Volume contrast imaging: A new approach to identify fetal thoracic structures

OBJECTIVE

To assess the potential of volume contrast imaging for evaluation of fetal intrathoracic structures.

METHODS

Volume contrast imaging is a new ultrasonographic method that increases the contrast between tissues. It consists of a 5- to 10-mm-thick slice-shaped volume image projected on a 2-dimensional screen. The rendering process applied on the slice smoothens the speckle pattern of the image by filling up the gaps with tissue information from the adjacent layers. To evaluate the potential of volume contrast imaging for enhancing the contrast between fetal lungs and surrounding tissues, we compared the ability of volume contrast imaging and conventional ultrasonography to image the fetal thymus in 50 controls. We also applied volume contrast imaging to prenatal imaging of 6 thoracic abnormalities (2 left congenital diaphragmatic hernias, 1 right diaphragmatic hernia, 2 congenital adenomatoid lung malformations, and 1 lung sequestration).

RESULTS

In controls, the thymus was identified in all cases by volume contrast imaging and in 42 cases (84%) by conventional 2-dimensional ultrasonography. Clear images of macrocystic and microcystic congenital adenomatoid malformations were obtained by volume contrast imaging, which provided precise contouring of the lesions. In cases with congenital diaphragmatic hernias, volume contrast imaging provided clear images of the limits of the lungs ipsilateral to the hernia.

CONCLUSIONS

Volume contrast imaging may enhance the contrast between fetal lungs and surrounding organs and can be applied to prenatal imaging of intrathoracic structures in cases with thoracic fetal abnormalities.

Fetal lung volume estimated by 3-dimensional ultrasonography and magnetic resonance imaging in cases with isolated congenital diaphragmatic hernia

OBJECTIVE

To assess the agreement of 3-dimensional ultrasonography and magnetic resonance imaging in estimating fetal lung volume in cases with isolated congenital diaphragmatic hernia.

METHODS

Fetal lung volume was measured in 11 cases of congenital diaphragmatic hernia (10 left and 1 right) by 3-dimensional ultrasonography and magnetic resonance imaging. These examinations were performed during the same week. The operators were blinded to each other's results. Intraclass correlation was used to evaluate the agreement between 3-dimensional ultrasonography and magnetic resonance imaging estimations of the ipsilateral, contralateral, and total fetal lung volume. A Bland-Altman graph was plotted to detect possible discordant observations.

RESULTS

The global intraclass correlation coefficient between magnetic resonance imaging and 3-dimensional ultrasonographic measurement of fetal lung volume was 0.94 (95% confidence interval, 0.78-0.98) with no outliers observed on the Bland-Altman plot.

CONCLUSIONS

There is a good agreement between 3-dimensional ultrasonography and magnetic resonance imaging for fetal lung volume estimation in cases with congenital diaphragmatic hernia.

Nonimmune fetal ascites: a series of 79 cases

OBJECTIVE

The purpose of this study was to analyze the precision of ultrasonography in defining the cause and prognosis in fetal ascites.

STUDY DESIGN

We conducted a retrospective study of 79 cases of fetal ascites.

RESULTS

The mortality rate was 57% overall and ranged from 100% (7/7 cases) for metabolic storage disease to 0% (0/3 cases) in chylous ascites. Ascites before 24 weeks of gestation or combined with fetal hydrops indicates poor prognosis (respectively, 78.6% vs 45% mortality rate after 24 weeks; P<.01; and 77% vs 50.8% without hydrops; P<.02). Ascites was organic in 45 cases, infectious in 13 cases, idiopathic in 12 cases, and genetic in 9 cases. The cause was defined ultrasonographically in 28 of the 45 organic ascites and in 8 of the 25 isolated ascites. Urinary cause was the most frequent and the most successfully specified cause (14/15 cases).

CONCLUSION

Routine ultrasonography detects fetal ascites, but the cause is extremely variable and difficult to specify. When associated with fetal hydrops, the prognosis is poor.

Prenatal sonographic diagnosis of congenital hiatal hernia

OBJECTIVES

To report a rare case of congenital hiatal hernia illustrating the importance of its prenatal diagnosis as well as to discuss the prenatal sonographic criteria.

