Second-trimester intra-abdominal bowel dilation in fetuses with gastroschisis predicts neonatal bowel atresia

OBJECTIVE

To determine in fetuses with gastroschisis the association between intra-abdominal bowel dilation in the second trimester and neonatal bowel atresia.

METHODS

We reviewed ultrasound and medical records of fetuses with gastroschisis from January 1998 to August 2004. Fetuses with intra-abdominal bowel dilation in the second trimester were identified and followed into the neonatal period.

RESULTS

We identified 58 mother-infant pairs showing fetal gastroschisis, with at least one prenatal ultrasound at our hospital and which were delivered there, or were transported there as newborns. Forty-eight of the 58 fetuses had no intra-abdominal bowel dilation and none of these neonates had bowel atresia. Ten of the 58 fetuses had intra-abdominal bowel dilation and all had bowel atresia at birth (P<0.0001). In eight cases in which ultrasound was performed at <25 weeks' gestation, intra-abdominal bowel dilation was already present.

CONCLUSION

Intra-abdominal bowel dilation in the second trimester predicts neonatal bowel atresia in fetuses with gastroschisis.

Predicting the outcome of newborns with gastroschisis

OBJECTIVE

The objective of the study was to determine factors predicting outcome in newborns with gastroschisis.

METHODS

A retrospective analysis of 155 consecutive cases admitted from 1 January 1990 to 31 December 2007 was performed. Prenatal ultrasound findings were available for 89 of 155 (57%) patients and were compared with final outcome. Both univariate and multiple regression analyses were used.

RESULTS

All patients survived to discharge home. The primary outcome measure was length of stay. Multiple regression identified 4 factors associated with length of stay: (1) gestational age (P = .004), (2) nonelective silo (P < .001), (3) gastrointestinal (GI) complication (intestinal atresia, perforation, or resection) (P < .001), and (4) non-GI anomaly (P = .029). Non-GI anomalies occurred in 17 of 155 (11%) patients and tended to increase the risk of a nonelective silo or GI complication (59% vs 39%, P = .190). Dilated bowel (>10 mm) on prenatal ultrasound was associated with GI complications (22% vs 3%, P = .010). However, 78% of patients with dilated bowel on prenatal ultrasound did not have a GI complication. The absence of dilated bowel on prenatal ultrasound accurately predicted the absence of GI complications in 97% of cases.

CONCLUSION

Prematurity, nonelective silo, GI complications, and non-GI anomalies predict the short-term outcome of newborns with gastroschisis. Prenatal ultrasound serves primarily to predict the absence of GI complications.

Overexpression of RET leads to vesicoureteric reflux in mice

RET, a tyrosine kinase receptor essential for kidney development, has recently been shown to be important for the formation of the urinary tract. When RET is overexpressed in the HoxB7/Ret transgenic mouse, kidneys are small and cystic, and in some of the mice, the ureters are grossly dilated. Here, we report that the observed ureteral dilatation is associated with the urinary tract abnormality vesicoureteric reflux (VUR), in which urine flows retrogradely from the bladder to the ureter. Reflux was determined in vitro by injecting methylene blue into the bladders of HoxB7/Ret and wild-type mice. At postnatal day 1, 30% of HoxB7/Ret mice had VUR compared with 4% of wild-type mice (P < 0.05). The length of the intravesical ureteral tunnel was shorter in HoxB7/Ret mice compared with wild-type mice, on both the right and the left sides (P < 0.05), suggesting a basis for the higher incidence of VUR in these mutants. At embryonic day 11, the ureteric bud was found to exit more caudally from the mesonephric duct in HoxB7/Ret mice, and this may predispose them to VUR (P < 0.05). Wild-type and HoxB7/Ret mice were tested for reflux at embryonic day 17, and both showed a high frequency of VUR (59 and 75%, respectively). These results suggest that VUR may occur transiently during normal urinary tract development before the ureter has completed its insertion into the bladder. In the HoxB7/Ret mouse, overexpression of RET appears to delay the maturation of the distal ureter, resulting in postnatal VUR. The HoxB7/Ret mouse is thus an important model in which to examine how vesicoureteric reflux arises during urinary tract development.

