Perinatal outcomes of fetoscopic selective laser photocoagulation for spontaneous twin-anemia polycythemia sequence

OBJECTIVES

Antenatal management of monochorionic pregnancies complicated by twin anemia polycythemia sequence (TAPS) remains sub-optimally defined. Our objective was to evaluate the safety and efficacy of fetoscopic selective laser photocoagulation with respect to fetal and neonatal survival.

METHODS

A case series is reported with patients referred to the Texas Children's Fetal Center for evaluation and management of suspected spontaneous TAPS without concomitant twin-to-twin syndrome from 2014 to 2023. All evaluations were performed by our team and patients with stage II-IV TAPS were offered expectant management, intrauterine transfusion, or laser therapy. Cases of post-laser TAPS were excluded from this study. Pregnancy and neonatal outcomes were obtained from electronic medical records.

RESULTS

During a 10-year time period, 18 patients presented to our center for the management of TAPS. Thirteen patients had stage II-IV TAPS (13/18, 72%) and elected to proceed with laser photocoagulation. All procedures were completed, and "solomonization" was performed for 12/13. Normalization of middle cerebral artery Dopplers in both fetuses was noted after all cases. There was one intrauterine fetal death of the 26 viable fetuses after laser treatment, which was complicated by selective growth restriction. Most patients (12/13) were delivered by Cesarean section at a mean gestational age of 29 ± 3 weeks. Subsequently, there was one ex-donor neonatal death in an infant who had prenatal hydrops. Overall, 30-day postnatal survival was 24/26 fetuses (92.3%).

CONCLUSIONS

In the setting of spontaneous TAPS, laser therapy is feasible and appears to be an effective approach with overall favorable perinatal outcomes.

The NICHD Fetal 3D Study: A Pregnancy Cohort Study of Fetal Body Composition and Volumes

There's a paucity of robust normal fractional limb and organ volume standards from a large and diverse ethnic population. The Fetal 3D Study was designed to develop research and clinical applications for fetal soft tissue and organ volume assessment. The NICHD Fetal Growth Studies (2009-2013) collected 2D and 3D fetal volumes. In the Fetal 3D Study (2015-2019), sonographers performed longitudinal 2D and 3D measurements for specific fetal anatomical structures in research ultrasounds of singletons and dichorionic twins. The primary aim was to establish standards for fetal body composition and organ volumes, overall and by maternal race/ethnicity, and determine whether these standards vary for twins versus singletons. We describe the study design, methods, and details about reviewer training. Basic characteristics of this cohort, with their corresponding distributions of fetal 3D measurements by anatomical structure, are summarized. This investigation is responsive to critical data gaps in understanding serial changes in fetal subcutaneous fat, lean body mass, and organ volume in association with pregnancy complications. In the future, this cohort can answer critical questions regarding the potential influence of maternal characteristics, lifestyle factors, nutrition, and biomarker and chemical data on longitudinal measures of fetal subcutaneous fat, lean body mass, and organ volumes.

Prenatal diagnosis and postnatal outcome of closed spinal dysraphism

OBJECTIVE

To evaluate the prenatal diagnosis of closed dysraphism (CD) and its correlation with postnatal findings and neonatal adverse outcomes.

METHODS

A retrospective cohort study including pregnancies diagsnosed with fetal CD by prenatal ultrasound (US) and magnetic resonance imaging (MRI) at a single tertiary center between September 2011 and July 2021.

RESULTS

CD was diagnosed prenatally and confirmed postnatally in 12 fetuses. The mean gestational age of prenatal imaging was 24.2 weeks, in 17% the head circumference was ≤fifth percentile and in 25% the cerebellar diameter was ≤fifth percentile. US findings included banana sign in 17%, and lemon sign in 33%. On MRI, posterior fossa anomalies were seen in 33% of cases, with hindbrain herniation below the foramen magnum in two cases. Mean clivus-supraocciput angle (CSA) was 74°. Additional anomalies outside the CNS were observed in 50%. Abnormal foot position was demonstrated prenatally in 17%. Neurogenic bladder was present in 90% of patients after birth.

CONCLUSION

Arnold Chiari II malformation and impaired motor function can be present on prenatal imaging of fetuses with CD and may be associated with a specific type of CD. Prenatal distinction of CD can be challenging. Associated extra CNS anomalies are frequent and the rate of neurogenic urinary tract dysfunction is high.

Fetoscopic Endoluminal Tracheal Occlusion for Severe, Left-Sided Congenital Diaphragmatic Hernia: The North American Fetal Therapy Network Fetoscopic Endoluminal Tracheal Occlusion Consortium Experience

OBJECTIVE

To report the outcomes of fetoscopic endoluminal tracheal occlusion in a multicenter North American cohort of patients with isolated, left-sided congenital diaphragmatic hernia (CDH) and to compare neonatal mortality and morbidity in patients with severe left-sided congenital diaphragmatic hernia who underwent fetoscopic endoluminal tracheal occlusion with those expectantly managed.

METHODS

We analyzed data from 10 centers in the NAFTNet (North American Fetal Therapy Network) FETO (Fetoscopic Endoluminal Tracheal Occlusion) Consortium registry, collected between November 1, 2008, and December 31, 2020. In addition to reporting procedure-related surgical outcomes of fetoscopic endoluminal tracheal occlusion, we performed a comparative analysis of fetoscopic endoluminal tracheal occlusion compared with contemporaneous expectantly managed patients.

RESULTS

Fetoscopic endoluminal tracheal occlusion was successfully performed in 87 of 89 patients (97.8%). Six-month survival in patients with severe left-sided congenital diaphragmatic hernia did not differ significantly between patients who underwent fetoscopic endoluminal tracheal occlusion and those managed expectantly (69.8% vs 58.1%, P =.30). Patients who underwent fetoscopic endoluminal tracheal occlusion had higher rates of preterm prelabor rupture of membranes (54.0% vs 14.3%, P <.001), earlier gestational age at delivery (median 35.0 weeks vs 38.3 weeks, P <.001), and lower birth weights (mean 2,487 g vs 2,857 g, P =.001). On subanalysis, in patients for whom all recorded observed-to-expected lung/head ratio measurements were below 25%, patients with fetoscopic endoluminal tracheal occlusion required fewer days of extracorporeal membrane oxygenation (ECMO) (median 9.0 days vs 17.0 days, P =.014).

CONCLUSION

In this cohort, fetoscopic endoluminal tracheal occlusion was successfully implemented across several North American fetal therapy centers. Although survival was similar among patients undergoing fetoscopic endoluminal tracheal occlusion and those expectantly managed, fetoscopic endoluminal tracheal occlusion in North American centers may reduce morbidity, as suggested by fewer days of ECMO in those patients with persistently reduced lung volumes (observed-to-expected lung/head ratio below 25%).

Performance Characteristics of Sepsis Screening Tools During Antepartum and Postpartum Admissions

OBJECTIVE

To evaluate the performance characteristics of existing screening tools for the prediction of sepsis during antepartum and postpartum readmissions.

METHODS

This was a case-control study using electronic health record data obtained between 2016 and 2021 from 67 hospitals for antepartum sepsis admissions and 71 hospitals for postpartum readmissions up to 42 days. Patients in the sepsis case group were matched in a 1:4 ratio to a comparison cohort of patients without sepsis admitted antepartum or postpartum. The following screening criteria were evaluated: the CMQCC (California Maternal Quality Care Collaborative) initial sepsis screen, the non-pregnancy-adjusted SIRS (Systemic Inflammatory Response Syndrome), the MEWC (Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System) obstetric SIRS, and the MEWT (Maternal Early Warning Trigger Tool). Time periods were divided into early pregnancy (less than 20 weeks of gestation), more than 20 weeks of gestation, early postpartum (less than 3 days postpartum), and late postpartum through 42 days. False-positive screening rates, C-statistics, sensitivity, and specificity were reported for each overall screening tool and each individual criterion.

