Volume 8 Issue 3 - Australasian Society for Ultrasound in Medicine

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LETTERSMid trimester biometric measurementsTo the Editor,We would like to bring to the attention of youand your readers our article entitled Ultrasonicfetal size measurements in Brisbane that wasrecently published in the peer reviewed sisterjournal, Australasian Radiology 1 . This articleconstructed population specific charts of fetalbiometry for 11 to 41 weeks gestation in relationto known gestational age from a large populationof normal Australian pregnancies wherethe examination was performed to an Australianand New Zealand (ANZ) standard protocol byexperienced operators. Motivation included thefact that overseas charts, up to 25 years old,are currently employed for many fetal parameterswithin ANZ 2,3 and that the development ofappropriate localised charts have been criticisedby some ultrasonic specialists and practitionersin Australia because of their suboptimalmethodological rigour 4 . To remedy this, we presentedmethodologically rigorous, current andpopulation appropriate biometric equations andtables of ultrasonic fetal measurement and 95%reference ranges for biparietal diameter (BPD),femur length (FL), abdominal circumference(AC) and head circumference (HC).We believe that this dataset can be used togenerate valid reference centiles for fetal size.In most respects, it meets Altman and Chitty's 5,6and Nisbet and de Crespigny's 4,7 criteria for design and isreadily exportable for statistical analysis, also consistentwith Altman and Chitty's recommendations. It has theadvantage of being a very large sample collected from anentirely Australian population using a customized database,PacUser TM 8 . All examinations were performed byvery experienced operators, yet none of the protocols formeasurement are beyond the capacity of any sonographer.An attempt should be made by each sonographer to achievethe same rigor with each examination. It is our belief thatneither fetal measurement nor gestational age should bedependent upon operator experience.In summary, we assert that the presented results are themost rigorously derived and applicable to the Australianpopulation. The resulting tables have been provided to theASUM Federal Council for their consideration with a viewto amending the current recommendations for fetal biometry.We would suggest that your readers investigate the useof these tables in their practice.We would also welcome readers to submit their deidentifieddatabases to us to increase the sample sizeand to check the reliability of these equations.We would like to thank the sonographers involved inthis project for their excellent work: Ms Teresa Clapham,Ms Helen Gofton, Ms Julie Naylor, Mr Neil Pennell andMs Sue Williams.For further information about the methodology, thestatistical analysis, the results and equations, readers areencouraged to access the journal articles 1,9 or to contact DrGary Pritchard directly.14 ASUM Ultrasound Bulletin 2005 August; 8 (3)Table 1 Ultrasonic fetal measurement means and 95% reference intervals (95% RI)by gestational age measured in weeks.Gestation BPD FL AC HC(weeks) mean (95%RI) mean (95% RI) mean (95% RI) mean (95% RI)11 21 (19, 23) 5 (2, 8) 53 (42, 63) 75 (66, 84)12 24 (21, 26) 8 (5, 11) 63 (52, 73) 85 (75, 94)13 26 (23, 29) 11 (8, 15) 73 (61, 84) 95 (84, 105)14 29 (26, 32) 14 (11, 18) 83 (71, 95) 105 (94, 116)15 32 (28, 35) 17 (14, 21) 94 (81, 106) 116 (104, 127)16 35 (31, 38) 20 (17, 24) 105 (92, 118) 126 (114, 139)17 38 (34, 41) 23 (20, 27) 116 (102, 130) 138 (125, 150)18 41 (36, 45) 26 (22, 30) 127 (112, 142) 149 (136, 162)19 44 (39, 48) 29 (25, 32) 138 (123, 154) 161 (147, 175)20 47 (42, 51) 31 (28, 35) 150 (133, 166) 172 (158, 187)21 50 (45, 55) 34 (30, 38) 161 (144, 178) 184 (169, 199)22 53 (48, 58) 37 (33, 41) 172 (154, 191) 195 (180, 211)23 56 (51, 61) 39 (35, 43) 184 (164, 203) 207 (190, 223)24 59 (54, 64) 42 (38, 46) 195 (175, 215) 218 (201, 235)25 62 (56, 68) 44 (40, 49) 206 (185, 228) 229 (212, 247)26 65 (59, 71) 47 (42, 51) 218 (195, 240) 240 (222, 259)27 68 (62, 74) 49 (45, 54) 229 (205, 252) 251 (232, 270)28 71 (65, 77) 51 (47, 56) 240 (215, 265) 261 (241, 281)29 74 (67, 80) 54 (49, 58) 251 (224, 277) 271 (250, 291)30 76 (70, 83) 56 (51, 61) 261 (234, 289) 280 (259, 301)31 79 (72, 85) 58 (53, 63) 272 (243, 301) 288 (267, 310)32 81 (74, 88) 60 (54, 65) 282 (252, 312) 297 (274, 319)33 83 (76, 90) 62 (56, 67) 292 (261, 324) 304 (281, 327)34 85 (78, 93) 63 (58, 69) 302 (269, 335) 311 (287, 334)35 87 (80, 95) 65 (59, 71) 312 (277, 347) 316 (292, 340)36 89 (81, 97) 67 (61, 73) 321 (285, 357) 321 (297, 346)37 90 (83, 98) 68 (62, 74) 330 (292, 368) 326 (300, 351)38 92 (84, 100) 70 (63, 76) 339 (300, 379) 329 (303, 355)39 93 (85, 101) 71 (64, 78) 348 (307, 389) 331 (305, 358)40 94 (85, 102) 72 (65, 79) 356 (313, 399) 332 (305, 359)41 94 (86, 102) 73 (66, 80) 364 (319, 406) 332 (305, 360)Prof Philip SchluterAuckland University of