Cleisson Fábio Andrioli Peralta

Placental volume measured by three-dimensional ultrasound at 11 to 13 + 6 weeks of gestation: relation to chromosomal defects: Placental volume and chromosomal defects

To determine the potential value of measuring the placental volume at 11 to 13 + 6 weeks of gestation in screening for chromosomal defects.

Lung-to-head ratio: a need to unify the technique

†Fetal Medicine Unit of the University Hospital Brugmann, Brussels, Belgium; ‡Department of Obstetrics and Gynecology, Center for Integral Assistance to Women’s Health, State University of Campinas Medical School, Campinas, Brazil; §Harris Birthright Research Centre of Fetal Medicine, King’s College Hospital, London, UK; ¶Department of Fetal Medicine, University College London NHS Foundation Trust, London, UK *Correspondence: Dr J. Jani, CHU Brugmann, Department of Obstetrics and Gynecology, Place A. Van Gehuchten n◦4, 1020 Bruxelles, Belgium (e-mail: jackjani@hotmail.com)

Fetoscopic Endotracheal Occlusion for Severe Isolated Diaphragmatic Hernia: Initial Experience from a Single Clinic in Brazil

Objective: To report on the initial experience in a single Brazilian university clinic of the use of fetoscopic endotracheal occlusion (FETO) to treat severe isolated congenital diaphragmatic hernia (CDH). Methods: The inclusion criteria for FETO for this prospective study were isolated CDH and intrathoracic herniation of the liver, as well as the lung area to head circumference ratio (LHR) <1.0. The main variables evaluated were LHR and observed to expected (o/e) LHR before and after FETO, gestational age (GA) at FETO, reversal of tracheal occlusion (TO), and birth and discharge of a living child from the hospital. Results: Among 8 isolated left-sided CDH cases with normal karyotypes, the median LHR and o/e LHR before FETO were 0.7 (range: 0.6–0.9) and 0.27 (range: 0.22–0.32), respectively. The median LHR and o/e LHR after FETO were 1.2 (range: 0.9–1.8) and 0.45 (0.31–0.67), respectively. The median GA at FETO, reversal of TO and birth were 26.8 (range: 26–29), 32.5 (range: 31.0–34.0) and 37 weeks (range: 35–37), respectively. Neonatal survival at the time of hospital discharge was 50% (4/8). Conclusion: FETO is feasible at our institution and may help to improve postnatal survival of children with severe CDH in developing countries.

Antenatal ultrasound prediction of pulmonary hypoplasia in congenital diaphragmatic hernia: Correlation with pathology

To examine the relationship between observed to expected (o/e) lung to head circumference ratio (LHR) and lung‐to‐body weight ratio (LBWR) in fetuses with congenital diaphragmatic hernia (CDH).

Birth‐weight prediction by two‐ and three‐dimensional ultrasound imaging

To compare the accuracies of birth‐weight predicting models derived from two‐dimensional (2D) ultrasound parameters and from total fetal thigh volumes measured by three‐dimensional (3D) ultrasound imaging; and to compare the performances of these formulae with those of previously published equations.

Intervalos de referência longitudinais de parâmetros doplervelocimétricos materno-fetais

PURPOSE To create longitudinal reference intervals for pulsatility index (PI) of the umbilical (UA), middle cerebral (MCA), uterine (UtA) arteries and ductus venosus (DV) in a Brazilian cohort. METHODS A longitudinal observational study performed from February 2010 to May 2012. Low risk pregnancies were scanned fortnightly from 18 to 40 weeks for the measurements of PI of the UA, MCA, DV and UtA. Linear mixed models were used for the elaboration of longitudinal reference intervals (5th, 50th and 95th percentiles) of these measurements. PI obtained for the placental and abdominal portions of the umbilical artery were compared by the t-test for independent samples. Two-sided p values of less than 0.05 were considered statistically significant. RESULTS A total of 164 patients underwent 1,242 scans. There was significant decrease in PI values of all vessels studied with gestational age (GA). From the 18(th) to the 40(th) week of pregnancy, the median PI values of UA (abdominal and placental ends of the cord), MCA, DV and the mean PI of the UtA ranged from 1.19 to 0.74, 1.33 to 0.78, 1.56 to 1.39, 0.58 to 0.41, and 0.98 to 0.66, respectively. The following equations were obtained for the prediction of the medians: PI-UA=1.5602786 - (0.020623 x GA); Logarithm of the PI-MCA=0.8149111 - (0.004168 x GA) - [0.02543 x (GA - 28.7756)²]; Logarithm of the PI-DV=-0.26691- (0.015414 x GA); PI-UtA = 1.2362403 - (0.014392 x GA). There was a significant difference between the PI-UA obtained at the abdominal and placental ends of the umbilical cord (p<0.001). CONCLUSIONS Longitudinal reference intervals for the main gestational Doppler parameters were obtained in a Brazilian cohort. These intervals could be more adequate for the follow-up of maternal-fetal hemodynamic modifications in normal and abnormal pregnancies, a fact that still requires further validation.

Fetal thigh volumetry by three-dimensional ultrasound: comparison between multiplanar and VOCAL techniques.