RESULTS

We identified 525 patients with sepsis during an antepartum hospitalization and 728 patients with sepsis during a postpartum readmission. For early pregnancy and more than 3 days postpartum, non-pregnancy-adjusted SIRS had the highest C-statistics (0.78 and 0.83, respectively). For more than 20 weeks of gestation and less than 3 days postpartum, the pregnancy-adjusted sepsis screening tools (CMQCC and UKOSS) had the highest C-statistics (0.87-0.94). The MEWC maintained the highest sensitivity rates during all time periods (81.9-94.4%) but also had the highest false-positive rates (30.4-63.9%). The pregnancy-adjusted sepsis screening tools (CMQCC, UKOSS) had the lowest false-positive rates in all time periods (3.9-10.1%). All tools had the lowest C-statistics in the periods of less than 20 weeks of gestation and more than 3 days postpartum.

CONCLUSION

For admissions early in pregnancy and more than 3 days postpartum, non-pregnancy-adjusted sepsis screening tools performed better than pregnancy-adjusted tools. From 20 weeks of gestation through up to 3 days postpartum, using a pregnancy-adjusted sepsis screening tool increased sensitivity and minimized false-positive rates. The overall false-positive rate remained high.

Performance Characteristics of Sepsis Screening Tools During Delivery Admissions

OBJECTIVE

To evaluate the screening performance characteristics of existing tools for the diagnosis of sepsis during delivery admissions.

METHODS

This was a case-control study using electronic health record data, including vital signs and laboratory results, for all delivery admissions of patients with sepsis from 59 nationally distributed hospitals. Patients with sepsis were matched by gestational age at delivery in a 1:4 ratio with patients without sepsis to create a comparison group. Patients with chorioamnionitis and sepsis were compared with a complete cohort of patients with chorioamnionitis without sepsis. Multiple screening criteria for sepsis were evaluated: the CMQCC (California Maternal Quality Care Collaborative), SIRS (Systemic Inflammatory Response Syndrome), the MEWC (the Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System), and the MEWT (Maternal Early Warning Trigger Tool). Sensitivity, false-positive rates, and C-statistics were reported for each screening tool. Analyses were stratified into cohort 1, which excluded patients with chorioamnionitis-endometritis, and cohort 2, which included those patients.

RESULTS

Delivery admissions at 59 hospitals were extracted for patients with sepsis. Cohort 1 comprised 647 patients with sepsis, including 228 with end-organ injury, matched with a control group of 2,588 patients without sepsis. Cohort 2 comprised 14,591 patients with chorioamnionitis-endometritis, of whom 1,049 had sepsis and 238 had end-organ injury. In cohort 1, the CMQCC and the UKOSS pregnancy-adjusted criteria had the lowest false-positive rates (6.9% and 9.6%, respectively) and the highest C-statistics (0.92 and 0.91, respectively). Although other screening criteria, such as SIRS and the MEWC, had similar sensitivities, it was at the cost of much higher false-positive rates (21.3% and 38.3%, respectively). In cohort 2, including all patients with chorioamnionitis-endometritis, the highest C-statistics were again for the CMQCC (0.67) and UKOSS (0.64). All screening tools had high false-positive rates, but the false-positive rates for the CMQCC and UKOSS were substantially lower than those for SIRS and the MEWC.

CONCLUSION

During delivery admissions, the CMQCC and UKOSS pregnancy-adjusted screening criteria have the lowest false-positive results while maintaining greater than 90% sensitivity rates. Performance of all screening tools was degraded in the setting of chorioamnionitis-endometritis.

Outcomes of fetal lower urinary tract obstruction based on timing of oligohydramnios onset

OBJECTIVE

Fetal Lower Urinary Tract Obstruction (LUTO) is associated with oligohydramnios and significant fetal morbidity, resulting in poor lung development and perinatal death. However, oligohydramnios may develop at different gestational periods, and the impact of timing on fetal outcomes remains unknown. Our objective was to characterize the impact onset of oligohydramnios had on prenatal outcomes.

METHODS

This study is a retrospective cohort study of all patients with a prenatal diagnosis of LUTO at our tertiary referral center from 2014 to 2023. All patients underwent detailed ultrasonography and interdisciplinary counseling and were subsequently delivered at our institution. Data were obtained from electronic medical records and complete extraction was required for final inclusion.

RESULTS

During the study time period, 93 patients met inclusion criteria of which 68 (73.1%) developed oligohydramnios during their pregnancy. 63 (93%) of these pregnancies resulted in livebirths with 28 (41.1%) perinatal deaths. Onset of oligohydramnios was earlier in pregnancies with perinatal death (23 vs. 28 weeks, p = 0.004) and associated with pulmonary hypoplasia.

CONCLUSIONS

Our data show the impact of oligohydramnios timing in pregnancy on pulmonary hypoplasia and ultimately perinatal death. This allows for detailed patient counseling on the impact oligohydramnios may have on pregnancies by the gestational age of onset.

Maternal and perinatal health among pregnant patients in the context of a migratory crisis

OBJECTIVE

To compare maternal and perinatal outcomes of migrant Venezuelan women with local pregnant patients in a Colombian institution in the context of a migratory crisis.

STUDY DESIGN

This cross-sectional study included 11 304 deliveries from the Clínica de Maternidad Rafael Calvo in Cartagena de Indias, Colombia, a tertiary referral center on the north coast of Colombia. Data on maternal demographics and perinatal outcomes were obtained by chart review.

RESULTS

In total, 595 patients were identified as Venezuelan migrants, and their perinatal outcomes were compared against those of 10 709 local pregnant patients. Despite similar baseline maternal conditions in both groups, poorer prenatal follow-up care (3 [1-5] vs. 5 [4-7] visits; P < 0.001) and severe complications were more common in Venezuelan migrant pregnant patients and their children. In addition, maternal hypertension was significantly more common in migrants (11.4% [68/595] vs. 8.3% [887/10709]; P = 0.009). Furthermore, in the group of pregnant migrant patients, the rates of severe maternal morbidity (13.4% [80/575] vs. 9.45%, [1013/10709]; P = 0.002), neonatal respiratory distress syndrome (22/595 [3.7%] vs. 237/10709 [2.23%]; P = 0.03), and perinatal mortality (11/586 [1.88%] vs. 67/10651 [0.63%]; P = 0.003) were significantly higher than in the local pregnant population.

CONCLUSION

Forced migration during pregnancy may be associated with poorer prenatal care, which may predispose women and their newborns to more frequent adverse maternal and perinatal outcomes.

Fetal Anemia: Determinants and Perinatal Outcomes according to the Method of Intrauterine Blood Transfusion

INTRODUCTION

Fetal anemia from hemolytic disease treated by intrauterine transfusion (IUT) can be performed by intraperitoneal, intracardiac, and intravascular transfusion (IVT). Objective of our study was to compare different transfusion techniques.

METHODS

Retrospective review of IUT secondary to red cell alloimmunization was conducted at eight international centers from 2012 to 2020. Severe anemia suspected if middle cerebral artery peaks systolic velocity ≥1.5 multiples of the median. Demographic, delivery, and postnatal variables were analyzed.

RESULTS

Total of 344 procedures, 325 IVT and 19 other techniques (non-IVT) included. No difference in demographics, history of stillbirth (20.5 vs. 15.8%, p = 0.7), prior pregnancy IUT (25.6 vs. 31.6%, p = 0.5) or neonatal transfusion (36.1 vs. 43.8%, p = 0.5). At first IUT, non-IVT had higher hydrops (42.1% vs. 20.4%, p = 0.03), lower starting hematocrit (13.3% [±6] vs. 17.7% [±8.2], p = 0.04), and trend toward lower gestational age (24.6 [20.1-27] vs. 26.4 [23.2-29.6] weeks, p = 0.08). No difference in birthweight, neonatal phototherapy, exchange, or simple transfusion was observed.

CONCLUSION

This is one of the largest studies comparing techniques to treat fetal anemia. IVT was most performed, other techniques were more likely performed in hydrops, and lower starting hematocrit was seen. Neither technique affected outcomes. This study may suggest that physician's experience may be the strongest contributor of outcomes.

