasis are no longer visible. Outcome: A healthy baby boy weighing 3,500 grams is born at term, without visible abnormalities. Case 2: Gravida 1, age 33. No grounds for concern following first-­‐trimester screening. At 20 weeks + 4 days’ gestation, we detect a single umbilical artery. An advanced scan confirms our finding. Outcome: A healthy baby girl weighing 3,380 grams is born at term, without visible abnormalities. Case 3: Gravida 2, para 1, age 31. No grounds for concern following first-­‐trimester screening. At 19 weeks + 6 days’ gestation, the scan shows increased foetal bowel echogenicity, and both renal pelvises are >5mm dilated (5.5 and 5.9mm, respectively). Since more than one soft marker has been detected, we advise the client to undergo an advanced scan, which confirms our findings. The parents do not wish to undergo an invasive diagnostic procedure. In the repeat scan performed at 34 weeks’ gestation, the anomalies are no longer visible. Outcome: A healthy baby boy weighing 4,440 grams (P80/P85 at 41 weeks + 3 days’ gestation) is born at term, without visible abnormalities. March Case 4: Gravida 2, para 1, age 29. No grounds for concern following first-­‐trimester screening. However, since a previous pregnancy was terminated due to 22Q11 deletion, there is an indication for an advanced scan. The parents wish to undergo a 20-­‐week scan instead, with the same sonographer who discovered the abnormalities in their first foetus. The 20-­‐week scan only shows a white spot on the foetal heart. The expecting parents are concerned about this and request an advanced scan, after all. The advanced scan confirms our finding. Outcome: A healthy baby girl weighing 3,500 grams is born at term, without visible abnormalities. April Case 5: Gravida 2, para 1, age 30. At 20 weeks + 3 days’ gestation, a short femur is detected (<P3). It should be noted that the client herself is short (150cm), so the foetus may just be small for its gestational age. An advanced scan confirms our finding (femur <P5). The parents do not wish to undergo any invasive diagnostic procedures. Outcome: A healthy baby weighing 3,670 grams is born at term, without visible abnormalities. May Case 6: Gravida 1, age 25. At 18 weeks + 1 day’s gestation, a choroid plexus cyst is detected on the right, as well as an echogenic focus in the left ventricle of the heart. Since more than one soft marker has been detected, we advise the client to undergo an advanced scan, which only confirms the echogenic focus in the foetal heart. No follow-­‐up examinations are performed. Outcome: A healthy baby boy weighing 3,120 grams is born at term, without visible abnormalities. June Case 7: Gravida 1, age 29. At 19 weeks + 4 days’ gestation, we detect a single umbilical artery. An advanced scan confirms our finding. Outcome: A healthy baby girl weighing 3,085 grams is born at term, without visible abnormalities. July Case 8: Gravida 1, age 24. At 19 weeks + 6 days’ gestation, we detect a single umbilical artery, as well as short long bones. Apart from these findings, there are no anomalies. An advanced scan confirms 19 our findings. Amniocentesis does not detect any anomalies. Follow-­‐up scans show some growth restriction (long bones remain <P5), but the bones are growing symmetrically and there is a good growth curve. Outcome: A baby boy weighing 2,350 grams is born at term (<P2.3). His height is 46cm. Maybe he is just small for his gestational age? Apart from that, the neonate is healthy and has no visible abnormalities. August Case 9: Gravida 2, para 1, age 30. At 19 weeks + 5 days’ gestation, we detect a single umbilical artery. An advanced scan confirms our finding. Outcome: A healthy baby boy weighing 3,580 grams is born at term, without visible abnormalities. September Case 10: Gravida 1, age 23. At 20 weeks + 3 days’ gestation, we detect a single umbilical artery. An advanced scan confirms this finding. Outcome: A healthy baby girl weighing 2,840 grams is born at term (P50 at 37 weeks and 2 days’ gestation), without visible abnormalities. Case 11: Gravida 1, age 24. At 19 weeks + 6 days’ gestation, the scan shows multiple white spots, particularly around the mitral valve. However, the valve does seem to function well. Due to the incidence of echogenic foci around the mitral valve, we advise the client to undergo an advanced scan, which confirms our findings but does not detect any other anomalies. Outcome: A healthy baby girl weighing 3,412 grams is born at term, without visible abnormalities. Case 12: Gravida 1, age 30. At 20 weeks’ gestation, the scan reveals hyperechogenecity of the foetal bowel. The client’s daughter may recently have suffered from fifth disease (parvovirus B19). Apart from that, there are no soft markers. Foetal biometry shows that the foetus is on the small side, so we advise a growth scan as well as an advanced scan. The client herself is 160cm and 54kg. The advanced scan confirms our findings. Client undergoes TORCH screening and amniocentesis. Neither test picks up any anomalies. Outcome: A healthy baby girl weighing 2,935 grams, height 47cm (SGA?), is born at term, without visible abnormalities. Case 13: Gravida 4, para 3, age 40. At 20 weeks + 3 days’ gestation, we detect a single umbilical artery. We have difficulty assessing the foetal heart due to the foetus’ presentation. Potential ventricular septal defect. An advanced scan confirms the SUA but not the VSD. Outcome: Unknown. 2013 REFERRALS FOR ADVANCED DIAGNOSTIC SONOGRAPHY DUE TO THE PRESENCE OF SOFT MARKERS In 2013 we referred 19 clients who had undergone a 20-­‐week scan for an advanced scan due to the presence of soft markers. This equals 2.8 per cent of the total number of 20-­‐week scans carried out (up from 1.7 per cent in 2012 and 2.7 per cent in 2011) and 40.4 per cent of the total number of referrals for an advanced scan (up from 25.5 per cent in 2012 and 26.8 per cent in 2011). January Case 1: Gravida 1, age 36. No grounds for concerns following first-­‐trimester screening. At 20 weeks’ gestation we detect a single umbilical artery. An advanced scan confirms this finding. Outcome: A healthy baby boy weighing 3,365 grams is born at term, without visible abnormalities. March 20 Case 2: Gravida 1, age 35. At 19 weeks + 4 days’ gestation, the 20-­‐week scan reveals a short femur (<P5). Both parents are short. No other soft markers are detected. An advanced scan carried out on 22 March 2013 shows no anomalies; fetal biometry is within normal range. A follow-­‐up advanced scan performed on 26 June 2013 shows the same short femur (<P3). The parents do not wish to undergo an invasive diagnostic procedure. Outcome: A healthy baby girl weighing 3,160 grams, height 47cm, is born at term, without visible abnormalities. Case 3: Gravida 2, age 32. At 19 weeks’ gestation, the 20-­‐week scan reveals a single umbilical artery. An advanced scan confirms this finding, and also shows an anomalous right aortic arch artery and possibly a VSD. The VSD is no longer visible in the repeat advanced scan. Outcome: A healthy baby boy weighing 3,450 grams is born at term, without visible abnormalities. April Case 4: Gravida 1, age 25. At 20 weeks + 5 days’ gestation, the 20-­‐week scan shows a single umbilical artery. An advanced scan confirms our finding. Outcome: A healthy baby boy weighing 3,120 grams is born at term, at 41 weeks + 3 days’ gestation, without visible abnormalities. Case 5: Gravida 1, age 24. At 20 weeks’ gestation, the 20-­‐week scan shows a single umbilical artery, plus slightly dilated renal pelvises. The ureters can be traced to some extent. The male foetus does not seem to have a keyhole. An advanced scan confirms this finding. The dilated renal pelvises are no longer visible in the repeat scan performed later. Outcome: A healthy baby boy weighing 3,460 grams is born at term, without visible abnormalities. Case 6: Gravida 2, para 1, age 33. The 20-­‐week scan shows some hyperechogenecity of the foetal bowel, but it does not show up too brightly. We advise the client to undergo an advanced scan just to be on the safe side. The advanced scan does not confirm our finding. Outcome: A healthy baby girl weighing 3,750 grams is born at term, without visible abnormalities. Case 7: Gravida 1, age 27. The 20-­‐week scan shows mild pyelectasis, as well as a white spot in the heart and slight hyperechogenecity of the bowel (not “as white as bone”), approximate biometry performed (P90). An advanced scan only confirms mild pyelectasis, so the client undergoes another scan at 32/34 weeks’ gestation, at another hospital. This time there is no sign of pyelectasis. Outcome: A healthy baby boy weighing 4,798 grams (>P97.7) is born at term, without visible abnormalities. May Case 8: Gravida 4, para 0, age 25. The 20-­‐week scan shows a single umbilical artery. An advanced scan confirms this finding. Outcome: A healthy baby boy weighing 2,850 grams is born at term, at 37 weeks + 3 days’ gestation, without visible abnormalities. June Case 9: Gravida 1, age 24. The 20-­‐week scan shows hyperechogenecity of the bowel, with peristalsis. An advanced scan confirms this finding. We do not perform amniocentesis, but do screen for TORCH and parvovirus B19. The