CASE REPORT

A case of congenital hiatal hernia was diagnosed by ultrasound at 33 weeks of gestation. After a normal second-trimester morphologic ultrasound examination, a hypoechogenic mass was detected in the posterior mediastinum juxtaposed to the vertebral body and seemed to be in continuity with the intra-abdominal stomach bubble. Congenital hiatal hernia was suspected mainly because of the dynamic position of the stomach during the examination, without mediastinal shift, and normal appearance of the diaphragm on parasagittal sections of the thorax. Postnatal management was planned with no urgency and surgery was successfully performed, confirming the diagnosis.

CONCLUSION

This rare case illustrates the importance of prenatal diagnosis of congenital hiatal hernia for prenatal counseling and postnatal management. The ultrasound criterion for prenatal diagnosis is the presence of a herniated stomach in the posterior mediastinum, sometimes having a dynamic position during examination, with no mediastinal shift associated with normal diaphragm appearance on parasagittal sections of the thorax.

Antenatal manifestations of Smith-Lemli-Opitz (RSH) syndrome: A retrospective survey of 30 cases

Smith-Lemli-Opitz (SLO) syndrome or RSH syndrome is an autosomal recessive multiple malformation, and mental retardation syndrome ascribed to 7-dehydrocholesterol reductase deficiency, and usually diagnosed in the early postnatal period. Reviewing a series of 30 cases of SLO, we have investigated the variable antenatal expression of the disorder. Intrauterine growth retardation (IUGR) was the most frequent detectable trait (20/30). IUGR was either isolated (9/20) or associated with at least one other anomaly (11/20), including nuchal edema, renal, cardiac, cerebral malformations, genital anomalies, or polydactyly. In this last group, 3/11 presented with multiple malformations (> or =3 anomalies). In 5/30 cases, isolated nuchal edema (3/30), and isolated cardiac (1/30) or renal malformations (1/30) were the only detectable anomalies. Ultrasound findings were considered normal in 5/30 cases and were abnormal in 25/30 cases (83%), but early detection of multiple malformations was rare (3/30, 10%). We suggest giving consideration to a more systematic sterol analysis when dealing with IUGR, especially when associated anomalies are detected.

Can Three-Dimensional Ultrasound Be Used for the Assessment of the Fetal Lung Volume in Cases of Congenital Diaphragmatic Hernia?

We report on 2 fetuses with congenital diaphragmatic hernia (CDH) in whom the fetal lung volumes were estimated by three-dimensional ultrasound and the results compared with the postmortem lung volume measurements. Both examiners (sonographer and pathologist) were blinded to each other's results. The 1st case was a right CDH diagnosed at 20 weeks of gestation. The 2nd case was a left CDH diagnosed at 22 weeks of gestation. Both pregnancies were terminated upon request of the parents. Three-dimensional ultrasound estimation of the fetal lung volume was performed 1 day before termination of pregnancy using the technique of rotation of the three perpendicular planes. The left and right lung volumes estimated by three-dimensional ultrasound were 3.88 and 1.87 cm(3), respectively, in the 1st case and 0 and 5.52 cm(3), respectively, in the 2nd case. On postmortem examination, the left and right lung volumes were 3.0 and 2.2 cm(3), respectively, in case 1 and 1.1 and 5.6 cm(3), respectively, in case 2. This suggests that a three-dimensional estimation of pulmonary volumes may be correlated with postmortem findings in cases with CDH.

Perinatal three-dimensional color power Doppler ultrasonography of vein of Galen aneurysms

OBJECTIVE

To present the prenatal and postnatal three-dimensional color power Doppler ultrasonographic features in cases of vein of Galen aneurysmal malformation.

METHODS

Prenatal three-dimensional color power Doppler ultrasonography was used to image the neurovascular malformations in 3 fetuses with vein of Galen aneurysms and in unaffected control fetuses at the same gestational age. Postnatal transfontanel three-dimensional power Doppler ultrasonography was also performed in the third affected case and in an unaffected control neonate. The feeding and drainage vessels were analyzed in the three-dimensional rendering mode.

