Transient hydropic signs in the donor fetus after fetoscopic laser coagulation in severe twin-twin transfusion syndrome: incidence and clinical relevance

OBJECTIVE

To evaluate the incidence, characteristics, and impact on perinatal outcome of the development of hydropic signs in the donor fetus after laser coagulation for severe twin-twin transfusion syndrome in the second trimester.

METHODS

Forty cases of second-trimester severe twin-twin transfusion underwent fetoscopic laser coagulation of placental anastomoses and were followed up with serial ultrasound up to 14 days after therapy. Ultrasound scans were performed just before, and on days 1, 3, 5 and 14 after therapy, and fetuses were monitored for the presence of hydropic signs (skin edema, pleural effusion, ascites and pericardial effusion). Response to therapy and perinatal outcome in terms of neonatal survival were recorded for all cases.

RESULTS

Four recipients (10%) and three donors (7.5%) died over the first 72 h after therapy. During the study period, two recipients (5.5%) developed frank hydrops fetalis, and eventually died in utero. Ten donors (27.0%) developed one or more hydropic signs. In nine (90%), signs were mild or moderate and transient (mean, 3.2 days), while in one case hydrops worsened and the fetus eventually died. No donors with transient hydrops died in utero, and two died postnatally due to extreme prematurity. Gestational age at procedure and deepest amniotic fluid vertical pocket were similar between hydropic and non-hydropic donors. Discrepancy in estimated fetal weight at procedure was significantly lower in donors developing hydrops (9.6 (SD, 6.4) vs. 17.8 (14.4)%,P = 0.018). In pregnancies with hydropic donors, gestational age at delivery (33.1 (3.4) vs. 29.7 (3.5) weeks,P = 0.015) and birth weight for recipient (2392 (423) vs. 1631 (576) g, P < 0.001) and donor (1908 (774) vs. 1281 (583) g,P = 0.021) were significantly higher. The development of transient hydrops had no influence on neonatal survival at 28 days nor on the rate of clinical resolution of intertwin transfusion.

CONCLUSIONS

Transient hydropic signs may develop in a proportion of donor fetuses after laser coagulation for severe twin-twin transfusion syndrome. This phenomenon is normally not associated with a poor prognosis, and possibly indicates an hemodynamic adaptation response following interruption of the transfusion process.

Prenatal findings in a monozygotic twin pregnancy with Costello syndrome

This report describes the prenatal findings in monozygotic twins with Costello syndrome. At 16 weeks one twin had 9 mm of nuchal oedema: coarctation of the aorta was diagnosed after birth. At 22(5/7) weeks relative macrocephaly, mild pyelectasia and moderate polyhydramnios were noted in both twins. In the following 4 weeks the polyhydramnios increased significantly without visualisation of filling of the stomach. Between 27(5/7) and 30(2/7) weeks a total of 9 l amniotic fluid was drained and at 30(4/7) weeks prelabor premature rupture of membranes (PPROM) occurred followed by premature labor and delivery. The neonatal period was complicated by growth retardation, deglutition problems, hypotonia, cardiac and respiratory problems. Both twins died on Day 57 because of respiratory insufficiency.

Two siblings with early onset fetal akinesia deformation sequence and hydranencephaly: further evidence for autosomal recessive inheritance of hydranencephaly, fowler type

We report a 13-week-old female fetus with early onset fetal akinesia deformation sequence (FADS) and hydranencephaly. In a previous pregnancy, the same ultrasonographic findings were noted at 13 weeks. Fetopathological examination of both female fetuses confirmed FADS with severe arthogryposis, multiple pterygia, and muscular hypoplasia. Neuropathological examination showed massive cystic dilatation of the cerebral ventricles (hydranencephaly) with calcification of the basal ganglion and brain stem and a proliferative vasculopathy throughout the central nervous system. The findings in the two female siblings document the earliest echographic diagnosis of hydranencephaly, Fowler type, and this observation further supports autosomal recessive inheritance of this distinct type of hydranencephaly.

