Jeffrey Livingston

Early manifestations and spectrum of recipient twin cardiomyopathy in twin–twin transfusion syndrome: relation to Quintero stage

To examine cardiac structural and functional changes in twin–twin transfusion syndrome (TTTS), relative to Quintero stage, as a means of evaluating the spectrum of cardiomyopathy in TTTS.

High-risk fetal congenital pulmonary airway malformations have a variable response to steroids

BACKGROUND/PURPOSE Anecdotal reports suggest that maternal steroids may arrest the growth of congenital pulmonary airway malformations (CPAMs), preventing or reversing hydrops. We reviewed our experience with CPAMs to determine the fetal response to steroid therapy. METHODS This study is a retrospective review of all fetal CPAMs from 2004 to 2008. Fetuses with high-risk CPAMs that received at least one course of steroids were identified. Fetal magnetic resonance imaging and ultrasound data were used to classify the CPAMs, identify hydrops fetalis and follow the fetuses poststeroid dosing. RESULTS Forty-four fetuses with CPAM were identified. Fifteen patients were found to have received at least one course of steroids. Thirteen were hydropic and 2 were nonhydropic. Seven of the 13 hydropic fetuses (54%) showed an initial response to steroid administration, whereas the 2 nonhydropic high-risk fetuses progressed to birth without developing hydrops. Seven of the 15 patients, however, resulted in fetal demise or early postnatal death, giving a survival rate of 53%. CONCLUSIONS High-risk CPAMs have a variable response to steroids. This variable response demonstrates the need for a placebo-controlled randomized study to more accurately determine the effect of steroids on hydrops and CPAM growth rates. Repeated steroid courses may not be helpful, and progression in CPAM volume to head circumference ratio (CVR) or hydrops should prompt open fetal surgery to prevent irreversible fetal insult.

Acute effects of selective fetoscopic laser photocoagulation on recipient cardiac function in twin-twin transfusion syndrome

OBJECTIVE This study evaluated the acute effects of selective fetoscopic laser photocoagulation (SFLP) on recipient cardiovascular function in a twin-twin transfusion syndrome (TTTS) pregnancy. STUDY DESIGN This was a retrospective chart review of echocardiographic data in TTTS including right (RV) and left (LV) ventricular Doppler myocardial performance index (MPI); LV and RV end diastolic wall thickness; and umbilical artery (UA), vein (UV), and ductus venosus (DV) Dopplers. The primary outcome measures were improved MPI defined as greater than 10% interval decrease in left and/or right MPI. Data were analyzed by Student t test and Fishers exact test. RESULTS Sixty-five patients met inclusion criteria. SFLP results in a significant improvement in UV and DV Doppler and an increase in both RV and LV wall thickness. A 10% or greater improvement in recipient LV MPI after SFLP is associated with improved recipient survival as compared with unimproved LV MPI (100% vs 86.1%, P = .05). CONCLUSION Improved recipient myocardial performance index after SFLP is associated with improvement in recipient survival.

Prenatal MRI Findings of Fetuses with Congenital High Airway Obstruction Sequence

Objective To define the MRI findings of congenital high airway obstruction sequence (CHAOS) in a series of fetuses. Materials and Methods Prenatal fetal MR images were reviewed in seven fetuses with CHAOS at 21 to 27 weeks of gestation. The MRI findings were reviewed. The MRI parameters evaluated included the appearance of the lungs and diaphragm, presence or absence of hydrops, amount of amniotic fluid, airway appearance, predicted level of airway obstruction, and any additional findings or suspected genetic syndromes. Results All the fetuses viewed (7 of 7) demonstrated the following MRI findings: dilated airway below the level of obstruction, increased lung signal, markedly increased lung volumes with flattened or inverted hemidiaphragms, massive ascites, centrally positioned and compressed heart, as well as placentomegaly. Other frequent findings were anasarca (6 of 7) and polyhydramnios (3 of 7). MRI identified the level of obstruction as laryngeal in five cases and tracheal in two cases. In four of the patients, surgery or autopsy confirmed the MRI predicted level of obstruction. Associated abnormalities were found in 4 of 7 (genetic syndromes in 2). Postnatal radiography (n = 3) showed markedly hyperinflated lungs with inverted or flattened hemidiaphragms, strandy perihilar opacities, pneumothoraces and tracheotomy. Two fetuses were terminated and one fetus demised in utero. Four fetuses were delivered via ex utero intrapartum treatment procedure. Conclusion MRI shows a consistent pattern of abnormalities in fetuses with CHAOS, accurately identifies the level of airway obstruction, and helps differentiate from other lung abnormalities such as bilateral congenital pulmonary airway malformation by demonstrating an abnormally dilated airway distal to the obstruction.

