Objective. In patients with preeclampsia maternal plasma concentration of plasminogen activator inhibitor-2 (PAI-2) is reduced. The objective of the study was to determine if the altered levels of PAI-2 precede the onset of the disease. Methods. Plasma PAI-2 was measured at 11-13 weeks of gestation in 119 pregnancies that developed preeclampsia, 85 that developed gestational hypertension and 204 controls. Results. There were no significant differences in PAI-2 between the preeclampsia, gestational hypertension and controls (1.07 MoM, 1.08 MoM and 0.96 MoM). Conclusion. The decrease in plasma PAI-2 observed in preeclampsia does not precede the clinical onset of the disease.

Objective. To determine if development of preeclampsia is preceded by altered maternal plasma P-selectin and if the levels are related with uterine artery pulsatility index. Methods. Plasma P-selectin and uterine artery pulsatility index were measured at 11-13 weeks in 121 cases that subsequently developed preeclampsia, 87 cases that developed gestational hypertension and 208 unaffected controls. Results. In the preeclampsia group the median multiple of the median in controls (MoM) P-selectin and uterine artery PI were significantly increased (1.2 MoM and 1.3 MoM). There was no significant association between P-selectin and uterine artery pulsatility index in either the preeclampsia or control group. Conclusion. In pregnancies that develop preeclampsia there is evidence of platelet activation from the first trimester. However, there is no direct link between the degree of impaired placentation and platelet activation.

OBJECTIVES:: To examine the performance of screening for preeclampsia (PE) by a combination of maternal factors, soluble endoglin (sEng), pregnancy associated plasma protein A (PAPP-A), placental growth factor (PlGF) and uterine artery lowest pulsatibility index (L-PI) at 11-13 weeks of gestation. METHODS:: Uterine artery L-PI, sEng, PAPP-A and PlGF were measured at 11-13 weeks in 90 singleton pregnancies that subsequently developed PE, including 30 that required delivery before 34 weeks (early-PE) and 60 with late-PE, and 180 unaffected controls. Screening performance for PE by maternal factors, sEng, PAPP-A, PlGF and uterine artery L-PI and their combinations was determined. RESULTS:: In early-PE, compared to controls, plasma sEng and uterine L-PI were significantly increased and serum PAPP-A and PlGF were decreased. In late-PE, compared to controls, serum PlGF was decreased and uterine L-PI was increased but plasma sEng and serum PAPP-A were not significantly different. In screening for early-PE, the detection rate at a 10% false positive rate was 46.7% for sEng alone and 96.3% for a combination of maternal factors, sEng, PlGF and uterine artery L-PI. CONCLUSIONS:: Effective screening for early-PE can be provided by a combination of maternal factors, sEng, PlGF and uterine artery L-PI at 11-13 weeks. Copyright (c) 2010 ISUOG. Published by John Wiley & Sons, Ltd.

Ultrasound may play an important role in the management of labor and delivery. Induction of labor is a common obstetric intervention, performed in about 20% of pregnancies. Pre-induction cervical length, measured by transvaginal sonography, has been shown to have a significant association with the induction-to-delivery interval and the risk for cesarean section. In the management of labor there is extensive evidence that digital pelvic examination does not provide accurate assessment of the position and descend of the fetal head both during the first but also in the second stage of labor. Several recent studies using both two- and three-dimensional ultrasound have now described objective measures of progression of the fetal head during labor. In instrumental deliveries an important determinant of a successful and safe use of vacuum and forceps is the correct determination of the fetal head position and appropriate application of the instrument. However, ultrasound studies have shown that digital examination before instrumental delivery fails to identify the correct fetal position in a high proportion of cases. The use of ultrasound is of crucial importance in performing a safe operative delivery and can help in the prediction of whether a vaginal delivery would be successful.

OBJECTIVE: To determine the number of ultrasound examinations required to train sonographers to accurately measure the fetal frontomaxillary facial (FMF) angle at 11(+0) to 13(+6) weeks of gestation. METHODS: Eight sonographers accredited for nuchal translucency thickness (NT) measurement were trained to measure the fetal FMF angle using specially acquired three-dimensional (3D) volumes. Training was provided in cycles, and each cycle consisted of a training period on 20 randomly selected cases followed by an examination using 10 randomly selected cases. During training, the sonographer was informed of the "true FMF angle value" after each FMF angle measurement on a case by case basis. During examination, the difference between the measured and the true value of the FMF angle (i.e. the delta angle) was calculated. A measurement for a case was considered accurate if the delta angle was less than 5( masculine). The sonographer was considered to be competent and the training finished if all 10 examination cases satisfied this criteria. Otherwise, the sonographer would undergo further cycles of training-examination, until he became competent. RESULTS: The number of training cases required for a sonographer to be competent was 40 in two sonographres, 60 in one, 80 in one, 100 in two, 120 in one and 140 in one, with an average of 85. The median number of failed cases reduced from 2.5 (out of 10) at the first cycle to 0 by the 7th cycle. As training cycles increased, the mean angle deviation and measurement time required both reduced significantly. The average delta angle of the passing examination cycle was 2.06 degrees +/-1.40 degrees . The number of training cases required to be competent in FMF angle measurement was 40 for each of the two experienced trainees and 80, 120, and 140 for three less experienced trainees respectively. CONCLUSION: We have demonstrated that competence in FMF angle measurement was achieved after a median number of 90 cases with a range up to 140. The number required was substantially lower at 40 cases among those with extensive experience on NT measurement. Copyright (c) 2010 ISUOG. Published by John Wiley & Sons, Ltd.

