Re: Anomaly scan, Serum testing, Down Syndrome and Lateral
From: DuBose, Terry (DuboseTerryJ@uams.edu)
Wed Jul 16 14:35:06 2008
Great image! "CRL was 6.14 cm, and the BPD was 2.12 cm." So by my estimation
this is about 12.3 LMP weeks.
I am envious of you and our graduates that get to work with these wonderful
new sonographic instruments. 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/
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-----Original Message-----
From: ultrasound@obgyn.net [mailto:ultrasound@obgyn.net] On Behalf Of
jworrall@alaska.net
Sent: Tuesday, July 15, 2008 12:16 PM
To: Multiple recipients of list ULTRASOUND
Subject: Re: Anomaly scan, Serum testing, Down Syndrome andLateralventricles
Here is a measurement of the lateral cerebral ventricle - not sure you could
call it the atrium, of a scan done yesterday for nuchal translucency. CRL
was 6.14 cm, and the BPD was 2.12 cm.
Unrelated, but in this case, transvaginally, I could see a four chamber view
of the fetal heart, obtain the pulsed Doppler of the tricuspid valve, and
using color, could see diastolic filling, and the right and left outflow. At
this time in pregnancy the color flow is very nice, because it is much clean
with no "blooming" than 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 12:16 PM
Subject: Re: Anomaly scan, Serum testing, Down Syndrome andLateralventricles
> That is an interesting question. I have Nicolaides book "The 11-14 week
> scan" in front of me, and it has no CRL age tables and very few references
> for the CRL. The original study by Robinson & Fleming is referenced in
> the
> book and also in his article in the May, 2008 issue of Ultrasound Obstet
> Gynecol 2008; 31: 493-502. Both reference this old article, which is
> still
> very valid.
>
> 13. Robinson HP, Fleming JE. A critical evaluation of sonar crown-rump
> length
> measurements.Br J Obstet Gynaecol 1975; 82: 702-710.
>
> Perhaps someone in this discussion can give us a specific reference to the
> CRL table that Nicolaides used.
>
> When I crunched the 10,000 cases from which the Basic Baby age tables were
> constructed (FETAL SONOGRAPHY, W.B. Saunders, 1996, p. 97-100), I took the
> mean CRL at the even week (13.0 weeks = 71 mm CRL, 23 mm BPD; and 14.0
> weeks
> = 83 mm CRL, and 27 mm BPD). That is pretty close to "Hadlock's table, 84
> mm
> is 14.3 weeks."
>
> I looked in Callen's and the CRL table stops at 12 weeks. Rumack,
> Wilson,
> and Charboneau has a CRL table that ends at 13.7 weeks = 80 mm, but no
> citation for the table is given. In the text they reference Robinson and
> Fleming, and MacGregor, Tamara, Sabbagha, et al.
>
> I suspect that Nicolaides uses Robinson and Fleming CRL table... he
> references almost no Americans that I recognize.
>
> 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/
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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 2:00 PM
> To: Multiple recipients of list ULTRASOUND
> Subject: Re: Anomaly scan, Serum testing, Down Syndrome
> andLateralventricles
>
> 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/
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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
>>> ---------------------------------------------------------------
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>>> ---------------------------------------------------------------
>>>
>>> -----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/
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>>> P Please consider the environment before printing this e-mail
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>>>
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>>>
>>> -----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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