RESULTS

The first case was complicated by porencephaly and fetal heart failure, and the pregnancy was terminated. The other 2 cases were uncomplicated prenatally, but 1 of the infants died after aneurysmal embolization due to acute cerebral ischemia. The angioarchitecture of the arteriovenous fistula was characterized in greater detail by three-dimensional color power Doppler ultrasonography than by two-dimensional ultrasonography, especially regarding the anatomic features of the feeding and drainage vessels and their connections with the dilated vein of Galen.

CONCLUSIONS

Three-dimensional color power Doppler ultrasonography provided detailed images of the aneurysmal malformation and its vascular connections. Further studies are needed to correlate three-dimensional vascular imaging patterns with outcome.

Diminutive fetal left ventricle at mid-gestation associated with persistent left superior vena cava and coronary sinus dilatation

In a fetus with a small left ventricle diagnosed at mid-gestation, a persistent left superior vena cava connected to a dilated coronary sinus was detected. Although the size of the mitral annulus appeared to be normal, opening of the mitral valves was restricted in diastole. Echocardiographic follow-up showed no significant growth of the left ventricle and termination of pregnancy was carried out at 31 weeks at the parents' request. In addition to the prenatal findings, postmortem examination revealed a small mitral annulus with abnormal insertion of the mitral valve chordae tendineae. We hypothesized that abnormal venous return to a dilated coronary sinus may have led to mitral valve dysfunction and hypoplasia. On the other hand the left ventricular hypoplasia we observed may have involved a global abnormality of the left-sided cardiac structures.

Pericardial teratoma complicated by hydrops: successful fetal therapy by thoracoamniotic shunting

Pericardial teratoma is a potentially curable lesion that may become life threatening when it induces mediastinal compression and fetal hydrops. So far, cases with fetal hydrops have been managed by elective delivery or pericardial needle decompression. We report a case in which pericardial teratoma resulted in fetal hydrops. Following transpleural needling of the fetal pericardium at 29 weeks and 6 days, pericardial effusion decreased but hydrops persisted, while major unilateral pleural effusion appeared. A thoracoamniotic shunt was placed at 30 weeks and 5 days. Hydrops resolved, although incompletely. The baby was delivered at 32 weeks and was operated upon on day 3. This observation suggests that fetal hydrops associated with pericardial teratoma may improve following thoracoamniotic shunting. Fetal therapy may limit the risks of respiratory distress arising from the combined effect of airways compression and lung immaturity.

Systemic arteriovenous fistula leads to pulmonary artery remodeling and abnormal vasoreactivity in the fetal lamb

Several cases of systemic arteriovenous fistula diagnosed in the human fetus have been associated with the postnatal development of persistent pulmonary hypertension. The aim of this study was to determine the effects of a prenatally created systemic arteriovenous fistula on the structure and reactivity of the pulmonary circulation in the fetal lamb. A fistula between the jugular vein and carotid artery was created in fetal lambs at 119-124 days of gestation. At delivery (134-139 days), left pulmonary artery (LPA) pressure was increased in the fistula group (n = 12) compared with controls (n = 11, P < 0.01). The pulmonary vascular resistance was significantly higher in the fistula group (P < 0.05), whereas mean LPA blood flow was not statistically different between the two groups. Morphometric analysis of the pulmonary vascular bed revealed an increase in the number of peripheral muscular arteries, together with an increase in pulmonary arterial medial thickness in the fistula group. There was no difference in the relative number or size of intraacinar arteries. In vitro organ bath studies on pulmonary arterial rings showed impaired endothelium-dependent relaxation in the fistula group compared with controls. However, endothelial nitric oxide synthase protein expression was similar in both groups, whereas endothelium-independent relaxation to sodium nitroprusside was greater in the fistula group compared with controls. A systemic arteriovenous fistula leads to both structural and functional alteration of the pulmonary vasculature, which might lead to the development of persistent pulmonary hypertension after birth.

Fetal hypertension: an insight into the pathogenesis of the twin-twin transfusion syndrome

OBJECTIVES

To investigate if systemic hypertension occurs in fetuses with twin-to-twin transfusion syndrome (TTTS).

