Patient empowerment improves follow-up data collection after fetal surgery for spina bifida: institutional audit

OBJECTIVES

To define and grade fetal and maternal adverse events following fetal surgery for spina bifida and to report on the impact of engaging patients in collecting follow-up data.

METHODS

This prospective single-center audit included 100 consecutive patients undergoing fetal surgery for spina bifida between January 2012 and December 2021. In our setting, patients return to their referring unit for further pregnancy care and delivery. On discharge, referring hospitals were requested to return outcome data. For this audit, we prompted patients and referring hospitals to provide data in cases of missing outcomes. Outcomes were categorized as missing, returned spontaneously or returned following additional request, by the patient and/or referring center. Postoperative maternal and fetal complications until delivery were defined and graded according to Maternal and Fetal Adverse Event Terminology (MFAET) and the Clavien-Dindo classification.

RESULTS

There were no maternal deaths, but severe maternal complications occurred in seven women (anemia in pregnancy, postpartum hemorrhage, pulmonary edema, lung atelectasis, urinary tract obstruction and placental abruption). No cases of uterine rupture were reported. Perinatal death occurred in 3% of fetuses and other severe fetal complications in 15% (perioperative fetal bradycardia/cardiac dysfunction, fistula-related oligohydramnios, chorioamnionitis and preterm prelabor rupture of membranes (PPROM) before 32 weeks). PPROM occurred in 42% of patients and, overall, delivery took place at a median gestational age of 35.3 weeks (interquartile range, 34.0-36.6 weeks). Information provided following additional request, from both centers and patients but mainly from the latter, reduced missing data by 21% for gestational age at delivery, 56% for uterine-scar status at birth and 67% for shunt insertion at 12 months. Compared with the generic Clavien-Dindo classification, the MFAET system ranked complications in a more clinically relevant way.

CONCLUSIONS

The nature and rate of severe complications following fetal surgery for spina bifida were similar to those reported in other large series. Spontaneous return of outcome data by referring centers was low, yet patient empowerment improved data collection. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Application of Automatic Segmentation on Super-Resolution Reconstruction MR Images of the Abnormal Fetal Brain

BACKGROUND AND PURPOSE

Fetal brain MR imaging is clinically used to characterize fetal brain abnormalities. Recently, algorithms have been proposed to reconstruct high-resolution 3D fetal brain volumes from 2D slices. By means of these reconstructions, convolutional neural networks have been developed for automatic image segmentation to avoid labor-intensive manual annotations, usually trained on data of normal fetal brains. Herein, we tested the performance of an algorithm specifically developed for segmentation of abnormal fetal brains.

MATERIALS AND METHODS

This was a single-center retrospective study on MR images of 16 fetuses with severe CNS anomalies (gestation, 21-39 weeks). T2-weighted 2D slices were converted to 3D volumes using a super-resolution reconstruction algorithm. The acquired volumetric data were then processed by a novel convolutional neural network to perform segmentations of white matter and the ventricular system and cerebellum. These were compared with manual segmentation using the Dice coefficient, Hausdorff distance (95th percentile), and volume difference. Using interquartile ranges, we identified outliers of these metrics and further analyzed them in detail.

RESULTS

The mean Dice coefficient was 96.2%, 93.7%, and 94.7% for white matter and the ventricular system and cerebellum, respectively. The Hausdorff distance was 1.1, 2.3, and 1.6 mm, respectively. The volume difference was 1.6, 1.4, and 0.3 mL, respectively. Of the 126 measurements, there were 16 outliers among 5 fetuses, discussed on a case-by-case basis.

CONCLUSIONS

Our novel segmentation algorithm obtained excellent results on MR images of fetuses with severe brain abnormalities. Analysis of the outliers shows the need to include pathologies underrepresented in the current data set. Quality control to prevent occasional errors is still needed.

Longitudinal MRI Evaluation of Brain Development in Fetuses with Congenital Diaphragmatic Hernia around the Time of Fetal Endotracheal Occlusion

BACKGROUND AND PURPOSE

Congenital diaphragmatic hernia is associated with high mortality and morbidity, including evidence suggesting neurodevelopmental comorbidities after birth. The aim of this study was to document longitudinal changes in brain biometry and the cortical folding pattern in fetuses with congenital diaphragmatic hernia compared with healthy fetuses.

MATERIALS AND METHODS

This is a retrospective cohort study including fetuses with isolated congenital diaphragmatic hernia between January 2007 and May 2019, with at least 2 MR imaging examinations. For controls, we used images from fetuses who underwent MR imaging for an unrelated condition that did not compromise fetal brain development and fetuses from healthy pregnant women. Biometric measurements and 3D segmentations of brain structures were used as well as qualitative and quantitative grading of the supratentorial brain. Brain development was correlated with disease-severity markers.

RESULTS

Forty-two fetuses were included, with a mean gestational age at first MR imaging of 28.0 (SD, 2.1) weeks and 33.2 (SD, 1.3) weeks at the second imaging. The mean gestational age in controls was 30.7 (SD, 4.2) weeks. At 28 weeks, fetuses with congenital diaphragmatic hernia had abnormal qualitative and quantitative maturation, more extra-axial fluid, and larger total skull volume. By 33 weeks, qualitative grading scores were still abnormal, but quantitative scoring was in the normal range. In contrast, the extra-axial fluid volume remained abnormal with increased ventricular volume. Normal brain parenchymal volumes were found.

CONCLUSIONS

Brain development in fetuses with congenital diaphragmatic hernia around 28 weeks appears to be delayed. This feature is less prominent at 33 weeks. At this stage, there was also an increase in ventricular and extra-axial space volume.

Anatomical and diffusion-weighted imaging of brain abnormalities in third-trimester fetuses with cytomegalovirus infection

OBJECTIVES

In this study of cytomegalovirus (CMV)-infected fetuses with first-trimester seroconversion, we aimed to evaluate the detection of brain abnormalities using magnetic resonance imaging (MRI) and neurosonography (NSG) in the third trimester, and compare the grading systems of the two modalities. We also evaluated the feasibility of routine use of diffusion-weighted imaging (DWI) fetal MRI and compared the regional apparent diffusion coefficient (ADC) values between CMV-infected fetuses and presumed normal, non-infected fetuses in the third trimester.

METHODS

This was a retrospective review of MRI and NSG scans in fetuses with confirmed first-trimester CMV infection performed between September 2015 and August 2019. Brain abnormalities were recorded and graded using fetal MRI and NSG grading systems to compare the two modalities. To investigate feasibility of DWI, a four-point rating scale (poor, suboptimal, good, excellent) was applied to assess the quality of the images. Quantitative assessment was performed by placing a freehand drawn region of interest in the white matter of the frontal, parietal, temporal and occipital lobes and the basal ganglia, pons and cerebellum to calculate ADC values. Regional ADC measurements were obtained similarly in a control group of fetuses with negative maternal CMV serology in the first trimester, normal brain findings on fetal MRI and normal genetic testing.