Systematic classification and comparison of maternal and obstetrical complications following 2 different methods of fetal surgery for the repair of open neural tube defects

BACKGROUND

In utero repair of open neural tube defects using an open hysterotomy approach (hereafter referred to as "open") has been shown to reduce the need for ventriculoperitoneal shunting and to improve motor outcomes for affected infants. Laparotomy-assisted fetoscopic repair (hereafter referred to as "hybrid") is an alternative approach that may confer similar neurologic benefits while reducing the incidence of hysterotomy-related complications.

OBJECTIVE

This study aimed to analyze procedure-related maternal and fetal complications of in utero repair using the Clavien-Dindo classification, and to compare the outcomes of the hybrid and open approaches.

STUDY DESIGN

This was a retrospective cohort study conducted in a single center between September 2011 and July 2021. All patients who met the Management of Myelomeningocele Study criteria and who underwent either hybrid or open fetal surgery were included. Maternal complications were classified using a unique adaptation of the Clavien-Dindo scoring system, allowing the development of a comprehensive complication index score specific to fetal surgery. Primary fetal outcome was defined as gestational age at delivery and summarized according to the World Health Organization definitions of preterm delivery.

RESULTS

There were 146 fetuses with open neural tube defects who were eligible for, and underwent, in utero repair during the study period. Of these, 102 underwent hybrid fetoscopic repair and 44 underwent open hysterotomy repair. Gestational age at the time of surgery was higher in the hybrid group than in the open group (25.1 vs 24.8 weeks; P=.004). Maternal body mass index was lower in the hybrid than in the open group (25.4 vs 27.1 kg/m2; P=.02). The duration of hybrid fetoscopic surgery was significantly longer in the hybrid than in the open group (250 vs 164 minutes; P<.001). There was a significantly lower Clavien-Dindo Grade III complication rate (4.9% vs 43.2%; P<.001) and a significantly lower overall comprehensive maternal complication index (8.7 vs 22.6; P=.021) in the hybrid group than in the open group. Gestational age at delivery was significantly higher in the hybrid group than in the open group (38.1 vs 35.8 weeks; P<.001), and this finding persisted when gestational age at delivery was analyzed using the World Health Organization definitions of preterm delivery.

CONCLUSION

Use of our adaptation of the standardized Clavien-Dindo classification to assess the maternal complications associated with in utero open neural tube defect repair provides a new method for objectively assessing different fetal surgical approaches. It also provides a much-needed standardized tool to allow objective comparisons between methods, which can be used when counseling patients. The hybrid open neural tube defect repair was associated with lower rates of maternal adverse events , and later gestational age at delivery compared with the open approach.

Impact of Transfer of Maternal Care for Fetal Anomalies on Maternal Depression and Anxiety Screening: A Prospective Cohort at a Tertiary Care Center

INTRODUCTION

Perinatal depression and anxiety are major causes of maternal morbidity, and are more common in high-risk pregnancies compared to low-risk pregnancies. This study used validated screening tools to assess the prevalence of depression and anxiety symptoms in pregnant patients who transferred their obstetric care to a specialized fetal center for fetal anomaly.

METHODS

This is a prospective cohort of patients with a fetal anomaly prompting transfer of obstetric care to Texas Children's Hospital Fetal Center between January 2021 and February 2022. The primary outcome was a self-assessed Edinburgh Postnatal Depression Scale score of 13 or higher, either antepartum or postpartum ("ever-positive EPDS"). Secondary outcomes included self-assessed Perinatal Anxiety Screening Scale (PASS) scores of 21 or higher ("ever-positive PASS"), obstetric outcomes, and neonatal outcomes. A frequentist analysis was performed.

RESULTS

Of 149 women who transferred to Texas Children's Hospital during the study period, 94 enrolled in this study. Twenty-six percent of women had an ever-positive EPDS; 20% of patients had an ever-positive PASS. Patients were more likely to have an ever-positive EPDS if they were single (46% compared to 20%, p = 0.025). Women who had an ever-positive EPDS were more likely to be referred to psychiatry (46% compared to 14%, p = 0.004) and psychotherapy (29% compared to 1%, p < 0.001). Surprisingly, patients were more likely to have an ever-positive PASS if they reported good social support (p = 0.03). Antepartum EPDS and PASS scores had no relationship with postpartum EPDS scores.

CONCLUSION

Women who transfer care to a tertiary setting have positive EPDS scores at double the rate of the general population, but tend to experience this either antepartum or postpartum (not both). Fetal centers should be prepared to screen for mental health symptoms before and after delivery and provide appropriate referral or treatment.

Laser therapy versus expectant management for selective fetal growth restriction in monochorionic twins: A systematic review

Selective fetal growth restriction (sFGR) complicates 10%-26% of monochorionic twins. Treatment options include cord coagulation, expectant management, and fetoscopic laser photocoagulation. This review compared laser to expectant management for situations when cord coagulation is not an option. The MEDLINE, EMBASE, and Cochrane databases were queried for studies that compared laser to expectant management for sFGR. GRADE was used to assess quality prior to meta-analysis. A random-effects model was used to generate relative risks. Six studies were included, encompassing 299 pregnancies. One study was randomized and the remainder were retrospective cohorts. Laser is associated with more fetal deaths of the FGR twin compared to expectant management (risk ratio [RR] 2.5, 95% confidence interval [CI] 1.43-4.37, p = 0.001, I2 = 48%). Neonatal deaths and gestational age at delivery did not differ. Laser was associated with decreased abnormal neuroimaging in the AGA twin (RR 0.25, 95% CI 0.07-0.97, p = 0.05). Neurodevelopmental outcomes did not differ, although these data are limited. Laser causes more fetal deaths of the FGR twin without altering gestational age at delivery or rates of neonatal death. The literature is heterogeneous and the level of bias is high. Randomized trials that address laser for type II sFGR are needed and should include long-term neurological outcomes.

Characterization of suboptimal responses to fetoscopic endoluminal tracheal occlusion in congenital diaphragmatic hernia

INTRODUCTION

To characterize the changes in fetal lung volume following endoluminal tracheal occlusion (FETO) that are associated with infant survival and need for extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH).

METHODS

Fetuses with CDH who underwent FETO at a single institution were included. CDH cases were reclassified by MRI metrics, [observed-to-expected total lung volume (O/E TLV) and percent liver herniation]. The percent changes of MRI metrics after FETO were calculated. ROC-derived cutoffs of these changes were derived to predict infant survival to discharge. Regression analyses were done to determine the association between these cutoffs with infant survival and ECMO need, adjusted for site of CDH, gestational age at delivery, fetal sex, and CDH severity.

RESULTS

Thirty CDH cases were included. ROC analysis demonstrated that post-FETO increases in O/E TLV had an area under the curve of 0.74 (p=0.035) for the prediction of survival to hospital discharge; a cutoff of less than 10% was selected. Fetuses with a <10% post-FETO increase in O/E TLV had lower survival to hospital discharge [44.8% vs. 91.7%; p=0.018] and higher ECMO use [61.1% vs. 16.7%; p=0.026] compared to those with an O/E TLV increase ≥10%. Similar results were observed when the analyses were restricted to left-sided CDH cases. A post-FETO <10% increase in O/E TLV was independently associated with lower survival at hospital discharge (aOR: 0.073, 95% CI: 0.008 - 0.689; p=0.022) and at 12 months of age (aOR: 0.091, 95% CI: 0.01 - 0.825; p=0.036) as well as with higher ECMO use (aOR: 7.88, 95% CI: 1.31 - 47.04; p=0.024).

DISCUSSION/CONCLUSION

Fetuses with less than 10% increase in in O/E TLV following the FETO procedure are at increased risk for requiring ECMO and for death in the postnatal period when adjusted for gestational age at delivery, CDH severity, and other confounders.