Serial transverse enteroplasty as primary therapy for neonates with proximal jejunal atresia

Small bowel atresia is associated with a large size discrepancy between the proximal and distal segments of bowel that has traditionally been managed by resection of the dilated segment, tapering enteroplasty, or plication. Longitudinal intestinal lengthening is rarely performed at the time of the initial operation. Many patients with small bowel atresia also have a short length of residual small intestine secondary to in utero resorption. The authors present the clinical application of the novel intestinal lengthening procedure, the serial transverse enteroplasty, in a neonate with proximal jejunal atresia and suggest that it become part of the armamentarium for surgeons treating patients with this anomaly.

Reduced subcommissural organ glycoprotein immunoreactivity precedes aqueduct closure and ventricular dilatation in H-Tx rat hydrocephalus

The H-Tx rat has fetal-onset hydrocephalus associated with closure of the cerebral aqueduct and a reduction in the secretory cells of the subcommissural organ (SCO), a circumventricular organ situated in the dorsal wall of the cerebral aqueduct. The objective of this study was to determine the role of the SCO in hydrocephalus pathogenesis. Serial brain sections through aqueduct regions containing the SCO from H-Tx rats, together with non-hydrocephalic Fischer F344 rats, were studied at E16, before hydrocephalus onset, at E17, the beginning of onset, and at P0 when the hydrocephalus was overt. Tissues were immunostained by AFRU, an antibody against the SCO glycoprotein, and for the intermediate filament nestin. The area of SCO cells with AFRU immunostaining and the severity of lateral ventricle dilatation were quantified by image analysis. At E16 all fetuses had distinct SCO ependymal cells, open aqueducts and normal lateral ventricles. The H-Tx fetuses fell into two groups with large areas and small areas of AFRU immunoreactivity, all with a full complement of SCO cells. By E17, fetuses with small areas of immunoreactivity had reduced numbers of tall SCO secretory cells, and most had aqueducts closed posteriorly and dilated ventricles. Three additional fetuses with small areas of immunoreactivity had narrow but patent aqueducts and normal ventricles, and another had an open aqueduct and dilated ventricles. At P0, pups previously identified as hydrocephalic had small areas of AFRU immunoreactivity, an aqueduct that was closed anteriorly but open posteriorly, ventricular dilatation, and an absence of SCO secretory cells. The aqueduct even when closed was lined by typical ependymal cells throughout. Decreased nestin immunostaining accompanied the SCO changes. It is concluded that reduced SCO glycoprotein immunoreactivity precedes both aqueduct closure and expansion of the lateral ventricles in the H-Tx rat.

Ectasia of the rete testis with ipsilateral renal agenesis

Scrotal masses are a common problem in children. Cystic lesions usually are found to be hydroceles, while solid masses suggest the possibility of neoplasia. A rare cause of a cystic scrotal mass is ectasia of the rete testis. A review of the literature reveals only 1 case similar to the patient herein described. Both patients had agenesis of the ipsilateral kidney, which explained on the basis of the embryologic overlapping of the genitourinary system. Our patient bears clinical similarity to the ACI rat and correlation is made with this animal model system. Excision of the multiloculated rete testis cyst, rather than orchiectomy, appears to be curative.

A hypothesis for the higher incidence of vesico-ureteral reflux and primary megaureters in male babies

The authors propose a new explanation for the male preponderance in cases with prenatally diagnosed vesico-ureteral reflux and primary megaureters. The theory is based on conclusions drawn from the characteristics of 4 patients (3 perinatal cases and 1 occurring in a 14-year-old boy) presenting with unusual anomalies of the lower urinary tract. In this hypothesis, the male preponderance could be related to an abnormal dilatation of the posterior urethra occurring during the embryological development of the male urethra. The dilatation leads to a flap valve mechanism and to a functional obstruction of the bladder outlet and finally to secondary dilatation of the upper urinary tract. This obstruction may be transitory; reflux and megaureters found in utero or after birth could be considered as sequellae of this phenomenon.

