Volume 157 Number I

oni G, Fabro S, eds. Chorionic villus sampling. New York: Marcel Dekker, 1986:99-118.

7. Bossi A, Caccamo ML, De Scrilli AM, Milani S. Weight of the Italian newborn infants (from the 32nd to the 43rd week of gestation). Ita! J Ped 1980;6: 153-70.

8. Maxwell D, Lilford R, Czepulkowski B, Heaton D, Cole­man D. Transabdominal chorionic villus sampling. Lancet 1986; i:123-6.

9. Simpson NE, Dallaire L, Miller JR. Prenatal diagnosis of genetic disease in Canada: report of a collaborative study. Can Med Assoc J 1976; 115:739-46.

Transabdominal chorionic villus sampling

10. Daffos F, Cappella-Pavlovsky M, Forestier F. A new pro­cedure for fetal blood sampling in utero: preliminary re­sults of fifty-three cases. AM J 0BSTET GYNECOL 1983; 146:985-7.

11. Hobbins JC, Grannum PA, Romero R, Reece EA, Ma­honey MJ. Percutaneous umbilical blood sampling. AM J 0BSTET GYNECOL 1985;152:1-6.

12. Brambati B, Oldrini A, Ferrazzi E, Lanzani A. Chorionic villus sampling: an analysis of the obstetric experience of 1,000 cases. Prenat Diagn 1987;7:157-69.

The immediate effects of chorionic villus sampling on fetal movements

A. Boogert, M.D., A. Mantingh, M.D., and G. H. A. Visser, M.D., Ph.D. Groningen, The Netherlands

The immediate effects of chorionic villus sampling on the fetus was studied by real-time ultrasound observation of fetal movements. Thirty-minute recordings, directly before and after chorionic villus sampling, were made in 10 women. No changes were observed in the incidence or distribution of the four movement patterns studied. This held true even in the two cases that ended in a spontaneous abortion. It is concluded that chorionic villus sampling does not stimulate movements or alter the intrauterine situation in such a way that fetal movements decrease. (AM J OBSTET GYNECOL 1987;157:137-9.)

Key words: Chorionic villus sampling, real-time ultrasound, fetal movements, first trimester of pregnancy

Chorionic villus sampling has become an increasingly popular technique for early prenatal diagnosis. More than I 0,000 investigations have been performed world­wide to date.' So far the fetal consequences of this pro­cedure have been assessed in terms of the abortion rate, fetal growth as observed via serial ultrasound, and peri­natal outcome.2·1 With real-time ultrasound equipment, distinct patterns of fetal behavior have been described from 7 weeks of gestation onward.5 We attempted to determine the acute effects of this invasive diagnostic procedure on fetal motor behavior by means of two 30-minute observations taken immediately before and af­ter chorionic villus sampling.

Patients and methods

Ten multiparous women were selected at random from those referred for chorionic villus sampling. After

From the Department of Obstetrics and Gynaecology, University H os­pital, The Netherlands.

Received for publication November 7, 1986; accepted February 6, 1987.

Reprint requests: G. H. A. Visser, M.D., Department of Obstetrics and Gynaecology, University Hospital, 59 Oostersingel, 9713 EZ Groningen, The Netherlands.

receiving a detailed explanation of the investigation, they agreed to take part in the study.

Continuous real-time ultrasound images were ob­tained and recorded on videotape for 30 minutes im­mediately before and 30 minutes directly after chori­onic villus sampling with an Aloka SSD-256, which was equipped with a 3.5 MHz linear array transducer. The fetuses were usually visualized in the mid- or parasag­ittal longitudinal section. The analysis of fetal motility was carried out during playback of the video recordings in the presence of an independent observer to minimize bias and reduce interobserver error. The incidence and duration of the different movements were marked on an event recorder (model 7754a, Hewlett-Packard, Palo Alto, Calif.) by a handheld push buttons. General movements, startles, hiccups, and breathing move­ments were analyzed according to the criteria described by de Vries et al.' General movements were expressed as a percentage of the time they were present; the other movements were simply counted. In case the recording time differed slightly from 30 minutes, the incidence of movements was normalized by conversion to 30 min­utes. The results were analyzed by the Wilcoxon signed rank test.

137

138 Boogert, Mantingh, and Visser July 1987 Am J Obstet Gynecol

before 1CVB

1 after

I •• 1111 II .I I II I I II I I I I

2 11.11111111111 II Iii Ill I IIIII II I I .1111

3 I I II 1111 U I I Ill I I •1 ~II I I 1.1 I I

4 I I Ill I I II I I I I I II I II I Ill

5 Ill II I • I Ill I I I I I I II I II • I I

6 I II I I I I I .I I I I I I Ill I

7 I I IIIII I I I I I •Ill II I I I

8 II II Ill I I Ill Ill Ill Ill IIIII U •1111 I I

9 I I II I I II I Ill I II II I II I ••u 1

10 1•11111 IIIII I I 111111111111 101m lOIII Ill I II Ill II 11111111

mins -30 -20 -10 0 0 10 20 30

Fig. 1. Compressed actogram of general fetal movements before and after chorionic villus biopsy

(CVB) in the 10 cases.