Solomon versus selective fetoscopic laser photocoagulation for twin-twin transfusion syndrome: A systematic review and meta-analysis

This meta-analysis aims to compare the perinatal outcome of twin-twin transfusion syndrome (TTTS) pregnancies undergoing selective versus vascular equator (Solomon) fetoscopic laser photocoagulation (FLP). We performed a systematic search in PubMed and Web of Science from inception up to 25 July 2021. Studies comparing the Solomon and selective techniques of FLP for treatment of TTTS pregnancies were eligible. Random-effects or fixed-effect models were used to pool standardized mean differences (SMD) and log odds ratio. Seven studies with a total of 1664 TTTS pregnancies (n = 671 undergoing Solomon and n = 993 selective techniques) were included. As compared to the selective FLP, Solomon was associated with a lower risk of recurrent TTTS compared to the selective technique (Log odds ratio [OR]: -1.167; 95% credible interval [CrI]: -2.01, -0.33; p = 0.021; I² : 67%). In addition, Solomon was significantly associated with a higher risk of placental abruption than the selective technique (Log [OR]: 1.44; 95% CrI: 0.45, 2.47; p = 0.012; I² : 0.0%). Furthermore, a trend for the higher risk of preterm premature rupture of membranes was observed among those undergoing Solomon (Log [OR]: 0.581; 95% CrI: -0.43, 1.49; p = 0.131; I² : 17%). As compared to selective FLP, the Solomon technique for TTTS pregnancies is associated with a significantly lower recurrence of TTTS; however, it significantly increases the risk of placental abruption.

Fetoscopic laser surgery for twin-to-twin transfusion syndrome in DCTA triplets compared to MCDA twins: collaborative study and literature review

OBJECTIVE

To compare the outcomes of dichorionic triamniotic (DCTA) triplets with that of monochorionic diamniotic (MCDA) twin gestations undergoing fetoscopic laser surgery (FLS) for treatment of twin-to-twin transfusion syndrome (TTTS).

METHODS

Retrospective cohort study of prospectively collected data of consecutive DCTA triplet and MCDA twin pregnancies with TTTS that underwent FLS at two fetal treatment centers between 2012 and 2020. Preoperative, operative and, postoperative variables were collected. Perinatal outcomes were investigated. Primary outcome was survival to birth and to neonatal period. Secondary outcomes were gestational age (GA) at birth and procedure-to-delivery interval. Literature review was conducted in which PubMed, Web of Science, and Scopus were searched from inception to September, 2020.

RESULTS

Twenty four sets of DCTA triplets were compared to MCDA twins during the study period. There were no significant differences in survival (no survivor, single, or double survivors) to birth and to the neonatal period of the MC twin pairs of the DCTA triplets vs MCDA twins. Median GA at delivery was approximately three weeks earlier in DCTA triplets compared to MCDA twins (28.4 weeks vs 31.4 weeks, p = .035, respectively). Rates of preterm birth (PTB) less than 32 and less than 28 weeks were significantly higher in DCTA triplets compared to twins (<32 weeks: 70.8% vs 51.1%, p = .037, respectively, and <28 weeks: 37.5% vs 20.8%, p = .033, respectively).

CONCLUSION

Perinatal survival including fetal and neonatal are comparable between DCTA triplets and MCDA twins. However, this might have resulted from the small sample size of the DCTA triplets. GA at delivery is earlier in triplets, which could be due to the nature of triplet gestation rather than to the laser procedure itself.

Co-twin survival after selective fetal reduction in complicated multiple gestations: A systematic review and meta-analysis of survival rate according to indication for intervention

OBJECTIVE

Determine the impact of indication for selective reduction (SR) on co-twin survival in monochorionic gestations undergoing radiofrequency ablation (RFA) or bipolar cord coagulation (BCC).

METHODS

PubMed and Web of Science were systematically searched from inception of databases to April 2021. Frequency of indications was compared between post-intervention co-twin survival and demise groups undergoing SR. Random-effect model was used to pool mean differences or odds ratios (OR) and corresponding 95% confidence intervals (CIs). Heterogeneity was assessed using the I² value.

RESULTS

Of 1060 studies assessed for eligibility, nine studies met criteria. A total of 666 pregnancies underwent RFA (n = 483 co-twin survival) and 235 pregnancies underwent BCC (n = 188 co-twin survival). Twin twin transfusion syndrome (TTTS), as an indication for RFA, was associated with decreased co-twin survival (OR 0.61, 95% CI 0.41, 0.90, P 0.01, I² 0.0%). Other indications for RFA were not associated with significant difference in co-twin survival. With BCC, none of the indications were found to significantly influence the co-twin survival following intervention.

CONCLUSION

RFA was found to have lower co-twin survival when performed for TTTS. No other indications was associated with differences in co-twin survival. BCC was not associated with any differences in co-twin survival based on indication.

Selective reduction in complicated monochorionic pregnancies: a systematic review and meta-analysis of different techniques

OBJECTIVE

This systematic review and meta-analysis aimed to compare the perinatal outcomes of complicated monochorionic pregnancies after selective reduction by radiofrequency ablation, bipolar cord coagulation, and interstitial laser.

DATA SOURCES

We searched PubMed, Scopus, and Web of Science, from the inception of the database up to April 26, 2021.

STUDY ELIGIBILITY CRITERIA

Studies comparing at least 2 selective reduction techniques among complicated monochorionic pregnancies and presenting data on perinatal outcomes, including gestational age at procedure, gestational age at delivery, procedure to delivery interval, preterm premature rupture of membranes, preterm birth, survival rate, and birthweight, were eligible.

METHODS

The random-effects model was used to pool the mean differences or odds ratios and corresponding 95% confidence intervals. Heterogeneity was assessed using the I² value.

RESULTS

A total of 10 studies with 734 cases of fetal reduction met the inclusion criteria, of which 9 studies with 674 fetuses were eligible for quantitative synthesis. In 8 studies that compared radiofrequency ablation with bipolar cord coagulation, radiofrequency ablation was associated with increased procedure to delivery interval (days) (mean difference, 13.42; 95% confidence interval, 1.90-24.94; P=.02; I²=0.0%), decreased preterm birth (odds ratio, 0.50; 95% confidence interval, 0.29-0.85; P=.01; I²=3.0%), and decreased preterm premature rupture of membranes (odds ratio, 0.45; 95% confidence interval, 0.27-0.73; P=.001; I²=0.0%). Radiofrequency ablation and bipolar cord coagulation had comparable survival rates (odds ratio, 0.85; 95% confidence interval, 0.54-1.35; P=.49; I²=0.0%). In 3 studies that compared radiofrequency ablation with interstitial laser, there was no significant difference in gestational age at delivery (P=.07) or survival (P=.15). In 3 studies that compared bipolar cord coagulation with interstitial laser, bipolar cord coagulation was associated with a higher survival rate (odds ratio, 3.21; 95% confidence interval, 1.13-9.10; P=.03; I²=0.0%), but the gestational age at delivery was comparable between groups (P=.16).

CONCLUSION

This study demonstrated that radiofrequency ablation has a greater procedure to delivery interval and decreased preterm premature rupture of membranes and preterm birth than bipolar cord coagulation. Although there was no difference in gestational age at delivery for either bipolar cord coagulation, radiofrequency ablation, or interstitial laser, survival was higher with bipolar cord coagulation than with interstitial laser.

Gestational age and Quintero staging as predictors of single fetal demise in twin-twin transfusion syndrome after fetoscopic laser photocoagulation: a systematic review and meta-analysis

BACKGROUND

Single fetal demise after intervention for twin-twin transfusion syndrome is a relatively common complication and is often devastating for the patients.

OBJECTIVE

This meta-analysis aimed to evaluate the risk of single fetal demise based on gestational age and Quintero staging at the time of interventions in twin-to-twin transfusion syndrome after fetoscopic laser photocoagulation.