METHODS

We conducted an observational cohort study in a tertiary care centre in 23 pregnant women with TTTS. Polyhydramnios stuck twin sequence occurred at a median gestational age of 22 weeks (range 15-27). Biventricular myocardial hypertrophy was diagnosed in 22/23 recipient fetuses. In cases with atrioventricular valve regurgitation (AVR), it was possible to estimate the fetal systolic systemic blood pressure by ultrasound, on the basis of the simplified Bernouilli equation. The diagnosis of fetal hypertension (FHT) was made when the estimated systolic arterial pressure was equal to or above 1.6-fold the expected value.

RESULTS

In 10 pregnancies (group A), fetal blood pressure could be assessed in recipients with AVR. The maximum velocities ranged from 2.9 to 5 m/s, leading to estimates of systemic fetal arterial pressure from 37 to 104 mmHg, that is, 1.6- to 2.8-fold the expected values. In 13 pregnancies (group B), fetal blood pressure could not be assessed in the absence of AVR. In group A, perinatal death (16/20) and hydrops (7/20) were significantly more frequent than in group B (8/26 and 1/26 respectively).

CONCLUSION

Fetal systemic hypertension may occur in recipient twins and could play a role in the pathophysiology of TTTS.

Antenatal manifestations of mitochondrial respiratory chain deficiency

OBJECTIVE

To review the antenatal manifestations of disorders of oxidative phosphorylation.

STUDY DESIGN

A total of 300 cases of proven respiratory chain enzyme deficiency were retrospectively reviewed for fetal development, based on course and duration of pregnancy, antenatal ultrasonography and birth weight, length, and head circumference. Particular attention was given to fetal movements, oligo/hydramnios, fetal cardiac rhythm, fetal heart ultrasound, and ultrasonography/echo Doppler signs of brain, facial, trunk, limb, and organ anomalies.

RESULTS

Retrospective analyses detected low birth weight (<3rd percentile for gestational age) in 22.7% of cases (68/300, P<.000001). Intrauterine growth retardation was either isolated (48/300, 16%) or associated with otherwise unexplained anomalies (20/300, 6.7%, P<.0001). Antenatal anomalies were usually multiple and involved several organs sharing no common function or embryologic origin. They included polyhydramnios (6/20), oligoamnios (2/20), arthrogryposis (1/20), decreased fetal movements (1/20), ventricular septal defects (2/20), hypertrophic cardiomyopathy (4/20), cardiac rhythm anomalies (4/20), hydronephrosis (3/20), vertebral abnormalities, anal atresia, cardiac abnormalities, tracheoesophageal fistula/atresia, renal agenesis and dysplasia, and limb defects (VACTERL) association (2/20), and a complex gastrointestinal malformation (1/20).

CONCLUSIONS

Although a number of metabolic diseases undergo a symptom-free period, respiratory chain deficiency may have an early antenatal expression, presumably related to the time course of the disease gene expression in the embryofetal period. The mechanism triggering malformations is unknown and may include decreased ATP formation and/or an alteration of apoptotic events controlled by the mitochondria.

Fetal DNA in maternal serum: does it persist after pregnancy?

Fetal DNA and cells present in maternal blood have previously been used for non-invasive prenatal diagnosis. However, some fetal cells can persist in maternal blood after a previous pregnancy. Fetal rhesus status and sex determination have been performed by using amplification by real-time polymerase chain reaction (PCR) of fetal DNA sequences present in maternal circulation; no false-positive results related to persistent fetal DNA from a previous pregnancy have been reported. This idea has recently been challenged. An SRY real-time PCR assay was performed on the serum of 67 pregnant women carrying a female fetus but having previously given birth to at least one boy and on the serum of 30 healthy non-pregnant women with a past male pregnancy. In all cases, serum was negative for the SRY gene. These data suggest that fetal DNA from a previous pregnancy cannot be detected in maternal serum, even by using a highly sensitive technique. Therefore, non-invasive prenatal diagnosis by fetal sex determination for women at risk of producing children with X-linked disorders, and fetal RHD genotyping is reliable and secure as previously demonstrated.