RESULTS

Fifty-three MRI examinations of 46 fetuses with confirmed first-trimester CMV infection were included. NSG detected 24 of 27 temporal cysts seen on MRI scans, with a sensitivity of 78% and an accuracy of 83%. NSG did not detect abnormal gyration visible on two (4%) MRI scans. Periventricular calcifications were detected on two MRI scans compared with 10 NSG scans. While lenticulostriate vasculopathy was detected on 11 (21%) NSG scans, no fetus demonstrated this finding on MRI. MRI grading correlated significantly with NSG grading of brain abnormalities (P < 0.0001). Eight (15%) of the DWI scans in the CMV cohort were excluded from further analysis because of insufficient quality. The ADC values of CMV-infected fetuses were significantly increased in the frontal (both sides, P < 0.0001), temporal (both sides, P < 0.0001), parietal (left side, P = 0.0378 and right side, P = 0.0014) and occipital (left side, P = 0.0002 and right side, P < 0.0001) lobes and decreased in the pons (P = 0.0085) when compared with non-infected fetuses. The ADC values in the basal ganglia and the cerebellum were not significantly different in CMV-infected fetuses compared with normal controls (all P > 0.05). Temporal and frontal ADC values were higher in CMV-infected fetuses with more severe brain abnormalities compared to fetuses with mild abnormalities.

CONCLUSIONS

Ultrasound and MRI are complementary during the third trimester in the assessment of brain abnormalities in CMV-infected fetuses, with a significant correlation between the grading systems of the two modalities. On DWI in the third trimester, the ADC values in several brain regions are abnormal in CMV-infected fetuses compared with normal controls. Furthermore, they seem to correlate in the temporal area and, to a lesser extent, frontal area with the severity of brain abnormalities associated with CMV infection. Larger prospective studies are needed for further investigation of the microscopic nature of diffusion abnormalities and correlation of different imaging findings with postnatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Prevalence of supratentorial anomalies assessed by magnetic resonance imaging in fetuses with open spina bifida

OBJECTIVES

To determine the prevalence of brain anomalies at the time of preoperative magnetic resonance imaging (MRI) assessment in fetuses eligible for prenatal open spina bifida (OSB) repair, and to explore the relationship between brain abnormalities and features of the spinal defect.

METHODS

This was a retrospective cross-sectional study, conducted in three fetal medicine centers, of fetuses eligible for OSB fetal surgery repair between January 2009 and December 2019. MRI images obtained as part of the presurgical assessment were re-evaluated by two independent observers, blinded to perinatal results, to assess: (1) the type and area of the defect and its anatomical level; (2) the presence of any structural central nervous system (CNS) anomaly and abnormal ventricular wall; and (3) fetal head and brain biometry. Binary regression analyses were performed and data were adjusted for type of defect, upper level of the lesion (ULL), gestational age (GA) at MRI and fetal medicine center. Multiple logistic regression analysis was performed in order to identify lesion characteristics and brain anomalies associated with a higher risk of presence of abnormal corpus callosum (CC) and/or heterotopia.

RESULTS

Of 115 fetuses included, 91 had myelomeningocele and 24 had myeloschisis. Anatomical level of the lesion was thoracic in seven fetuses, L1-L2 in 13, L3-L5 in 68 and sacral in 27. Median GA at MRI was 24.7 (interquartile range, 23.0-25.7) weeks. Overall, 52.7% of cases had at least one additional brain anomaly. Specifically, abnormal CC was observed in 50.4% of cases and abnormality of the ventricular wall in 19.1%, of which 4.3% had nodular heterotopia. Factors associated independently with higher risk of abnormal CC and/or heterotopia were non-sacral ULL (odds ratio (OR), 0.51 (95% CI, 0.26-0.97); P = 0.043), larger ventricular width (per mm) (OR, 1.23 (95% CI, 1.07-1.43); P = 0.005) and presence of abnormal cavum septi pellucidi (OR, 3.76 (95% CI, 1.13-12.48); P = 0.031).

CONCLUSIONS

Half of the fetuses assessed for OSB repair had an abnormal CC and/or an abnormal ventricular wall prior to prenatal repair. The likelihood of brain abnormalities was increased in cases with a non-sacral lesion and wider lateral ventricles. These findings highlight the importance of a detailed preoperative CNS evaluation of fetuses with OSB. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Complex gastroschisis: a new indication for fetal surgery?

Gastroschisis (GS) is a congenital abdominal wall defect, in which the bowel eviscerates from the abdominal cavity. It is a non-lethal isolated anomaly and its pathogenesis is hypothesized to occur as a result of two hits: primary rupture of the 'physiological' umbilical hernia (congenital anomaly) followed by progressive damage of the eviscerated bowel (secondary injury). The second hit is thought to be caused by a combination of mesenteric ischemia from constriction in the abdominal wall defect and prolonged amniotic fluid exposure with resultant inflammatory damage, which eventually leads to bowel dysfunction and complications. GS can be classified as either simple or complex, with the latter being complicated by a combination of intestinal atresia, stenosis, perforation, volvulus and/or necrosis. Complex GS requires multiple neonatal surgeries and is associated with significantly greater postnatal morbidity and mortality than is simple GS. The intrauterine reduction of the eviscerated bowel before irreversible damage occurs and subsequent defect closure may diminish or potentially prevent the bowel damage and other fetal and neonatal complications associated with this condition. Serial prenatal amnioexchange has been studied in cases with GS as a potential intervention but never adopted because of its unproven benefit in terms of survival and bowel and lung function. We believe that recent advances in prenatal diagnosis and fetoscopic surgery justify reconsideration of the antenatal management of complex GS under the rubric of the criteria for fetal surgery established by the International Fetal Medicine and Surgery Society (IFMSS). Herein, we discuss how conditions for fetoscopic repair of complex GS might be favorable according to the IFMSS criteria, including an established natural history, an accurate prenatal diagnosis, absence of fully effective perinatal treatment due to prolonged need for neonatal intensive care, experimental evidence for fetoscopic repair and maternal and fetal safety of fetoscopy in expert fetal centers. Finally, we propose a research agenda that will help overcome barriers to progress and provide a pathway toward clinical implementation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Outcome of monochorionic twin pregnancy with selective fetal growth restriction at 16, 20 or 30 weeks according to new Delphi consensus definition

OBJECTIVES

To report the outcome of selective fetal growth restriction (sFGR) diagnosed according to the new Delphi consensus definition, and determine potential predictors of survival, in a cohort of unselected monochorionic diamniotic twin pregnancies.

METHODS

This was a retrospective study of monochorionic diamniotic twin pregnancies followed from the first trimester onward, which were diagnosed with sFGR at 16, 20 or 30 weeks' gestation. sFGR was defined according to the new Delphi consensus criteria as presence of either an estimated fetal weight (EFW) < 3^rd centile in one twin or at least two of the following: EFW of one twin < 10^th centile, abdominal circumference of one twin < 10^th centile, EFW discordance ≥ 25% or umbilical artery pulsatility index of the smaller twin > 95^th centile. The primary outcomes were the overall survival rate (up to day 28 after birth) and risk of loss of one or both twins. We further determined possible predictors of survival using uni- and multivariate generalized estimated equation modeling.