STUDY DESIGN

Systematic search was performed in PubMed, Web of Science, and Scopus from inception to August 2021. The primary outcome was to compare the incidence of fetal demise between low (I and II) and high (III and IV) twin-to-twin transfusion syndrome Quintero stages. The rate of donor and recipient fetal demise in each stage was compared with that in stage I. Gestational age at fetoscopic laser photocoagulation was compared between surviving fetuses and fetuses that died.

RESULTS

A total of 10 studies (4031 fetuses with twin-to-twin transfusion syndrome) were included in this review. Donor demise was associated with high Quintero stages compared with surviving donors (odds ratio, 2.42; 95% confidence interval, 1.78–3.29; P<.001; I², 0%). Recipient fetal demise had a trend for higher Quintero stage compared with surviving recipients, but the analysis did not achieve statistical significance. Pregnancies with donor demise had lower gestational at the time of fetoscopic laser photocoagulation (mean difference, −0.56; 95% confidence interval, –0.93 to –0.18; P=.003; I², 36%), whereas pregnancies complicated by recipient demise had similar gestational at time of fetoscopic laser photocoagulation compared with those without demise.

CONCLUSION

Demise of the donor fetus was significantly increased after fetoscopic laser photocoagulation for higher stages compared with lower ones. Lower gestational age at the time of fetoscopic laser photocoagulation was associated with an increased risk of single fetal demise in twin-to-twin transfusion syndrome. This was attributed to increased donor demise but not recipient death.

Fetal reduction of triplet pregnancies to twins vs singletons: a meta-analysis of survival and pregnancy outcome

OBJECTIVE

This systematic review and meta-analysis aimed to compare the fetal survival rate and perinatal outcomes of triplet pregnancies after selective reduction to twin pregnancies vs singleton pregnancies.

DATA SOURCES

PubMed, Web of Science, Scopus, and Embase were systematically searched from the inception of the databases to January 16, 2022.

STUDY ELIGIBILITY CRITERIA

Studies comparing the survival and perinatal outcomes between reduction to twin pregnancies and reduction to singleton pregnancies were included. The primary outcomes were fetal survival, defined as a live birth at >24 weeks of gestation. The secondary outcomes were gestational age at birth, preterm birth at <32 and <34 weeks of gestation, early pregnancy loss (<24 weeks of gestation), low birthweight, and rate of neonatal demise (up to 28 days after birth).

METHODS

The random-effect model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. To provide a range of expected effects if a new study was conducted, 95% prediction intervals were calculated for outcomes presented in >3 studies.

RESULTS

Of note, 10 studies with 2543 triplet pregnancies undergoing fetal reduction, of which 2035 reduced to twin pregnancies and 508 reduced to singleton pregnancies, met the inclusion criteria. Reduction to twin pregnancies had a lower rate of fetal survival (odds ratio, 0.61; 95% confidence interval, 0.40-0.92; P=.02; 95% prediction interval, 0.36-1.03) and comparable rates of early pregnancy loss (odds ratio, 0.89; 95% confidence interval, 0.58-1.38; P=.61; 95% prediction interval, 0.54-1.48) and neonatal demise (odds ratio, 0.57; 95% confidence interval, 0.09-3.50; P=.55) than reduction to singleton pregnancies. Reduction to twin pregnancies had a significantly lower gestation age at birth (weeks) (mean difference, -2.20; 95% confidence interval, -2.80 to -1.61; P<.001; 95% prediction interval, -4.27 to -0.14) than reduction to singleton pregnancies. Furthermore, reduction to twin pregnancies was associated with lower birthweight and greater risk of preterm birth at <32 and <34 weeks of gestation.

CONCLUSION

Triplet pregnancies reduced to twin pregnancies had a lower fetal survival rate of all remaining fetuses, lower gestational age at birth, higher risk of preterm birth, and lower birthweight than triplet pregnancies reduced to singleton pregnancies; reduction to twin pregnancies vs reduction to singleton pregnancies showed no substantial difference for the rates of early pregnancy loss and neonatal death.

Experience of 300 cases of prenatal fetoscopic open spina bifida repair: report of the International Fetoscopic Neural Tube Defect Repair Consortium

BACKGROUND

The multicenter randomized controlled trial Management of Myelomeningocele Study demonstrated that prenatal repair of open spina bifida by hysterotomy, compared with postnatal repair, decreases the need for ventriculoperitoneal shunting and increases the chances of independent ambulation. However, the hysterotomy approach is associated with risks that are inherent to the uterine incision. Fetal surgeons from around the world embarked on fetoscopic open spina bifida repair aiming to reduce maternal and fetal/neonatal risks while preserving the neurologic benefits of in utero surgery to the child.

OBJECTIVE

This study aimed to report the main obstetrical, perinatal, and neurosurgical outcomes in the first 12 months of life of children undergoing prenatal fetoscopic repair of open spina bifida included in an international registry and to compare these with the results reported in the Management of Myelomeningocele Study and in a subsequent large cohort of patients who received an open fetal surgery repair.

STUDY DESIGN

All known centers performing fetoscopic spina bifida repair were contacted and invited to participate in a Fetoscopic Myelomeningocele Repair Consortium and enroll their patients in a registry. Patient data entered into this fetoscopic registry were analyzed for this report. Fisher exact test was performed for comparison of categorical variables in the registry with both the Management of Myelomeningocele Study and a post-Management of Myelomeningocele Study cohort. Binary logistic regression analyses were used to assess the registry data for predictors of preterm birth at <30 weeks' gestation, preterm premature rupture of membranes, and need for postnatal cerebrospinal fluid diversion in the fetoscopic registry.

RESULTS

There were 300 patients in the fetoscopic registry, 78 in the Management of Myelomeningocele Study, and 100 in the post-Management of Myelomeningocele Study cohort. The 3 data sets showed similar anatomic levels of the spinal lesion, mean gestational age at delivery, distribution of motor function compared with upper anatomic level of the lesion in the neonates, and perinatal death. In the Management of Myelomeningocele Study (26.16±1.6 weeks) and post-Management of Myelomeningocele Study cohort (23.3 [20.2-25.6] weeks), compared with the fetoscopic registry group (23.6±1.4 weeks), the gestational age at surgery was lower (comparing fetoscopic repair group with the Management of Myelomeningocele Study; P<.01). After open fetal surgery, all patients were delivered by cesarean delivery, whereas in the fetoscopic registry approximately one-third were delivered vaginally (P<.01). At cesarean delivery, areas of dehiscence or thinning in the scar were observed in 34% of cases in the Management of Myelomeningocele Study, in 49% in the post-Management of Myelomeningocele Study cohort, and in 0% in the fetoscopic registry (P<.01 for both comparisons). At 12 months of age, there was no significant difference in the number of patients requiring treatment for hydrocephalus between those in the fetoscopic registry and the Management of Myelomeningocele Study.

CONCLUSION

Prenatal and postnatal outcomes up to 12 months of age after prenatal fetoscopic and open fetal surgery repair of open spina bifida are similar. Fetoscopic repair allows for having a vaginal delivery and eliminates the risk of uterine scar dehiscence, therefore protecting subsequent pregnancies of unnecessary maternal and fetal risks.

Intertwin differences in umbilical artery pulsatility index are associated with infant survival in twin-to-twin transfusion syndrome

OBJECTIVES

To evaluate the association of intertwin differences in umbilical artery pulsatility index (DUAPI) and infant survival in twin-to-twin transfusion syndrome (TTTS).

METHODS

Absolute DUAPI was calculated prior to laser surgery. Receiver-operating characteristics (ROC) curve analysis provided an intertwin DUAPI cutoff of 0.4 for the prediction of double twin survival to 30 days of life. Infant survival was compared between women with an intertwin DUAPI <0.4 and ≥0.4 in the whole cohort, in TTTS cases with Quintero stages I/II and in those with Quintero stages III/IV. Regression analyses were performed to evaluate the association of intertwin DUAPI <0.4 and infant survival adjusted for confounders.

