F. Taddei

Prognostic role of umbilical artery Doppler velocimetry in growth-restricted fetuses.

Objective: To correlate umbilical artery Doppler velocimetry with perinatal outcome in a group of growth-restricted fetuses. Design: The study was a retrospective analysis of 578 singleton pregnancies with diagnosis of intrauterine growth restriction (IUGR), delivered in a single obstetric unit, at the Spedali Civili, Brescia, Italy, a university and teaching hospital with 3500 deliveries a year and neonatal intensive care unit (NICU). Methods: During 1991-99 we studied 578 pregnancies with a diagnosis of IUGR referred for Doppler velocimetry. From this population, four subsets were formed: normal umbilical artery pulsatility index (NUAPI; 334 fetuses); increased pulsatility index but with telediastolic flow (abnormal umbilical artery pulsatility index AUAPI; 137 fetuses); absent end-diastolic flow (AEDF; 70 fetuses); reverse telediastolic flow (RF; 37 fetuses). Fetal biometry, amniotic fluid and fetal-maternal Doppler velocimetry were evaluated in all patients, with biophysical profile and routine non-stress test, when indicated. The following outcomes were examined: mean gestational age at delivery, number of preterm deliveries (< 34 weeks), mean neonatal weight, Apgar score at 5 min < 7, prenatal and neonatal deaths (within the first 28 days of life), admission to the NICU and number of days spent after birth in hospital. Neonatal morbidity was analyzed, including respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH, grade 2-3), necrotizing enterocolitis (NEC) and retinopathy of prematurity. Long-term neurological follow-up is still ongoing and will not be presented in this paper. Results: Out of 578 fetuses with IUGR, 547 were born alive. There were 26 neonatal deaths. The mean gestational age at delivery was 35.6 ± 4 weeks and mean birth weight 1844 ± 612 g. There were 28 intrauterine deaths and three elective terminations of pregnancy. A total of 60 cases (11%) were complicated by RDS, 13 cases (2.4%) by retinopathy of prematurity, IVH was present in nine cases (1.6%) and NEC in seven cases (1.3%). Total perinatal mortality was 9.8%; in the 26 cases of neonatal death, the mean week at delivery was 29.6 ± 4 with a mean weight of 840 ± 425 g. Patients with NUAPI had a mean week at delivery of 37 ± 3, those with AUAPI delivered at 34 ± 3.2, those with AEDF delivered at 31 ± 3 and those with RF delivered at 29 ± 2 weeks. In progressively worsening umbilical velocimetry, we observed an increase of incidence of low Apgar score. Days of admission to the NICU and incidence of perinatal mortality increased with the worsening of Doppler velocimetry. Conclusions: Our study underlines the existence of a strict correlation between umbilical Doppler velocimetry and an increased incidence of perinatal complications in IUGR fetuses.

Impact of in utero environment on the offspring of lupus patients

The number of patients affected by systemic lupus erythematosus (SLE) that decide to have children has greatly increased probably because of recent improvements in the diagnosis and management of the disease. This has stimulated our interest in defining the outcome of children, focusing both on neonatal problems and long term development. SLE patients still carry a risk of pregnancy loss. However, due to careful monitoring and treatment by a multidisciplinary team, the number of losses has dramatically decreased, but an increased number of preterm deliveries is still a problem. Neonatal lupus is linked to the presence of anti-Ro/SS-A and anti-La/SS-B antibodies in the mother, although other factors probably of fetal origin are important. Neonatal lupus is a complex condition whose most serious manifestation is the congenital heart block (CHB). Usually, children with complete CHB need permanent pacing, but apparently do not have neuropsychological problems. Studies focusing on the neuropsychological development of SLE offspring show an increased number of learning disabilities in children with normal intelligence levels. Fetal consequence of maternal treatment need to be considered choosing non teratogenic drugs, but the withdrawal of medications just because the patient is pregnant should be avoided to avoid SLE flares.

The use of radiofrequency in the treatment of twin reversed arterial perfusion sequence: a case series and review of the literature

OBJECTIVE To evaluate the initial experience at our centre in the treatment of monochorionic twin pregnancies complicated by twin reversed arterial perfusion sequence (TRAP), using radiofrequency ablation (RFA) with expandable needles, and to review the existing literature on the subject. STUDY DESIGN Between July 2007 and October 2010, 11 monochorionic twin pregnancies complicated by TRAP were referred to our centre. Seven patients underwent intrafetal ablation of the acardiac twin with RFA using LeVeen™ expandable needle electrodes. Data on the procedures and the obstetric outcome were reviewed, and subsequently we performed a review of the literature on the use of RFA in TRAP. RESULTS Median gestational age at the intervention was 17(+3) weeks (range 14(+1)-23(+1) weeks). Technical success was obtained in all cases. Preterm premature rupture of membranes (PPROMs) occurred in 4/7 (57%) patients. Intrauterine death of the pump twin occurred in one patient at 21(+5) weeks, and one patient opted for termination of pregnancy because of PPROM at 21(+4) weeks. Five fetuses were delivered alive at a median gestational age of 33(+0) weeks (range 31(+0)-39(+5) weeks). All five infants (71%) were alive and had a normal examination at 6 months of age. The review identified 6 studies, for a total of 78 pregnancies (either monochorionc twins or triplets with a monochorionic component). Including our data, overall neonatal survival was 75/88 (85%). CONCLUSION RFA appears to be a relatively safe and reliable technique in the treatment of TRAP sequence pregnancies. Further research is needed to define the best timing of the procedure.