Rapid prenatal diagnosis of trisomy 21 in 5049 consecutive uncultured amniotic fluid samples by fluorescence in situ hybridisation (FISH)

OBJECTIVES

This was a retrospective study on the results of interphase fluorescence in situ hybridization (FISH), performed routinely for chromosome 21 and on ultrasonographic indications for chromosomes 13, 18, X and Y in a series of 5049 amniotic fluid samples.

METHODS

Interphase FISH for chromosome 21 was performed in 5049 consecutive amniotic fluid samples for the rapid prenatal diagnosis of Down syndrome. Aneuploidy for four other chromosomes (13, 18, X and Y) was tested following ultrasonographic indications. Karyotypes from standard cytogenetic analysis were compared to the FISH results.

RESULTS

Using conventional cytogenetics 3.6% (183/5049) chromosomal anomalies were detected. After exclusion of familial chromosome rearrangements, i.e. balanced autosomal reciprocal or Robertsonian translocations (30/5049) and inversions (19/5049), 2.65% chromosomal anomalies (134/5049) were diagnosed. Of this group 0.18% (9/5049) were chromosomal rearrangements not detectable by FISH and 2.47% (125/5049) were numerical chromosomal anomalies detectable by interphase FISH for chromosomes 13, 18, 21, X and Y. With routine interphase FISH for chromosome 21 and FISH on echographic indication for the other four chromosomes we detected 107/125 of these numerical chromosomal anomalies, i.e. 85.6%. All 70 cases of trisomy 21 were detected by FISH and confirmed with conventional cytogenetics (sensitivity=100%) and there were no false-positive results (specificity=100%). Maternal cell contamination of amniotic fluid samples occurred in 1.27% (64/5049) of samples; 0.26% (13/5049) of these samples were uninformative by FISH due to maternal cell contamination (12/5049) or absence of nuclei in one sample (1/5049).

CONCLUSION

In this group of 5049 samples we found that FISH is a reliable technique for the rapid prenatal diagnosis of trisomy 21. The number of uninformative cases due to maternal cell contamination was low. The strategy to perform FISH for chromosome 21 in all samples and only on ultrasonographic indication for the four other chromosomes (13, 18, X and Y) followed by standard cytogenetics is effective.

Associated malformations and chromosomal anomalies in 42 cases of prenatally diagnosed diaphragmatic hernia

We present a retrospective study of the frequency and type of associated malformations and chromosomal anomalies in 42 consecutive cases of congenital diaphragmatic hernia (CDH) diagnosed in utero during the period from 1985 to 1999. In 26% (11/42) of the cases, associated malformations were detected. Chromosomal anomalies were present in 9.5% (4/42). In this group of 15 cases (15/42 = 36%) with associated malformations or chromosomal anomalies, all cases, except one, had prenatal sonographic evidence of additional problems. The survival rate of fetuses with CDH and associated malformations or chromosomal anomalies was poor (1/15). Therefore, the overall survival rate of in utero-diagnosed CDH was only 31% (13/42), while isolated left CDH had a survival rate of 52% (12/23). The in utero diagnosis of CDH implies a detailed echographic examination to exclude additional anomalies. The risk for a syndromal or chromosomal malformation becomes small when no additional anomalies are seen on ultrasound.

Semilobar holoprosencephaly in a 46,XY female fetus

We report the prenatal echographic diagnosis of holoprosencephaly (HPE) at 11 weeks' gestation. Fetopathological examination revealed an unusual variant of semilobar HPE with middle interhemispheric fusion associated with sex-reversal: 46,XY normal male karyotype, normal external and internal female genitalia and streak gonads.