RESULTS

In total, 349 TTTS cases were included. Double twin survival to 30 days was observed in 67% (234/349) of cases. Significant differences in double twin survival was seen between intertwin DUAPI groups in the whole cohort (76.8 vs. 52.2%; p<0.001), in women with TTTS Quintero stage I or II (77.8 vs. 58.5%; p=0.015) as well as in women with TTTS Quintero stage III or IV (75 vs. 49.5%; p=0.001). Intertwin DUAPI <0.4 conferred a threefold increased chance for double twin survival.

CONCLUSIONS

Small intertwin DUAPI is associated with increased double infant survival in early and advanced TTTS stages.

Efficacy of long-term indomethacin therapy in prolonging pregnancy after fetoscopic laser surgery for twin-to-twin transfusion syndrome: a collaborative cohort study

OBJECTIVE

To evaluate the efficacy of long-term indomethacin therapy (LIT) in prolonging pregnancy and reducing spontaneous preterm birth (PTB) in patients undergoing fetoscopic laser surgery (FLS) for the management of twin-to-twin transfusion syndrome (TTTS).

DESIGN

Retrospective cohort study of prospectively collected data.

SETTING

Collaborative multicentre study.

POPULATION

Five hundred and fifty-seven consecutive TTTS cases that underwent FLS.

METHODS

Long-term indomethacin therapy was defined as indomethacin use for at least 48 hours. Log-binomial regression was used to estimate the relative risk of PTB in the LIT group compared with a non-LIT group. Cox regression was used to evaluate the association between LIT use and FLS-to-delivery survival.

MAIN OUTCOME MEASURES

Gestational age (GA) at delivery.

RESULTS

Among the 411 pregnancies included, a total of 180 patients (43.8%) received LIT after FLS and 231 patients (56.2%) did not. Median GA at fetal intervention did not differ between groups (20.4 weeks). Median GA at delivery was significantly higher in the LIT group (33.6 weeks) compared with the non-LIT group (31.1 weeks; P < 0.001). FLS-to-delivery interval was significantly longer in the LIT group (P < 0.001). The risks of PTB before 34, 32, 28 and 26 weeks of gestation were all significantly lower in the LIT group compared with the non-LIT group (relative risks 0.69, 0.51, 0.37 and 0.18, respectively). The number needed to treat with LIT to prevent one PTB before 32 weeks of gestation was four, and to prevent one PTB before 34 weeks was five.

CONCLUSION

Long-term indomethacin after FLS for TTTS was found to be associated with prolongation of pregnancy and reduced risk for PTB.

TWEETABLE ABSTRACT

Long-term indomethacin used after fetoscopic laser surgery for twin-to-twin transfusion syndrome is effective in prolonging pregnancy and reducing the risk for preterm birth; especially extreme preterm birth.

Twin twin transfusion syndrome with and without selective fetal growth restriction: Predictors of donor demise

OBJECTIVE

Evaluate survival in twin twin transfusion syndrome (TTTS) with and without selective fetal growth restriction (sFGR) after fetoscopic laser surgery (FLS).

METHODS

Retrospective study of monochorionic diamniotic twins undergoing FLS. The cohort was classified as TTTS and TTTS with sFGR. Baseline, intra-operative and postoperative variables were analyzed. Mann-Whitney U, Pearson chi-square, Fisher's exact, t-test and receiver operating characteristic (ROC) curve analysis were performed.

RESULTS

Four hundred and ninety-two pregnancies were included, 304 (61.78%) TTTS and 188 (38.22%) TTTS with sFGR. No difference in donor outcomes. TTTS group had higher donor estimated fetal weight (EFW%) percentile (19.7 ± 18.8 vs. 2.2 ± 2.1, p < 0.001). Significant predictors for demise at 30 days were 37% intertwin weight discordance (IWD) with donor EFW% < first (area under ROC curve [AUC] = 0.85, p = 0.001) or IWD >25% and intertwin umbilical artery pulsatility index discordance (DUAPI) ≥0.4 (AUC = 0.71, p = 0.001).

CONCLUSION

Combination of IWD of 37% and donor EFW% <first was most predictive for demise 30 days after birth. DUAPI ≥0.4 was also associated with increased risk for demise.

Twin anemia polycythemia sequence: Successful laser photocoagulation treatment and placental histopathological findings

OBJECTIVE

Twin anemia polycythemia sequence (TAPS) is a rare complication of monochorionic twin pregnancies, which can occur either spontaneously or after laser photocoagulation procedure for twin to twin transfusion syndrome. TAPS is associated with poor perinatal outcomes and clear screening guidelines for this disease are lacking resulting in under-diagnosis of TAPS.

CASE REPORT

The purpose of this report is to discuss a case of severe spontaneous TAPS, which was successfully treated with favorable outcome, to describe the placental histopathological findings, and to propose an algorithm for management and follow up of this rare condition.

CONCLUSION

Laser photocoagulation of the placental anastomoses, despite technical challenges, can be safely performed in cases of TAPS. Even with prenatal evidence of successful resolution of TAPS, close fetal surveillance is warranted because of the persistence of placental villous immaturity.

Impact of the cystic neural tube defects on fetal motor function in prenatal myelomeningocele repairs: A retrospective cohort study

OBJECTIVE

To determine the impact of the lesion type (cystic [myelomeningocele] or flat [myeloschisis]) on the fetal motor function (MF) in cases candidates for prenatal open neural tube defect (ONTD) repair.

METHODS

Retrospective cohort study of patients with ONTD who underwent prenatal repair at a single institution between 2011 and 2019. The lesion type and the measurements of the length and width of the lesions to calculate the surface of the ellipsoid lesion were performed using MR scans. Prenatal MF of the lower extremities was evaluated by ultrasound following a metameric distribution at the time of referral. Intact MF was defined as the observation of plantar flexion of the ankle. Logistic regression was performed to determine the predictive value of the type of lesion for having an intact MF at the time of referral.

RESULTS

103 patients were included at 22.9 (19-25.4) weeks; 65% had cystic and 35% had flat lesions. At the time of referral, there was a higher proportion of cases with an intact MF in the presence of flat lesions (34/36; 94.4%) as compared to cystic lesion (48/67; 71.6%, p < 0.01). When adjusting for gestational age and anatomical level of the lesion, flat ONTD were 3.1 times more likely to be associated by intact motor function (CI%95 [2.1-4.6], p < 0.01) at the time of referral.

CONCLUSION

Cystic ONTD are more likely to be associated with impaired MF at mid-gestation in candidates for prenatal ONTD repair.

Is ventriculomegaly and hindbrain herniation seen before and after prenatal neural tube defect repair associated with a worse functional level than anatomical level at birth?

OBJECTIVE

To determine if the evaluation of the fetal ventricular system and hindbrain herniation (HBH) is associated with motor outcome at birth in prenatally repaired open neural tube defect (NTD).

METHODS

Retrospective cohort study of 47 patients with NTD who underwent prenatal repair (17 fetoscopic; 30 open-hysterotomy). At referral and 6 weeks postoperatively, the degree of HBH, ventricular atrial widths and ventricular volume were evaluated by MRI. Head circumference and ventricular atrial widths were measured on ultrasound at referral and during the last ultrasound before delivery. Anatomic level of the lesion (LL) was determined based on the upper bony spinal defect detected by ultrasound. We considered the functional level as worse than anatomical level at birth when the motor level was equal or worse than the anatomical LL.

RESULTS

26% (12/47) of the cases showed worse functional level than anatomical level at birth. Having a HBH below C1 at the time of referral was associated with a worse functional level than anatomical level at birth (OR = 9.7, CI95 [2.2-42.8], p < 0.01). None of the other brain parameters showed a significant association with motor outcomes at birth.

CONCLUSIONS

HBH below C1 before surgery was associated with a worse functional level than anatomical level at birth.

Accuracy of Ultrasound to Predict Neonatal Birth Weight Among Fetuses With Gastroschisis: Impact on Timing of Delivery

OBJECTIVES

To determine the accuracy of ultrasound estimation of fetal weight among fetuses with gastroschisis and how the diagnosis of fetal growth restriction (FGR) affects the timing of delivery.