Outcome of fetal pyelectasis diagnosed antenatally

Renal pelvis dilatation is a common anomaly detected at the 20-week anomaly scan. The aim of this study was to evaluate the postnatal outcome of fetal pyelectasis in an unselected obstetric population. This was a retrospective study of fetal pyelectasis detected at midtrimester anomaly scan. Fetal pyelectasis was classified as mild if the anteroposterior renal pelvis diameter measured >5 mm-< or= 7 mm, moderate >7-< or = 10 mm and severe as >10 mm. Persistant fetal pyelectasis was defined as >7 mm in the third trimester.

RESULTS

During the study period fetal pyelectasis was identified in 74 women. 6 were excluded, as case records were not available. Mild pyelectasis was identified in 38/67(56.7%), moderate pyelectasis in 20/67(29.8%) and severe pyelectasis in 9/67(13.4%). None of the infants in the mild pyelectasis subgroup required surgery. 3/29(10%) in the moderate and severe pyelectasis subgroup required postnatal surgery. Of the 38 with mild fetal pyelectasis 13.1% had a positive postnatal diagnosis out of which 7.9% had vesico-ureteric reflux, 2.6% renal dysplasia and 2.6% pelvi-ureteric junction (PUJ) stenoses.

CONCLUSION

74% of pregnancies in the mild pyelectasis subgroup demonstrated spontaneous resolution. However persistent mild pyelectasis may lead to postnatal morbidity and should be followed up.

Embryonic hydromyelia: cystic dilatation of the lumbosacral neural tube in human embryos

In a large collection of human embryos (the Kyoto Collection of Human Embryos, Kyoto University), we encountered five cases with abnormal dilatation of the neural tube at the lumbosacral level. In these examples, the central canal was enlarged, and the roof plate of the neural tube was extremely thin and expanded. The mesenchymal tissue was scarce or lacking between the roof plate and the surface ectoderm. This type of anomaly was assumed to be formed after neural tube closure and may be an early form of spina bifida. In two of the cases, some abnormal cells were found ectopically between the thin roof plate and the surface ectoderm. Morphologically, these cells resembled those forming spinal ganglia and could be of the neural crest origin. Since neural crest cells are pluripotent and can differentiate into a variety of tissues, such ectopic cells might undergo abnormal differentiation into teratomatous tumors and/or lipomas, which are frequently associated with spina bifida. We also discuss the definition of spina bifida and the classification of neural tube defects from the embryological and pathogenic viewpoints and propose a new classification of neural tube defects.

Mild pyelectasis diagnosed by prenatal ultrasound is not a predictor of urinary tract morbidity in childhood

OBJECTIVES

To determine whether children with prenatally diagnosed mild pyelectasis have more urinary tract morbidity during childhood than children without this finding.

METHODS

Case-control study in children with pyelectasis (anteroposterior diameter of the fetal renal pelvis of 5-10 mm). A validated questionnaire was sent to the parents of 208 cases and 416 matched controls.

RESULTS

The questionnaire was returned by 146 cases and 250 controls. There was a male predominance in the case group (p = < 0.0001). There was no difference in voiding habits or in prevalence of urinary tract infections (UTI). The prevalence of UTI was high: 11.6% in cases and 10.0% in controls. The only difference was a higher prevalence of constipation in the case group (p = 0.003). Postnatally, 41 children had an ultrasound examination and 16 were referred to a paediatrician or urologist: 3 had persisting pyelectasis, 3 had a recurrent UTI and 1 required surgery (a pyeloplasty). Four of the controls were referred to a paediatrician or urologist: 3 had recurrent UTI and 1 had urinary incontinence.

CONCLUSION

Children with a mild fetal pyelectasis do not have more urinary tract morbidity during childhood than children without this finding. Therefore, there seems to be no need for additional investigation after birth.

Fetal obstructive uropathy: is urine sampling useful for prenatal counselling?

OBJECTIVES

To evaluate whether fetal urinary sodium and chloride provide clinically useful information in addition to ultrasound in bilateral obstructive uropathy.