Ultrasound determination of chorionicity in twin pregnancy: accuracy and operator experience

To evaluate the accuracy of ultrasound in early detection of chorionicity and amnionicity in twin pregnancies and evaluate the role of operator-experience, a prospective follow up of 87 consecutive twin pregnancies was performed. Chorionicity and amnionicity were determined by 17 different observers, divided in 2 groups on the basis of their experience, using a composite of US markers at the first US examination confirming a viable intrauterine twin pregnancy. Accuracy of prediction was determined for both groups by comparison with postnatal pathology. From the 87 pregnancies examined at 10.1 (minimum 5.5 weeks, maximum 26.0) weeks of gestation, pathology was available in 82 cases and a correct prediction of chorionicity was made in all but two cases, both being diagnosed as monochorionic while dichorionic by observers belonging the more experienced group. No monochorionic pregnancy was missed and amnionicity was correctly diagnosed in all cases, including two monoamniotic twins. We conclude that use of a composite of ultrasound markers for early detection of chorionicity and amnionicity is reliable in a clinical setting where physicians with a variable degree of experience perform ultrasound examination.

Does local anesthesia at mid-trimester amniocentesis decrease pain experience? A randomized trial in 220 patients

OBJECTIVES

To evaluate whether local anesthesia decreases patients' pain experience during mid-trimester amniocentesis.

METHODS

In a randomized trial, one group did not receive local anesthesia while, in another group, lignocaine 1% was injected subcutaneously prior to amniocentesis. Five different scoring systems were used to evaluate patients' pain experience.

RESULTS

Two hundred and twenty women entered the study: 114 received local anesthesia, while 106 did not. The mean (SD) Visual Analog Scale was 1.4 (1.5) on a 0-10 scale (range 0-7.6). Some 97% of patients described the procedure as not painful or bearable, 79% had expected the procedure to be more painful and 59% reported the amniocentesis to have a comparable discomfort as venous blood sampling; 98% of women declared they would undergo an amniocentesis again if indicated. There were no statistical differences between both randomization groups.

CONCLUSIONS

Mid-trimester amniocentesis is not a painful procedure. Local anesthesia does not affect pain experience during amniocentesis.

Vascular malformations in the uterus: ultrasonographic diagnosis and conservative management

OBJECTIVE

To investigate the presence and outcome of uterine vascular malformations in women with abnormal premenopausal bleeding.

STUDY DESIGN

In this observational study 265 consecutive patients with abnormal premenopausal bleeding were examined by the same ultrasonographer with transvaginal gray-scale ultrasonography and color Doppler imaging. A final diagnosis of uterine vascular malformation was based on ultrasonographic findings, hysteroscopy or histological findings. Patients suspected of uterine vascular malformations at ultrasonography were closely monitored.

RESULTS

In nine patients (3.4%) we found ultrasonographic features of uterine vascular malformations. Color Doppler imaging showed hypervascularity, marked turbulence, and low-impedance, high-velocity flow. In six patients the condition resolved spontaneously. Two patients with hydatiform mole needed chemotherapy and their condition normalized. One patient underwent a selective embolization of the uterine artery. Subsequently, five patients had uncomplicated pregnancies after resolution of the vascular malformation.

CONCLUSION

Uterine vascular malformations are more common than previously thought. We conclude that conservative management is a valuable option in many of the acquired pregnancy-related cases that are diagnosed with color Doppler imaging.

Bipolar coagulation of the umbilical cord in complicated monochorionic twin pregnancy

OBJECTIVES

In monochorionic twin pregnancy in which one twin is a nonviable fetus, selective feticide may be considered. We aimed to occlude the umbilical cord with a bipolar forceps for doing so.

STUDY DESIGN

This was a multicenter experience in 10 consecutive patients either with twin-to-twin transfusion syndrome and one fetus affected by a condition not compatible with normal extrauterine life or with acardiac twinning.

RESULTS

There were no intraoperative problems, and the mean procedure time was 17.5 minutes. The flow was stopped in all 10 cases. Two cases were complicated by rupture of the fetal membranes within 2 days, and the pregnancies were terminated. The other 8 pregnancies resulted in the live birth of a healthy baby. The mean interval between procedure and birth was 15.1 weeks (range, 7-20 weeks). In one patient emergency cesarean delivery for abruptio placentae was done at 26 weeks, 7 weeks after the procedure. The other 7 patients were delivered beyond the 36th week of gestation. All 8 children are alive and well, with a mean follow-up of at least 1 year.