METHODS

This was a retrospective cohort study including all fetuses with a diagnosis of gastroschisis at our institution from November 2012 through October 2017. We excluded multiple gestations, pregnancies with major structural or chromosomal abnormalities, and those for which prenatal and postnatal follow-up were unavailable. Performance characteristics of ultrasound to predict being small for gestational age (SGA) were calculated for the first and last ultrasound estimations of fetal weight.

RESULTS

Our cohort included 75 cases of gastroschisis. At the initial ultrasound estimation, 15 of 58 (25.9%) fetuses met criteria for FGR; 48 of 70 (68.6%) met criteria at the time of the last ultrasound estimation (median, 34.7 weeks). Cesarean delivery was performed for 37 of 75 (49.3%), with FGR and concern for fetal distress as the indication for delivery in 17 of 37 (45.9%). Only 6 of 17 (35.3%) of the neonates born by cesarean delivery for an indication of FGR and fetal distress were SGA. The initial ultrasound designation of FGR corresponded to SGA at birth in 8 of 15 (53.3%), whereas the last ultrasound estimation corresponded to SGA in 17 of 48 (35.4%). The initial ultrasound estimation agreed with the last ultrasound estimation before delivery with the diagnosis of FGR in 13 of 15 (86.7%).

CONCLUSIONS

Ultrasound in the third trimester was sensitive but had a low positive predictive value and low accuracy for the diagnosis of SGA at birth for fetuses with gastroschisis. A large proportion of fetuses were born by cesarean delivery with indications related to FGR or fetal concerns.

Novel scoring system for determining fetal candidacy for prenatal intervention for severe congenital lower urinary tract obstruction

OBJECTIVES

To evaluate a novel scoring system that combines several prenatal parameters for selecting ideal candidates for fetal intervention, and for predicting postnatal survival in patients with severe fetal lower urinary tract obstruction (LUTO).

METHODS

We retrospectively reviewed all cases of severe LUTO evaluated for fetal intervention in a single large fetal center between January 2013 and December 2017. A scoring system for determining fetal candidacy for intervention was retrospectively developed based on postnatal outcomes. The proposed scoring system included fetal urinary biochemistry, renal ultrasound parameters, initial bladder volume, and degree of bladder refill. Relevant demographic characteristics, ultrasound reports and laboratory results were reviewed. Receiver operating characteristic (ROC) curves were used to select the cut-off values for initial bladder volume and degree of bladder refill and to evaluate the performance of the scoring system in predicting postnatal death.

RESULTS

Of the 79 LUTO patients evaluated, 31 were eligible for the study. The overall 6-month postnatal survival was 64.5 % (20/31). A scoring system (0-8) was suggested with 2 points for unfavorable biochemistry, 4 points for ultrasound evidence of dysplastic kidneys, 1 point for inadequate initial bladder volume and 1 point for inadequate bladder refill. Scores>3 (N = 7) were associated with 0 % 6-month survival. The ROC curve for predicting postnatal mortality showed area under curve (AUC) of 0.82 (95 % CI 0.65-0.99). Subgroup analysis within subjects who underwent fetal intervention (N = 22) also confirmed the significance of the distribution of the scoring system between groups who survived and those who did not after adjustment for GA at delivery (p = 0.01).

CONCLUSION

We propose a novel scoring system for antenatal evaluation of patients with severe LUTO which may be useful in selecting those candidates most appropriate for intervention and in counseling parents about predicted postnatal outcome.

Enhanced Recovery after Surgery: Benefits for the Fetal Surgery Patient

BACKGROUND

The fetoscopic approach to the prenatal closure of a neural tube defect (NTD) may offer similar advantages to the newborn compared to prenatal open closure of a NTD, with a reduction in maternal risks. Enhanced recovery after surgery (ERAS) protocols have been applied to different surgical procedures with documented advantages. We modified the perioperative care of patients undergoing in utero repair of myelomeningocele with the goal of enhancing the recovery. A retrospective study comparing traditional management to the ERAS protocol was conducted.

AIMS

Primary aim was to evaluate the length of stay (LOS). Secondary outcomes included pain scores, time to oral intake, opioid-induced side effects, and respiratory complications.

METHODS

Thirty patients who underwent a mid-gestation fetoscopic closure of a NTD were included. Data analyzed include demographics, comorbidities, LOS, anatomical location of the NTD, magnesium sulfate doses and duration of administration, oxygen requirements, duration of the postoperative epidural infusion, duration of surgery and anesthesia, incidence of postoperative nausea and vomiting, respiratory complications, time to oral intake, pain scores, and sedation scores. Differences between the treatment groups were compared using the independent sample t-test or Mann-Whitney Ʋ test.

RESULTS

Of the 30 patients, 10 patients were managed according to the ERAS protocol and 20 patients according to the traditional management (1:2 ratio). The mean gestational age at the time of intervention for the traditional and ERAS groups was 24.9 ± 0.5 weeks and 24.8 ± 0.5 weeks, respectively. Compared to the traditional group, the LOS was reduced in the ERAS group to 112.5 ± 12.6 h (4.7 ± 0.5 days) from 179.7 ± 87.9 h (7.5 ± 3.7 days) (p = 0.012). The time to oral intake was also shorter 502.6 ± 473.4 min versus 1015.6 ± 698.2 min; p = 0.049. Oxygen requirements were prolonged in the traditional group (1843.7 ± 1262.6 min vs. 1051.7 ± 1078.1 min p = 0.052). The total duration of magnesium sulfate was longer for patients in the traditional group (2125.6 ± 727.1 min vs. 1429.5 ± 553.8 min; p = 0.006). No statistically significant difference in pain scores was observed between the groups.

CONCLUSIONS

Establishing an ERAS protocol for fetoscopic in utero repair of NTDs approach is feasible with the advantages of decreased postoperative LOS, reduced oxygen requirements, lower duration of magnesium sulfate infusion, and facilitation of earlier oral intake without compromising the pain scores.

Perinatal outcome of twin-to-twin transfusion syndrome complicated with incidental septostomy after laser photocoagulation: A systematic review and meta-analysis

AIM

To evaluate perinatal outcomes of incidental septostomy (IS) after laser photocoagulation for twin-to-twin transfusion syndrome (TTTS), and to compare the outcomes with those who had intact intertwin membrane.

METHODS

Databases such as PubMed, Web of Science, Scopus, and Embase were systematically searched from inception up to August 2020. The random-effects model was used to pool the mean difference (MD) or odds-ratio (OR) with the corresponding 95% confidence intervals (CIs). Primary outcome was incidence of preterm delivery, and preterm premature rupture of membranes (PPROM), while secondary outcomes included gestational age (GA) at intervention, GA at delivery, neonatal survival, and incidence of pseudoamniotic band syndrome (PABS).

RESULTS

Four studies (1442 patients) met our inclusion criteria. Postoperative identification of IS was associated with earlier GA at delivery (MD = -2.52; 95% CI: -3.22, -1.82; p < 0.00), higher risk of PPROM < 32 weeks (OR = 2.82; 95% CI: 1.80, 4.40; p < 0.001), and preterm delivery < 32 weeks (OR = 4.01; 95% CI: 1.27, 12.63; p = 0.02). No differences were noted in pseudoamniotic band syndrome, at least one or dual neonatal survival rate between IS and non-IS groups.

CONCLUSIONS

Occurrence of IS after laser photocoagulation for TTTS is associated with earlier GA at delivery, increased risk for PPROM and preterm delivery <32 weeks' gestation. However, neonatal survival does not appear to be affected by this complication.

Magnesium sulfate titration reduces maternal complications following fetoscopic closure of spina bifida

OBJECTIVE

To evaluate if magnesium sulfate (MgSO₄ ) titration following fetoscopic spina bifida closure is associated with fewer maternal complications than the Management of Myelomeningocele Study (MOMS) tocolytic regimen.