METHODS

Sonographic features and urinary concentrations of sodium and chloride were evaluated in fetuses with bilateral obstructive uropathy. After a minimum of 12 months of postnatal follow-up, cases that developed increased serum creatinine (greater than 50 micromol/L) were compared with those that did not.

RESULTS

Of the cases studied, 16/35 died perinatally, all showing anamnios and markedly elevated urinary electrolytes. Of the survivors, ten maintained normal postnatal serum creatinine, whereas nine did not. The frequency of reduced amniotic fluid/olygohydramnios was higher in cases that developed increased serum creatinine (four out of nine) than in those that did not (nil). Sodium above the 95th percentile was 100% specific and 44% sensitive to predict an increased serum creatinine during early infancy, while chloride above the 95th percentile was 70% specific and 56% sensitive. All seven cases in which urinary sodium was elevated and/or amniotic fluid volume was reduced developed renal failure.

CONCLUSION

Urine sampling slightly improved renal function prediction, but this must be balanced against its fetal risks.

Congenital segmental dilatation of the colon with anorectal malformation

Segmental dilatation of the colon is a rare entity. The authors report unique case of segmental dilatation of the cecum and ascending colon with high anorectal malformation in a newborn, and the possible embryogenesis of this condition is discussed.

Sonography of fetal micturition

OBJECTIVE

To describe the sonographic visualization of fetal micturition and its role in the diagnosis of posterior urethral valves and hypospadias.

METHODS

This was a prospective study of 25 male fetuses (21 with bilateral pyelectasis, one whose bladder was being studied because of ureterocele and three with hypospadias), and five female fetuses (with bilateral pyelectasis). A midline sagittal scan of the fetal pelvis, perineum and external genitalia was obtained and observed continuously during fetal micturition.

RESULTS

In 19 of the 21 male fetuses and the five female fetuses with bilateral pyelectasis micturition was normal, with visualization of urinary bladder contraction, slight fluid distention of the urethra and a urinary stream from the external urethral meatus. In three male fetuses, two with bilateral pyelectasis and the one with ureterocele, the posterior urethra was normal at rest and it ballooned out during micturition, diagnostic of posterior urethral valves. In the three male fetuses with hypospadias the ventral jet of the urinary stream was visualized.

CONCLUSION

Fetal micturition can be visualized on sonography. It may be of value in the diagnosis of posterior urethral valves and hypospadias.

Megacystis microcolon intestinal hypoperistalsis syndrome with bilateral duplicated systems

A 29-year-old multigravida woman presented for her second prenatal ultrasound evaluation at 30 weeks of gestation. The study showed a female fetus, bilateral duplicated systems with severe hydronephrosis in the upper pole moieties and a massively distended bladder. Initial interpretation suggested ectopic/obstructing bilateral ureteroceles. To evaluate these findings further, a prenatal magnetic resonance imaging scan was obtained, documenting the absence of ureteroceles. The presumptive diagnosis of megacystis microcolon intestinal hypoperistalsis syndrome was made. After birth, contrast enema confirmed the presence of microcolon. This appears to be the first reported case of megacystis microcolon intestinal hypoperistalsis syndrome with bilateral duplex systems evaluated with prenatal magnetic resonance imaging.

Visual development in infants with prenatal post-haemorrhagic ventricular dilatation

OBJECTIVE

The aim of this study was to assess visual function in 13 infants with evidence of prenatal post haemorrhagic ventricular dilatation.

DESIGN

Infants were assessed at 5, 12 and 24 months using a battery of tests specifically designed to assess various aspects of visual function in infancy. Visual findings were correlated with several variables, including extent of the lesion and presence of epilepsy.

RESULTS AND CONCLUSIONS

Abnormalities of visual function were frequent (over 60%) in our cohort at age 2 years, ranging from isolated abnormal ocular movements to severe abnormalities of all the aspects of visual function assessed. The most severe and persistent abnormalities of visual function were found in infants with grade IV intraventricular haemorrhage and shunted hydrocephalus who also had epilepsy in the first year.