First-trimester diagnosis of osteogenesis imperfecta associated with encephalocele by conventional and three-dimensional ultrasound

To illustrate the three-dimensional sonographic features of a rare genetic disorder, we report on prenatal diagnosis of osteogenesis imperfecta congenita associated with encephalocele at 13 weeks of gestation, using conventional and three-dimensional ultrasound. Because the parents were first-degree cousins and on the basis of the family history, a recessive autosomal inheritance was suspected. Of seven previous pregnancies, five were unaffected and two had been terminated in the second trimester owing to a similar abnormality (one affected boy and one affected girl). In the case we present, the diagnosis was made on the basis of two-dimensional ultrasound performed by physicians aware of the history; the quality of three-dimensional ultrasound imaging suggests that this technique might have contributed toward establishing a precise diagnosis in the absence of a positive family history. Besides, the global view provided by three-dimensional surface-rendering images made the parents more confident of the accuracy of the diagnosis. Although osteogenesis imperfecta congenita is generally considered as autosomal dominant, the case we report suggests that it may be inherited in a recessive autosomal fashion at least when associated with encephalocele. Three-dimensional ultrasound confirmed the conventional two-dimensional examination and was helpful in convincing the parents of the accuracy of the diagnosis.

[Results of prenatal management of fetuses with supraventricular tachycardia. A series of 66 cases]

OBJECTIVE

To describe the prenatal management and outcome of a series of 66 fetuses with supraventricular tachycardia (SVT).

MATERIAL AND METHODS

The perinatal data of 66 fetuses with SVT were retrospectively studied from January 1990 to December 2000. Junctional tachycardia was found in 50 fetuses and atrial flutter was found in 16 fetuses. Two groups were studied depending on the absence (n=40) or the presence of hydrops (n=26) at the time of the diagnosis. All fetuses but one were treated prenatally via the mother. Anti-arrhythmic drugs used were: digoxin, sotalol, flecainide or amiodarone.

RESULTS

Group of fetuses with no hydrops: digoxin was used in 32 cases and allowed 26 fetuses to be converted to sinus rhythm (80%). One intra uterine death (IUD) occurred in this group. Hydropic fetuses group: nine fetuses were converted to sinus rhythm using either flecainide (n=7) or amiodarone (n=2) as first line therapy, whilst digoxin alone or in association with sotalol failed to restore sinus rhythm in all cases. After first line therapy, SVT persisted in 10 fetuses. Nine fetuses received amiodarone alone or in association with digoxin as second line therapy, five of whom were converted to sinus rhythm. Among the 18 alive neonates treated by amiodarone in utero, three presented elevated thyroid stimulating hormone at day 3-4 and required thyroid hormonal substitution therapy for 2-6 months with normal outcome.

Three-dimensional ultrasonographic appearance of the fetal akinesia deformation sequence

OBJECTIVE

To present the appearance of the fetal akinesia deformation sequence by three-dimensional ultrasonography after four-dimensional ultrasonographic scanning.

METHODS

Three-dimensional surface-rendering images were used to show the fixed postural abnormalities of the fetal extremities and body. Four-dimensional ultrasonography was used to show that the postural abnormalities were fixed and to confirm the absence of fetal movements. These images were compared with the postmortem examination findings.

RESULTS

Three-dimensional ultrasonographic images of 3 cases of fetal akinesia deformation sequence are presented. Surface-rendering imaging and imaging in the skeletal mode were performed to show the postural abnormalities and the arthrogryposis.

CONCLUSIONS

Facilitated by polyhydramnios, three- and four-dimensional ultrasonography provided clear images of the fixed postural abnormalities, which were confirmed by postmortem examination. Although prenatal diagnosis can be easily made by conventional ultrasonography, three-dimensional ultrasonography might be used as a confirmatory approach. In addition, the quality of recent three-dimensional imaging might help prenatal counseling by providing images more readily understandable to the parents than those obtained by two-dimensional ultrasonography.

[CMV infection: when should medical termination of pregnancy be discussed?]

OBJECTIVES

To determine in which circumstances termination of pregnancy (TOP) could be proposed in case of CMV infection.

PATIENTS AND METHODS

An inquiry was conducted concerning the practice of doctors working in French foetal medicine units in case of CMV infection. The question asked was: "What is your attitude if confronted to a CMV seroconversion at 23 weeks of amenorrhoea with positive PCR at 28 WA, and normal MRI and ultrasound scan at third trimester?"