Table I. Clinical data on the IO women, as well as the incidence (percentage of time or number per 30

minutes) of fetal movements before and after chorionic villus sampling

General movements Duration of (%of time)

Case Age pregnancy I No. (yr) (wk and days) Before After

1 37 10 25 18 2 36 ll +I 24 27 3 38 9+1 28 25 4 41 9+6 15 20 5 26 10+1 20 17 6 38 g+5 23 24 7 38 9+6 21 24 8 39 g+5 20 22 9 36 9+5 20 19

10 40 ll +5 27 19 Mean 37 10+1 22.3 21.4

Chorionic villus sampling was performed with a tro­phoblast aspiration catheter (Trophocan), which was introduced transcervically under ultrasound guidance. A maximum of three aspirations per session were car­ried out to obtain approximately 20 mg net weight of good quality villi for analysis. No anesthetic agents or maternal sedation was used. The perineum, vagina, and cervix were thoroughly cleansed with povidine io­dine solution before the procedure was begun.

Startles Breathing (n) movements (n) Hiccups

Before I After Before I After Before I After

8 18 24 39 41 51 1 1 0 2 0 1 5 10 0 0 0 2

11 4 13 2 35 ll 4 9 4 0 4 ll 8 8 1 0 0 1 9 7 2 0 10 10 5 3 0 0 11 21

19 8 10 0 24 33 7 11 22 ll 1 9 7.7 7.9 7.6 5.4 12.6 15.0

Results

The study population comprised part of the first I 00 diagnostic chorionic villus samplings carried out in our department. The overall abortion rate in this series was 3%, with successful sampling in 96 patients and suc­cessful karyotyping in 95 patients. Interestingly, two of the three patients who aborted spontaneously after cho­rionic villus sampling were part of the study population (cases I and IO, Table 1). In the latter case the gesta-

Volume 157 Number 1

tiona! sac was accidentally ruptured during the pro­cedure. The results of the procedure were otherwise unremarkable. A mean weight of 36 mg of chorionic villi was obtained after an average of I. 7 aspirations between 9 and I2 weeks of gestation. No abnormal karyotypes were found in the series.

The statistical analyses of fetal movements before and after chorionic villus sampling did not show sig­nificant differences for all four modalities analyzed (Table I). In the two cases ending in a spontaneous abortion (7 and I4 days after chorionic villus sampling), no significant change was noted immediately after the procedure, although there was a tendency toward re­duced general movements in these fetuses.

The actogram of general fetal movements is dis­played in Fig. I, which shows a high overall incidence of movements both before and after chorionic villus sampling. It also shows that the incidence of general movements directly after chorionic villus sampling was the same as at the end of the second 30-minute re­cording.

Comment

The only other study on the immediate effects of chorionic villus sampling on the fetus to date was con­ducted by Lofberg et a!.," who describe transient fetal bradycardia during direct-vision sampling by means of the extra-amniotic instillation of 150 ml of physiologic saline. This effect appears to be the result of a rise in intrauterine pressure and consequently is not relevant to our study.

Fetal movements can be observed from 7 weeks' post­menstrual age. 5 There is an early emergence of specific movement patterns; at I6 weeks I5 distinct patterns are already present, which closely resemble those ob­served in preterm and term newborn infants. 5 When the different movement patterns are rank ordered ac­cording to their first appearance, a specific sequence emerges. It has been demonstrated that in embryos and fetuses of type 1 diabetic women, there is a delay of about 1 week in the first occurrence of these move­ments, except for breathing.7 Furthermore, it appears

Chorionic villus sampling and fetal movements 139

that in anencephalic fetuses, movement patterns are (already) qualitatively abnormal in the first half of pregnancy. 8

In Fig. 1 the compressed actogram of general move­ments shows that there is already a high base rate of spontaneous fetal movements at 9 to 11 weeks. With respect to these and the other movements studied, the data show that chorionic villus sampling does not stim­ulate movements or alter the intrauterine situation in such a way as to decrease fetal movements. The latter is known to occur in threatened abortions. 9 In the two cases of a subsequent spontaneous abortion, the inci­dence of general movements but not the other move­ments studied was slightly decreased after chorionic villus sampling. However, more data are required to determine the significance of this finding.

We are most grateful to Dr. E. J. H. Mulder for tech­nical assistance and to Ms. Y. Lems for preparing the illustration.

REFERENCES 1. Jackson LG. Chorionic Villus Sampling, Jan. 21, 1986. 2. Gustavii B. Chorion biopsy and miscarriage in first trimes­

ter. Lancet 1984;i:562. 3. Brambati B, Simoni S, Danesino C, et a!. First trimester

fetal diagnosis of genetic disorders: clinical evaluation of 250 cases. J Med Genet 1985;22:92-9.

4. Hogge WA, Shonberg SA, Golbus MS. Prenatal diagnosis by chorionic villus sampling: lessons of the first 600 cases. Prenat Diagn 1985;5:393-400.

5. de Vries JIP, Visser GHA, Prechtl HFR. The emergence of fetal behaviour. 1. Qualitative aspects. Early Hum Dev 1982;7:301-22.

6. Lofberg L, Iosif CS, Edvall H, Gustavii B. Direct-version sampling of chorionic villi during extra-amniotic instilla­tion of physiologic saline solution: effects on intrauterine pressure and fetal heart activity. AM J OBSTET GYNECOL 1985; 152:591-2.

7. Visser GHA, Bekedam DJ, Mulder EJH, van Ballegooie E. Delayed emergence of fetal behaviour in type-1-diabetic women. Early Htim Dev 1985;12:167-72.

8. Visser GHA, Laurini RN, de Vries JIP, et a!. Abnormal motor behaviour in anencephalic fetuses. Early Hum Dev 1985; 12:173-82.

9. Schmidt W, Garoff L, Heberling D, et a!. Oberwachung der fetalen BewegungsaktiviUit mit Real-Time~ Ultraschall und deren Bedeutung fiir den Schwangerschaftsverlauf. Geburtshilfe Frauenheilkd 1981 ;41 :601-6.