César Meller

Association and prediction of amniotic fluid measurements for adverse pregnancy outcome: systematic review and meta‐analysis

Measurements of amniotic fluid volume are used for pregnancy surveillance despite a lack of evidence for their predictive ability.

Feasibility and Safety of Prophylactic Uterine Artery Catheterization and Embolization in the Management of Placenta Accreta

PURPOSE To evaluate the feasibility and safety of prophylactic uterine artery catheterization and embolization in the management of placenta accreta (PA). MATERIALS AND METHODS Retrospective chart review was performed of 95 consecutive patients with prenatal suspicion of PA managed in a 10-year period with a strategy that included prophylactic bilateral uterine artery catheterization, delivery of the baby, uterine artery embolization if indicated, and subsequent surgery. Feasibility was defined as catheterization being possible to perform, technical success as embolization being possible when indicated and complete stasis of the vessels achieved, and clinical success as no maternal death or major blood loss. Median gestational age at delivery was 36 weeks (interquartile range, 24-39 wk). RESULTS PA was confirmed in 79 patients (83%). Feasibility was 97% (92 of 95); in three cases (3%), acute early massive hemorrhage forced emergency delivery without catheterization. Embolization was performed in 83 of 92 patients (87%) to the extent of complete stasis; in the remaining nine, it was unnecessary because spontaneous placental detachment was visualized after fetal delivery (technical success rate, 100%). There were several complications, including bleeding requiring blood transfusion (49%) and bladder surgery (37%), but there were no major complications attributable to the endovascular procedures. There was one minor complication presumably related to embolization (transient paresthesia and decreased temperature of lower limb), with uneventful follow-up. Clinical success rate was 86%, with no maternal deaths, but 14% of patients received large-volume blood transfusion. CONCLUSIONS Prophylactic uterine artery catheterization and embolization in the management of PA appeared to be feasible and safe in this consecutive series of patients.

Prenatal Diagnosis of Isolated Right Pulmonary Agenesis Using Sonography Alone Case Study and Systematic Literature Review

Pulmonary agenesis is a rare congenital anomaly, estimated to complicate around 1 per 15,000 pregnancies, in which there is complete absence or severe hypoplasia of one or both lungs, frequently associated with other abnormalities. A prospective prenatal diagnosis is a challenge, and a substantial proportion of cases are diagnosed by fetal magnetic resonance imaging, postnatal computed tomography, or postmortem. Thus, there are only a few reported cases of prenatal diagnosis in the literature. We report the prenatal diagnosis of isolated right lung agenesis diagnosed with sonography alone at a relatively early gestational age. We also present a systematic review of the literature for this condition to accompany this case study.

Stomach in Contact with the Bladder: A Sonographic Sign of Left Congenital Diaphragmatic Hernia.

The evaluation of the characteristics of the fetal stomach should be part of every routine prenatal ultrasound after 11 weeks. A position that has not been previously described in the literature is the stomach in contact with the bladder. We describe 6 cases with the ultrasonographic finding of the stomach in contact with the bladder, all of them in fetuses with left-sided congenital diaphragmatic hernia. Even though the reasons for this striking position of the stomach are not clear, our series highlights the fact that the visualization of the stomach in contact with the bladder may be a specific sonographic marker of congenital diaphragmatic hernia.

Prenatal diagnosis of congenital heart disease: improving survival

We read with interest the article, ‘Prenatal diagnosis of critical congenital heart disease reduces risk of death from cardiovascular compromise prior to planned neonatal cardiac surgery: a meta-analysis’, by Holland et al.1, in which the authors noted that prenatal diagnosis was associated with a reduction in the risk of death prior to planned cardiac surgery relative to the risk in patients with comparable postnatal diagnosis. However, the intention-to-treat analysis did not show a significant decrease in the prenatal diagnosis group because of the death of a patient who did not receive optimal newborn care. As the authors state, failure to follow the optimal postnatal pathway, even with prenatal diagnosis, is an important practical consideration in fetal medicine. In our country, as in many others, prenatal diagnosis of congenital heart disease (CHD) is usually made in the third trimester (in our series the mean gestational age was 29.9 ± 5 weeks at initial assessment)2 and it is not possible to refer all patients to a tertiary healthcare center because of scarce resources2. In this context, we have developed a prediction model based on prenatal ultrasonographic findings to estimate the probability of the need for neonatal cardiac invasive therapy, defined as heart surgery or catheter-based therapy performed during the first month of postnatal life for clinical stabilization or for life-saving purposes2. In the limited-resource scenario of lowand mid-income countries2,3, this score may be a tool to aid non-specialist physicians in fetal medicine or fetal cardiology in their decision regarding referral. However, we agree with Gardiner, in her Opinion article in the same issue3, on the importance of the development of networks between maternity units and the specialist cardiac center. Moreover, we have reported a reduction in economic costs when comparing cases with prenatal and those with postnatal diagnosis of CHD4. We therefore believe that the importance of three points should be emphasized: first, improving the prenatal detection rate of CHD because it reduces the risk of death1; second, timely in-utero referral, if needed, in order to follow the optimal postnatal pathway – hand in hand with this, efforts should be made to achieve diagnosis earlier in pregnancy; third, even with early prenatal diagnosis, focusing on proper allocation of resources, not referring those patients who do not need referral and directing efforts towards those patients who would benefit from this policy.

