Gustavo Izbizky

Prenatal diagnosis of fetal bilateral adrenal carcinoma

Fetal malignancies that are capable of metastasizing to other fetal organs and the placenta are exceedingly rare. Fetal tumors are suspected on ultrasonography in the presence of structures of abnormal shape or size that are occasionally associated with polyhydramnios and hydrops. Most of the large abdominal masses detected antenatally are renal in origin, although adrenal tumors should also be kept in mind in their differential diagnosis.

The effect of early versus delayed postcaesarean feeding on women’s satisfaction: a randomised controlled trial

Objective  To evaluate the effect of early versus delayed feeding after caesarean section on the woman’s satisfaction.

Diagnóstico genético prenatal no invasivo de factor Rh y sexo fetal a través del análisis de ADN fetal libre en plasma materno

INTRODUCTION The analysis of free fetal DNA in maternal plasma allows the assessment of fetal genetic material avoiding the necessity of invasive procedures during pregnancy. OBJECTIVE To evaluate the feasibility and the diagnostic performance of fetal sex and fetal RhD detection through the analysis of free fetal DNA in maternal plasma using standard reagents in molecular biology. MATERIAL AND METHODS A hundred and nine blood samples of pregnant women were obtained. Amplification by real time PCR a sequence from the RhD gene in Rh negative patients and a Y-chromosome sequence, for the diagnosis of fetal Rh and sex respectively, were performed. Results were compared with neonatal outcomes. RESULTS From the 109 samples, 26 are still ongoing, 4 ended in spontaneous abortions and in 3 were lost to follow up. From the remaining 76 samples with neonatal result, the determination of fetal Rh from the RhD gene was performed in 65 Rh negative women, whereas in 66 samples the fetal sex analysis was evaluated. Overall, 15 samples had not conclusive results and were excluded from the study. The predictive values for RhD positive and negative were 85% and 90%, respectively, while the prediction for male sex was 94.3% and for female sex 95%. CONCLUSION The non invasive determination of fetal RhD and sex in maternal plasma using standard reagents in molecular biology was feasible in the majority of the samples, with a diagnostic performance similar to the reported in the literature.

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.

Pregnancy and Voice: Changes During the Third Trimester

INTRODUCTION From conception to postpartum, pregnancy is a state in which physiologic, metabolic, and anatomic parameters are altered. Pregnancy could affect voice attributes by changing quality and perturbation rates, mainly during the third trimester. The aim of this study was to compare voice attributes between third trimester pregnant and nonpregnant matched women. STUDY DESIGN A case-control study was undertaken with third trimester pregnant women attending the antenatal care clinic of the Hospital Italiano in Buenos Aires. We analyzed and compared values of fundamental frequency, maximum phonation time, vocal intensity, perturbation rates, and physical acoustic qualities. RESULTS Most pregnant women showed abnormal parameters of auditory perceptual evaluation, a higher incidence of gastroesophageal reflux, predominance of clavicular breathing, and a reduction of phonation time. CONCLUSIONS Significant differences found in both groups suggest that physiologic and body changes produced during pregnancy affect voice quality.

Fetal Doppler mechanical PR interval: correlation with fetal heart rate, gestational age and fetal sex

To establish normal fetal values for the mechanical PR interval by pulsed‐wave Doppler at 16–36 weeks of gestation, and to evaluate the influence of fetal heart rate (FHR), gestational age (GA) and fetal sex.

Foetal aortic valvuloplasty: experience of five cases

OBJECTIVES Foetal aortic valvuloplasty has been proposed as a strategy to improve left heart growth and function in foetuses with severe aortic stenosis at risk of progression to hypoplastic left heart syndrome. We report our experience with this intervention. METHODS AND RESULTS Between 2005 and 2010, five foetuses with aortic stenosis and at risk of progression to hypoplastic left heart syndrome underwent ultrasound-guided percutaneous foetal aortic valvuloplasty. There were no associated maternal complications or foetal demise. In one case, the pregnancy was terminated a couple of weeks after the intervention, one foetus evolved to hypoplastic left heart syndrome, and three did not. CONCLUSIONS Foetal aortic valvuloplasty seems to be a safe and feasible procedure. It has been reported that it has the potential to prevent progression to hypoplastic left heart syndrome in selected foetuses with severe aortic stenosis. Further investigation regarding physiological and clinical aspects of this disease both prenatally and postnatally will probably allow to improve therapeutic strategies and clinical outcome.

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.&

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