Re: Anomaly scan, Serum testing, Down Syndrome andLateralventricles
From: jworrall@alaska.net
Mon Jul 14 13:57:07 2008
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I believe the Fetal Medicine Foundation still advocates 11 weeks to 13 weeks
6 days, or CRL 45 to 84 mm. I have always wondered whose table of CRL they
use, because in Hadlock's table, 84 mm is 14.3 weeks.
Yes, I shall post some images if I can obtain the measurement of the atria
of the lateral cerebral ventricle during the Nuchal Translucency scan.
Allen
>----- Original Message -----
From: "DuBose, Terry" <DuboseTerryJ@uams.edu>
To: "Multiple recipients of list ULTRASOUND" <ultrasound@mail.obgyn.net>
Sent: Monday, July 14, 2008 10:21 AM
Subject: Re: Anomaly scan, Serum testing, Down Syndrome andLateralventricles
> Allen. That will be great. Especially at the end of the 13th week.
> Can
> you post an image or two?
>
> Has Nicolaides, et al changed the date of the scan from 11-14 weeks?
>
> Thanks, Terry
>
> Terry J. DuBose, M.S., RDMS, FSDMS, FAIUM
>
> Associate Professor & Director
> Diagnostic Medical Sonography Program
> University of Arkansas for Medical Sciences, CHRP
> 4301 West Markham St. Mail Slot #563
> Little Rock, Arkansas, 72205 USA
> 501-686-6510 or 501-686-5948
> DuBoseTerryJ@UAMS.edu
> http://www.uams.edu/chrp/sonography/
> http://www.obgyn.net/us/panel/panel.htm
> http://www.io.com/~dubose/
> ---------------------------------------------------------------
> P Please consider the environment before printing this e-mail
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>
> -----Original Message-----
> From: ultrasound@obgyn.net [mailto:ultrasound@obgyn.net] On Behalf Of
> jworrall@alaska.net
> Sent: Monday, July 14, 2008 1:00 PM
> To: Multiple recipients of list ULTRASOUND
> Subject: Re: Anomaly scan, Serum testing, Down Syndrome
> andLateralventricles
>
> I shall try to measure the atrium of the lateral cerebral ventricle at
> 12-13
> weeks, when I am doing a nuchal translucency and first trimester
> evaluation.
> I have only measured the atria in the second trimester.
>
> Allen
>> ----- Original Message -----
> From: "DuBose, Terry" <DuboseTerryJ@uams.edu>
> To: "Multiple recipients of list ULTRASOUND" <ultrasound@mail.obgyn.net>
> Sent: Monday, July 14, 2008 8:50 AM
> Subject: RE: Anomaly scan, Serum testing, Down Syndrome
> andLateralventricles
>
>> Well... depends on the author. Callen's new textbook (5th edition)
>> shows
>> the BPD to be from 20 to 23 mm during the 13th week (13.2-13.8 weeks).
>> My
>> own measurements show the BPD to be 23 mm at 13 weeks, based upon several
>> thousands of cases. We really don't have any precise measurements, and
>> many
>> refer to any fetus between 13.0 and 13.9 weeks, "as 13 weeks". This is
>> the
>> reason I have always advocated estimating fetal age to the 1/10 of a
>> week,
>> rather than just weeks or even weeks + days... it is easier to average
>> the
>> multiple fetal parameter ages after Hadlock's method.
>>
>> This really does not tell us the precise measurement, "I have a 33yr old
>> gravida2, with 13 weeks pregnancy, scan done today shows mild
>> ventriculomegaly...."
>>
>> It may be that because at 13 weeks the choroid plexus and lateral
>> ventricles
>> appear to fill the cerebral hemispheres that the "mild ventriculomegaly"
>> call
>> was made. Without measurements we can't argue the point.
>>
>> But I do believe that by the start of the 1st trimester, the lateral
>> ventricular atria has reached 7-10 mm and remains that size as the head
>> and
>> cerebrum enlarges around them.
>>
>> Terry J. DuBose, M.S., RDMS, FSDMS, FAIUM
>>
>> Associate Professor & Director
>> Diagnostic Medical Sonography Program
>> University of Arkansas for Medical Sciences, CHRP
>> 4301 West Markham St. Mail Slot #563
>> Little Rock, Arkansas, 72205 USA
>> 501-686-6510 or 501-686-5948
>> DuBoseTerryJ@UAMS.edu
>> http://www.uams.edu/chrp/sonography/
>> http://www.obgyn.net/us/panel/panel.htm
>> http://www.io.com/~dubose/
>> ---------------------------------------------------------------
>> P Please consider the environment before printing this e-mail
>> ---------------------------------------------------------------
>>
>> ---------------------------------------------------------------
>>
>> -----Original Message-----
>> From: ultrasound@obgyn.net [mailto:ultrasound@obgyn.net] On Behalf Of
>> James
>> Smeltzer
>> Sent: Friday, July 11, 2008 5:44 PM
>> To: Multiple recipients of list ULTRASOUND
>> Subject: RE: Anomaly scan, Serum testing, Down Syndrome
>> andLateralventricles
>>
>> Just a comment that the normal 13 week BPD is 20. Even though the LVs are
>> close to 10, as every cell in the brain must come from the wall of the
>> tube,
>> and few cells have been made yet, the whole cannot be greater (or less)
>> than
>> the sum of its parts.