Re: Balancing the efficacy and safety of misoprostol: a meta‐analysis comparing 25 versus 50 μg of intravaginal misoprostol for the induction of labourSafety of 25‐μg intravaginal tablet of misoprostol for the induction of labour

Sir, We thank colleagues Ramaekers, Mannaerts, and Jacquemyn for their positive comments on our article. They report a markedly lower detection rate for severe congenital heart disease (CHD) in a comparable population, despite efforts to adequately train all ultrasonographers. They state that certification and permanent quality control may be an important determinant in our detection rates. Although the aim of the study was not to compare the monitoring system in the Netherlands with other systems, we do agree that quality control may contribute to our good results. In the Netherlands, prenatal screening is centrally organised, with a uniform protocol and regulations. The quality control is divided in eight prenatal screening regions, affiliated with the eight academic fetal medicine units and clinical genetics departments. These eight regions are responsible for and carry out quality monitoring of prenatal screening. In this system, licensing is compulsory. In order to perform anomaly scans, an ultrasonographer requires a license from one of the acknowledged training institutes, as well as a contract with one of the eight prenatal screening regions. Without these prerequisites, insurance companies will not reimburse. National regulations on quality management of the anomaly scan comprise a minimal number of anomaly scans per year (250 per year for starters, and 150 per year for experienced ultrasonographers) and a biannual review of their anomaly scans: the regional quality manager checks images of five randomly selected anomaly scans and scores these scans according to a nationally developed scoring system. We believe that these measures help to maintain the high quality of the anomaly scans. The cost-effectiveness of this quality monitoring system has not been investigated. The cost of a routine anomaly scan in the Netherlands is €160, of which €17 is used to run the regional centres. The overhead costs of the National Health Service (RIVM) must also be taken into account. On the other hand, missed congenital defects would also introduce costs to society. These types of costs are extremely difficult to compare. We agree with Ramaekers et al. that if prenatal screening is offered to women, then quality monitoring should be mandatory, and we strongly believe that the Dutch quality monitoring system contributed to our CHD detection rates. We did not, however, elaborate on these details extensively in our article, as the system itself was not our topic of study. The comment from Ramaekers et al. provides us with a welcome opportunity to explain more about this important underlying aspect of our study.&

Comment on “Secondary bladder herniation in isolated gastroschisis justifies increased surveillance”

We read with interest the article ‘Secondary bladder herniation in isolated gastroschisis justifies increased surveillance’ by Mousty et al., where the authors propose that bladder herniation seems to be a risk factor for perinatal death. Out of 37 cases of gastroschisis with confirmed perinatal outcome managed in a 10-year period at our institution, Hospital Italiano de Buenos Aires, 1/37 (2.7%) was associated with secondary bladder herniation and resulted in an intrauterine death (IUD) at 29weeks’ gestation. A 20-year-old woman, gravida 1, with a diagnosis of gastroschisis at 13 weeks’ gestation, was referred at 22weeks to our institution. A detailed scan confirmed the diagnosis and showed only the small bowel protruding from the abdomen, with the remaining anatomy within normal limits, including the bladder in the pelvis and a three-vessel umbilical cord. A sonographic examination at 29 + 1 weeks showed a normally grown fetus (49th centile), with normal amniotic fluid volume and normal Doppler, but with bladder herniation and only one umbilical artery visualized with Color Doppler (Figure 1). There was neither hydronephrosis nor bowel dilatation. We planned a weekly follow-up, but 72 h later, the patient was admitted with an IUD. An induction of labor and a vaginal delivery were performed, with a female fetus that weighed 1460 g. The autopsy described a gastroschisis with herniation of the bowel, with hemorrhagic necrosis of some loops of the bowel and peritonitis, herniation of the bladder, and thrombosis of one of the umbilical vessels (Figure 2).