RESULTS

Thirty-five obstetricians answered. Forty-nine percent do not perform foetal blood sampling (FBS). Among them 1/17 would accept TOP. Fifty-one percent do perform FBS. In this group, 33% would accept TOP in case of negative FBS and 83% if FBS shows foetal infection.

DISCUSSION AND CONCLUSION

Techniques available for diagnosis and prognosis of foetal infections are based on PCR on amniotic fluid, ultrasound, MRI and FBS. To date correlation of those tests with foetal outcome has not been fully validated. TOP could therefore be an option in 2 circumstances: when signs of certain severe foetal disease with positive PCR and ultrasound abnormalities; on statistical arguments: if positive PCR, and normal ultrasound, the risk of handicap is approximately 10%, the severity of the handicap being impossible to predict. In this last hypothesis, it is tempting to use additional arguments such as FBS even if the interpretation of the results of this test has not been scientifically validated. Such cases with positive PCR and normal ultrasound in which inconsistent decisions are made are likely to be more frequent because of routine serologic screening policy.

Genotyping microsatellite DNA markers at putative disease loci in inbred/multiplex families with respiratory chain complex I deficiency allows rapid identification of a novel nonsense mutation (IVS1nt -1) in the NDUFS4 gene in Leigh syndrome

Complex I deficiency, the most common cause of mitochondrial disorders, accounts for a variety of clinical symptoms and its genetic heterogeneity makes identification of the disease genes particularly tedious. Indeed, most of the 43 complex I subunits are encoded by nuclear genes, only seven of them being mitochondrially encoded. In order to offer urgent prenatal diagnosis, we have studied an inbred/multiplex family with complex I deficiency by using microsatellite DNA markers flanking the putative disease loci. Microsatellite DNA markers have allowed us to exclude the NDUFS7, NDUFS8, NDUFV1 and NDUFS1 genes and to find homozygosity at the NDUFS4 locus. Direct sequencing has led to identification of a homozygous splice acceptor site mutation in intron 1 of the NDUFS4 gene (IVS1nt -1, G-->A); this was not found in chorion villi of the ongoing pregnancy. We suggest that genotyping microsatellite DNA markers at putative disease loci in inbred/multiplex families helps to identify the disease-causing mutation. More generally, we suggest giving consideration to a more systematic microsatellite analysis of putative disease loci for identification of disease genes in inbred/multiplex families affected with genetically heterogeneous conditions.

[CT pelvimetry: a new approach using multi detector CT and volume rendering]

The authors describe a new technique of CT pelvimetry, using multi detector CT. This protocol is able to provide an anatomic view of the bony pelvis as well as classical measurements for pelvimetry. The acquisition is made using low technical parameters allowing the radiation dose to remain similar to that of conventional CT. Helical acquisition with thin slices and interleaved reconstruction provides adequate material for Volume Rendering reconstruction. Presets of the software may give readily available images within seconds, saving time for the radiologist. Although this technique might be performed using single slice helical CT, multi detector CT makes it faster and more accurate as the acquisition time is shorter. Final images are more easily understood by obstetricians and midwives, leading to a better understanding of dystocias. This anatomical information is obviously superior to that of conventional CT. Because it is simple to perform, has no medical time cost for the radiologist if a Volume Rendering software is available, and does not require additional radiation, we believe that this technique should replace conventional CT or conventional pelvimetry.

Prenatal diagnosis of spinal muscular atrophy by genetic analysis of circulating fetal cells

Spinal muscular atrophy (SMA) has a prevalence of one in 6000 births and a one in 40 heterozygote frequency. We aimed to develop a routine test for non-invasive prenatal diagnosis. We tested blood with ISET (isolation by size of epithelial tumour or trophoblastic cells) in 12 pregnant women whose babies were at risk of SMA. Using genetic analysis of fetal cells, we identified SMA in all nine isolated from the three mothers carrying an affected child. There was no mutation in any of the 26 fetal cells isolated from the nine women with an unaffected child. Our results show that non-invasive detection of genetic diseases by the analysis of maternal blood is feasible.