EXIT (Ex utero Intrapartum Treatment) in lymphatic malformations of the head and neck: Discussion of three cases and proposal of an EXIT-TTP (Team Time Procedure) list

OBJECTIVES Ex utero Intrapartum Treatment (EXIT) is a technique to secure the fetal airway while oxygenation is maintained through utero-placental circulation. The aim of the study is to present three cases of fetal lymphatic malformation of the head and neck that required EXIT and to summarize EXIT details. METHODS The cases were studied before the delivery and EXIT was planned with a multidisciplinary team. The key factors of EXIT are considered and the type, stage and clinical score of the three lymphatic malformations are defined. RESULTS In the three cases of EXIT the time working on placental support to secure the airway was 9, 7, and 9 min, respectively (from the hysterotomy to clamping the umbilical cord). Procedures performed on the airway were laryngo-tracheo-bronchoscopy in the first case, laryngoscopy and intubation in the second one, laryngoscopy, drainage of the lymphatic macro-cyst, and intubation in the third case. A sketching to detail the EXIT steps are presented: EXIT-Team Time Procedure list (EXIT-TTP list). Lymphatic malformations were classified as mixed (micro/macro-cystic) in two cases, and macro-cystic in one. de Serres Stage was IV, V and II. Therapy varied in the three neonates (surgery alone, surgery+Picibanil+Nd-YAG, or Picibanil alone). CONCLUSIONS In case of prenatal suspicion of airway obstruction, EXIT should be planned with a multidisciplinary team. The EXIT-Team Time Procedure list (EXIT-TTP list), reviews the most critical phases of the procedure when different teams are working together. The type of lymphatic malformation, the anatomic location and the clinical score predict the outcome.

Pregnancies complicated by Twin-Twin transfusion syndrome: outcome and long-term neurological follow-up.

Abstract Objective : To relate prenatal data of monochorionic pregnancies complicated by Twin–Twin transfusion syndrome (TTTS) with survival rates and neurological morbidity. Study design : Thirty-two cases of TTTS underwent biweekly ultrasound examinations. Amnioreduction was the standard of care. Mortality and neurological morbidity were evaluated; the children had neurodevelopmental follow-up with a mean follow-up time of 24 months. Results : Ten out of 32 pregnancies terminated before 24 weeks of gestation, six after induction and four after spontaneous abortion. Among the 22 pregnancies followed up after 24 weeks, the overall survival rate at 28 days was 70% (31/44) with 10 intrauterine deaths including three cases of single selective terminations, and with three neonatal deaths. Eighteen out of 31 babies (58%) had a normal neurological development, eight cases had major and five cases minor neurological disabilities. Neonatal survival was not related to gestational age at diagnosis, number of amnioreductions or weeks at delivery. Absence of end diastolic flow in the umbilical artery, either in the donor or the recipient twin, and birth weight 2) and birth weight Conclusion : In TTTS, absent end diastolic flow in the umbilical artery and birth weight can predict perinatal survival; neurological development is correlated with number of amnioreductions and birth weight.

Prenatal diagnosis of ventriculocoronary arterial communications combined with pulmonary atresia

We report our findings in a case of pulmonary atresia with intact ventricular septum and ventriculocoronary artery fistula in which power Doppler was used to make the diagnosis. A 30-year-old primiparous woman with no significant medical history presented at the fetal echocardiography service of our prenatal diagnosis center at 21 + 2 weeks of gestation after a routine sonographic examination had demonstrated a slightly enlarged fetal left cardiac ventricle. Sonography was performed using a Siemens Elegra ultrasound machine (Siemens, Erlangen, Germany) with a 3,5C40H transabdominal transducer. This showed fetal biometry to be consistent with gestational age and the extracardiac fetal morphology was normal. Twodimensional imaging of the four-chamber view confirmed that the left ventricle was slightly enlarged. The left outflow tract and the aortic arch were normal. Color Doppler examination demonstrated normal blood flow to the ventricles in diastole and absence of tricuspid valve regurgitation. The right ventricle was slightly hypoplastic with a hypertrophic myocardium and reduced movement. The main pulmonary artery diameter was reduced, the pulmonary arteries were perfused by retrograde flow from the ductus arteriosus and no flow through the pulmonary valve was detected. Power Doppler identified the presence of an anomalous vessel on the external wall of the heart which was confirmed by color Doppler and which demonstrated turbulent flow from the apex along the external wall of the right ventricle (Figures 1 and 2). Pulsed Doppler examination of this vessel demonstrated the presence of bidirectional flow: antegrade flow with a peak velocity of 150 cm/s and retrograde flow with a peak velocity of 110 cm/s (Figure 3). A diagnosis of pulmonary atresia with intact ventricular septum and abnormal communication between the right ventricle and left coronary artery was made. Fetal karyotyping following amniocentesis was normal and excluded the presence of the 22q11.2 deletion. The patient was counseled about the possibility of Figure 1 Power Doppler ultrasound image showing the fistula surrounding the right ventricle (RV) and connecting with the aorta (arrow).