parvo test yields a positive result. At 35 weeks’ gestation, the advanced scan is repeated. It shows some hyperechogenecity of the loop colon, but no peristalsis this time. Outcome: A healthy baby boy is born at term, with a normal body weight and without visible abnormalities. He seems fine. 21 Case 10: Gravida 2, para 1, age 33. The 20-­‐week scan shows a single umbilical artery. An advanced scan confirms this finding. Outcome: A healthy baby girl is born at term, with a body weight in the P40 range, without visible abnormalities. Case 11: Gravida 2, para1, age 33. The 20-­‐week scan shows hyperechogenecity of the bowel. Apart from that, no other soft markers are detected. An advanced scan confirms our finding. We screen for TORCH and parvovirus B19. The client does not wish to undergo any invasive diagnostic procedures. No anomalies detected. At 31 weeks + 6 days’ gestation, a repeat advanced scan shows slight hyperechogenecity of the bowel, but no bowel dilation and/or peristalsis. Outcome: A healthy baby boy weighing 3,620 grams is born at term, without visible abnormalities. July Case 12: Gravida 1, age 21. The 20-­‐week scan shows hyperechogenecity of the bowel, but not too severe. An advanced scan confirms this finding. No further examinations are performed. Outcome: A healthy baby is born at term, without visible abnormalities. Body weight unknown. August Case 13: Gravida 1, age 36. No grounds for concern following first-­‐trimester screening. The 20-­‐week scan only shows a single umbilical artery. An advanced scan confirms this finding. Foetal biometry is within normal range. Outcome: a baby girl weighing 4,020 grams (>P97.5) is born at 38 weeks + 3 days’ gestation. Shoulder dystocia occurs during delivery. No visible injuries with mother or child. Case 14: Gravida 1, age 24. At 20 weeks + 2 days’ gestation, the 20-­‐week scan shows a single umbilical artery. An advanced scan confirms this finding. Outcome: A healthy baby girl weighing 3,310 grams is born at term, without visible abnormalities. Case 15: Gravida 2, para 1, age 27. At 20 weeks + 6 days’ gestation, the 20-­‐week scan shows mild unilateral pyelectasis. An advanced scan confirms this finding. A repeat scan performed at our own centre does not reveal any anomalies. Outcome: A healthy baby girl weighing 3,660 grams is born at term, without visible abnormalities. October Case 16: Gravida 3, para 2, age 33. The 20-­‐week scan shows hyperechogenecity of the bowel. Apart from that, no other soft markers are detected. An advanced scan shows that the bowel echogenecity is not too severe. No further examinations are performed. Outcome: A healthy baby girl weighing 3,335 grams is born at term, without visible abnormalities. December Case 17: Gravida 1, age 23. The 20-­‐week scan shows mild hydronephrosis of the right kidney, plus a marginal insertion of the umbilical cord. An advanced scan confirms this finding. A follow-­‐up scan detects a right renal pelvis with 12mm dilation. No anomalies are detected on the left renal pelvis. Outcome: A baby girl weighing 3,240 grams is born at term with hydronephrosis of the right kidney requiring treatment. Case 18: Gravida 1, age 20. The 20-­‐week scan shows mild bilateral hydronephrosis. Apart from that, no other anomalies are detected. An advanced scan confirms our finding. When the scan is repeated at 32 weeks’ gestation, no anomalies are detected. Outcome: A healthy baby boy weighing 3,440 grams is born at term, without visible abnormalities. 22 Case 19: Gravida 1, age 19. The 20-­‐week scan shows a single umbilical artery as well as hyperechogenecity of the bowel. Client suffered blood loss in the first trimester. The advanced scan only shows the SUA. Outcome: A healthy baby boy weighing 2,520 grams (P16/P20) is born at 37 weeks’ gestation, without visible abnormalities. In both 2012 and 2013 no severe congenital disorders were detected in those foetuses who had one soft marker. All babies with short long bones turned out to be small for their gestational age or suffered from intrauterine growth restriction rather than from a genetic disorder. Apart from a few cases of hydronephrosis, we did not receive any reports of abnormalities. 2012 REFERRALS FOR ADVANCED DIAGNOSTIC SONOGRAPHY DUE TO A SUSPICION OF ABNORMALITY In 2012 we referred 22 clients for advanced diagnostic sonography due to a suspicion of abnormality. This equals 2.9 per cent of the total number of 20-­‐week scans (up from 2.7 per cent in 2011) and 47.8 per cent of the total number of referrals for advanced scans (up from 26.8 per cent in 2011). January Case 1: Gravida 1, age 23. The three-­‐vessel view of the 20-­‐week scan shows that the aorta is wider than, or as wide as, the pulmonary artery. Apart from this finding, no other anomalies are detected. An advanced scan confirms our finding. Normal flow from the outflow tracts; normal cardiac diameters. At 30 weeks’ gestation the client undergoes a repeat scan, which yields the same results. Outcome: A healthy baby girl weighing 3,450 grams is born at term, without visible abnormalities. Case 2: Gravida 3, para 1, age 30. The 20-­‐week scan shows a transposition of the great vessels, as well as a VSD with a possibly overriding pulmonary artery. An advanced scan confirms the transposition and the VSD, but not the overriding pulmonary artery. Outcome: A baby girl weighing 3,000 grams is born at term with the aforementioned condition. February Case 3: Gravida 1, age 30. The three-­‐vessel view of the 20-­‐week scan shows that the aorta is wider than, or as wide as, the pulmonary artery. Apart from this finding, no anomalies are detected. An advanced scan confirms our finding. Normal flow from the outflow tracts; normal cardiac diameters. At 25 weeks + 6 days’ gestation, the client undergoes a repeat scan, which yields the same results. Outcome: A healthy baby girl weighing 2,900 grams is born at 36 weeks + 6 days’ gestation, without visible abnormalities. March Case 4: Gravida 2, para 1, age 29. The 20-­‐week scan shows pes equinovarus, as well as somewhat restricted growth. Apart from these findings, no anomalies are detected. An advanced scan confirms that the foetus has pes equinovarus, but apart from a slightly smaller head, the growth rate appears to be normal. At 25+ weeks’ gestation, another scan is performed at our centre to monitor the growth rate of the foetus. The growth curve seems to be on a downward slant. We advise the client to undergo a scan at Radboud Hospital, which does not confirm the downward growth curve. Outcome: A dysmature but healthy daughter weighing 2,760 grams (<P3) is born at 40 weeks’ gestation. She has pes equinovarus but no other visible abnormalities. 23 April Case 5: Gravida 3, para 1, age 30. The 20-­‐week scan shows intestine loops in the lower abdomen. No signs of peristalsis or hyperechogenecity. An advanced scan shows a somewhat prominent rectum just behind the bladder, but within normal range. Outcome: A healthy baby girl weighing 3,770 grams is born at term, without visible abnormalities. May Case 6: Gravida 2, para 1, age 34. The 20-­‐week scan shows potential transposition of the great vessels. The pulmonary artery is very thin and the aorta seems dilated. The three-­‐vessel view presents an anomalous image. The quality of the image is poor due to maternal adiposity. The advanced scan seems to point towards pulmonary atresia with a ventricular septal defect and pulmonary hypoplasia. It also picks up a truncus arteriosus. Amniocentesis reveals a 22Q11 deletion. Outcome: Termination of pregnancy. Case 7: Gravida 1, age 28. The 20-­‐week scan reveals a thickened neck, as well as short long bones (<P3) and oedema at both hands and feet. The foetus is female. An advanced scan confirms our findings. Amniocentesis results in a diagnosis of Turner syndrome. Outcome: A baby girl weighing 2,720 grams is born at 38 weeks + 5 days’ gestation, with the aforementioned condition. Case 8: Gravida 1, age 30. The 20-­‐week scan shows an echolucent zone behind the stomach and from the stomach downwards. It has an echogenic outline at the bottom. The hospital performing the advanced scan does not consider this to be anomalous. Outcome: A healthy baby boy weighing 2,845 grams is born at 37 weeks + 1 day’s gestation, without visible abnormalities. Case 9: Gravida 2, para 1, age 35. The 20-­‐week scan shows a white spot in the foetal heart. In addition, both renal pelvises are slightly dilated (approx. 