Impaired mitochondrial pyruvate importation in a patient and a fetus at risk

The patient was the first child of healthy consanguineous parents. She presented at birth with hypotonia, mild facial dysmorphism, periventricular cysts, marked metabolic acidosis, hyperlactacidemia with normal lactate/pyruvate molar ratios, normoglycemia, and normal ammonia. Hyperlactacidemia was severe (5-14 mmol/l) and not corrected with bicarbonate, thiamine (10 mg/d), 2-chloropropionate (100 mg/kg/d) and a ketogenic diet. Pyruvate dehydrogenase (PDHC) activity was normal in lymphocytes and fibroblasts. Functional assays were performed in digitonin-permeabilized fibroblasts to measure oxidation rates from radiolabeled pyruvate and malate. The production of [14C]acetylcarnitine or [14C]citric cycle intermediates derived from [2-14C]pyruvate as well as the release of 14CO(2) from [1-14C]pyruvate was severely impaired, whereas decarboxylation of [U-14C]malate was normal. With increasing concentrations of [1-14C]pyruvate, the patient's fibroblasts behave like control fibroblasts incubated in the presence of alpha-cyano-4-hydroxycinnamate, a specific inhibitor of mitochondrial pyruvate uptake: a progressive increase in 14CO(2) production was observed, likely due to passive diffusion of [1-14C]pyruvate through the mitochondrial membranes. Our results are consistent with a defect of mitochondrial pyruvate transport in the patient. Mutational analysis was precluded as the cDNA sequence of the pyruvate carrier has not been identified as yet in any organism. An affected fetus was recognized in a subsequent dichorionic twin pregnancy using the coupled assay measuring [2-14C]pyruvate oxidation rates on digitonin-permeabilized trophoblasts. After selective feticide, the pregnancy was uncomplicated with delivery at 37w of a healthy female, who is currently 2-month old.

Feticide during second- and third-trimester termination of pregnancy: opinions of health care professionals

OBJECTIVE

To study the opinions of professionals on feticide being performed as the first step of late termination of pregnancy (TOP).

SETTING

Tertiary care obstetrical unit with policy of routine feticide in late TOP.

METHOD

Questionnaire survey.

RESULTS

101/109 professionals responded (23 midwives, 22 doctors, 24 nurses, 21 auxiliaries, 9 others). 90 had heard of feticide, 83 knew about how and 38 about when the procedure was done. When asked about what the goals of feticide were, 94 respondents quoted, 'preventing parents from facing neonatal agony', 73 'avoiding fetal pain', 85 'preventing labor ward staff from facing neonatal agony', and 60 'complying with legal rules'. 54 respondents thought feticide was beneficial to their patients or improved their own professional practice, and 71 declared the procedure was emotionally positive, yet stressful. 48 respondents declared lacking information on feticide. Respondents who had attended to feticide at least once (n = 59) knew more on feticide, and were more positive on the impact feticide had on their practice than those who had never attended a feticide (n = 42).

CONCLUSIONS

In a highly specialized center, professionals had positive opinions on feticide, expecting it would avoid fetal or neonatal agony and pain.

Fetal supraventricular tachycardia: a role for amiodarone as second-line therapy?

OBJECTIVE

The aim of this study was to evaluate the role of amiodarone for the prenatal treatment of hydropic fetuses with supraventricular tachycardia.

METHODS

A group of 26 hydropic fetuses with supraventricular tachycardia was studied retrospectively.

RESULTS

Twenty-five fetuses received transplacental treatment. The overall prenatal conversion rate was 60%. Nine fetuses were converted to sinus rhythm using either flecainide (n = 7) or amiodarone (n = 2) as first line therapy, whilst digoxin alone or in association with sotalol failed to restore sinus rhythm in all cases. After first-line therapy, supraventricular tachycardia persisted in 10 fetuses. Nine fetuses received amiodarone alone or in association with digoxin as second-line therapy, five of whom were converted to sinus rhythm. Among the 11 live neonates treated by amiodarone in utero, 2 (17%) presented an elevated thyroid stimulating hormone at day 3-4. These two infants received thyroid hormone substitution therapy and had a normal outcome.

CONCLUSION

When first-line therapy fails to restore sinus rhythm in hydropic fetuses with supraventricular tachycardia, amiodarone therapy should be considered as it allows a substantial number of fetuses to be converted prenatally.