TechnologyDr Gary PritchardBrisbane Ultrasound for Women Email bufw@bigpond.comMs Margo Gill Brisbane Ultrasound for WomenReferences1 Schluter P, Pritchard G, Gill M. Ultrasonic fetal size measurementsin Brisbane, Australia. Australas Radiol 2004; 48: 480-486.2 Westerway S, Davison A, Cowell S. Ultrasonic fetal measurements:new Australian standards for the new millennium. Aust N Z J ObstetGynaecol; 40 (3): 297–302.3 Australasian Society for Ultrasound in Medicine. Statement on normalultrasonic fetal measurements. ASUM Ultrasound Bulletin 2001;4 (3): 28–31.4 Nisbet D, de Crespigny L. Policy Statement on normal ultrasonicfetal measurements. ASUM Ultrasound Bulletin 2002; 5 (4): 32.5 Altman D, Chitty L. Design and analysis of studies to derive chartsof fetal size. Ultrasound Obstet Gynecol 1993; 3 (6): 378–384.6 Altman D, Chitty L. Charts of fetal size: 1. Methodology. BJOG1994; 101: 29–34.7 Nisbet D, de Crespigny L. How should the ultrasound estimated duedate be calculated? ASUM Ultrasound Bulletin 2002; 5 (1): 20–21.8 Precise Accurate Convenient Ultrasound Examination Reporting(Pacuser) [computer program]. Version 1. Brisbane: Pacuser, www.pacuser.com.au; 1993.9 Schluter P, Pritchard G, Gill M. Corrigendum: Ultrasonic fetal size measurementsin Brisbane, Australia. Australas Radiol 2005; 49: 345.
ASUM Ultrasound Bulletin 2005 August; 8 (3): 15–17DIAGNOSTIC ULTRASOUNDAbnormal fetal feet – the differentialdiagnosesD Fauchon A AMS, S Watson BHA, Grad Dip Ultrasound A , RJ Benzie MBChB, FRCS(c), FRANZCOG, ARDMS ABAChristopher Kohlenberg Department of Perinatal Ultrasound, Nepean Hospital, University of Sydney,Penrith, New South Wales, AustraliaBCorrespondence to David Fauchon email FauchoD@wahs.nsw.gov.auFigure 1 2D Ultrasound at 21 weeks gestationIntroductionUltrasound diagnosis of fetal anomalies is not alwaysstraightforward. There are situations that are ‘black andwhite’, however, some ultrasound findings leave both theclinician and the patient in a ‘grey area’, the implications ofwhich are uncertain. This case report of abnormal feet is agood example.Case reviewA 29-year-old gravida 2 para 1 in her second pregnancyhad her first ultrasound at 19 weeks gestation. This was afetal anatomy scan, which revealed an isolated finding oflateral ventricles at the upper limits of normal (1.0 cm). Thepatient was referred to our unit two weeks later where weconfirmed that finding, and in addition diagnosed bilateralfeet deformities. It was unclear whether they were ectrodactylyin nature or fusion deformities. Two dimensionalultrasound images of both feet are demonstrated in Figures1 and 5. The fetal anatomy scan appeared otherwise normal.Further investigations revealed a normal karyotype and anegative TORCH screen. Antenatal genetic counselling wasinconclusive.Subsequent ultrasounds were essentially unchangeduntil 28 weeks gestation, when there was a marked increasein the size of the lateral ventricles to 2.0 cm. The right kidneywas noted to have pelvicalyceal dilatation with a dilatedright ureter. The left kidney was normal.Three-dimensional imaging of the fetal feet demonstratedthe abnormalities more clearly, particularly of the rightfoot (Figures 3 and 7). Postnatal photographs and x-rays areFigure 2 2D Ultrasound at 28 weeks gestationshown in Figures 4, 8 and 9.Ultrasounds at 32, 36 and 37 weeks gestation providedno additional information on the feet anomalies, however,they showed a gradual increase in dilatation of the lateralventricles up to 2.7 cm.Postnatal examinationsA live female baby was delivered by planned caesareansection at 38 weeks gestation in Nepean Hospital. Postnatalx-rays, MRI and ultrasound demonstrated the followingfindings:Head: Circumference above the 90th percentile withenlarged ventricles and agenesis of the corpus callosum.Heart: Patent foramen ovale.Limbs: Bilateral polysyndactyly of hands and feet.Kidneys: Right duplex collecting system withobstructed upper pole moiety and a normal left kidney.Hips: Bilateral mild-moderate hip dysplasia.Postnatal genetic review was important in reaching adifferential diagnosis.DiscussionThe incidence of major limb anomalies in newborns is 2 in1000 1 . Anomalies of the toes and metatarsals may be classifiedinto five broad categories including:Absence deformities : Ectrodactyly;Syndactyly;Polydactyly;Brachydactyly; andContracture deformities 2 .ASUM Ultrasound Bulletin 2005 August; 8 (3)15
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Page 11 and 12: THE EXECUTIVEAdelaide ASMLooking ah
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Page 42 and 43: THE SOCIETYSUMCertified ISO 9001:20
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Page 46 and 47: EDUCATIONExamination dates for 2005
Page 48 and 49: THE SOCIETYThe 2004 Beresford Butte
Page 50 and 51: OBITUARYJames Robert Syme MD, FRACP
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Page 54 and 55: CALENDARContact Byung Ihn Choi MDCo
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