Multiple jejunoileal atresia and colonic atresia managed by multiple primary anastomosis with a single gastroperineal transanastomotic tube without stomas

Multiple jejunoileal atresia is a challenge to the pediatric surgeon. The aim of the study is to preserve bowel length and prevent the long-term complications of short bowel syndrome. The authors present a rare case of combined multiple jejunoileal atresia and colonic atresia managed by 9 primary anastomoses over a gastroperineal transanastomotic tube. This technique avoided the use of stomas and their attendant complications.

Fetal intra-abdominal bowel dilation in prediction of complex gastroschisis

OBJECTIVE

To investigate intra-abdominal bowel dilation (IABD) in the prediction of complex gastroschisis.

METHODS

This was a retrospective study of 174 singleton pregnancies with isolated fetal gastroschisis, resulting in live birth and with available ultrasound images from visits at both 20-22 and 30-32 weeks' gestation. IABD was measured as the greatest transverse diameter of the most dilated intra-abdominal bowel segment, by an operator blinded to postnatal outcome. The distribution of IABD measurements in those with complex and those with simple gastroschisis was determined and the best cut-off value to predict complex gastroschisis was selected using receiver-operating characteristics (ROC) curves. The area under the ROC curve (AUC), detection rate (DR), false-positive rate (FPR), positive predictive value (PPV) and negative predictive value (NPV) were determined.

RESULTS

The study population included 39 (22.4%) cases of complex and 135 (77.6%) cases of simple gastroschisis. In the prediction of complex gastroschisis, the AUC at 20-22 weeks' gestation was 0.742 (95% CI, 0.628-0.856) and the respective value for 30-32 weeks was 0.820 (95% CI, 0.729-0.910). At the IABD cut-off of 7 mm at 20-22 weeks, DR, FPR, PPV and NPV for complex gastroschisis were 61.5%, 6.7%, 72.7% and 89.4%, respectively, and at IABD cut-off of 14 mm at 30-32 weeks, the respective values were 64.9%, 5.9%, 75.0% and 90.7%.

CONCLUSION

Measurement of IABD at 20-22 or at 30-32 weeks' gestation is useful in the prediction of complex gastroschisis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Prenatal ultrasound in the prediction of bowel obstruction in infants with gastroschisis

OBJECTIVE

To assess the value of prenatal ultrasound in predicting bowel obstruction requiring surgery in fetuses with prenatal diagnosis of gastroschisis.

METHODS

The database of our center was searched for cases with an antenatal diagnosis of gastroschisis. The ultrasound images were reviewed blindly to assess the presence of intra- or extra-abdominal bowel dilatation. Details of surgical procedures were noted and the discharge letters were obtained. Pediatric follow-up was also obtained from pediatric surgeons, general practitioners or parents.

RESULTS

In the 10-year period between November 1998 and September 2008 there were 62 cases with a prenatal diagnosis of gastroschisis. Postnatal outcome was not available for five cases, four pregnancies underwent termination and intrauterine fetal demise occurred in five cases. A final population of 48 liveborn infants was available for analysis. Intra-abdominal bowel dilatation was identified in 14 of these 48 fetuses (29.2%) and extra-abdominal bowel dilatation in 30 (62.5%) fetuses on prenatal ultrasound images. Eight fetuses (16.7%) had bowel obstruction. The relative risk of bowel obstruction with intra-abdominal bowel dilatation was 4.05 (95% CI, 1.12-14.70). On the other hand, the relative risk of bowel obstruction with extra-abdominal bowel dilatation was 1.0 (95% CI, 0.37-3.70). Four babies died, two of whom had intra- and one had extra-abdominal bowel dilatation.

CONCLUSIONS

Intra-abdominal dilatation of the bowel on prenatal ultrasound examination appears to predict postnatal bowel obstruction and the need for surgical resection. Extra-abdominal bowel dilatation is observed frequently on prenatal ultrasound scans, but is not predictive of bowel obstruction.

