J.L. Miller

Ductus venosus Doppler in the assessment of fetal cardiovascular health: an updated practical approach

The ductus venosus has a central role in the distribution of highly oxygenated umbilical venous blood to the heart. Its waveform is related to the pressure‐volume changes in the cardiac atria and it is therefore important in the monitoring of any fetal condition that may affect forward cardiac function. The cardiovascular parameters that can influence forward cardiac function include afterload, myocardial performance and preload. Decreased forward flow during atrial systole (a‐wave) is the most sensitive and ubiquitous finding when any of these parameters is affected. In contrast, decreased forward velocities during end‐systolic relaxation (v‐wave) are more specifically related to myocardial performance. The ductus venosus pulsatility index alone does not accurately reflect cardiac function, and in cases of suspected fetal cardiac dysfunction, echocardiography is required to identify the underlying mechanism. The role of ductus venosus Doppler in the assessment of fetal growth restriction, supraventricular tachycardia, fetal hydrops, complicated monochorionic twins and congenital heart disease is discussed with these considerations in mind.

Fetoscopic tracheal occlusion for treatment of non-isolated congenital diaphragmatic hernia

Fetoscopic endotracheal occlusion (FETO) is a prenatal treatment that may increase survival in severe congenital diaphragmatic hernia (CDH). In the USA, FETO is offered for isolated severe left‐sided CDH in the context of an FDA‐approved feasibility study. FETO in non‐isolated cases of severe CDH is only performed with a compassionate use exemption from US regulatory bodies. Anomalies frequently associated with CDH include congenital cystic lesions of the lung and cardiac defects. We describe two cases of non‐isolated severe left‐sided CDH that underwent prenatal FETO, survived after birth and underwent postnatal surgical repair. The potential benefit of FETO in this setting is discussed.

Discordant anomalies and karyotype in a monochorionic twin pregnancy: a call for comprehensive genetic evaluation

Monochorionic twins are generally considered to be genetically identical, thus presenting a difficult counseling scenario when they have discordant anomalies. A 28-year-old primigravida with a monochorionic diamniotic twin pregnancy was referred at 13 weeks’ gestation for first-trimester screening. Twin A had a crown–rump length (CRL) of 73.5 mm, a nuchal translucency (NT) measurement of 1.9 mm, normal anatomy and normal amniotic fluid volume. Twin B (the anomalous twin) had a CRL of 51.0 mm (< 10th percentile), NT measurement of 0.6 mm, a midline brain defect consistent with alobar holoprosencephaly, a flattened profile and normal amniotic fluid volume. Transcervical chorionic villus sampling (CVS) was performed and the karyotype was normal 46,XX. On follow-up ultrasound, a congenital heart defect was suspected in Twin B, and at 14 weeks the patient had developed Stage III twin-to-twin transfusion syndrome (TTTS). As treatment for TTTS, the patient elected selective reduction of the anomalous twin by cord occlusion at 16 weeks. To evaluate selectively the genetics of this fetus, an amniotic fluid sample was obtained for chromosomal microarray at the time of the procedure. A 19.4-megabase terminal deletion of chromosome 7 (7q34→qter) was detected. This region includes the Sonic Hedgehog gene (SHH) which, when found in the haploinsufficient state, is associated with holoprosencephaly1. To evaluate for Twin A

Prenatal ultrasound and Doppler findings of progressing portal hypertension in a fetus with congenital cystic hepatobiliary disease

A 37-year-old woman, gravida 3 para 0, was referred at 24 + 5 weeks’ gestation for suspected fetal ascites. On examination, ascites and hepatomegaly with multiple subcapsular hepatic cysts were noted (Figure 1). The brain, kidneys and lungs, and the hepatic vasculature, umbilical artery (UA), middle cerebral artery (MCA), umbilical vein (UV) and ductus venosus flow velocity waveforms were all normal. Fetal magnetic resonance imaging confirmed the findings and raised concern for hepatic cystic dysplasia with cirrhosis. A diagnostic amniocentesis and fetal paracentesis revealed the predominance of lymphocytes and monocytes in the ascites, normal karyotype, normal microarray analysis and negative viral polymerase chain reaction studies. On follow-up, hepatomegaly and cyst numbers had increased; at 30 weeks’ gestation, maternal

Ultrasound‐based three‐dimensional printed medical model for multispecialty team surgical rehearsal prior to fetoscopic myelomeningocele repair

Recently a two-port open fetoscopic myelomeningocele (MMC) repair technique, performed together by a pediatric neurosurgeon and maternal-fetal medicine specialist was described.1 Acquiring skills for this type of fetoscopic surgery is complex since MMC lesions are anatomically variable and collaboration of two surgical specialists is required. We utilized ultrasound-based 3D multi-material printing to generate a patient-matched medical model to prepare the surgical team for fetoscopic MMC repair.