OBJECTIVE: To describe the outcome of pregnancies with trisomy 2 in cultures of first-trimester chorionic villous samples (CVS) and determine whether amniocentesis is necessary in the management of such cases. METHODS: Cultures of chorionic villi were performed at 11-13 weeks in 37 474 pregnancies. In those with trisomy 2 cells, amniocentesis was performed at 16 weeks. Pregnancy outcome was obtained from maternity records. RESULTS: Trisomy 2 cells in CVS cultures were observed in 45 of 37 474 pregnancies (1.2 per 1000). In 43 cases ultrasound examination at 16-20 weeks showed no fetal abnormalities, amniocentesis demonstrated the presence of only normal cells, and all 43 pregnancies ended in normal healthy live births. The birth weight was below the 5th centile in six neonates (13.9%). There was a significant association between the birth weight centile and the percentage of trisomic cells in the CVS culture (r = 0.409, p = 0.010). In one case, there was fetal death at 15 weeks. In a second case, amniocentesis showed one cell with trisomy 2 in a total of 53 cells, and ultrasound examination at 18 weeks showed severe fetal growth restriction and coarctation of the aorta. CONCLUSION: In at least 95% of cases with trisomy 2 in CVS cultures there is confined placental mosaicism (CPM). The prognosis is good, but in about 15% of cases there is fetal growth restriction. Copyright (c) 2010 John Wiley & Sons, Ltd.

OBJECTIVE: To explore if the addition of pregnancy-associated plasma protein-A (PAPP-A) to maternal factors and biophysical markers yields a significant improvement in the detection of hypertensive disorders before the clinical onset of disease. METHODS: Prospective screening study for early preeclampsia (PE), late PE and gestational hypertension (GH) in women attending their first hospital visit at 11(+0)-13(+6) weeks of gestation. The performance of screening for PE and GH by combinations of maternal factors, uterine artery with the lowest pulsatility index (L-PI), mean arterial pressure (MAP) and serum PAPP-A was determined. RESULTS: There were 8061 unaffected controls, 37 of whom developed early PE, 128 with late PE and 140 with GH. Compared to the controls, in early PE and late PE MAP and uterine artery L-PI were increased and PAPP-A was decreased. In GH PAPP-A was not significantly different from controls. In screening for a combination of maternal factors, uterine artery L-PI, MAP and PAPP-A the detection rate of early PE was 83.8%, at a 5% false-positive rate. In the prediction of late PE and GH there was no significant improvement from the addition of PAPP-A to the combination of maternal factors, MAP and uterine artery L-PI. CONCLUSION: Measurement of PAPP-A improves the performance of screening for early PE provided by a combination of maternal factors and biophysical tests at 11-13 weeks. Copyright (c) 2010 John Wiley & Sons, Ltd.

OBJECTIVE: To investigate the maternal plasma concentration of soluble fms-like tyrosine kinase-1 (sFlt-1) and free vascular endothelial growth factor (free-VEGF) at 11 to 13 weeks of gestation in patients destined to develop preeclampsia (PE) and to examine whether any possible differences in maternal plasma levels are related to uterine artery pulsatility index (PI) and maternal serum placental growth factor (PlGF). METHODS: Plasma free-VEGF, plasma sFlt-1, serum PlGF and uterine artery PI were measured at 11 to 13 weeks in 90 cases that subsequently developed PE and in 180 unaffected controls. RESULTS: In the majority of cases of PE and controls the levels of free-VEGF were undetectable. In the pregnancies that developed PE, compared to unaffected controls, uterine artery PI was higher, serum PlGF was lower but there was no significant difference in levels of sFlt-1. CONCLUSION: Measurement of free-VEGF and sFlt-1 in maternal blood at 11 to 13 weeks of gestation is not useful in the prediction of pregnancies destined to develop PE. Copyright (c) 2010 John Wiley & Sons, Ltd.

OBJECTIVE: To investigate the maternal serum concentration of human placental growth hormone (hPGH) in trisomy 21 and trisomy 18 pregnancies at 11 to 13 weeks of gestation and to examine the possible association between fetal nuchal translucency (NT) thickness and maternal serum free beta-human chorionic gonadotrophin (beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A). METHODS: The maternal serum concentration of hPGH at 11 to 13 weeks was measured in a case-control study from 28 pregnancies with fetal trisomy 21, 28 with trisomy 18 and 112 pregnancies with euploid fetuses. The median hPGH multiple of the median (MoM) in trisomy 21 and trisomy 18 pregnancies were compared with euploid pregnancies. RESULTS: Serum hPGH was significantly lower in trisomy 21 (0.93 MoM) and trisomy 18 (0.62 MoM) compared to euploid pregnancies (1.02 MoM). There was a significant association between serum hPGH and PAPP-A in both the euploid (r = 0.258, p = 0.006) and trisomy 21 pregnancies (r = 0.410, p = 0.030) but not in trisomy 18 pregnancies (p = 0.445). CONCLUSION: In the first trimester, serum hPGH in trisomy 21 and trisomy 18 pregnancies is reduced. This is the opposite of findings in previous studies reporting that in the second trimester, trisomy 21 and 18 pregnancies have increased hPGH. Copyright (c) 2010 John Wiley & Sons, Ltd.