>> JSS
>>
>>>>> "DuBose, Terry" <DuboseTerryJ@uams.edu> 7/11/2008 6:06 PM >>>
>> Not necessarily for 10 mm... 15 mm is too large at any age. However, at
>> 13
>> weeks the ventricles fill most of the cranium and appear to be huge
>> compared
>> to the rest of the head. The choroid appears to fill the hemispheres of
>> the
>> cranium at 13 weeks.
>>
>> I can't find a specific image with measurements at 13 weeks, but in Fetal
>> Sonography, p. 431 there is a sonogram that shows the choroid plexus and
>> lateral ventricles to be at 10 mm in width (the scale is on the image).
>> Also, I found an image of a 13 week fetal head in Callen's latest edition
>> (5th edition, p. 364) that show the structures and describe them as ",
>> the
>> intercrainal anatomy is dominated by the prominent choroid plexuses of
>> the
>> lateral ventricles."
>>
>> I don't know when the width of the lateral ventricles actually reaches
>> 7-10
>> mm, but it is during the end of the 1st trimester. The head then grows
>> larger around the ventricles, which make them appear to become smaller,
>> but
>> they remain about <10mm in width throughout the rest of the gestation.
>>
>> Terry J. DuBose, M.S., RDMS, FSDMS, FAIUM
>>
>> Associate Professor & Director
>> Diagnostic Medical Sonography Program
>> University of Arkansas for Medical Sciences, CHRP
>> 4301 West Markham St. Mail Slot #563
>> Little Rock, Arkansas, 72205 USA
>> 501-686-6510 or 501-686-5948
>> DuBoseTerryJ@UAMS.edu
>> http://www.uams.edu/chrp/sonography/
>> http://www.obgyn.net/us/panel/panel.htm
>> http://www.io.com/~dubose/
>> ---------------------------------------------------------------
>> P Please consider the environment before printing this e-mail
>> ---------------------------------------------------------------
>>
>> ---------------------------------------------------------------
>>
>> -----Original Message-----
>> From: ultrasound@obgyn.net [mailto:ultrasound@obgyn.net] On Behalf Of
>> jworrall@alaska.net
>> Sent: Thursday, July 10, 2008 12:52 PM
>> To: Multiple recipients of list ULTRASOUND
>> Subject: Re: Anomaly scan, Serum testing, Down Syndrome and
>> Lateralventricles
>>
>> Thanks Dr. Smeltzer. Yes, I realize now that an atrium of 10-15 mm at 13
>> weeks would mean the fetal head had to be enormous.
>>
>> Allen
>>> ----- Original Message -----
>> From: "James Smeltzer" <James.Smeltzer@wellstar.org>
>> To: "Multiple recipients of list ULTRASOUND" <ultrasound@mail.obgyn.net>
>> Sent: Thursday, July 10, 2008 1:44 AM
>> Subject: Anomaly scan, Serum testing, Down Syndrome and Lateralventricles
>>
>>> Hi!
>>>
>>> All the cells of the CNS are lining cells of the wall of the tube that
>>> started there, migrated out to their final position and did what they
>>> were
>>> supposed to do, based on where they came from and other factors.
>>>
>>>>From a CNS perspective we are all totally tubular!
>>>
>>> It only stands to reason that the starting mass of cells outside the
>>> tube
>>> is small, and grows as more join them.
>>>
>>> This is the way of the tube.
>>>
>>> Allen, 10-15mm seems a bit generous for the LV tube diameter at the
>>> atrium
>>> at 13 weeks, since as the BPD is only 20mm and has to include one side
>>> of
>>> the skull and the entire brain, and the two LVs are at a slightly
>>> higher - and narrower - level of the brain (but still have SOME brain
>>> substance at 13 weeks.
>>>
>>> A nuchal translucency of 2.6mm at 13 weeks (~CRL 67) is sufficient to
>>> discuss/offer an amnio or CVS and fetal echo, or serum testing,
>>> tqargeted
>>> sonogram (our preferred route), as the odds ratio for Down Synd is about
>>> .75/.05. or about 15 fold the baseline age and other screening risk
>>> (Snijders & al, Lancet 1998; 351:343-6). Yagel & al Ult. (Obstet.