6mm), and the aorta seems to widen after the valve. Furthermore, the scan picks up a placenta praevia. Apart from these findings, no other anomalies are detected. An advanced scan confirms the white spot, dilated renal pelvises and placenta praevia, but the aorta presents normally. Outcome: A healthy baby boy weighing 3,535 grams is born at term, without visible abnormalities. Case 10: Gravida 3, para 1, age 35. The three-­‐vessel view of the 20-­‐week scan shows that the aorta is wider than the pulmonary artery. No other demonstrable anomalies, although foetal biometry suggests that the foetus is on the large side. We advise the client to undergo growth scans. An advanced diagnostic scan confirms our findings. Outcome: a healthy baby boy weighing 4,820 grams (>P97.5) is born at term, without visible abnormalities. Case 11: Gravida 1, age 28. The 20-­‐week scan shows unilateral hydronephrosis (left 12mm). The scan does not pick up any other anomalies. However, the image quality is very poor due to maternal adiposity (BMI>40). An advanced scan confirms our finding. Outcome: Unknown. June Case 12: Gravida 1, age 18. The 20-­‐week scan shows duplex kidneys on the right. No other visible anomalies. An advanced scan confirms our finding. Outcome: A baby weighing 3,245 grams is born at term, with the aforementioned condition. Case 13: Gravida 1, age 27. The 20-­‐week scan only reveals that the foetus is on the small side (<P3). Other than that, no anomalies are detected. Some doubt as to how long the client has been pregnant. 24 Elevated PI of the uterine artery. An advanced scan results in the foetus’ gestational age being adjusted and the foetus’s growth rate being regarded as normal. Outcome: A severely dysmature baby girl weighing 1,100 grams is born at 34 weeks + 3 days’ gestation. Case 14: Gravida 2, para 1, age 29. The 20-­‐week scan shows the left ureter, which may or may not be dilated. No other visible anomalies are detected. The kidneys look normal. An advanced scan does not confirm our findings. Outcome: Unknown. Case 15: Gravida 1, age 30. The three-­‐vessel view of the 20-­‐week scan shows that the aorta is wider than the pulmonary artery, albeit not at the level of the aortic and pulmonary valves. In other words, the aorta seems to widen. Closure of the valves and the descending aorta can be traced easily. No other anomalies visible. An advanced scan does not confirm our findings. Outcome: A healthy baby boy weighing 3,795 grams is born at term, without visible abnormalities. July Case 16: Gravida 2, para 1, age 27. The three-­‐vessel view of the 20-­‐week scan shows that the aorta is wider than the pulmonary artery, albeit not at the level of the aortic and pulmonary valves. In other words, the aorta seems to widen. Closure of the valves and the descending aorta can be traced easily. There is some uncertainty about the size of the two ventricles. The lateral ventricles in the caput are on the large side, but well within the <10mm range. An advanced scan does confirm these findings, but they are considered insignificant. Outcome: Unknown. Case 17: Gravida 11, para 8, age 35 (the client is a smoker). The 20-­‐week scan shows dextrorotation of the heart. Outflow tracts and four-­‐chamber view present a normal aspect. Possible hyperechogenecity of the lungs. Apart from a somewhat low-­‐lying placenta with a marginal insertion of the umbilical cord, the scan does not pick up any anomalies. An advanced scan confirms our findings. The lungs are given the all clear. A repeat scan at 30 weeks’ gestation gives rise to a suspicion of Ebstein’s anomaly. Outcome: A healthy baby boy weighing 2,780 grams (=P5) is born at term. The baby is allowed to leave the hospital one day post partum. Follow-­‐up examinations by a paediatric cardiologist have been scheduled. October Case 18: Gravida 1, age 33. The 20-­‐week scan shows duplex kidneys on the left. No other visible anomalies. An advanced scan confirms our finding. Outcome: A baby weighing 3,120 grams is born at 37 weeks + 4 days’ gestation with the aforementioned condition. November Case 19: Gravida 1, age 25. The 20-­‐week scan shows an echolucent space in the lower abdomen which is hard to trace cranially (Rectum? Does it present a normal aspect?). An advanced scan confirms this finding. The sonographer suspects a normal but visible rectum. Another scan is performed at 31 weeks + 6 days’ gestation, and this time no anomalies are detected. Outcome: A healthy baby boy weighing 2,960 grams is born at 39 weeks + 5 days’ gestation, without visible abnormalities. Case 20: Gravida 1, age 27. The 20-­‐week scan shows a cheilo-­‐gnato-­‐palatoschisis. Apart from this and a slightly low-­‐lying placenta, the scan does not pick up any other anomalies. An advanced scan confirms our findings. Outcome: A baby boy weighing 3,240 grams is born at term with the aforementioned condition. 25 December Case 21: Gravida 3, para 1, age 38. The 20-­‐week scan shows a transposition of the great vessels. There is a suspicion of pulmonary stenosis. The ventricular septum appears to be intact. In addition, the foetus appears to be on the small side, particularly de fac (<P3). No other visible anomalies. An advanced scan confirms our findings. An invasive diagnostic procedure reveals a 22Q11 deletion. Outcome: Termination of pregnancy. Case 22: Gravida 1, age 33. The 20-­‐week scan shows a mild ventriculomegaly (>10mm). In addition, the nasal bone seems small in relation to pre-­‐nasal thickness, and both femurs are on the small side, albeit >P3. An advanced scan does not confirm these findings. Outcome: A healthy baby boy weighing 3,500 grams is born at term, without visible abnormalities. 2013 REFERRALS FOR ADVANCED DIAGNOSTIC SONOGRAPHY DUE TO A SUSPICION OF ABNORMALITY In 2013 we referred 14 clients for an advanced scan due to a suspicion of abnormality. This equals 2 per cent of the total number of 20-­‐week scans performed in 2013 (down from 2.9 per cent in 2012 and 2.7 per cent in 2011) and 35 per cent of the total number of referrals for advanced scans (down from 43 per cent in 2011, up from 26.8 per cent in 2011). January Case 1: Gravida 1, age 34. The 20-­‐week scan shows that the foetus is small overall (>P5<P10), but the head and cerebellum are especially small (<P3). No other anomalies are detected. (Miscalculated gestational age? Early-­‐onset IUGR?). The Dopplers of the umbilical arteries, uterine artery and middle cerebral artery come back normal. An advanced scan confirms our findings, but also shows elevated PI on the left, with notching. This could point to low placental circulation. The client agrees to undergo repeat growth scans. Outcome: A healthy baby girl weighing 2,605 grams (=P16) is born at term, without visible abnormalities. Case 2: Gravida 2, para 1, age 32. First-­‐trimester screening does not raise any grounds for concern. The 20-­‐week scan shows bilateral pes equinovarus. Apart from a slightly low-­‐lying placenta, no other anomalies are detected. An advanced scan confirms our findings. Amniocentesis does not reveal any anomalies. Outcome: A baby boy weighing 3,268 grams is born at term with the aforementioned condition. May Case 3: Gravida 1, age 30. The foetus’ stomach appears empty for the entire duration of the 20-­‐week scan. An hour afterwards, it is still empty. No other anomalies are detected. An advanced scan does show stomach contents. Outcome: A healthy baby with a normal birth weight is born at term, without visible abnormalities. Case 4: Gravida 4, para 2, age 30. The client’s BMI is close to 40. The foetus’ presentation also makes it hard to assess its heart. Possible case of aortic valve stenosis. No other anomalies are detected. An advanced scan also raises suspicion of the aforementioned condition. In addition, a high to normal flow is detected across the aortic valve. A repeat scan is carried out at 28 weeks + 4 days’ gestation, and this time there is no indication of aortic valve stenosis. Outcome: Unknown. The client has moved house without passing on her new address. 26 Case 5: Gravida 1, age 26. The 20-­‐week scan shows severe intrauterine growth restriction, as well as elevated PI in both uterine arteries, with notching. The middle cerebral artery cannot be measured due to the baby’s presentation. No other anomalies are detected. An advanced scan confirms our findings. Repeat scans show a deterioration in the foetus’ condition, and also reveal anhydramnios. Outcome: Termination of pregnancy. July Case 6: Gravida 1, age 38. The 20-­‐week scan shows a fragile-­‐looking aorta, although it can be traced in its entirety. In addition, foetal biometry suggests the foetus is on the large side, so we advise the client to undergo growth scans. No other anomalies are detected. An advanced scan shows coarctation of the aorta. Furthermore, the foetus appears to have duplex kidneys on the right. The renal pelvises and ureters present a normal aspect. No invasive diagnostic procedures are carried out. Outcome: A baby boy weighing 3,425 grams is born at term. The feedback we receive afterwards only mentions the aortic coarctation, not the duplex kidneys. Case 7: Gravida 3, para 1, age 31. First-­‐trimester screening does not raise any grounds for concern. There is some tricuspid valve regurgitation, but ductus venosus flow appears to be normal. The 20-­‐