To evaluate the agreement between multiplanar and Virtual Organ Computer‐aided AnaLysis (VOCAL™) techniques for the measurement of total fetal thigh volume and to assess the repeatability and reproducibility of measurements performed using these methods; to derive birth weight‐predicting models for both methods and to compare their accuracies.

Fetal brain lesion associated with spontaneous twin anemia–polycythemia sequence

A healthy 21-year-old primigravida with monochorionic diamniotic twins was referred to our fetal medicine unit at 23 weeks’ gestation for follow-up. Twin A had a middle cerebral artery Doppler peak systolic velocity (MCA-PSV) of 1.72 multiples of the median (MoM), and Twin B had an MCA-PSV of 0.95 MoM (Figure 1)1. Spontaneous Stage 1 twin anemia–polycythemia sequence (TAPS) was suspected2. After discussion about the treatment options, the couple opted for expectant management2. At 24 weeks, an extensive echogenic brain lesion was observed in the left hemisphere of Twin B, in addition to severe ipsilateral ventriculomegaly of 15 mm, which is compatible with a Grade 3 peri-intraventricular hemorrhage (Figure 2). It was suspected that TAPS had progressed to Stage 2 (MCA-PSV MoM values of 1.93 and 0.6 in Twin A (donor) and Twin B (recipient), respectively)2. Fetal brain diffusion-weighted (DW) magnetic resonance imaging (MRI) in Twin B revealed areas of water diffusion restriction around the left ventricle and confirmed the suspicion of a Grade 3 peri-intraventricular hemorrhage (Figure 2).

Balloon removal after fetoscopic endoluminal tracheal occlusion for congenital diaphragmatic hernia

BACKGROUND: Isolated congenital diaphragmatic hernia defect allows viscera to herniate into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. Antenatal measurement of lung size and liver herniation can predict survival after birth. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion under local anesthesia. This in utero treatment requires a second intervention to reestablish the airway, either before birth or at delivery. OBJECTIVE: To describe our experience with in utero endotracheal balloon removal. MATERIALS AND METHODS: This is a retrospective analysis of prospectively collected data on consecutive patients with congenital diaphragmatic hernia treated in utero by fetal endoscopic tracheal occlusion from 3 centers. Maternal and pregnancy‐associated variables were retrieved. Balloon removal attempts were categorized as elective or emergency and by technique (in utero: ultrasound‐guided puncture; fetoscopy; ex utero: on placental circulation or postnatal tracheoscopy). RESULTS: We performed 351 balloon insertions during a 144‐month period. In 9 cases removal was attempted outside fetal endoscopic tracheal occlusion centers, 3 of which were deemed impossible and led to neonatal death. We attempted 302 in‐house balloon removals in 292 fetuses (217 elective [71.8%], 85 emergency [28.2%]) at 33.4 ± 0.1 weeks (range: 28.9−37.1), with a mean interval to delivery of 16.6 ± 0.8 days (0‐85). Primary attempt was by fetoscopy in 196 (67.1%), by ultrasound‐guided puncture in 62 (21.2%), by tracheoscopy on placental circulation in 30 (10.3%), and postnatal tracheoscopy in 4 cases (1.4%); a second attempt was required in 10 (3.4%) cases. Each center had different preferences for primary technique selection. In elective removals, we found no differences in the interval to delivery between fetoscopic and ultrasound‐guided puncture removals. Difficulties during fetoscopic removal led to the development of a stylet to puncture the balloon, leading to shorter operating time and easier reestablishment of airways. CONCLUSION: In these fetal treatment centers, the balloon could always be removed successfully. In 90% this was in utero, with the use of fetoscopy preferred over ultrasound‐guided puncture. Ex utero removal was a fall‐back procedure. In utero removal does not seem to precipitate immediate membrane rupture, labor, or delivery, although the design of the study did not allow for a formal conclusion. For fetoscopic removals, the introduction of a stylet facilitated retrieval. Successful removal may rely on a permanently prepared team with expertise in all possible techniques.

Endoscopic laser dichorionization of the placenta in the treatment of severe twin-twin transfusion syndrome.

Objectives: To describe the results of a technique of laser ablation of placental vessels in the treatment of severe twin-twin transfusion syndrome (TTTS), which is characterized by separation of the fetoplacental vascular territories and dichorionization of the placenta. Patients and Methods: Descriptive analysis of TTTS cases treated with the endoscopic laser dichorionization of the placenta (ELDP) procedure. The variables evaluated were the occurrence of reversal of the donor-recipient phenotype, persistence of TTTS or twin anemia-polycythemia sequence (TAPS); gestational age at delivery; discharge from the hospital of at least 1 or 2 live neonates, and incidence of neurological alterations among survivors. Results: 67 patients were treated with the ELDP procedure. There was no persistence of TTTS, reversal of the donor-recipient phenotype or TAPS. The median gestational age at delivery was 33.0 (23.6-37.7) weeks. The rate of discharge from the hospital of at least 1 or 2 live neonates was 88.2% (67/76) and 71.1% (54/76), respectively. Among survivors, 17 (17/121 = 14.0%) children presented with neurodevelopmental alterations during clinical follow-up. Conclusions: The major contribution of this study was the demonstration that the ELDP technique appears to be associated with a low risk of persistence or recurrence of TTTS and TAPS.