RESULTS

We analyzed 675 pregnancies, of which 177 (26%) were diagnosed with sFGR at 16, 20 or 30 weeks. The overall survival rate was 313/354 (88%) with 146/177 (82%) pregnancies resulting in survival of both twins, 21/177 (12%) in survival of one twin and 10/177 (6%) in loss of both twins. Subsequent twin anemia-polycythemia sequence (TAPS) developed in 6/177 (3%) and twin-twin transfusion syndrome (TTTS) in 17/177 (10%) pregnancies. All TAPS fetuses survived. The survival rate in sFGR pregnancies that subsequently developed TTTS was 65% (22/34), compared with 91% (279/308) in those with isolated sFGR (no subsequent TAPS or TTTS) (P < 0.001). The majority of sFGR cases were Type I (110/177 (62%)) and had a survival rate of 96% (212/220), as compared with a survival of 55% (12/22) in those with Type-II (P < 0.001) and 83% (55/66) in those with Type-III (P = 0.006) sFGR. The majority of sFGR pregnancies (130/177 (73%)) were first diagnosed at 16 or 20 weeks (early onset), with a survival rate of 85% (221/260), as compared with a survival of 98% (92/94) in sFGR first diagnosed at 30 weeks (late onset) (P = 0.04). A major anomaly in at least one twin was present in 28/177 (16%) sFGR cases. In these pregnancies, survival was 39/56 (70%), compared with 274/298 (92%) in those without an anomaly (P < 0.001). Subsequent development of TTTS (odds ratio (OR), 0.18 (95% CI, 0.06-0.52)), Type-II sFGR (OR, 0.06 (95% CI, 0.02-0.24)) and Type-III sFGR (OR, 0.21 (95% CI, 0.07-0.60)) and presence of a major anomaly in at least one twin (OR, 0.12 (95% CI, 0.04-0.34)), but not gestational age at first diagnosis, were independently associated with decreased survival.

CONCLUSIONS

Isolated sFGR is associated with a 90% survival rate in monochorionic diamniotic twin pregnancies. The subsequent development of TTTS, absent or reversed end-diastolic flow in the umbilical artery of the smaller twin and the presence of a major anomaly adversely affect survival in sFGR. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Laser for twin-to-twin transfusion syndrome: a guide for endoscopic surgeons

Twin-to-twin-transfusion syndrome (TTTS) is the most important cause of handicap and death in monochorionic twin pregnancies. It is caused by a certain pattern of anastomoses between the two fetal circulations leading to an unbalanced blood and fluid transfer. This leads to severe amniotic fluid discordance and variable degrees of cardiac dysfunction. Untreated, this condition has a very poor survival rate. Fetoscopic laser has been shown to be the best first line treatment, which aims to dichorionise the placenta therefore arresting the inter-twin transfusion. Fetoscopic laser is a causative therapy, which aims to functionally create a dichorionized placenta hence arresting inter-twin transfusion. This is achieved by percutaneous sono-endoscopic coagulation of placental anastomoses. In addition, redundant amniotic fluid is drained. Fetoscopic laser coagulation of chorionic plate anastomoses is safe and effective. There is level I evidence that it is the best treatment modality, in particular when the placental surface is lined along the vascular equator. A recent meta-analysis confirmed an increased fetal survival and decreased risk for neonatal and pediatric neurologic morbidity. Laser therapy is the first line therapy for TTTS. The technique is quite standardized and safe and effective in experienced hands. Herein we describe the technique and current instrumentation used for this procedure.

Prevention of maternal-fetal transmission of cytomegalovirus after primary maternal infection in the first trimester by biweekly hyperimmunoglobulin administration

OBJECTIVE

To examine the efficacy of biweekly hyperimmunoglobulin (HIG) administration to prevent maternal-fetal transmission of cytomegalovirus (CMV) in women with primary first-trimester CMV infection.

METHODS

This was a prospective observational study of women with confirmed primary CMV infection in the first trimester who had the first HIG administration at or before 14 weeks' gestation. All women had biweekly HIG treatment until 20 weeks' gestation at a dose of 200 IU/kg of maternal body weight. Each subject underwent amniocentesis at least 6 weeks after first presentation at about 20 weeks. Primary outcome was maternal-fetal transmission at the time of amniocentesis, and secondary outcome was the frequency of congenital CMV infection at birth. The results were compared with a historic cohort of women with first-trimester CMV infection who did not undergo HIG treatment and who had amniocentesis at about 20 weeks.

RESULTS

Subjects were 40 pregnant women with a primary CMV infection, with a median gestational age at first presentation of 9.6 (range, 5.1-14.3) weeks. On average, HIG administration started at 11.1 weeks and continued until 16.6 weeks. Within this interval, HIG was administered between two and six times in each patient. While CMV immunoglobulin-G (IgG) monitoring showed periodic fluctuations during biweekly HIG administration cycles, high CMV-IgG avidity indices remained stable over the whole treatment period. Maternal-fetal transmission before amniocentesis occurred in only one of the 40 cases (2.5% (95% CI, 0-13.2%)). At delivery, two additional subjects were found to have had late-gestation transmission. Considering all three cases with maternal-fetal transmission, the transmission rate was 7.5% (95% CI, 1.6-20.4%) in our 40 cases. All infected neonates were asymptomatic at birth. The matched historical control group consisted of 108 pregnancies. Thirty-eight transmissions (35.2% (95% CI, 26.2-45.0%)) occurred in the control group, which was significantly higher (P < 0.0001) than the transmission rate in the HIG treatment group.

CONCLUSION

After a primary maternal CMV infection in the first trimester, biweekly HIG administration at a dose of 200 IU/kg prevents maternal-fetal transmission up to 20 weeks' gestation. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Reliability of MR Imaging-Based Posterior Fossa and Brain Stem Measurements in Open Spinal Dysraphism in the Era of Fetal Surgery

BACKGROUND AND PURPOSE

Fetal MR imaging is part of the comprehensive prenatal assessment of fetuses with open spinal dysraphism. We aimed to assess the reliability of brain stem and posterior fossa measurements; use the reliable measurements to characterize fetuses with open spinal dysraphism versus what can be observed in healthy age-matched controls; and document changes in those within 1 week after prenatal repair.

MATERIALS AND METHODS

Retrospective evaluation of 349 MR imaging examinations took place, including 274 in controls and 52 in fetuses with open spinal dysraphism, of whom 23 underwent prenatal repair and had additional early postoperative MR images. We evaluated measurements of the brain stem and the posterior fossa and the ventricular width in all populations for their reliability and differences between the groups.

RESULTS

The transverse cerebellar diameter, cerebellar herniation level, clivus-supraocciput angle, transverse diameter of the posterior fossa, posterior fossa area, and ventricular width showed an acceptable intra- and interobserver reliability (intraclass correlation coefficient > 0.5). In fetuses with open spinal dysraphism, these measurements were significantly different from those of healthy fetuses (all with P < .0001). Furthermore, they also changed significantly (P value range = .01 to < .0001) within 1 week after the fetal operation with an evolution toward normal, most evident for the clivus-supraocciput angle (65.9 ± 12.5°; 76.6 ± 10.9; P < .0001) and cerebellar herniation level (-9.9 ± 4.2 mm; -0.7 ± 5.2; P < .0001).