>>> Gynecol
>>> 11:262, 1998) come up with more conservative numbers, and if your normal
>>> data fit their curve, you are right not to routinely offer an amnio to a
>>> womal under 31, as their predicted nuchal lucency is 2.6 mm. (Odds ratio
>>> of ~2 - not sure of their Down results).
>>>
>>> I am not recommending everyone rely as heavily on dysmorphology as we
>>> do,
>>> as there is a learning curve, amnio is 100% (99.4%) reliable and we do a
>>> ridiculously low number of amnios - with a ridiculously high positive
>>> rate. But looking never killed a baby.
>>>
>>> I would definitely look for tricuspid regurgitation, brachycephaly -
>>> which
>>> can be seen early - short femur, and humerus, and an absent nose bone,
>>> at
>>> least. Of course an AV septal defect alone would be sufficient to
>>> warrant
>>> an amniocentesis. Personally, in our hands, serum markers have helped to
>>> identify Down syndrome only once in the absence of a suggestive
>>> sonogram,
>>> but have - with quad screen - gotten to an acceptably low false positive
>>> rate, low enough to raise the odds, and significantly increase the
>>> detection of Down syndrome in the absence of early careful sonography.
>>>
>>> Know your results and your normal curve for NL as these are essential
>>> for
>>> interpretation of results. (I still do not understand how we get such
>>> different normals. Maybe we should all take the same course;^)
>>>
>>> Hope this helps! Jim Smeltzer
>>>
>>> James S. Smeltzer, MD, FACOG, SMFM
>>> Consultant, Maternal Fetal Medicine
>>> Wellstar Physicians' Group
>>> Northwest Women's Care
>>> 787 Campbell Hill St
>>> Marietta GA 30060
>>> James.Smeltzer@wellstar.org
>>> VM 678-290-3035
>>> Off 770-528-0260
>>> Page 404-318-3451
>>>
>>>>>> Terry DuBose <terrydubose@sbcglobal.net> 7/5/2008 2:14 PM >>>
>>> I think Allen is correct, the ventricles often appear large early on,
>>> but
>>> as the head grows up around them, they tend to look more normal... need
>>> measurements later. Terry
>>>
>>> jworrall@alaska.net wrote: At 13 weeks a transvaginal scan will often
>>> (but not always) permit a very
>>> good view of the fetal head. I am not sure what "mild" ventriculomegaly
>>> is,
>>> but probably the atrium of the lateral cerebral ventricle measures
>>> between
>>> 10 and 15 mm. If a good view of the fetal head can be obtained, you
>>> would
>>> be
>>> able to evaluate the posterior cerebral fossa, and look at the posterior
>>> end
>>> of the occipital horn (is it rounded or pointed?) the cisterna magna,
>>> and
>>> the cerebellum. Remember that this early in pregnancy the cerebellar
>>> vermis
>>> is not completely formed, so as you scan the posterior cerebral fossa
>>> inferiorly, you may mistakenly think you have a Dandy Walker situation.
>>> I
>>> am not sure you would see the cavum septi pellucidi that early.
>>>
>>> Hopefully, in addition to the nuchal translucency, the patient has been
>>> able
>>> to obtain the blood test part of that genetic screen, the PAPP-A and
>>> beta
>>> hcg, so that you will get a proper evaluation of her risk of having a
>>> baby
>>> with Trisomy 21. I do NOT think mild ventriculomegaly and a nuchal
>>> translucency of 2.6 mm would be an indication for amniocentesis or
>>> chorionic
>>> villus sampling but I guess that depends on where you practice and what
>>> the
>>> custom is in your location. As always, I hope Anita and Prathima will
>>> comment.
>>>
>>> Allen
>>>
>>> --------------------------------------------------
>>> From: "cjayankar" Sent: Saturday, July 05, 2008 3:16 AMTo: "Multiple
>>> --------------------------------------------------
>>> recipients of list ULTRASOUND"
>>> --------------------------------------------------
>>> Subject: anomaly scan
>>>
>>>> hello
>>>>
>>>> I have a 33yr old gravida2,with 13 weeks pregnancy,sacn done today
>>>> shows mild ventriculomegaly and NT 2.6mm.Her first child is 7yrs old
>>>> and
>>>> autistic.No significant family or past history.
>>>>
>>>> Planning for anomaly sceening,can the mild ventriculomegaly be taken
>>>> as very significant.
>>>>
>>>> Thank You
>>>> jayankar
>>
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