METHODS

This prospective cohort study included 73 consecutive patients undergoing fetoscopic closure of spina bifida between 2015 and 2020. A policy of using the MgSO₄ regimen per the MOMS trial was changed to a flexible one in which MgSO₄ was titrated according to the frequency of the uterine contractions following surgery. The frequency of maternal pulmonary edema, low maternal oxygen saturation requiring oxygen supplementation, atelectasis, hypocalcemia, and preterm delivery was compared before and after the policy was changed.

RESULTS

A higher proportion of women in the group that used the MOMS MgSO₄ regimen had pulmonary edema compared to those in the flexible one (26.1% [6/23] vs. 6% [3/50]; p = 0.024). Multivariate analysis showed that the MOMS tocolytic regimen was independently associated with a higher risk of pulmonary edema (adjusted odds ratio: 8.57; 95% confidence interval: 1.54-47.7; p = 0.014) than a flexible one. There was no difference in the rate of preterm delivery.

CONCLUSION

Following fetoscopic closure of spina bifida, the MOMS MgSO₄ regimen is associated with an increased risk of pulmonary edema than a more flexible regimen.

Cost-effective fetal lung volumetry for assessment of congenital diaphragmatic hernia

OBJECTIVES

(1) To investigate the reproducibility of total fetal lung volume (TFLV) measurements using a free 3D modeling software (3DSlicer); (2) To correlate these measurements with lung-to-head ratio (LHR) or TFLV measured using PACS and; (3) To determine the role of 3DSlicer in predicting perinatal outcomes in cases with congenital diaphragmatic hernia (CDH) who had fetal tracheal occlusion (FETO).

METHODS

Retrospective cohort study between 2012 and 2017 at Texas Children's Hospital (2011-2017), including all patients who underwent FETO for CDH. LHR was measured by ultrasound and TFLV was measured by MRI at the time of referral and 6 weeks after FETO using 3DSlicer and PACS. We evaluated intra- and inter-rater reliability of TFLV measurement using 3DSlicer, infant survival to 1 year, need for ECMO and pulmonary hypertension.

RESULTS

The intra- and inter-rater reliability of TFLV measured with 3DSlicer was excellent before and after FETO (Intra-class correlation coefficient: 0.98-0.99 and 0.94-0.99, respectively). There was a good correlation between TFLV measured with PACS and with 3DSlicer before and after FETO (r = 0.78 and r = 0.99, respectively). Similarly, there was a good correlation between TFLV measurements using PACS or 3DSlicer and LHR after FETO (r = 0.86 and r = 0.88, respectively). Infants who survived to 1 year had a significantly higher TFLV evaluated with 3DSlicer before FETO compared to non-surviving infants (OR = 1.16[1.1-1.3], p = 0.03) as well as a significantly higher TFLV evaluated by 3DSlicer after FETO (OR = 1.2[1-1.4], p = 0.04).

CONCLUSION

Lung volume measurements using free 3DSlicer in infants with severe CDH who underwent FETO are reproducible and reliable, and have comparable predictive capability for survival as those measured using conventional software.

Maternal serum alpha-fetoprotein level and the relationship to ventriculomegaly in fetal neural tube defect: A retrospective cohort study

OBJECTIVE

To estimate the significance of the association between mid-trimester maternal serum alpha-fetoprotein (MSAFP) level and fetal neuroanatomic findings in cases of open neural tube defect (ONTD).

METHODS

Retrospective study of patients referred for prenatal ONTD repair between 2012 and 2018. Cases were classified into three groups based on their MSAFP level: 1)High MSAFP (>3.8MoM - n = 22), 2)Moderately high MSAFP (≤3.8 and ≥2.5MoM - n = 28), 3)Normal MSAFP (<2.5MoM - n = 18). MRI scans at the time of referral were used to assess the relationship between MSAFP and: A)Type of ONTD; B) Ventriculomegaly; C) Size of the myeloschisis lesion; D) Volume of myelomeningocele; E) Anatomical level of the lesion (LL).

RESULTS

Having a high MSAFP level was more likely to be associated ventriculomegaly at mid-gestation than a moderately high or normal MSAFP level (OR = 8.4;CI95[0.9-73.4];p = 0.05 and OR = 2.8;CI95[0.9-8.8];p = 0.07). There were no differences between the three groups regarding type of lesion, size of the myeloschisis lesion, anatomic LL, or volume of the myelomeningocele sac. Myeloschisis cases with normal MSAFP had a larger surface area when compared to myeloschisis cases with moderately high MSAFP (219.8[104.4-551] vs 155.4[38.5-502.4] mm², p = 0.04).

CONCLUSION

A 2nd trimester MSAFP level >3.8MoM in a fetus with ONTD is associated with mid-gestation ventriculomegaly.

Inter-twin differences in fetal echocardiographic findings are associated with decreased dual twin survival in twin-twin transfusion syndrome

OBJECTIVE

To determine if inter-twin differences in fetal echocardiographic findings are associated with fetal survival in monochorionic pregnancies complicated by twin-to-twin transfusion syndrome (TTTS).

METHODS

This study included women who underwent laser surgery for TTTS between 2012 and 2018 at a single institution. Echocardiographic cardiac parameters in the donor and recipient twins were compared using Z-scores and regression analyses (adjusted for confounding variables) to determine whether any measurable inter-twin differences were associated with neonatal survival at birth. Results are expressed as (Odds ratio [95% confidence interval], p-value).

RESULTS

Fetal echocardiography and delivery information was available in 124 TTTS cases. Dual live-birth occurred in 72% and at least one live-birth was seen in 89% of cases. Sixty-four percent (51/79) of recipient twins had evidence of cardiac dysfunction compared to 10% (8/79) of the donor twins (p < .01). In the logistic regression, inter-twin differences in left ventricle short axis dimension (0.62[0.44-0.87], p < .01), aortic valve diameter (0.67[0.45-0.99], p = .047), peak systolic velocity across the pulmonary artery (PA-PSV) (0.09[0.01-0.53], p < .01) and mitral valve diameter (0.56[0.38-0.84], p < .01) were associated with lower dual twin survival at birth.

CONCLUSION

Inter-twin differences in left cardiac geometry and function are associated with decreased survival at delivery in TTTS.

Umbilical Artery Doppler Patterns and Right Ventricular Outflow Abnormalities in Twin-Twin Transfusion Syndrome

OBJECTIVES

To evaluate the association of abnormal Doppler velocimetric patterns in the umbilical arteries (UAs) and right ventricular outflow tract abnormalities (RVOTAs) in twin- twin transfusion syndrome (TTTS) cases.

METHODS

This retrospective study involved women who had laser surgery for TTTS between January 2012 and May 2018 at a single institution. The prevalence of an RVOTA in either twin was compared among TTTS cases in which both twins had positive end-diastolic flow (EDF) in the UA and those in which either twin had intermittent or persistent absent/reversed UA EDF. Nonparametric tests were used for comparisons. Logistic regression was performed to identify variables associated with an RVOTA in either twin, adjusted for moderate or severe tricuspid regurgitation, right ventricular hypertrophy, right ventricular systolic or diastolic dysfunction, the Quintero stage, and other confounders. P < .05 was considered significant.

RESULTS

A total of 126 consecutive TTTS cases were included. Right ventricular outflow tract abnormalities were seen in 8.7% (11of 126) of cases, all in recipient twins. Significant differences in the rate of RVOTAs in the recipient twin were seen between TTTS cases with intermittent absent/reversed UA EDF and those with positive UA EDF (26.9% [7 of 26] versus 3.7% [3 of 82]; P = .002]. However, no significant differences were noted among the other study groups. Intermittent absent/reversed UA EDF was associated with a significantly increased risk for an RVOTA (adjusted odds ratio, 20.6 [95% confidence interval, 3.1-138]; P = .002) after adjusting for confounders.

CONCLUSIONS

Intermittent changes in vascular impedance to UA flow may contribute to the pathogenesis of acquired right-sided cardiac lesions in the recipient twin affected with TTTS.