CONCLUSIONS

In fetuses with open spinal dysraphism, brain stem measurements varied substantially between observers. However, measurements characterizing the posterior fossa could be reliably assessed and were significantly different from normal. Following a fetal operation, these deviations from normal values changed significantly within 1 week.

Does site of cord insertion increase risk of adverse outcome, twin-to-twin transfusion syndrome and discordant growth in monochorionic twin pregnancy?

OBJECTIVES

It is not currently well known to what extent the sites of cord insertion influence the risk of complicated outcome in monochorionic twin pregnancy. The objectives of this study were to examine whether the sites of cord insertion, as determined on prenatal ultrasound examination, affect the risks of adverse outcome, twin-to-twin transfusion syndrome (TTTS) and discordant growth, and whether discordance in insertion sites or velamentous insertion in one or both twins best predicts risk.

METHODS

This was a retrospective cohort study of monochorionic diamniotic twin pregnancies followed from the first trimester. The cohort was divided into three groups of increasing discordance in cord insertion sites: concordant (normal-normal; marginal-marginal; velamentous-velamentous), intermediate (normal-marginal; marginal-velamentous) and discordant (normal-velamentous). Adverse outcome was defined as fetal or neonatal loss or birth prior to 32 weeks. The associations of adverse outcome, TTTS and discordant growth were assessed using logistic regression analysis with the following predictors: the three groups of insertion sites and velamentous insertion in one or both twins.

RESULTS

Included in the analysis were 518 pregnancies. On univariate analysis, both discordant and velamentous insertions in one twin increased the risk of adverse outcome, TTTS and discordant growth. Intermediate insertion only increased the risk of discordant growth. Velamentous insertion in both twins increased the risk of adverse outcome and TTTS, but not of discordant growth. Multivariate logistic regression analysis showed velamentous insertion in one or both twins to independently predict adverse outcome and TTTS. For discordant growth, both intermediate/discordant and velamentous cord insertion in one twin were independent predictors.

CONCLUSIONS

Velamentous cord insertion in one or both twins increases the risk of adverse outcome and TTTS, irrespective of discordance in the insertion sites, whereas the risk of discordant growth is determined by both discordance in insertion sites and velamentous cord insertion in one twin. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Sonographic Development of the Pericallosal Vascularization in the First and Early Second Trimester of Pregnancy

BACKGROUND AND PURPOSE

Anomalies of the corpus callosum are rare. Routine scanning in midtrimester of the pregnancy often fails to identify defective development. The purpose of the study was to identify the pericallosal artery and all its main branching arteries during early gestation from the first trimester onward, to measure the length of the pericallosal artery during its development, and to establish a normal vascular map for each week of development.

MATERIALS AND METHODS

We performed a single-center prospective, longitudinal clinical study in 15 patients between 11 and 22 weeks of gestation. The origin and course of the different blood vessels were identified.

RESULTS

There was a linear association among gestational age, the biparietal diameter, and the length of the pericallosal artery. The curvature of the developing pericallosal artery increases linearly with the gestational age and biparietal diameter, and 4 variations of branching of the callosomarginal artery were observed.

CONCLUSIONS

The pericallosal artery and its branches can be identified and measured from 11 weeks on, and the pericallosal artery takes its characteristic course. A defective course or an abnormal biometry of the pericallosal artery could be an early sonographic marker of abnormal development of the corpus callosum.

Sonographic detection of central nervous system defects in the first trimester of pregnancy

The fetal central nervous system can already be examined in the first trimester of pregnancy. Acrania, alobar holoprosencephaly, cephaloceles, and spina bifida can confidently be diagnosed at that stage and should actively be looked for in every fetus undergoing first-trimester ultrasound. For some other conditions, such as vermian anomalies and agenesis of the corpus callosum, markers have been identified, but the diagnosis can only be confirmed in the second trimester of gestation. For these conditions, data on sensitivity and more importantly specificity and false positives are lacking, and one should therefore be aware not to falsely reassure or scare expecting parents based on first-trimester findings. This review summarizes the current knowledge of first-trimester neurosonography in the normal and abnormal fetus and gives an overview of which diseases can be diagnosed.

Simulator training in fetoscopic laser surgery for twin-twin transfusion syndrome: a pilot randomized controlled trial

OBJECTIVE

To evaluate the effect of a newly developed training curriculum on the performance of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS) using an advanced high-fidelity simulator model.

METHODS

Ten novices were randomized to receive verbal instructions and either skills training using the simulator (study group; n = 5) or no training (control group; n = 5). Both groups were evaluated with a pre-training and post-training test on the simulator. Performance was assessed by two independent observers and comprised a 52-item checklist for surgical performance (SP) score, measurement of procedure time and number of anastomoses missed. Eleven experts set the benchmark level of performance. Face validity and educational value of the simulator were assessed using a questionnaire.

RESULTS

Both groups showed an improvement in SP score at the post-training test compared with the pre-training test. The simulator-trained group significantly outperformed the control group, with a median SP score of 28 (54%) in the pre-test and 46 (88%) in the post-test vs 25 (48%) and 36 (69%), respectively (P = 0.008). Procedure time decreased by 11 min (from 44 to 33 min) in the study group vs 1 min (from 39 to 38 min) in the control group (P = 0.69). There was no significant difference in the number of missed anastomoses at the post-training test between the two groups (1 vs 0). Subsequent feedback provided by the participants indicated that training on the simulator was perceived as a useful educational activity.

CONCLUSIONS

Proficiency-based simulator training improves performance, indicated by SP score, for fetoscopic laser therapy. Despite the small sample size of this study, practice on a simulator is recommended before trainees carry out laser therapy for TTTS in pregnant women.

Outcome of 12 antenatally diagnosed fetal arachnoid cysts: case series and review of the literature

OBJECTIVES

To investigate the natural history, associated abnormalities and outcome of 12 fetuses with arachnoid cyst diagnosed antenatally by ultrasound and magnetic resonance imaging and to compare the outcome with cases in the literature.

METHODS

A retrospective study of all cases of antenatally detected fetal arachnoid cysts was performed in patients referred to a tertiary unit between 2007 and 2013. Associated abnormalities, pregnancy outcome and postnatal follow-up were analyzed. All papers about prenatally diagnosed arachnoid cysts, of the last 30 years, were evaluated (search terms in Pubmed: "prenatal diagnosis", "Arachnoid Cysts").

RESULTS

Fetal arachnoid cysts were diagnosed in 12 fetuses, 9 were females. The mean gestational age of diagnosis was 28 1/7 (range 19 1/7-34 2/7 weeks). A total of 9 cases were supratentorial, 3 were located in the posterior fossa. In 10 cases a fetal MRI was performed which confirmed brain compression in 4 out of 5 supratentorial arachnoid cyst. MRI did not reveal other malformations nor signs of nodular heterotopia. Only one fetus presented with additional major anomalies (bilateral ventricumomegaly of >20 mm and rhombencephalosynapsis) leading to a termination of pregnancy. Two neonates underwent endoscopic fenestration of the arachnoid cyst in the first week of life with no additional intervention in childhood. All but one (10/11) had a favorable postnatal outcome. This child suffered from visual impairment at autism was diagnosed at the age of 5. One child had a surgical correction of strabismus later in childhood. In one child the infratentorial arachnoid cyst regressed spontaneously on ultrasound and MRI in the postnatal period.

