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that series, only 8.2% of the patients were obese and a complete evaluation was possible in only 27.6% of them. Given the 69% rate of obesity in our study this would translate into an unsuccessful examination in almost 20% of diabetic women. Despite the diagnostic challenges secondary to maternal obesity, every major anomaly was identied prenatally in our study. Neonates had a standard pediatric examination rather than a targeted search for additional anomalies so it is conceivable that additional anomalies were present but not clinically detected in the population. However, this diagnostic accuracy, which was signicantly higher than reported for general prenatal diagnostic sonography,41 was not accomplished early in pregnancy and most likely would not be reproducible in a setting where follow-up at a specialist center is not available beyond the second trimester. Given the limited precision of combined HbA1c, NT, and DV Doppler to delineate fetal anomalies, detailed rsttrimester anatomic survey deserves prospective evaluation in women with pregestational diabetes. Studies on rsttrimester anatomic survey usually demonstrate the requirement for follow-up evaluation in the midtrimester and beyond.8,42,43 In a study of 536 women, Yagel et al44 showed that anomalies can be misdiagnosed or remain unidentied if only an early scan is used. In addition, anomalies, particularly of the central nervous system, may be difcult to diagnose in the rst trimester because this system is still undergoing development.45 However, a signicant advantage of the rst-trimester anatomic survey in women with pregestational diabetes with obesity is the availability of transabdominal and transvaginal examination approaches. Using transvaginal sonography, improved diagnostic accuracy has already been documented for unscreened populations and women at risk for fetal cardiac defects.46-48 Our results indicate that women with HbA1c 8.3%, increased NT, or reversed DV awave would be an appropriate target for a study on rst-trimester detailed anatomy utilizing transabdominal or transvaginal routes guided by imaging quality criteria. The prospective design and large sample size of our study provides important insight into the importance of serial evaluation for women at increased risk of fetal anomalies. The large number of anomalies and proportion of women with poorly controlled diabetes veries that we studied our target population. A standardized rst-trimester evaluation protocol and complete ultrasound data also ensured that the screening tests were performed according to quality criteria. Our patients had a high follow-up rate and most delivered at our institutions so the outcome data were obtained directly rather than from outside providers. Our study protocol did not allow us to evaluate the true capacity of a rst-trimester targeted anatomic survey as this was not performed in a systematic way. Another potential confounder that was not evaluated was the unblinding of the follow-up examiners to the ndings of the rst-trimester examination results, which could have positively skewed the diagnostic accuracy. As guidelines for detailed rst-trimester anatomy assessment are developed, this is anticipated to be a powerful tool that requires further study. Additional rst-trimester predictors for cardiac anomalies such as tricuspid regurgitation and cardiac axis as well as more detailed evaluation of the posterior fossa for central nervous system anomalies are important for investigation in this population. Our study indicates that rst-trimester screening with HbA1c, NT, and DV Doppler can signicantly stratify risks for fetal anomalies in women with pregestational diabetes. Following this early risk triage, high diagnostic accuracy can be achieved during follow-up sonograms. It remains to be determined if a targeted rst-trimester anatomic survey in women identied to be at highest risk can parallel this diagnostic accuracy with the advantage of a choice of scanning routes and the benet of early diagnosis. The high prevalence of anomalies in the presence of a high HbA1c and maternal obesity stresses the importance of preconceptional counseling and lifestyle f modication.

Obstetrics
ACKNOWLEDGMENTS

Research

We acknowledge Oza Bela for database management; Donna Ortiz, RDMS, and Annette Slater, RDMS, for quality control of ultrasound images; and Alfred Abuhamad, MD, for review and critical discussion. All are afliated with Eastern Virginia Medical School.

REFERENCES
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