Number of Yolk Sacs in the Diagnosis of Monoamnionicity

In a monochorionic twin pregnancy, differentiation between diamniotic and monoamniotic is extremely important and may not always be easy. Classically, the diagnosis of monoamnionicity was based on the absence of the intertwin membrane, visualization of cord entanglement, and the presence of only one yolk sac early in the first trimester. However, recently the “one yolk sac is monoamniotic, and two yolk sacs is diamniotic” concept has been challenged.1–3 A 39-year-old patient, gravida 5, para 2, presented for obstetric care at 10 weeks’ gestation. Sonography (Xario; Toshiba Medical Systems Co, Ltd, Tokyo, Japan) showed a twin pregnancy with two embryos, one chorion, and two yolk sacs (Figure 1A). Although the amniotic sacs and a dividing membrane were not clearly seen, the presence of two yolk sacs led to the diagnosis of a monochorionic diamniotic pregnancy. Two weeks later, the absence of the intergestational membrane was confirmed, and the scan showed umbilical cord entanglement, confirming the diagnosis of a monochorionic monoamniotic gestation

PP.23 Measurements of Amniotic Fluid: Association and Prediction of Small For Gestational Age and Compromise of Fetal Wellbeing: A Systematic Review and Meta-Analysis

Objective Evaluate the strength of association and predictive value of measurements of amniotic fluid volume (AFV) for small for gestational age and compromise of fetal wellbeing. Design Systematic literature review with random effects meta-analysis to compute summary odds ratios (OR) to assess prognostic association and assess predictive ability with sensitivity, specificity and likelihood ratios. Study characteristics, design, methodological and reporting quality were objectively assessed. Data Sources and Eligibility Systematic search (inception to October 2011) for studies comparing AFV measures and outcomes of fetal size or wellbeing. Results 43 studies reporting 244,493 fetuses included. Strong associations between oligohydramnios (heterogenic definition) and birth weight < 10th centile [OR 6.31 (4.15–9.58)] in a high risk population (6 studies, 28510 fetuses), and mortality [Neonatal death OR 8.72 (2.43–31.26) 6 studies, 55735 fetuses, and perinatal mortality in a high risk population OR 11.54 (4.05–32.9) 2 studies, 27891 fetuses] were identified. There was no significant association between oligohydramnios and abnormal cord pH or adverse perinatal outcome. There was no significant association between polyhydramnios (heterogenic definitions) and poor fetal growth [Birth weight < 10th centile OR 0.37 (0.07–1.95)]. A strong association between polyhydramnios (maximum pool depth > 8 cm or amniotic fluid index ≥ 25 cm) and birth weight > 90th centile [OR 11.41 (7.09–18.36) 1 study, 3960 fetuses] was found. Despite strong associations predictive ability was poor with significant heterogeneity despite sub-group analysis. Conclusion Oligohydramnios is associated with poor fetal growth and mortality. Polyhydramnios is associated with BW > 90th centile. Despite strong associations, overall predictive ability was poor. MPD accuracy was slightly improved over AFI and is the recommended technique.

Sonographic detection of open spina bifida in the first trimester: review of the literature

In the beginnings, sonographic diagnosis of open spina bifida (OSB) relied on the meticulous scanning of the fetal vertebrae for abnormalities but many defects were missed. After the mid-1980s, however, with the description of the intracranial findings in the second trimester (the “lemon sign” and the “banana sign”), the prenatal diagnosis of OSB was enhanced. In the last 2 decades, there has been widespread uptake of routine ultrasound examination in the first trimester of pregnancy with the purpose of the measurement of fetal crown-rump length to determine gestational age, to screen for trisomy 21 and other aneuploidies, mainly with the nuchal translucency, and for diagnosis of many major abnormalities. Many papers were published focusing on early diagnosis of myelomeningocele (MMC), and the objective of this review is to summarize the different techniques described regarding prenatal diagnosis of OSB in the first trimester of pregnancy.