CONCLUSIONS

The majority of arachnoid cysts in this series are of benign origin and remain stable. Based on the current series and the review of the literature, in the absence of other associated anomalies and when the karyotype is normal, the postnatal overall and neurological outcome is favorable. Large suprasellar arachnoid cysts however, may cause visual impairment and endocrinological disturbances. Rarely associated cerebral or cerebellar malformations are present. Modern postnatal management of suprasellar arachnoid cyst consists of endoscopic cystoventriculostomy.

Intrauterine transfusion for fetal anemia due to red blood cell alloimmunization: 14 years experience in Leuven

OBJECTIVE

The purpose of this study is to report on the pregnancy and neonatal outcome of intrauterine transfusion (IUT) for red blood cell (RBC-)alloimmunization.

MATERIAL AND METHODS

Retrospective cohort study of all IUT for RBC-alloimmunization in the University Hospital of Leuven, between January 2000 and January 2014. The influence of hydrops, gestational age and technique of transfusion on procedure related adverse events were examined.

RESULTS

135 IUTs were performed in 56 fetuses. In none of the cases fetal or neonatal death occurred. Mild adverse events were noted in 10% of IUTs, whereas severe adverse events occurred in 1.5%. Hydrops and transfusion in a free loop were associated with an increased risk of adverse events whereas gestational age (GA) at transfusion after 34 weeks was not. Median GA at birth was 35.6 weeks and 9% was born before 34 weeks. Besides phototherapy 65.4% required additional neonatal treatment for alloimmune anemia. Non-hematologic complications occurred in 23.6% and were mainly related to preterm birth.

CONCLUSION

In experienced hands, IUT for RBC-alloimmunization is a safe procedure in this era. Patients should be referred to specialist centers prior to the development of hydrops. IUT in a free loop of cord and unnecessary preterm birth are best avoided.

Comparison of matching by body volume or gestational age for calculation of observed to expected total lung volume in fetuses with isolated congenital diaphragmatic hernia

OBJECTIVE

To determine the bias induced by matching fetuses according to gestational age (GA) or fetal body volume (FBV) when calculating the observed to expected total fetal lung volume (o/e TFLV) in cases of isolated congenital diaphragmatic hernia (CDH).

METHODS

This was a single-center, retrospective study on archived magnetic resonance (MR) images of fetuses with isolated CDH over a 10-year period. We retrieved the TFLV, GA and o/e TFLVGA , and delineated FBV to obtain TFLVFBV in each case. We evaluated the relationship between o/e TFLVFBV and o/e TFLVGA by Bland-Altman analysis. All outliers were manually identified, and their specific clinical features were retrieved.

RESULTS

Records of a total of 377 MR examinations of 225 fetuses were identified and included in the analysis. The mean ( ± SD) time spent on FBV measurement was 16.12 ± 4.95 min. On reproducibility analysis of FBV measurement (n = 10), the intraobserver intraclass correlation coefficient (ICC) was 0.998 and the interobserver ICC was 0.999. FBV was highly correlated with GA (R(2)  = 0.899; P < 0.0001). There was good agreement between o/e TFLVGA and o/e TFLVFBV , with a mean difference of -1.10% and 95% limits of agreement of -8.58 to 6.39. There were no outliers in fetuses that had an o/e TFLV < 25%. Discrepancies induced by different methods were more likely in women with a body mass index ≥ 25 kg/m(2) (+16.5%), fetuses with an estimated fetal weight (EFW) ≤ 10(th) centile (+21.3%) or an EFW > 90(th) centile (+14.7%).

CONCLUSIONS

Discrepancies in matching by FBV and GA when calculating o/e TFLV are more likely in fetuses with an abnormal EFW or in fetuses carried by overweight women. The clinical relevance of using FBV rather than GA for calculation of the o/e TFLV might be limited, as there was no discrepancy between the two methods in fetuses with small lungs ( < 25%), which is the group of most interest for lung volume assessment.

Cardiac assessment in fetuses with right-sided congenital diaphragmatic hernia: case-control study

OBJECTIVE

To evaluate cardiac anatomy and function in fetuses with right-sided congenital diaphragmatic hernia (RCDH), and to compare these values with those of normal controls.

METHODS

Fetal echocardiography was performed in 17 consecutive cases with isolated RCDH and 17 gestational age-matched controls. Two-dimensional measurements included ventricular and outflow tract diameters. Doppler ultrasound was used to measure the flow pattern in the ductus venosus and over the pulmonary and aortic valves, right and left ventricular myocardial performance index and the E/A wave ratio over the atrioventricular valves. Stroke volume, cardiac output and shortening fraction were calculated.

RESULTS

Median gestational age at evaluation was 27.4 (interquartile range, 24.4-28.9) weeks. RCDH cases had a significantly smaller right ventricle and pulmonary valve diameter. Furthermore, stroke volume and cardiac output from the right ventricle were lower than in controls. Myocardial contractility, however, appeared normal.

CONCLUSIONS

Despite significantly reduced right ventricular dimensions and cardiac output, cardiac contractility was normal in a cohort of fetuses with RCDH.

Collagen plug sealing of iatrogenic fetal membrane defects after fetoscopic surgery for congenital diaphragmatic hernia

OBJECTIVES

To investigate the efficacy of collagen plugs at reducing the risk of preterm premature rupture of membranes (PPROM) after fetoscopic surgery for congenital diaphragmatic hernia (CDH).

METHODS

This was a single-center cohort study on all consecutive cases undergoing fetoscopic endoluminal tracheal occlusion (FETO) for severe or moderate CDH, between April 2002 and May 2011 (n = 141). Cases either received a collagen plug for sealing the fetal membrane defect after FETO or did not, depending on the operating surgeon. The principal outcome measure was the time from fetal surgery to PPROM, further referred to as 'latency'. A multivariable Cox regression model was used to investigate the association between collagen plug and latency while adjusting for risk factors for PPROM.

RESULTS

Of the 141 cases, 54 (38%) received a collagen plug and 87 (62%) did not. Sixty cases experienced PPROM, 26 among cases with and 34 among cases without a plug (48 vs 39%). The hazard ratio of plug use was 1.29 (95% CI, 0.76-2.19), which does not exclude a potentially increased risk for PPROM when a collagen plug is used. For cases with a plug, 24% had PPROM before balloon removal and 24% had PPROM after elective balloon removal. For cases without a plug, these rates were 30 and 9%, respectively. Perinatal outcomes were similar in both groups.

CONCLUSIONS

No evidence was found that collagen plugs reduce the risk of PPROM after FETO for CDH.