week scan seems to suggest the heart’s axis is leaning forward. The outflow tracts are normal, and there is no longer any sign of tricuspid valve regurgitation. Several choroid plexus cysts are detected. An advanced scan seems to confirm mesocardia and suggests a persistent left superior vena cava. The repeat scan confirms the presence of choroid plexus cysts. Outcome: A healthy baby boy weighing 3,750 grams is born at term, without visible abnormalities. August Case 8: Gravida 2, para 1, age 38. First-­‐trimester screening does not raise any grounds for concern. The 20-­‐week scan shows hyperechogenecity in the right lung (possibly a CCAM or pulmonary sequestration). In addition, the bowel lights up a little in the scan, but not worryingly so. An advanced scan suggests pulmonary sequestration, but a CCAM cannot entirely be ruled out. In addition, a segment of the foetal bowel does now present a very bright white aspect. Repeat scans are consistent with pulmonary sequestration; by this stage the bowel appears normal. Outcome: A baby boy weighing 4,496 grams (P90) is born at 41 weeks + 4 days’ gestation. Follow-­‐up examinations suggest the baby is suffering from pulmonary sequestration rather than a CCAM. Case 9: Gravida 4, para 1, age 33. The 20-­‐week scan shows a microcephalic foetus (<P3). Other foetal biometry results are within normal range. Both the client and her first-­‐born child have small heads. No other anomalies are detected. An advanced scan confirms the microcephaly, but the sonographers do not consider it a problem. Outcome: A healthy baby girl is born at term, without visible abnormalities. No mention is made of the size of the head in the feedback we receive afterwards. Case 10: Gravida 4, para 3, age 36. Even though the first-­‐trimester screening provides grounds for concern (risk for Down syndrome: 1:80), no invasive diagnostic procedures are carried out. A comprehensive ultrasound scan carried out at our centre at 13 weeks’ gestation shows no anomalies. The nasal bone is present, and the ductus venosus and tricuspid flow are normal. The 20-­‐week scan picks up an echogenic shape behind the CSP. In addition, the bowel lights up a little, although it is nowhere near white. An advanced scan shows the shape to be a somewhat overlarge cavum vergae, which is a common anatomical variant. The bowel is indeed found to be somewhat echogenic, but not worryingly so. A healthy baby boy weighing 3,965 grams is born at term, without visible abnormalities. 27 Case 11: Gravida 1, age 31. The 20-­‐week scan shows duplex kidneys on the right. In addition, there is an echogenic focus in the heart. No dilated renal pelvises or other anomalies. An advanced scan confirms our findings. No further examinations are carried out. Outcome: A healthy baby boy weighing 3,600 grams is born at term, without visible abnormalities. No follow-­‐up examinations are performed post partum. October Case 12: Gravida 3, para 0, A2, age 24. The 20-­‐week scan shows an empty stomach for the entire duration of the scan, as well as 45 minutes later. The amount of amniotic fluid appears to be normal, as do the kidneys and bladder. No other anomalies are detected. An advanced scan shows normal stomach contents. Outcome: A healthy baby boy weighing 3,140 grams (>P16<P20) is born at term, without visible abnormalities. Case 13: Gravida 5, para1, A3, age 32. Due to an unsuccessful non-­‐invasive prenatal test, the client requests an early 20-­‐week scan, which is performed at our centre at 16 weeks + 2 days’ gestation. The scan shows growth retardation as well as a single umbilical artery. The quality of the image is poor due to the angle at which the foetus presents. No other anomalies are detected. An advanced scan confirms our findings. Invasive diagnostic procedures are not desirable at this point. A repeat scan is performed at 20 weeks’ gestation. It shows severe growth retardation, with especially short long bones. The heart is characterised by malalignment-­‐type VSD with an overriding aorta. The off-­‐
set of the atrioventricular valves seems normal, but it is hard to tell, given the poor quality of the scan. In addition, the shape of the cranium is anomalous, with frontal bossing. CT ratio >>P95, and the ribs seem to be pointing straight forward. PI of the umbilical arteries and MCA: approximately 2.40. At 20 weeks’ gestation, invasive diagnostic procedures are once again deemed undesirable. Outcome: Intrauterine foetal demise results in the stillbirth of a baby boy weighing 130 grams on 11 November 2013. It is not known whether any follow-­‐up examinations were performed. December Case 14: Gravida 1, age 23. The 20-­‐week scan shows unilateral hydronephrosis on the right. The ureter can be traced. The bladder appears to have a normal shape. Advanced scans performed at 20, 30 and 35 weeks’ gestation confirm these findings. Outcome: A baby girl weighing 3,240 grams is born at 37 weeks’ gestation. Follow-­‐up examinations by paediatrician. Case 14: Gravida 2, para 1, age 36. We choose not to carry out first-­‐trimester screening or an invasive diagnostic procedure due to the client’s age. The 20-­‐week scan shows a cyst-­‐like, mole-­‐like placenta. No other anomalies are detected. Foetal biometry results are consistent with the foetus’ gestational age. An advanced scan confirms our finding. At 29 weeks’ gestation, a bulging, hyperechogenic shape shows up next to the umbilical cord insertion. There is no vascularisation, but it is remarkable that the umbilical cord should overlie it and insert next to it. As the pregnancy progresses, the cyst-­‐like placenta begins to present a more homogeneous aspect, and the bulge is becoming increasingly chorangioma-­‐like. No other anomalies are detected, but in view of the likelihood of unexpected complications, a tertiary practitioner at Radboud Hospital now assumes responsibility for the client’s well-­‐being. Outcome: Intrauterine foetal demise at 35 weeks’ gestation, and stillbirth of a baby boy weighing 2,450 grams, without visible abnormalities. The results of the autopsy are unknown. Examination of the placenta results in a diagnosis of mesodermal dysplasia as well as a chorangioma. 2012 REFERRALS FOR ADVANCED DIAGNOSTIC SONOGRAPHY DUE TO DOUBTS RAISED BY THE 20-­‐WEEK SCAN 28 In 2012 we referred nine clients for advanced scans due to doubts raised by the 20-­‐week scan, which equals 0.8 per cent of the total number of 20-­‐week scans performed in 2012 (down from 3.7 per cent in 2011) and 19.6 per cent of the total number of referrals for advanced scans (down from 36.6 per cent in 2011). Whenever there were doubts, they only concerned the foetal heart (VSD? Abnormal three-­‐vessel view? Abnormal outflow tracts?) or the kidneys (duplex kidneys?). In each of these cases, advanced scans did not pick up any anomalies, and no abnormalities or anomalies were detected in the neonate post partum. 2013 REFERRALS FOR ADVANCED DIAGNOSTIC SONOGRAPHY DUE TO DOUBTS RAISED BY THE 20-­‐WEEK SCAN In 2013 we referred four clients for advanced scans due to doubts raised by the 20-­‐week scan, which equals 0.6 per cent of the total number of 20-­‐week scans performed in 2013 (down from 0.8 per cent in 2012 and 3.7 per cent in 2011) and 10 per cent of the total number of referrals for advanced scans (down from 19.6 per cent in 2012 and 36.6 per cent in 2011). In all but one case, the doubts concerned the heart (anomalous four-­‐chamber view? Anomalous outflow tracts?). We dealt with a potential persistent left superior vena cava and a potential cleft palate. In each of these cases advanced scans did not pick up any anomalies, and no abnormalities or anomalies were detected in the neonate post partum. 2012 CASES WHERE WE OPTED FOR A 20-­‐WEEK SCAN DESPITE THE PRESENCE OF INDICATIONS FOR ADVANCED DIAGNOSTIC SONOGRAPHY In eight cases we opted for a 20-­‐week scan, despite the fact that there were indications for an advanced scan. This equals 1.1 per cent of the total number of 20-­‐week scans performed in 2012. In 2010 and 2011 we did not report on such cases. The indications ranged from a thick neck detected during first-­‐trimester screening to a family history of spina bifida or cheilo-­‐gnato-­‐palatoschisis, as well as previous pregnancies involving trisomy disorders (T18 and 22Q11 deletion). In all cases, the 20-­‐week scans came back normal, and no anomalies were detected in the neonate post partum. 2013 CASES WHERE WE OPTED FOR A 20-­‐WEEK SCAN DESPITE THE PRESENCE OF INDICATIONS FOR ADVANCED DIAGNOSTIC SONOGRAPHY In 22 cases we opted for a 20-­‐week scan, despite the fact that there were indications for an advanced scan. This equals 3.2 per cent of the total number of 20-­‐week scans performed in 2013 (up from 1.1 per cent in 2012). The indications ranged from a thick neck detected during first-­‐trimester screening to a family history of disorders (the most common indication), as well as previous pregnancies involving abnormalities such as gastroschisis, diaphragmatic hernia and kidney disorders. REFERRALS FOR ADVANCED DIAGNOSTIC SONOGRAPHY DUE TO AN INCOMPLETE 20-­‐WEEK SCAN 29 In 2012 we referred two clients for an advanced scan due to an incomplete 20-­‐week scan, which equals 0.3 per cent of the total number of 20-­‐week scans performed in 2012. In 2013 we referred one client for an advanced scan, which equals 0.1 per cent of the total number of 20-­‐week scans carried out that year. In all three cases the image quality of the 20-­‐week scans was poor due to maternal adiposity. CASES WHERE IT TRANSPIRED AFTERWARDS THAT THERE WAS AN INDICATION FOR ADVANCED DIAGNOSTIC SONOGRAPHY There are no known 2012 cases where the sonographer realised while performing the 20-­‐week scan that there was an indication for an advanced scan. In 2013 this happened five times, which equals 0.7 per cent of the total number of 20-­‐week scans performed that year. Three of the five clients in question chose not to undergo a follow-­‐up scan, whereas two did. 2012/2013 TERMINATIONS OF PREGNANCY FOLLOWING THE 20-­‐WEEK SCAN We opted for a termination of pregnancy twice in 2012 and once in 2013: -­‐ Twice because of a 22Q11 deletion -­‐ Once because of very severe early-­‐onset IUGR plus anhydramnios In addition, 2013 saw two intrauterine foetal demises: -­‐ Once because of a lethal skeletal disorder -­‐ Once because of placental abnormalities Five pregnancies were terminated in 2012 (including the one following first-­‐trimester screening), which equals approximately 0.7 per cent of the total number of clients, 9.1 per cent of the total number of referrals for an advanced scan due to the pregnancy having been identified as a high-­‐risk pregnancy, and 16.1 per cent of the number of referrals for an advanced scan due to a genuine, well-­‐