4D Fetal Echocardiography

Congenital heart defects (CHD) are the most frequent malformation in the human fetus and are the leading cause of mortality due to malformations in the first year of life. Despite its clinical importance screening performed by ultrasonographic examination during the second trimester of pregnancy has shown disappointingly low detection rates mainly due to the difficulties in obtaining an adequate examination of the fetal heart. Four-dimensional (4D) ultrasound of the fetal heart has been recently suggested as a tool to improve the detection rate of CHD by decreasing the dependency on operator skills required in two-dimensional ultrasound scans but up to now no practical manuals are available in describing its application in clinical practice for the study of fetal heart. The objective of this Ebook is to explain the role of 4D during second trimester examination and in fetuses with CHD. The technique of obtaining 4D volume of the fetal heart, how to navigate in the volume to obtain diagnostic planes and how to use semiautomatic and automatic software of analysis are described. We believe that after reading this book the standard fetal cardiac anatomy survey can be performed in the second trimester fetus by 4D in both normal and abnormal hearts. This approach may reduce the operator dependency in diagnosis CHD. This Ebook should prove to be a valuable resource for obstetricians, sonographers and pediatric cardiologists.

OP24.07: 3D ultrasound and MRI of fetal cervical cystic lymphangioma for intrapartum treatment planning

Objectives: To describe early changes in fetal cardiac function after laser treatment in severe twin–twin transfusion syndrome (TTTS). Methods: A prospective study was conducted over a fivemonth period. Cardiac function was assessed in 49 consecutive monochorionic pregnancies presenting with severe TTTS and referred for fetoscopic selective laser coagulation (FSLC) of placental anastomoses as first-line treatment. Echocardiography was performed on admission and after laser treatment (median = 1 day, IQR = 1–3). The studied parameters included cardiac output, myocardial performance index, shortening fraction (SF), and heart dimensions. Results: Median gestational age was 21 weeks (IQR = 19–23). Distribution across Quintero stages was as follow: 32.7%, 18.4%, 46.9% and 2.0% for stages 1, 2, 3 and 4 respectively. Cardiac output significantly increased after laser treatment in both donor (+33%) and recipient twins (+24%). In the recipient twin, a significant increase in LV SF was also found. The increase in cardiac output was not significantly correlated with Quintero stage, the volume of amniotic fluid drained, or gestational age. Conclusions: As early as 24 h after laser treatment, a significant increase in systolic function was found in both twins. These changes seem to be unrelated to initial severity of the syndrome.

OC71: Isolated mild ventriculomegaly (10–12 mm): very long-term prognosis

Methods: We considered 58 consecutive single pregnancies referred to our Centre for Prenatal Diagnosis with a lateral ventricle measurement between 9.5 and 9.9 mm. For all cases we obtained perinatal and long-term follow-up (> 24 months). Results: In 14 cases (24%) associated malformations were present: four aneuploidies (two trisomy 21, one trisomy 13 and one triploidy), one complex malformation, three spina bifida with myelomeningocele, one transposition of great arteries, two Beckwith syndromes, one Zellweger syndrome, one case of epilepsy associated with liver dysfunction, one renal pelvic dilatation. Among the 44 cases of isolated ventriculomegaly, one pregnancy was terminated because of psychiatric indication, 42 infants (97%) were healthy at more than 24 months of life, and only one newborn showed severe neurological dysfunction (neurodevelopmental delay and motor deficit) caused by a demyelinating disease of the white matter not diagnosable in utero. Conclusions: These data, comparable to those obtained for ventriculomegaly between 10 and 12 mm, suggest that the cut-off for mild ventriculomegaly should be lowered to 9.5 mm.

P05.16: Interobserver repeatability of transabdominal 3D ultrasound of the fetal brain

and those who didn’t(19 ± 7 mm vs 23 ± 8 mm, p > 0.1); 3) Severe ventriculomegaly (> 15 mm) was more common in cases who didn’t have associated abnormalities than in those who did(100%(5/5) vs 50%(5/10); p=0.1), and in cases who didn’t develop serious postnatal outcome than in those who did(89% vs 33%; p=0.09), without statistical significance; 4) All cases(n=6) with serious postnatal outcome had associated abnormalities. Conclusion: The presence of severe ventriculomegay wasn’t associated with the occurrence of serious postnatal outcome in liveborn cases diagnosed postnatally with ACC.