Imaging the fetal central nervous system

The low prevalence of fetal central nervous system anomalies results in a restricted level of exposure and limited experience-- for most of the obstetricians involved in prenatal ultrasound. Sonographic guidelines for screening the fetal brain in a systematic way will probably increase the detection rate and enhance a correct referral to a tertiary care center, offering the patient a multidisciplinary approach of the condition. This paper aims to elaborate on prenatal sonographic and magnetic resonance imaging (MRI) diagnosis and outcome of various central nervous system malformations. Detailed neurosonographic investigation has become available through high resolution vaginal ultrasound probes and the development of a variety of 3D ultrasound modalities e.g. ultrasound tomographic imaging. In addition, fetal MRI is particularly helpful in the detection of gyration and neurulation-- anomalies and disorders of the gray and white matter.

The fetal patient -- ethical aspects of fetal therapy

The pregnant patient is a vulnerable subject, and even more so when a serious fetal condition is diagnosed. (Invasive) fetal therapy should only be offered when there is a good chance that the life of the fetus will be saved, or irreversible damage by the disease or disability is prevented. Following diagnosis of a potentially treatable condition, the patient needs to be referred to a center with sufficient expertise in diagnosis and all therapeutic options. Preferences of the physician towards one or another antenatal intervention is not at stake prior to that moment. When fetal therapy is justified--, it should be offered with full respect for maternal choice and individual assessment and perception of potential-- risks, and should be at the location where there is sufficient expertise. For therapies of unproven benefit, the absence of evidence must be disclosed, and therapy should only be undertaken with full voluntary consent of the mother. These ought to be undertaken within well designed and approved trials and only by experts in the treatment modality. Potential risks and eventual morbidities in case of therapeutic failure should be part of the counselling, neither-- should fetal therapy be presented as an alternative to termination of pregnancy.

Can fetal ultrasound result in prenatal diagnosis of Prader-Willi syndrome?

OBJECTIVE

To define fetal ultrasound characteristics triggering an antenatal diagnosis of Prader Willi syndrome (PWS).

METHODS

Retrospective analysis of sonographic characteristics retrieved from obstetric ultrasound records. All children (n=11) had a postnatal genetically confirmed diagnosis of PWS.

RESULTS

All patients (n=11) showed at least one aspecific abnormality on prenatal ultrasound. Ten out of eleven (90.9 %) had decreased fetal movements, 7 (63.6%) presented in breech position, 7 (63.6%) had severe intra-uterine growth restriction (<5th centile) and 4 (36.4%) showed a polyhydramnios. Immobile flexed limbs and clenched hands were seen in one patient (9.1%). Severe growth restriction combined with polyhydramnios favors the diagnosis in 3/11 cases.

CONCLUSION

Prenatal sonographic phenotype of PWS includes decreased fetal movements, fetal malpresentation, severe intra-uterine growth restriction and polyhydramnios. These findings are not specific to PWS, but the combination of some of them (especially severe intra-uterine growth restriction and polyhydramnios) can prompt clinicians to perform invasive testing leading to a molecular cytogenomic diagnosis prenatally.

The role of magnetic resonance imaging in the diagnostic work-up of fetal ventriculomegaly

The indication for fetal magnetic resonance imaging (MRI) remains a subject of debate, partly because of questions concerning its diagnostic accuracy compared to ultrasound, partly because of practical factors such as accessibility, high costs and available expertise. Most studies advocate an added value for MRI in cases diagnosed with central nervous system pathology. MRI is a good modality to detect small foci of brain hemorrhage, to depict callosal anomalies, to add information about normal and pathological cortical development, and is a more sensitive imaging method to detect white matter pathology. This manuscript discusses the role of MRI as an adjunct to ultrasound for cases diagnosed-- with cerebral ventriculomegaly.

Prenatal diagnosis of congenital renal and urinary tract malformations

Congenital abnormalities of the kidneys and the urinary tract are the most common sonographically identified -malformations in the prenatal period. Obstructive uropathies account for the majority of cases. The aim of prenatal diagnosis and management is to detect those anomalies having impact on the prognosis of the affected child and -requiring early postnatal evaluation or treatment to minimize adverse outcomes. In this paper, we summarize the embryology of kidneys and urinary tract, the normal sonographic appearance through-out pregnancy and the prenatal diagnosis of their congenital malformations.

New crown-rump length curve based on over 3500 pregnancies

OBJECTIVES

The Robinson and Hadlock crown-rump length (CRL) curves are commonly used to estimate gestational age (GA) based on the CRL of an embryo or fetus. However, the Robinson curve was derived from a small population using transabdominal sonography and the Hadlock curve was generated using early transvaginal ultrasound equipment. The aim of this study was to use transvaginal and transabdominal ultrasound to study a large population of early pregnancies to assess embryonic or fetal size, and so create a new normal CRL curve from 5.5 weeks' gestation. We compared this with the Robinson and Hadlock CRL curves.

METHODS

A retrospective database study of CRL in first-trimester embryos was conducted in a fetal medicine referral center with a predominantly Caucasian population. Linear mixed-effects analysis was performed to determine the relationship between CRL and GA. After internal validation of this curve, the CRL was compared with the expected CRL at a given GA according to both the Robinson and Hadlock models based on the paired t-test. Bland-Altman plots were constructed to compare the CRL measurements obtained in our study population with those predicted according to GA by both the Robinson and Hadlock curves.

RESULTS

In total 3710 normal singleton pregnancies with a known last menstrual period were included in the study, corresponding to 4387 scans. Our data differed significantly from both the Robinson and the Hadlock curves (paired t-test, P < 0.0001). A mixed-effects model for CRL as a function of GA was developed on 70% of the data and internally validated with z-scores on the remaining 30%. The new curve extended from 5.5 to 14 weeks' gestation. Compared to our CRL curve, the Robinson curve gave a 4-day underestimation of GA at 6 weeks with a difference in CRL of 3.7 mm and a 1-day overestimation from 11 to 14 weeks with a difference in CRL of 0.9-1 mm. A comparison between our curve and the Hadlock curve showed a difference in CRL of 2.7 mm at 6 weeks, equivalent to an underestimation of 3 days, and a difference in CRL of 4.8 mm at 14 weeks, equivalent to an overestimation of 2 days. At 9 weeks all three curves were similar.

CONCLUSION

The new CRL curve suggests differences in the range of CRL measurements compared with the Robinson and Hadlock curves. These differences are most significant at the beginning and the end of the first trimester, and may lead to more accurate estimations of GA.

Validation of the fetal myocardial performance index in the second and third trimesters of gestation

OBJECTIVES

To test the validity of the myocardial performance index (MPI) and its components against the more conventional methods of fetal cardiac function assessment: the ejection fraction (EF) for systolic function and the E/A index (ratio of transmitral flow during early (E) ventricular filling to flow during atrial (A) contraction) for diastolic function, both in a normal population and in a population at risk for cardiac failure because of volume overload (recipient fetuses in cases of twin-twin transfusion syndrome (TTTS)).

METHODS

The MPI was measured prospectively in addition to more commonly used indices of systolic (EF) and diastolic (E/A index) cardiac function in 117 healthy fetuses (gestational age range, 20-36 weeks) and in 14 fetuses suspected of cardiac failure because of the presence of TTTS. Nomograms were constructed for all variables, and correlations between the MPI, EF and E/A index were assessed. The time taken to obtain the measurements as well as the interobserver and intraobserver variability were determined for the MPI and EF.