founded suspicion of nuchal translucency, i.e. referrals that do not come under the heading of ‘referred due to the presence of a soft marker / due to doubts about what we are seeing / due to an incomplete 20-­‐week scan’. Three pregnancies were terminated in 2013, which equals approximately 0.4 per cent of the total number of clients, 6.1 per cent of the total number of referrals for an advanced scan due to the pregnancy having been identified as a high-­‐risk pregnancy, and 13 per cent of the number of referrals for an advanced scan due to a genuine, well-­‐founded suspicion of nuchal translucency, i.e. referrals that do not come under the heading of ‘referred due to the presence of a soft marker / due to doubts about what we are seeing / due to an incomplete 20-­‐week scan’. 30 Terminations of pregnancy 6 Number 5 4 3 2 1 0 Top's 2012 2013 5 3 Duizenden 20-­‐week scans 1 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 2010 2011 2012 2013 Tot. Aant. Verw. Aant. Referrals for advanced scans 100 80 2010 60 2011 40 2012 20 2013 0 Verw. Aant. 31 1 2 3 4 5 6 7 = verwezen GUO'S = verwezen i.v.m. sonomarker = vermoeden op afwijking = twijfel over afwijking = incomplete SEO = achteraf indicatie GUO = indic.GUO gekozen voor SEO Referrals for advanced scans 90 80 70 60 2010 50 2011 40 2012 30 2013 20 10 0 1 2 3 4 5 6 7 Abnormalities and soft markers by year 25 20 2010 15 2011 10 2012 5 2013 0 Tot.sonom. Tot.afw. 32 Number Abnormalities detected in 2012 7 6 5 4 3 2 1 0 Aug Sept
Nov Dec
Janu Febr Maa Apri
Okto
Mei Juni Juli ustu emb
emb emb
ari uari rt l ber s er er er Afw. 2 1 1 1 6 4 2 0 0 1 2 2 Sonom. 3 0 1 1 1 1 1 1 4 0 0 0 Total number of 20-­‐week scans performed in 2012=755 Number Abnormalities detected in 2013 6 5 4 3 2 1 0 Aug Sept
Nov Dec
Janu Febr Maa Apri
Okto
Mei Juni Juli ustu emb
emb emb
ari uari rt l ber s er er er Afw. 2 0 0 0 3 0 2 4 0 2 0 2 Sonom. 1 0 2 4 1 3 1 3 0 1 0 4 Total number of 20-­‐week scans performed in 2013 = 689 NUMBER OF SOFT MARKERS THAT DID NOT WARRANT A REFERRAL In 2012 there were 28 soft markers that did not warrant a referral, which equals 3.4 per cent (up from 0.3 per cent in 2010). Number of white spots in foetal heart: 28 cases in 2012, none in 2013. (It seems likely that white spots went underreported in 2013.) In each of these cases, the white spots were the only soft marker detected; no other anomalies or soft markers were detected. None of the neonates in question had visible abnormalities post partum. Number of choroid plexus cysts: 5 cases in 2012, 12 cases in 2013. In each of these cases, no anomalies were reported post partum. 1 = Totaal aantal 2 = Chor.cystes 3 = Wh.spots 33 Soft markers that did not warrant a referral 35 30 25 20 15 10 5 0 2010 2011 2012 2013 1 2 3 IN-­‐HOUSE REPEAT SCANS FOR VERIFICATION PURPOSES 2012: one record of an in-­‐house repeat scan. 2013: no records of in-­‐house repeat scans. In 2012 and 2013, all 20-­‐week scans which did not yield a complete result within one 45-­‐minute session could be completed within 1.5 hours. These cases are not considered in-­‐house repeat scans. RECOMMENDATION: REPEAT PLACENTA LOCALISATION AT 32 WEEKS’ GESTATION 2012 In 2012 we recommended 27 clients to repeat the placenta localisation procedure. This equals 2.9 per cent of the total number of 20-­‐week scans performed in 2012 (down from 4 per cent in 2011). The recommendations were based on the following indications: -­‐ In 20 cases a low-­‐lying placenta, but not overlying the ostium (<2cm from the ostium internum), was picked up in the 20-­‐week scan. Repeat scans did not show any anomalies. -­‐ In 4 cases the 20-­‐week scan showed that the placenta reached the ostium internum. Repeat scans at 32 weeks’ gestation showed no signs of a low-­‐lying placenta. One client did suffer frequent blood loss during her pregnancy, as well as a preterm birth. -­‐ In 1 case the scan showed a placenta praevia, which resulted in a Caesarian section. 2013 In 2013 we advised 26 clients to repeat the placenta localisation procedure. This equals 3.8 per cent of the total number of 20-­‐week scans performed in 2013 (up from 2.9 per cent in 2012 and down from 4 per cent in 2011). The recommendations were based on the following indications: 34 -­‐
-­‐
-­‐
-­‐
In 16 cases a low-­‐lying placenta, but not overlying the ostium (<2cm from the ostium internum), was picked up in the 20-­‐week scan. Repeat scans did not show any anomalies. In 5 cases the 20-­‐week scan showed that the placenta reached the ostium internum. Repeat scans at 32 weeks’ gestation showed no signs of a low-­‐lying placenta. In 3 cases the placenta was slightly overlying the ostium internum. Repeat scans at 32 weeks’ gestation showed no anomalies. In 2 cases the scan showed a placenta praevia, which resulted in one confirmed Caesarian section. What happened in the other case is unknown. Placenta localisation 35 Number 30 25 20 15 10 5 0 Advies voorl.plac. 2011 33 0 2012 27 1 2013 26 2 Several bilobed placentas were detected in 2012 and 2013. There are no records of these findings. UMBILICAL CORD INSERTIONS 2012 -­‐ 7 cases of marginal cord insertion. No other anomalies were detected. -­‐ 1 case of cord insertion at the edge of the placental disk. This pregnancy ended in an emergency Caesarian section due to foetal distress. -­‐ 3 cases of velamentous cord insertion, including one case of preterm birth at 24+ weeks, one case of severe foetal distress and asphyxia, and one case without any anomalies. 2013 -­‐ 11 cases of marginal cord insertion. No other anomalies were detected. -­‐ 1 case of velamentous cord insertion. The neonate got off to a very bad start post partum. AMNIOTIC BANDS In 2012, four amniotic bands were detected. No other anomalies. In 2013, three amniotic bands were detected. No other anomalies. DILATED RENAL PELVISES (>5MM AND <10MM) 35 2012 Dilated renal pelvises were detected in five clients, who all underwent repeat scans at 32 weeks’ gestation. This equals 0.6 per cent of the total number of 20-­‐week scans performed in 2012 (down from 1.5 per cent in 2011) -­‐ In 2 cases the dilated renal pelvises no longer showed up on the 32-­‐week scan (in each case the pelvises were around 6mm at the time of the 20-­‐week scan) -­‐ In 3 cases the renal pelvises were still somewhat dilated at 32 weeks, but <10mm (they were >8mm at the time of the 20-­‐week scan) -­‐ In 1 case the baby’s renal pelvises continued to be dilated post partum, requiring antibiotic prophylaxis treatment. This equals 0.1 per cent of the total number of 20-­‐week scans carried out in 2012 (down from 0.4 per cent in 2011 – however, it should be noted that antibiotic prophylaxis was still prescribed in 2011 in cases where the pyelectasis measured less than 10mm). At the time of the 20-­‐week scan, the foetus in question recorded a 9mm unilateral pyelectasis. In one case the 20-­‐week scan did not show any anomalies, only for >9<10mm renal pelvises to show up on the presentation scan. This neonate was treated by a paediatrician post partum. 2013 Dilated renal pelvises were detected in five clients, who all underwent repeat scans at 32 weeks. This equals 0.7 per cent of the total number of 20-­‐week scans performed in 2013 (up from 0.6 per cent in 2012 and down from 1.5 per cent in 2011) -­‐ In 3 cases the dilated renal pelvises no longer showed up on the 32-­‐week scan (in each case the pelvises were around 6mm at the time of the 20-­‐week scan) -­‐ In 2 cases the renal pelvises were still somewhat dilated at 32 weeks’ gestation, but <10mm (they were >7mm at the time of the 20-­‐week scan) -­‐ In 0 cases the baby’s renal pelvises continued to be dilated post partum, requiring antibiotic prophylaxis treatment. This equals 0 per cent of the total number of 20-­‐week scans carried out in 2013. The reason why this percentage is so low is because all paediatricians in the area began to comply with the same prescription protocol in 2013. Antiobiotic prophylaxis is now prescribed only when the renal pelvises are more than 10mm dilated. 