CONCLUSION

Bipolar coagulation is a safe, effective, and simple procedure for cord coagulation that is feasible through a single port and can be performed solely under ultrasonographic guidance.

Prenatal diagnosis of a subamniotic hematoma

A case of a subamniotic hematoma was diagnosed at 34 weeks of gestation. Pregnancy and delivery were uneventful. The ultrasound features of a subamniotic hematoma, and the differential diagnosis with lesions of less favorable outcome are described.

Time-related cotyledonary effects of laser coagulation of superficial chorionic vessels in an ovine model

Endoscopic Nd:YAG laser coagulation of superficial chorionic plate vessels has been suggested as a 'causal' therapy for severe twin-to-twin transfusion syndrome (TTS), as it is believed to arrest flow over vascular anastomoses. The therapy remains debated, partly because it is questioned whether coagulation of superficial chorionic vessels can arrest blood flow over deeply located anastomoses. The latter are believed to be responsible for the majority of cases of severe TTs. In this study, the coagulation performance, and the immediate and delayed tissue effects of laser coagulation were evaluated in an in vivo ovine model. Eight pregnant ewes of about 100 days' gestational age (term= 145 days) were studied. In utero coagulation was done through a 1.2 mm fetoscope loaded with a 600 microm laser fibre, connected to an Nd:YAG laser in continuous mode. Superficial cotyledonary vessels were coagulated under visual control at a distance of 1 cm with a mean power of 60 watts. 31 lasered cotyledons were harvested, either immediately (n= 15), 14 days (n = 8) or 42 days (n = 8) after the surgery and evaluated by inspection and histology. Control cotyledons were either neighbouring cotyledons from the same amniotic sac (internal control) or cotyledons from another gestational-age-matched sac (external control). Immediate effects consisted of localized coagulation necrosis at the zone of laser impact with no significant histological effect at more than 2 mm distance, except tissue congestion. Long-term effects consisted of fibrosis without any vascular recanalization or tissue regeneration extending from the impact site over the whole cotyledon. All treated cotyledons underwent complete infarction over time. This study provides experimental evidence supporting that laser coagulation of superficial chorionic vessels entering a cotyledon achieves complete functional elimination of the involved cotyledon.

Marden-Walker syndrome versus isolated distal arthrogryposis: evidence that both conditions may be variable manifestations of the same mutated gene

In this report we present evidence that Marden-Walker syndrome and isolated distal arthrogryposis may be variable manifestations of the same entity. We describe the clinical and pathological findings in two affected siblings, the first two children of normal, non-consanguineous parents. The first child, a female, presented a typical Marden-Walker syndrome with Dandy Walker type CNS malformation, corpus callosum hypoplasia and enlarged ventricles. In the second pregnancy, echographic examination revealed joint contractures of the hands and feet. Fetopathological examination revealed a normocephalic male fetus with severe distal arthrogryposis. There was no facial dysmorphism and pathological examination of the brain, the spinal cord and muscle was normal.

Alternative technique for Nd: YAG laser coagulation in twin-to-twin transfusion syndrome with anterior placenta

Nd: YAG laser coagulation is used to treat severe twin-to-twin transfusion syndrome (TTS). Success of the technique depends on visualization of the placenta, the fetal membranes and the targeted vessels, as well as obtaining an optimal inclination angle for laser coagulation. In the rare case of an extensive anterior placenta, it may be difficult to achieve these conditions using the percutaneous approach. Here, we propose an alternative to the percutaneous procedure. Modifications involve an open access and the use of a flexible cannula and bent scope. An extraplacental area, usually at the fundus, is identified by B-mode and color Doppler imaging. A mini-laparotomy is made under general anesthesia. The viscera are retracted and the cannula is inserted under direct view and ultrasound control by the Seldinger technique. The curved fiberscope is passed through the flexible cannula, allowing adequate inspection of the placenta, and target vessels can be coagulated at an angle close to 90 degrees. After the procedure, the uterus is closed primarily to prevent postoperative leakage of amniotic fluid or hemorrhage. This technique has been successfully used in six patients with TTS and a completely anterior placenta, with a gestational age between 18.5 and 22.0 weeks. In all patients, the amniotic cavity was accessed without hemorrhage. The outcomes are similar to those published previously for laser coagulation. The mean interval from intervention until delivery was 10.5 weeks. All 12 fetuses were live born but four died from complications of extreme prematurity. No maternal complications occurred.