RESULTS

In healthy fetuses, the MPI and EF were independent of gestational age, whereas the E/A index and isovolumetric relaxation time (IRT) increased with gestational age. The MPI correlated inversely with the EF (P<0.001). The IRT showed a trend towards an inverse correlation with the E/A index (P=0.10). The mean+/-SD time needed to measure the MPI and EF was 140+/-65 s and 185+/-187 s, respectively (P=0.43). Interobserver and intraobserver intraclass correlation coefficients for the MPI were 0.98 (95% CI, 0.85-0.99) and 0.82 (95% CI, 0.14-0.95), respectively; those for the EF were 0.58 (95% CI, -0.16 to 0.85) and 0.51 (95% CI, -0.46 to 0.83), respectively; and those for the E/A index were 0.97 (95% CI, 0.88-0.99) and 0.91 (95% CI, 0.66-0.98), respectively. All variables, except ejection time, were significantly different between normal fetuses and those with TTTS.

CONCLUSIONS

The MPI is an indicator of the systolic component of fetal left ventricular function that can be easily acquired and reproduced. The MPI is strongly correlated with the EF but shows less interobserver and intraobserver variability.

Obstetric outcome after fetal reduction to singleton pregnancies

OBJECTIVE

To study the outcome after fetal reduction or selective termination to singleton pregnancies for various indications.

METHODS

Fetal reduction or selective feticide to singleton pregnancies was performed in 80 multiple gestations (congenital malformations, 17 cases; high-risk obstetric conditions, 25 cases; or social/psychological indications, 38 cases).

RESULTS

The overall pregnancy loss rate was 10%; however, pregnancy failure was significantly higher in selective reductions performed for preterm prelabor rupture of membranes (PPROM) (4/8) compared with monochorionic twin and bad obstetric history. Fetal reduction to singletons for psychological reasons resulted in a pregnancy wastage of 5.3% (2/38). Procedures performed at < or =14 weeks showed a significantly lower fetal loss rate (2/61; 3.3%), a higher mean gestational age at delivery (38.3+/-2.2 weeks), and a decreased prematurity rate (p< or =0.001). The number of reduced fetuses, prenatal diagnosis by chorionic villus sampling before the reduction and maternal age did not interfere with pregnancy outcome.

CONCLUSION

Fetal reduction to singleton pregnancies has a favorable outcome, especially when performed before 14 weeks of gestation.

Transient fetal hypothyroidism due to direct fetal administration of amiodarone for drug resistant fetal tachycardia

Amiodarone, an anti-arrhythmic drug that contains 39% iodine, is rarely known to cause negative effects on fetal thyroid function after gestational exposure, when given orally to a pregnant woman. Two cases of fetal hypothyroidism after gestational exposure to amiodarone by direct fetal intravenous route are described here.

Uterine artery pseudo-aneurysm: diagnosis and therapy during pregnancy

Arterial aneurysms and pseudo-aneurysms are a rare but recognized cause of obstetric hemorrhage. Diagnosis during pregnancy, prior to rupture, is exceptional. We report the first case of diagnosis and treatment of an uterine artery pseudo-aneurysm during pregnancy.

Outcome of twin gestations after first trimester chorionic villus sampling

OBJECTIVE

To tabulate genetic results and obstetric outcomes of twin pregnancies after first-trimester chorionic villus sampling (CVS).

METHODS

The study included 262 consecutive women with twin pregnancies who had first-trimester CVS between 1988 and 1998.

RESULTS

Major indications for prenatal diagnosis included maternal age (n = 82), pregnancies after intracytoplasmic sperm injection (n = 114), or both (n = 33). Among 524 fetuses, 519 were sampled adequately. Cytogenetic results were incorrect because of sampling the same fetus twice in two pregnancies. In three pregnancies, contamination caused by mixed sampling made cytogenetic results uncertain. Correct genetic diagnoses were obtained in 509 fetuses, 24 of which had chromosomal abnormalities on direct preparations and four of which had monogenetic conditions. Additional invasive procedures were done on five occasions. Fifteen fetuses were terminated selectively. The total fetal loss rate was 5.5% (28 of 509). The indication for the procedure did not significantly determine the fetal loss rate. The mean +/- standard deviation (SD) gestational age at birth was 35.9 +/- 2.9 weeks, and the mean +/- SD birth weights for twins A and B were 2429 +/- 589.1 g and 2378 +/- 588.5 g, respectively.

CONCLUSION

First-trimester CVS is an accurate means of prenatal genetic diagnosis in twins, offering early selective termination in cases of abnormal genetic results in one of the fetuses.

Neonatal screening for congenital cytomegalovirus infections

We evaluated a screening program for the detection of congenital cytomegalovirus in 3075 unselected pregnant women. From each live-born child urine for CMV culture was collected within 7 days after birth. Each fetus expelled after a spontaneous second trimester abortion and each stillborn infant were also evaluated for a possible congenital CMV infection. For each congenital infection stored maternal sera were analysed to determine whether maternal infection was primary or recurrent. Fifteen out of the 3075 pregnancies studied resulted in a congenitally infected infant (0.49%). Nine maternal CMV infections were primary infections; five were recurrent infections, and in one case the type of infection could not be determined. Three congenital infections resulted in severe sequelae, leading to the termination of pregnancy in two instances and to neonatal death in one case. One of these severe fetal infections was due to a recurrent maternal infection. Follow-up of the other 12 neonates demonstrated hearing disorders in two children. One was born after a primary maternal infection and one after a recurrent maternal infection. We conclude that congenital CMV infections occurs in 0.49% of all pregnancies in the population studied. Twenty percent of the congenitally infected infants present severe sequelae at birth or during pregnancy, and an additional 17% have audiological deficits at 1 year of age. Severe sequelae may occur after both primary and recurrent maternal CMV infection.

Obstetric outcome after prenatal diagnosis in pregnancies obtained after intracytoplasmic sperm injection

In this study we compared the pregnancy outcome of 576 pregnancies after prenatal diagnosis with that of 540 pregnancies without prenatal diagnosis in our microinjection programme. Amniocentesis was suggested for singleton pregnancies (n = 465) and chorionic villus sampling (CVS) was proposed for twin pregnancies (n = 111 pregnancies, 222 fetuses). A total of 365 patients with singleton pregnancies and 175 patients with twin pregnancies who did not undergo prenatal diagnosis were selected as controls. Compared with the controls, the odds ratios in the amniocentesis group for preterm delivery, low birthweight, very low birthweight and fetal loss were 0.97 [95% confidence interval (CI): 0.60-1.57], 1.27 (95% CI: 0.78-2.06), 1.57 (95% CI: 0.53-4.66) and 0.86 (95% CI: 0.32-2.37) respectively. Compared with the controls, the odds ratios in the CVS group for preterm delivery, low birthweight, very low birthweight and fetal loss were 0.89 (95% CI: 0.61-1.30), 1.03 (95% CI: 0.74-1.45), 0.79 (95% CI: 0.41-1.53) and 0.47 (95% CI: 0.17-1.30) respectively. We concluded that, in this series of intracytoplasmic sperm injection (ICSI) pregnancies, prenatal testing did not increase the preterm-delivery, the low-birthweight, or the very low-birthweight rates as compared with those of the controls. In the prenatal diagnosis group, the fetal loss rate was comparable to that of the control group. Larger prospective controlled studies are needed in order to inform patients reliably about the risks and the advantages of prenatal testing in ICSI pregnancies.