36 Dilated renal pelvises 14 12 Number 10 8 6 4 2 0 TOTAAL Verdw.32wk Aanw.pp 2011 12 8 3 2012 5 2 1 2013 5 3 0 OTHER ANOMALIES In July 2012 a 20-­‐week scan showed an intrauterine foetal demise in a client who had not menstruated for 20 weeks + 4 days. We had performed a CVS at 10 weeks’ gestation due to the client’s age (42), with good results. Due to maceration and the presentation of the foetus we had difficulty obtaining a clear scan. The foetal demise may have been due to an abdominal wall defect. The results of the obduction are unknown. ABNORMALITIES THAT WERE NOT DETECTED OR INVISIBLE AT THE TIME OF THE 20-­‐WEEK SCAN In 2012 there were four abnormalities that were not detected at the time of the 20-­‐week scan (which equals 0.5 of the total number of 20-­‐week scans performed that year) and in 2013 there was one, which equals 0.2 per cent of the total number of 20-­‐week scans carried out that year (down from 1 per cent in 2011). January 2012: The 20-­‐week scan shows no anomalies. Post partum, the neonate turns out to have three anomalous toes. June 2012: The 20-­‐week scan shows no anomalies. A growth scan performed at 30 weeks’ gestation shows an anomaly in the foetal skull, which turns out to be a Vein of Galen aneurysmal malformation. The neonate dies post partum in November 2012. September 2012: The 20-­‐week scan shows no anomalies. Post partum, the neonate turns out to suffer from aplasia cutis. Examination results are still to follow. October 2012: The 20-­‐week scan shows no anomalies. Post partum, the neonate turns out to suffer from microcephaly, possibly due to cytomegalovirus infection. In 2013 we received one report of a post-­‐partum abnormality which was not detected at the time of the 20-­‐week scan. The abnormality in question was hypospadias. 37 CHAPTER 6 Foetal Biometry Recommendation After 20-­‐Week Scan: Repeat Growth Scans 2012 In 2012, the sonographers carrying out the 20-­‐week scans issued 84 recommendations for repeat growth scans. This equals 11.1 per cent of the total number of 20-­‐week scans performed in 2012 (up from 9.4 per cent in 2011 and 3.2 per cent in 2010). In 15 cases, the recommendation for growth scans was issued because the foetal biometric test results in the 20-­‐week scan were on the low side: <P16 in one or more measurements. -­‐ 4x <P16 -­‐ 9x <P10 -­‐ 2x <P5 Including: -­‐ 3x >P10<P16 -­‐ 3x <P5 -­‐ 1x <P2.3 For a total of 7. In 69 cases, the recommendation for growth scans was issued because the foetal biometric test results in the 20-­‐week scan were on the heavy side: >P84 in one or more measurements. -­‐ 38x >P84 -­‐ 29x >P90 -­‐ 1x >P95 -­‐ 1x >P97.7 Including: -­‐ 9x P84 -­‐ 3x >P84<P90 -­‐ 9x >P90 -­‐ 8x >P95 -­‐ 4x >P97.7 For a total of 33. In 5 cases, we were unsure about the foetal biometry because we were unsure about the foetus’ gestational age. In each of those cases the neonate was born with a normal body weight. In 31 cases we did not recommend repeat growth scans, but the babies were born either dysmature or macrosomic. Dysmature : -­‐ 2x <P10 -­‐ 7x <P5 -­‐ 8x <P2.3 For a total of 17. Macrosomic: -­‐ 6x >P95 -­‐ 8x >P97.7 38 For a total of 14. The total number of dysmature babies born <P5 in 2012 was 19. Only in 4 of these 19 cases did the sonographer recommend repeat growth scans following the 20-­‐week scan. In other words, in 21 per cent of these cases repeat scans were recommended, whereas in 79 per cent they were not. Eleven clients were advised to undergo repeat growth scans because their babies’ biometric parameters were in the <P5 range. Only four (i.e. 36.4 per cent) of the babies in question were indeed <P5 at birth. The total number of macrosomic babies born >P95 in 2012 was 26. Only in 12 of these 26 cases did the sonographer recommend repeat growth scans following the 20-­‐week scan. In other words, in 46.2 per cent of the cases repeat scans were recommended, whereas in 53.8 per cent they were not. Two clients were advised to undergo repeat growth scans because their babies’ biometric parameters were in the >P95 range, while another 29 clients were advised to have repeat scans because of >P90 biometric parameters. In total, 31 clients were advised to undergo repeat scans due to a biometric result of >P90. Twelve of the babies in question (38.7 per cent) were indeed found to be macrosomic post partum. 2013 In 2013, the sonographers carrying out the 20-­‐week scan issued 60 recommendations for repeat growth scans. This equals 8.7 per cent of the total number of 20-­‐week scans performed in 2013 (compared to 11.1 per cent in 2012, 9.4 per cent in 2011 and 3.2 per cent in 2010). In 15 cases, the recommendation for growth scans was issued because the foetal biometric test results in the 20-­‐week scan were on the low side: <P16 in one or more measurements. -­‐ 3x <P16 -­‐ 1x <P10 Including: -­‐ 1x >P10<P16 -­‐ 1x <P10 Two clients were advised to undergo growth scans because their babies’ facs were small in relation to the rest of their biometry results. Neither of these babies was born <P10. In 46 cases, the recommendation for growth scans was issued because the foetal biometric test results in the 20-­‐week scan were on the heavy side: >P84 in one or more measurements. -­‐ 21x >P84 -­‐ 22x >P90 -­‐ 3x >P95 Including: -­‐ 4x P84 -­‐ 1x >P84<P90 -­‐ 3x >P90 -­‐ 3x >P95 -­‐ 4x >P97.7 For a total of 15. 39 Six clients were advised to undergo growth scans because their babies’ facs were large in relation to the rest of their biometry. Two of these babies were born >P97.7. In 31 cases we did not recommend repeat growth scans, but the babies were born either dysmature or macrosomic. Dysmature : -­‐ 1x <P5 -­‐ 1x <P2.3 For a total of 2. Macrosomic: -­‐ 1x >P95 -­‐ 9x >P97.7 For a total of 10. Number Recommendation: Repeat Growth Scans 90 80 70 60 50 40 30 20 10 0 =Advies = i.v.m <p16 = i.v.m >p84 = daadw. <p5 = =SEO gb, =SEO gb, daadw. toch>P9
toch<P5 >p95 5 2012 84 15 69 4 12 14 15 2013 60 16 46 0 7 10 2 2013 STANDARD GROWTH SCANS All three obstetric practices that refer to VEZ began to offer standard growth scans at 28/29 weeks’ gestation in 2013. One of these practices collected data on downward and upward growth curves, which are reproduced below. Number of upward growth curves: 12 In all of these cases, the neonates had a heavy birth weight: -­‐ 1x >P90 -­‐ 1x >P95 -­‐ 10x >P97.7 All the neonates whose birth weight was >P97.7 had a significant upward growth curve. Six of these cases of macrosomia were detected through palpation during the pregnancy. The following anomalies were recorded for neonates whose birth weight was >P97.7: -­‐ 1x planned Caesarian section because the baby was expected to be large, the mother was slightly built and there had been a previous case of severe shoulder dystocia. -­‐ 1x normal partus, but the multipara mother suffered a severe postpartum hemorrhage. -­‐ 1x severe shoulder dystocia resulting in Erb’s palsy. Labour after >40 weeks, not induced. 40 -­‐ 1x difficult birth; neonate admitted to NICU post partum due to intracranial bleeding. -­‐ 1x moderate shoulder dystocia. In all these cases, no record was made of the condition of the mother’s pelvic floor. Number of downward growth curves: 8 Of these eight neonates, three had a low birth weight, while one had a normal birth weight but looked dysmature due to his/her height. -­‐ 2x <P5 -­‐ 1x <P2.3 One of these cases of dysmaturity was detected through palpation at the end of the pregnancy (40+ weeks). The total number of dysmature neonates whose birth weight was <P5 was 3. None of the clients in question were advised to undergo repeat growth scans, but all cases of dysmaturity were detected in time through growth scans. The total number of macrosomic neonates whose body weight was >P95 was 18. In seven cases, the clients in question were advised to undergo repeat growth scans, which equals 38.9 per cent. 61.1 per cent of the clients carrying macrosomic babies were not advised to undergo repeat growth scans. In 25 cases clients were advised to undergo repeat growth scans due to the baby’s biometric test results being >P90: -­‐ 3x >P95 -­‐ 22x >P90 Only in 7 of these cases (= 28 per cent) was the baby actually born macrosomic. Aantal Biometrie Advies 90 80 70 60 50 40 30 20 10 0 =Advies = i.v.m <p16 = i.v.m >p84 = daadw. <p5 = =SEO gb, =SEO gb, daadw. toch>P9