Polyhydramnios as a prenatal symptom of the digeorge/velo-cardio-facial syndrome

Prenatal diagnosis of the DiGeorge/velo-cardio-facial syndrome has become possible since it was recognized that this syndrome is caused by a submicroscopic deletion in chromosome 22q11. In a sporadic patient presenting a conotruncal heart defect and polyhydramnios, the del 22q11 was made prenatally by fluorescence in situ hybridization (FISH) after amniocentesis. Seven additional patients with a del 22q11 were identified, who presented during pregnancy with polyhydramnios. In one of them, unilateral hydronephrosis was present. These findings further add to a growing list of clinical presentations of a del 22q11 and suggest that in patients with polyhydramnios and a conotruncal heart defect or uropathy, fetal karyotyping should be complemented by FISH for a del 22q11.

Prenatal diagnosis of a terminal short arm deletion of chromosome 8 in a fetus with an atrioventricular septal defect

We report the prenatal diagnosis at 30 weeks of gestation of a del(8)(p21.3-->pter) in a growth-retarded fetus with an unbalanced atrioventricular septal defect (AVSD) and a hypoplastic right ventricle. This observation further confirms the association of AVSD with terminal deletions of chromosome 8p. Terminal deletions of chromosome 8p are more frequent than previously thought, but small terminal deletions can easily be overlooked. This observation illustrates that when an AVSD is diagnosed prenatally, special attention should be paid to distal chromosome 8p.

Chromosome 22q11 deletion presenting as the Potter sequence

A female fetus with the Potter sequence, caused by unilateral renal agenesis and contralateral multicystic renal dysplasia, was found to have a submicroscopic deletion in chromosome 22q11. The only associated anomaly was agenesis of the uterus and oviducts (Von Mayer-Rokitansky-Küster anomaly). The deletion was inherited from the father, who presented the typical velocardiofacial syndrome phenotype, but no urological anomalies. This observation further extends the clinical spectrum associated with a deletion in 22q11.

Combining vaginal ultrasonography and office endometrial sampling in the diagnosis of endometrial disease in postmenopausal women

OBJECTIVE

To investigate the value of the combined use of vaginal ultrasonography and endometrial sampling in the office for the diagnosis of endometrial disease in postmenopausal women.

METHODS

One hundred forty consecutive postmenopausal women presenting with uterine bleeding or endometrial cells on cervical cytology entered the study. Vaginal ultrasonography was used to measure the endometrial thickness, followed by use of the Pipelle endometrial sampler. Pipelle biopsy was not feasible in two patients. The results of hysteroscopy with biopsy or hysterectomy, performed within 6 weeks in all but 12 patients, were considered the final diagnosis. The accuracy of ultrasound and Pipelle was measured against the final diagnosis.

RESULTS

The sensitivity of vaginal ultrasonography for endometrial disease was 98.2 and 82.0% if cutoff points for endometrial thickness of 2 and 4 mm, respectively, were used. All six patients with endometrial carcinoma had endometrial thicknesses exceeding 12 mm. Pipelle endometrial sampling had a sensitivity of 44.6% and a specificity of 98.5% for endometrial disease. All cases of endometrial carcinoma were detected by sampling in the office setting.

CONCLUSION

This study illustrates the value of vaginal scanning in the diagnosis of endometrial disease in symptomatic, postmenopausal women. A 4-mm cutoff point for endometrial thickness seemed appropriate. The sensitivity of Pipelle sampling for endometrial carcinoma was excellent, but relatively weak for other endometrial disease because it failed to detect endometrial polyps and submucous myomas. The combined use of ultrasound and Pipelle sampling offers sufficient diagnostic information for most symptomatic postmenopausal women.