Fetal ascites associated with an imperforate hymen: sonographic observation

We report a case of fetal ascites in which no abnormalities other than an imperforate hymen were noted. The ascites resolved after abdominal tap and incision of the hymen. A possible mechanism for an association between imperforate hymen and fetal ascites is proposed.

Prenatal diagnosis by chorionic villus sampling in multiple pregnancies prior to fetal reduction

Ovulation induction and assisted-reproduction techniques have dramatically increased the incidence of high-risk multiple pregnancies over the past 10 years. Perinatal outcome may be improved by the use of multifetal reduction. The fetus to be reduced used to be selected only on technical grounds. We report on the results of prenatal diagnosis by chorionic villus sampling (CVS) during the first trimester in 32 multifetal pregnancies in which fetal reduction was requested. The mean gestational age at CVS was 10.5 weeks. Chromosomal analyses were available for all sampled fetuses, three of which were chromosomally abnormal. In 24 couples, fetal reduction to twin pregnancies was successfully carried out within 1 week after the CVS. In seven cases, the couples elected not to proceed with fetal reduction after receiving information that the chromosomal analysis was normal in all fetuses. Mean gestational ages at delivery were, respectively, 34.6 and 31.8 weeks in the reduced and the nonreduced groups (p = 0.04). No fetal losses occurred in either group; one neonatal death was observed after a preterm delivery because of preeclampsia in a twin pregnancy. Prenatal cytogenetic diagnosis during the first trimester in multiple pregnancies prior to fetal reduction appears to be feasible, accurate, and safe. Abnormal chromosomal results indicate the fetus(es) to be reduced. The parents' decisions not to proceed with the fetal reduction procedure, where chromosomal results in all the fetuses were normal, were unexpected.

Selective feticide in twin pregnancies with very early preterm premature rupture of membranes

Nine consecutive multichorionic multiple gestations with early second-trimester (< or =20 weeks) preterm premature rupture of the membranes (PPROM) of the lower gestational sac were managed expectantly. Mean gestational age at PPROM was 17.5 weeks (13-20 weeks), and the mean PPROM delivery time interval was 6.2 weeks (0-11 weeks). A fetal loss of 63% (12 of 19), and a subsequent neonatal loss of 57% (4 of 7) were observed. Of the four pregnancies evolving beyond 25 weeks, three delivered before 30 weeks. The baby take-home rate was 16% (3 of 19). Histologic evidence of chorioamnionitis was present in 5 of 7 (71%) investigated pregnancies. Three other consecutive twin pregnancies were complicated by PPROM of the precervical gestational sac at 13 to 16 weeks of gestation (mean: 15 weeks). In the absence of clinical chorioamnionitis and amniotic fluid, selective feticide with potassium chloride was performed. Pregnancy was successfully prolonged beyond 33 weeks in two cases. The overall PPROM delivery time interval was 21 weeks (20-22 weeks). No neonatal losses were encountered. The baby take-home rate was 66% (2 of 3). Selective feticide of the fetus with early midtrimester PROM in the absence of maternal signs of infection may improve the former unfavorable pregnancy outcome.

Early prenatal diagnosis of oculoauriculovertebral dysplasia or the Goldenhar syndrome

We report a case of the sonographic detection of oculoauriculovertebral dysplasia in a fetus at 15 weeks' gestation. An early diagnosis was suggested by observation of a maxillar cleft in association with unilateral microphthalmia. In the presence of microphthalmia the syndrome is likely to include mental retardation. When the diagnosis is made in the perinatal period, management generally involves cosmetic surgery. If, however, the condition is recognized in the early stages of gestation, termination of pregnancy may be an option.

First trimester chorionic villus sampling in twin gestations

First-trimester prenatal diagnosis was offered to 104 twin pregnancies mainly for advanced maternal age and cytogenetic evaluation of a new fertilization technique. Chorionic villus sampling (CVS) was performed transcervically (35%), transabdominally (23%), or by combination of these two techniques (42%). Although no placental biopsy failures occurred, two errors in fetal sexing were recorded due to non-selective placental sampling. In these two cases, both fetuses were sampled transcervically. Cytogenetic results were available for all fetuses; six of them showed an abnormal direct chromosomal pattern, but long-term villi culture analysis or additional amniocentesis (n = 1) reduced the number to four. Early fetal loss (3.4%) and perinatal mortality (6.3%) after CVS were comparable with a control group of 101 consecutive twin pregnancies without prenatal diagnosis (respectively 6.9% and 5.3%). Perinatal loss in the CVS group was associated in 10 of 12 fetuses with preterm premature rupture of the membranes and consequent preterm delivery. Mean gestational age at delivery, mean birthweight and the frequency of preterm delivery, and low birthweight infants were nearly identical in both groups. This study shows that CVS in the first trimester of pregnancy is an accurate and fast approach for prenatal diagnosis in twin gestations with an acceptable risk of adverse pregnancy outcome. However, a transcervical approach for both fetuses is not recommended.

Single umbilical artery: analysis of Doppler flow indices and arterial diameters in normal and small-for-gestational age fetuses

In this study we examined the value of Doppler flow measurements of the umbilical artery in distinguishing normal fetuses from those with single umbilical artery, and studied the Doppler flow differences and the compensatory arterial dilatation in appropriate (AGA) and small-for-gestational-age (SGA) fetuses with single umbilical artery. The Doppler flow indices (pulsatility index, S/D ratio) and the arterial diameters were prospectively and serially measured in 26 and 15 fetuses with single umbilical artery and without congenital malformations, respectively. Longitudinal changes in Doppler flow indices in normal and SGA fetuses with single umbilical artery are comparable, and are within normal reference ranges for three-vessel cords; there is a fairly constant widening of the single umbilical artery throughout gestation and a mean increase in size of about 1 mm over that found in normal cords from 20 weeks onward. In fetuses with single umbilical artery at mid-gestation, an umbilical artery diameter of more than 4 mm occurred in only 5/15 cases and is therefore not a reliable criterion for single umbilical artery screening prior to 26 weeks of gestation. Doppler flow measurements in normal and SGA fetuses with single umbilical artery are not significantly different from normal fetuses. Compensatory arterial dilatation may prevent fetuses with single umbilical artery from becoming growth retarded.

Fetal hypothyroidism as a complication of amiodarone treatment for persistent fetal supraventricular tachycardia

We present a case of persistent fetal supraventricular tachycardia where transplacental and direct fetal treatment with amiodarone caused an iatrogenic hypothyroidism. This condition was successfully managed with the intra-amniotic instillation of 250 micrograms of L-thyroxine weekly, for 3 weeks. A male infant was delivered at 32 weeks by Caesarean section. The neonatal electrocardiogram showed Wolf-Parkinson-White (WPW) syndrome, which was controlled by digoxin alone. Thyroid function normalized quickly and the baby is developing normally.