Higher maternal doses of methadone does not increase neonatal abstinence syndrome

OBJECTIVE The purpose of this study is to assess the incidence of clinically significant neonatal abstinence syndrome (NAS) based on maternal antenatal methadone dosing in women with a history of narcotic dependence. STUDY DESIGN A retrospective review of 174 pregnant women on methadone maintenance was performed. Data were stratified based on maternal methadone dose at delivery: low (0-50 mg/day, n = 59), medium (51-100 mg/day, n = 63), and high (>100 mg/day, n = 52). NAS was defined by Finnegan as score greater than 7 on two occasions. Outcome measures were rate and severity of NAS, birth weight, preterm birth rate, and neonatal morbidities and mortality. RESULTS The rates of NAS (40.7% vs. 52.4% vs. 40.8%, p > .05), birth weight, and neonatal morbidities were similar regardless of the maternal methadone dose. Although there was a trend toward earlier delivery, the rate of preterm birth among the three groups (low dose, 17%; medium dose, 19%; high dose, 27%; p > .05) was not statistically significant. CONCLUSION Higher maintenance dosing of methadone is not associated with increased rate or severity of NAS or other adverse perinatal outcomes. Concerns about NAS should not restrict the methadone dosing during pregnancy. Methadone dosing should not be restricted to lower dosing during pregnancy.

The outcome of twin-twin transfusion syndrome complicated with placental insufficiency

OBJECTIVE The aim was to evaluate the incidence and perinatal outcomes of TTTS complicated with placental insufficiency (PI/TTTS). STUDY DESIGN This was a retrospective study of all TTTS with PI. PI is defined as estimated fetal weight < 10% with elevated head circumference/abdominal circumference ratio and weight discordance > 20%. RESULTS Fifty-two out of 270 (19%) pregnancies met criteria. Forty-nine (94.2%) donor twins were diagnosed with PI/TTTS. Fifteen were treated with amnioreduction, 26 with selective fetoscopic laser photocoagulation, 4 with donor intrafetal radiofrequency ablation (RFA), and 7 had expectant management. There was a high incidence of abnormal Dopplers and abnormal placental cord insertion in the donor twin (58% marginal, 35% membranous) with a mean estimated fetoscopic donor placental share of 26.1 +/- 14.3%. There was a significant decrease in the overall donor survival rate of 61% (4 RFA selected donors were excluded) as compared to overall recipient survival rate of 85%, respectively (P = .009). There was no significant difference in donor or recipient survival rate among the treatment groups (P = .058). CONCLUSION Placental insufficiency impacts the survival of the affected twins in the setting of TTTS. Studies are needed for appropriate treatment in TTTS with placental insufficiency.

Persistent Cloaca A 10-Year Review of Prenatal Diagnosis

The purpose of this study was to review antenatal sonographic findings in children born with persistent cloaca.

Influence of maternal exercise on fetal heart response during labor and delivery

The purpose of this study was to determine if prenatal exercise alters the maternal and fetal heart responses during labor and delivery. We hypothesized that fetuses of exercising mothers would exhibit a lower baseline heart rate (HR), increased HR variability (HRV), and no differences in fetal heart accelerations and decelerations.