toch<P5 >p95 5 2012 84 15 69 4 12 14 15 2013 60 16 46 0 7 10 2 41 CONCLUDING REMARKS Conclusions, Opinions and Objectives for the Next Few Years We are proud to be able to report that, as in all previous years since 2006, we did not fail to detect any anomalies in a foetus which could have been detected through the 20-­‐week scan. We always complied with the Fetal Medicine Foundation (FMF)’s protocol on mandatory scans. VEZ’s objective for the next few years is obviously to maintain this level of care, which is not just of the highest quality, but is also deemed accessible and emotionally involved by our clients. Referrals for advanced diagnostic sonography Even though our sonographers referred fewer clients for advanced scans, the number of undetected anomalies did not go up. It seems likely that this is due to our sonographers having become more proficient at their craft. The 2011 annual report made mention of the fact that a large number of anomalies had been found in 2011, both in terms of soft markers and in terms of other anomalies. The graph below shows that the number of anomalies detected at VEZ went down in 2012 en 2013. What is remarkable, however, is that the majority of 2013 referrals for advanced diagnostic sonography was due to the presence of soft markers. Anomalies and soft markers by year 25 20 2010 15 2011 10 2012 5 2013 0 Tot.sonom. Tot.afw. Clients increasingly opt for a 20-­‐week scan rather than for an advanced diagnostic scan Our records show that the number of clients who choose to undergo a 20-­‐week scan rather than an advanced scan, even when there is an indication for an advanced scan, is on the rise. In nearly all of these cases, there was a history of VEZ sonographers detecting an anomaly in a 20-­‐week scan in a previous pregnancy. This clearly inspired faith in our 20-­‐week scan’s ability to detect or rule out anomalies. It is also possible that expecting parents in the Netherlands increasingly opt for 20-­‐week scans rather than advanced scans because they don’t feel a pressing need to know everything about their 42 babies. If the 20-­‐week scan looks good, that is all the reassurance they need. The baby does not have to be 100 per cent perfect, as long as it does not have severe, demonstrable congenital defects. VEZ does not really approve of the 20-­‐week-­‐scan-­‐instead-­‐of-­‐an-­‐advanced-­‐scan trend that seems to be developing at its centre. However, the clients’ wishes are ours in these situations. If the client has received adequate genetic counselling and has made a well-­‐informed decision to undergo a 20-­‐week scan rather than an advanced scan, she is quite welcome to do so at VEZ. Low turn-­‐out for first-­‐trimester screening Although the numbers are going up ever so slightly, there is still a remarkably low turn-­‐out (25 to 30 per cent) for first-­‐trimester screening. By comparison, turn-­‐out is nearly 100 per cent in certain other Western countries, such as Denmark. Turn-­‐out rates differ significantly between Dutch regions, and even between individual obstetricians and gynaecologists working at the same practice. Which is to say that different ob-­‐gyns have different referral protocols, and that these protocols affect whether or not clients choose to undergo first-­‐trimester screening. The ultrasound scan delivered as part of the first-­‐trimester screening enables us to detect severe congenital defects at an early stage. However, medical practitioners are not allowed to tell clients this when counselling them. Under Dutch law, genetic counsellors must emphasise that first-­‐trimester screening mainly serves to detect trisomies 21, 18 and 13. This causes many expecting parents to give the screening a miss, for the following reasons: • A child with Down syndrome is welcome in their family, and the other two trisomies are so severe that they are sure to be picked up in a 20-­‐week scan. • Risk scores are not an accurate predictor. • Expecting parents do not wish to undergo invasive diagnostic procedures, and therefore do not wish to be offered the opportunity to do so. • Expecting parents do not wish to worry about things which may end up being completely meaningless. • Expecting parents do not feel a need to know absolutely everything about their baby. Current Dutch genetic counselling legislation ignores several factors which could significantly affect expecting parents’ decision as to which screening method to use: • An extensive 13-­‐week scan can help detect severe congenital defects at an early stage. • If an anomaly is detected in a 13-­‐week scan, e.g. a thickened nuchal fold, the client will not undergo a 20-­‐week scan, but rather an advanced diagnostic scan, which will help detect more cardiovascular anomalies. • A nuchal translucency may mean that the baby has a severe congenital defect, not limited to trisomies 21, 18 and 13. • Early recognition of what is wrong with a child may reduce postpartum cares. Sometimes, parents go through countless examinations with their child because the child has all sorts of unexplained issues. • Early detection of abnormalities helps one prepare better for postpartum care, for instance in the event of cardiovascular defects, where it it vital that babies be operated upon immediately after birth if necessary. Consider, for instance, a neonate with Down syndrome as well as a heart condition. A child like that should not be born in a regional hospital, but rather in an academic medical centre. This will increase the neonate’s QUALYs (Quality-­‐Adjusted Life Years) in the long term, also if he or she has Down syndrome! • Performing non-­‐standard blood tests as part of first-­‐trimester screening, such as PAPP-­‐A and PLGF, may help us determine a client’s risk for pre-­‐eclampsia. Severe pre-­‐eclampsia is one of the main causes of maternal and neonatal morbidity and mortality. 43 The current first-­‐trimester screening includes biochemical screening. Significantly anomalous biochemical test results may be indicative of a severe congenital defect. • Screening for severe abnormalities at an early stage leaves more time for follow-­‐up examinations and therefore more time to consider one’s options. • Terminating an early pregnancy is physically (and possibly mentally and emotionally) less draining than terminating a pregnancy after 21 or 22 weeks. Each examination, each ultrasound scan, has the potential to make expecting parents unnecessarily worried. This is inherent to modern technology, both in obstetrics and in other branches of medicine. If we always rejected opportunities to undergo new forms of examination on the grounds that the results might make us uneasy, we would never make any progress. We all want to live healthier lives and enjoy better medical care. If this means we will have to live with a certain amount of worry, so be it. It is up to us, medical practitioners, to explain to expecting parents the advantages and disadvantages of early first-­‐trimester screening, so that they can make a well-­‐informed decision as to whether or not to undergo the screening. We should bear in mind that it is hard to make a well-­‐informed decision if not all the consequences of that decision are known, but that, too, is something we can try to explain in a counselling session. Genetic counselling is not something which can be done in five minutes. If we wish to provide expecting parents with the best possible care, we will have to take at least half an hour to counsel them. And we will have to be upfront about what we can and cannot do – about the things comprehensive first-­‐trimester scans can tell us and the things they cannot detect (because many anomalies do not develop until later, or are not visible until later). It is vital that we counsel expecting parents in a well-­‐considered, honest and objective manner. Likewise, it is vital that we keep our explanations easy to understand. Risk scores are hard to understand for many people. It may be a good idea to ask expecting parents just one simple question: ‘Do you wish to discover at an early stage of the pregnancy whether your baby may have severe congenital defects?’ Then, depending on the results of the screening, we may choose one of three options: 1: Severe abnormalities are detected in the screening; the client may immediately undergo advanced testing. 2: Some anomalies are found, but these may not be significant; the client undergoes an advanced scan at 18-­‐20 weeks’ gestation. 3: No anomalies are found; the client undergoes a 20-­‐week scan at around 20 weeks’ gestation. Parents might prefer a comprehensive first-­‐trimester scan (without the risk score calculation for trisomies 21, 18 and 13) to the type of first-­‐semester screening currently offered in the Netherlands. So far, medical practitioners and politicians have always decided on the nature of the tests on offer, without consulting the clients and asking them what kind of tests they would like to be offered. In order to determine what caused our clients not to undergo first-­‐trimester screening, we send all our clients who have undergone a 20-­‐week scan a short and basic survey. We intend to incorporate the results of this survey into our 2014 annual report. The graph below [WAAR?] shows the number of 20-­‐week scans and first-­‐trimester screenings performed by age category. We will be interested to see what this graph will look like once the new non-­‐invasive prenatal test (NIPT) has been introduced (April 2014) and once the costs of first-­‐
trimester screening will no longer be covered by health funds in 2015. GROWTH SCANS •