P13.03: Pulmonary artery waveforms preceding lethal pulmonary hypoplasia: the “flash sign”: Poster discussion hub abstracts

Objectives: To explore the application of a macrovascular corrosion casting technique via ABS perfusionin clarifying the spatial relationship between cardiac chambers in the fetal human heart. Methods: Cardiovascular casting via ABS perfusion was performed for 28 fetal hearts, including 18 obtained from induced labor after permission due to congenital heart disease prenatally diagnosed by fetal ultrasound and10 normal ones obtained from induced labor due to other non-cardiac causes. Results: A total of 28 fetal cardiovascular casts were successfully prepared. The 10 normal fetal hearts generally showed a top-bottom spatial relationship between the atrium and ventricle at both the left and right sides, and a left-right spatial relationship between the two ventricles as well as between the two atriums. However, among the 18 fetal hearts with complex congenital heart defect (CHD), one heart had a front-back spatial relationship between the left atrium and ventricle, three had a left-right spatial relationship between the right atrium and ventricle, and others showed a normal top-bottom atrium-ventricle relationship. Besides, one heart had a front-back spatial relationship between the left and right atriums, 12 hearts had a front-back spatial relationship between the left and right ventricles, two hearts had a top-bottom spatial relationship between the left and right ventricles, while others showed a normal left-right relationship of the ventricles or atriums between the two sides. Conclusions: Clarification of the spatial relationship between cardiac chambers in the fetal heart helps us understand the anatomical structure of the heart. Macrovascular casting can serve as an effective tool to visually demonstrate the spatial relationship between cardiac chambers of heart with complex CHD. This technique can provide us with further information regarding the connection between the spatial relationship of cardiac chambers and CHD to improve accuracy of ultrasonic diagnosis, thereby possessing important clinical significance to surgical treatment.

OP11.08: Exchangeable modular patient-matched models for fetoscopic myelomeningocele repair: Short oral presentation abstracts

Objectives: Open surgery has been performed locally, with several maternal complications such as uterine ruptures or severe prematurity. Some series may be unreported. Instead, fetoscopic correction has claimed its place because of lower maternal risks. We report our local experience supported by the Brazilian team. Methods: Cases are selected with strict MOM‘s trial criteria. Surgery was performed with four trocars and biocellulose patch. The first case was operated by the Brazilian team and the second by the local team, with presence of the supporting team. Results: Two cases are operated. The patients: one primigravidae, the second with one previous Caesarean section. Fetuses had L2-5 lesions, with ventriculomegaly (12 and 19mm) and Arnold Chiari II. Both were operated at 27 weeks of GA. The patch could be placed and the skin closed without tension. Both had rupture of the membranes. The first child was born at 33 weeks, with complete skin closure and normal follow-up until 10 months of age. The hindbrain recovered before delivery, no need of valve, and normal development. The second pregnancy is ongoing, without recovery of the hindbrain, and stable ventriculomegaly, at 33 weeks. The surgery has been safe for fetuses and women. Conclusions: Fetoscopic procedure for MMC repair has been feasible with the support of a more experienced team. The procedure is identical in order to lower complications. One case has satisfactory outcome, the second is ongoing.

EP08.09: Annotation-assisted multiplanar volume contrast imaging (VCI) to assess the level of fetal meningomyelocele: Electronic Poster Abstracts

Objectives: Atrial width measurement is the representative method for evaluation of ventriculomegaly. However, ventricular shape varies and it is questionable to use the same rule for small brain before 20 weeks. The first aim was to create reference range of ventricular occupying ratio(VOR). The second aim was to evaluate VOR in ventriculomegaly cases. Methods: For the first study, 260 appropriately grown live singleton fetuses with no suspected structural and chromosomal defects between 18 and 30 weeks were enrolled. Whole brain volume dataset by transvaginal three-dimensional ultrasound was used. Volumetry of intracranial cavity volume, left and right lateral ventricle volume were calculated by virtual organ computer-aided analysis (VOCAL) with manual 15-degree rotation. Calculation was done as VOR(%)= (left ventricular volume + right ventricular volume / whole intracranial cavity volume) x 100. Intraexaminer/interexaminer test was done. Reference equations were constructed for VOR for gestational age. As the second study, ventricular volume, intracranial cavity volume and VOR in 8 cases with ventriculomegaly, were longitudinally calculated. The outcome of pregnancy and postnatal neurological prognosis were investigated. Results: The normal references were obtained with increase of ventricular volume and intracranial cavity volume and decrease of VOR with advanced gestational weeks. Intraexaminer and intraexaminer test showed intra-class correlation (95% confidence interval) of both more than 0.9. In the 8 Ventriculomegaly cases, intracranial cavity volume was along with reference range but lateral ventricular volume were all above 90 percentile. Six cases with decreasing VOR delivered at term and favourable prognosis at 5 months to 6 years. Two cases with increasing VOR were 3-month-old and still not evaluated. Conclusions: It is still difficult at present to conclude whether increase and decrease of VOR is related with fetal neurological prognosis or not. However, longitudinal VOR measurement may be one of assessment methods for evaluating ventriculomegaly.

P15.09: The impact of operative fetoscopy on the cervical length

ablation for TRAP sequence, fetal cord blood sampling, fetal blood transfusion, fetal ascites aspiration, thoraco-centesis for severe fetal pleural effusion, amnioinfusion and fetal intramuscular injection for anesthesia. We descriptively analysed the feasibility and efficacy of real-time two-dimensional B-mode bi-plane image using eM6C probe. Results: In all cases, we found the safety because of the real-time two-dimensional images would provide other organ positions such as liver, lung, and heart that we could not see in using 1 dimensional image. In centesis into small cavity such as umbilical cord or thoracic cavity, 3D information supported us the successful centesis by leading tip position. The technical limit is that the well-trained assistant must chase the needle tip by tracking ball just online the guided needle after operator. We needed ‘‘momentary stop ’’ just before final insertion from the edge of the organ surface. Conclusions: A biplane mode of real-time 4D imaging may be a promising tool for applying fetal interventions.

Maternal blood pressure trends throughout pregnancy and development of pre-eclampsia in women receiving first trimester aspirin prophylaxis

To study women who initiated aspirin in the first trimester for high risk of pre‐eclampsia, and compare blood‐pressure trends throughout pregnancy between those with normal outcome and those who subsequently developed pre‐eclampsia.