Uterine contractions might increase heart preload in the recipient fetus in early-onset twin-twin transfusion syndrome: an ultrasound assessment

OBJECTIVES

Uterine contractions (UC) in twin pregnancy are often experienced, yet the effects of UC in twin-twin transfusion syndrome (TTTS) remain to be clarified. The recipient heart preload condition and the effects of UC were evaluated and the final objective was to clarify the effects of tocolysis.

METHODS

Firstly, the preload indexes (PLIs) and cardiothoracic area ratios (CTARs) were analyzed on both fetuses of 10 TTTS cases, aged from 14 to 28 gestational weeks in stage III/IV cases for evaluating the preload condition. Then, the PLIs in the presence and absence of UC in the recipient fetuses were determined to evaluate the difference.

RESULTS

The PLIs of the recipient and the donor fetuses were 0.78 +/- 0.34 (n = 163) and 0.35 +/- 0.13 (n = 71) respectively. The CTARs were 30.2 +/- 6.1 (n = 62) and 23.4 +/- 5.4 (n = 62) respectively. The PLIs in the absence and presence of UC in the recipient fetuses were 0.69 +/- 0.29 and 0.99 +/- 0.38 (n = 35). All above comparisons showed highly significant differences (p < 0.0001).

CONCLUSION

The recipient fetuses have signs of cardiac dilatation and a high-preload condition. UC transiently further raises high-preload conditions of the recipient fetus. Thus, tocolysis may be necessary for management in cases of early-onset severe TTTS.

Megautricles: embryogenic hypothesis

We present 4 cases of megautricle emphasizing the relationship between it and the ejaculatory ducts. We develop an embryogenic hypothesis to explain the different forms of megautricles in relation to the seminal pathway.

[Prognostic value of neonatal pyelectasia diagnosed in utero]

Sixty-six children (48 male-18 female) with prenatal diagnosis of pyelectasia that was conformed at birth were examined between 1986-1994. All newborns carried out urinalysis and urine culture and performed a renal sonogram to reconfirm the diagnosis at 1 month of age. After 3 month of life the pelvic dilatation was confirmed in 61 patients while 5 showed a complete disappearance, 61 patients underwent micturitional cystography that evidenced 30 renal units (RU) with moderate to severe vesicoureteral reflux. In the patients without reflux, a scintigraphy was carried out with DTPA or MAG 3 and/or IVP and evidenced a functional junctional pathology in 32 RU and an organic junctional pathology in 24 RU, a primary megaureter with pre-vesical stenosis in 6 RU and a pyelo-ureteral complete double system in 4 RU. The patients with organic stenosis or those patients with parenchymal damage due to the vesicoureteral reflux underwent surgical intervention during the 1st year of life while all the remaining patients are continuously monitored to date with biohumoral exams and echography. With these results we can safely confirm the important role of the sonogram in the initial diagnosis of pyelectasia and to its eventual modifications in order to benefit the patients with a nephro-urological pathology and direct them toward a correct follow up.

[The role of transforming growth factor-beta (TGF-beta) in the pathogenesis of primary megaureter. A histological and immunocytochemical study]

Histologic and Transforming Growth Factor Beta (TGF-beta) immunostain patterns were sought in resected distal urinary tracts from 17 Primary Megaureter (PM) affected children, referred to surgery. Comparative observations were also carried out on embryonal and fetal ureteral buds of both humans and bovines. A reciprocal resemblance was mainly objectivized between the resected "narrowed" ureters of patients under 18 months, and the fetal ureteral buds at 26th and 38th gestational week. A development delay was irrespectively observed in PM "narrowed" ureters, at the longitudinal muscle-bundles in the parietal juxta-luminal compartment. A consistent TGF-beta immunostain cytoplasmic reaction there selectively depicted the growing mesenchymal lines, including both the undifferentiated single cells and the muscle-like profiled ones. These results agree with very recent reports perspecting a segmental maturation delay as a pathogenetic moment of PM. Because of the acquired potent TGF-beta inhibitory role on myoblasts differentiation, the present study substantiates a persistent TGF-beta role in perinatal ureter dilations.