44 Back in 2011 we promoted in great detail the usefulness of standard growth scans. The clear figures we reported in 2011 regarding growth anomalies detected at the time of the 20-­‐week scan and requiring repeat growth scans, were less pronounced in 2012 en 2013. However, the figures pertaining to standard growth scans performed in 2013 clearly demonstrate that downward curves are great predictors. The 20-­‐week scan is incorporated into the calculation of the growth curve. Even now many Dutch people are not convinced that healthy pregnant women should be offered standard growth scans, and KNOV (the Royal Dutch Organisation of Midwives) feels that palpation of the abdomen should suffice as a growth check-­‐up. We would like to give a few short comments on the subject below. -­‐ It is very hard to assess the contents of the uterus using palpation of the client’s abdomen alone. -­‐ KNOV advises that the growth of the uterus be monitored by two obstetricians at most. This is impracticable in most midwifery clinics as one client is generally seen by three or more different obstetricians or midwives over the course of her pregnancy. -­‐ 2013 figures show that the use of palpation alone still results in many growth anomalies (both overweight and underweight babies) being overlooked. Therefore, VEZ continues to feel that standard growth scans are a useful tool and that they are a necessary part of high-­‐quality care for pregnant clients. VEZ’ current protocol regarding foetal biometry results: If the foetus is very small: -­‐ If the 20-­‐week scan shows that the foetus’ growth is <P3, we will refer the client to tertiary care (i.e. Radboud Hospital in Nijmegen or Rijnstate Hospital in Arnhem). -­‐ If the 20-­‐week scan shows that <P5 growth is the only anomaly, we will refer the client to secondary care. The 20-­‐week scan report will mention the PI of the uterine artery, as well as the mother’s height and body weight, since it might just be a case of the foetus being small for its gestational age. -­‐ If the 20-­‐week scan shows a growth rate between >P5 and <P10, we also measure the uterine artery. If the PI of the uterine artery is anomalous, we will advise the client to see a secondary obstetrician. If the PI is not anomalous, we will generally advise the client to undergo a repeat growth scan. In that case, too, the scan report will mention the mother’s height and body weight. A clear distinction must be made between foetuses which are small for their gestational age and foetuses suffering from intrauterine growth restriction (IUGR). Measuring the uterine artery can help us make that distinction. Severe IUGR can result in foetuses seeming small in general, which means they will also have short femurs! A foetus which suffers from bad placentation from the beginning of the pregnancy will adapt to its condition. Not only will it present an anomalous growth rate, but its vascular system and organs will be affected. When they are much older, these babies will be at increased risk for cardiovascular disease, diabetes, etc. Doppler flow profiles will present an increasingly anomalous picture as the pregnancy progresses. Will the anomalies of an early IUGR present differently in a Doppler echocardiogram than the anomalies associated with a late IUGR? Will a middle cerebral artery deteriorate more slowly in an early severe IUGR situation (where the foetus starts early to adapt to its bad condition) than in a late IUGR situation? And does an anomalous middle cerebral artery in a late IUGR situation herald an acute problem? Is it possible that, since these infants suffered for a shorter period, they will have fewer problems at an older age than infants who suffered from IUGR right from the start? Or does the fact that infants with late IUGR have had less time to adapt to their bad condition mean they will have less resilience in utero? Those are just a few questions dealing with children whose growth results are <P5... 45 Looking at the recommendations for repeat growth scans issued in 2012 and 2013, especially those regarding overweight babies, one might think that 20-­‐week scans are now a less accurate predictor than they were in 2011. However, we have no idea what kind of growth curves these children had. If the 20-­‐week scan predicts a body weight of >P95 and the child is born with a body weight of around P40, there has clearly been a significant downward growth curve. It would be very interesting for us to examine these children’s partus data. Did they suffer from foetal distress? Was there any meconeum? Was it an assisted vaginal delivery? What was the APGAR score? VEZ has committed to collating 2014 growth curve data and analysing them in conjunction with the above-­‐mentioned questions. If the foetus is very big: -­‐ If the foetus’ growth is >P90, we will advise the client to undergo at least one more growth scan. Depending on the development of the growth curve, this scan may or may not have to be repeated. We also advise the client to take an oral glucose tolerance test between 24 and 28 weeks’ gestation. As we noted in 2011, we will need to change our current pregnancy policy if we are to introduce standard growth scans, particularly with regard to macrosomic foetuses. No policy amendments are required for foetuses whose growth curves display a clear downward slant. These policy changes have already been introduced. The main thing that needs to change is Dutch policy relating to women who are about to give birth to children who are expected to be large. In these cases, there is a great deal of risk involved for both mother and child, and yet our legislation barely touches upon the subject. The number of emergency Caesarian sections performed due to botched attempts at vaginal delivery is 50 per cent, and the number of assisted vaginal deliveries is approximately 20 per cent. Babies whose birth weight is between 4.5 and 4.75 kgs have a 14-­‐percent chance of shoulder dystocia; babies whose body weight is between 4.75 and 5 kgs have a 21-­‐percent chance. They are also 18 to 21 times more likely to suffer from perinatal brachial plexus palsy, and have a 20-­‐percent chance of damage to the central nervous system (>6 months post partum). Their mothers, too, may sustain severe damage. Ten per cent of women who give birth to a very heavy baby sustain sphincter damage with long-­‐term complications. (It should be noted that just because a woman has an intact perineum doesn’t mean that her anal sphincters are not damaged.) In addition, they are seven times more likely than women who undergo an assisted delivery to suffer prolapse, and are at greater risk for postpartum bleeding. In short, vaginal delivery of a macrosomic baby may result in severe morbidity and even mortality in both mother and child. This report presents several 2012 and 2013 cases involving complications arising from macrosomia. They do make one wonder – how many Caesarians should we perform in order to prevent one case of shoulder dystocia? In other words, how many women and children should we expose to the risks associated with Caesarian section in order to prevent one of the above-­‐mentioned complications? We are asking these questions because we would like to instigate a discussion on this subject. Of course, anomalous biometric test results should also lead one to consider the possibility that the baby’s gestational age may be younger than previously believed, or the possibility that a baby whose growth is lagging behind may have a genetic condition or syndrome, or a congenital defect. PLACENTA LOCALISATION Since the change in our policy regarding placenta localisation (see our 2011 annual report), we have issued fewer recommendations that clients undergo localisation. Over the last two years we have found that, even though we have had several cases in which the placenta was found to be more than 1cm away from the ostium internum in the early stages of the pregnancy, we have had no actual 46 cases of low-­‐lying placentas at 32 weeks’ gestation. For this reason, we no longer advise our clients to undergo placenta localisation unless the placenta is less than 1cm away from the ostium. In cases where the 20-­‐week scan includes a vaginal ultrasound scan, we always measure the cervix. This is a relatively easy measurement, and a useful one, as a short cervix (<1.5cm) often heralds a preterm delivery and therefore requires follow-­‐up. Unfortunately, cervix measurements are not yet standard practice in the Netherlands for all pregnant women. DILATED RENAL PELVISES The number of times we advised clients to have a repeat renal pelvis scan following a dilated renal pelvis (>5<10mm) diagnosis at the time of the 20-­‐week scan went down in 2012 and 2013. We received no reports of dilated renal pelvises post partum. The ongoing reduction in repeat scans seems to have reached a lower limit, which may or may not be due to the fact that our sonographers have become more proficient at their craft. However, in 2014 we began to measure foetal renal pelvises every time we performed a 20-­‐week scan, which may result in the number of referrals for repeat scans going up again. VELAMENTOUS INSERTION VEZ sonographers always examine the way in which the umbilical cord is inserted into the placenta. Since velamentous insertions nearly always cause severe problems during the delivery, we strongly recommend that clients with a velamentous insertion be dissuaded from giving birth at home, and that, in consultation with a secondary obstetrician, they give birth in a hospital using cardiotocography. Through its education programme, VEZ will continue to get ready for the future. In addition, VEZ will continue to try and give its clients the best possible ultrasound scans, with a view to getting the best results for the foetus, its mother, the neonate and ultimately the entire family! Judith Snelder 47