Letizia Galli

Is the short axis view of the fetal heart useful in improving the diagnostic accuracy of outlet ventricular septal defects

Outlet ventricular septal defects (VSDs) are usually suspected on the five‐chamber view of the fetal heart; however, postnatal confirmation occurs only in a small number of cases. The aim of this study was to evaluate if the systematic assessment of the short axis view may improve the prediction of prenatally detected outlet VSDs.

Endoloop technique for laparoscopic cornuectomy: A safe and effective approach for the treatment of interstitial pregnancy

Interstitial pregnancy (IP) occurs within the intramural portion of the tube and accounts for 2% of ectopic pregnancies. Surgery is considered the most definitive treatment for IPs, although there is no clear consensus regarding the optimal approach. In this paper we describe the advantages of cornual resection performed using the Endoloop technique and present three patients who were successfully treated using this approach. IP diagnosis was confirmed at two and three‐dimensional ultrasound and laparoscopy in all cases. Fertility sparing surgery with cornuectomy by Endoloop ligature technique demonstrated low mean operating time and blood loss, and allowed the quick recovery and discharge of all patients. Laparoscopy has become the gold standard surgical approach for IP. Cornual resection or excision is the most commonly performed procedure. In our case series, the Endoloop technique showed excellent treatment outcomes in terms of effectiveness, blood loss, operative time, recovery and post‐procedure fertility. Because of these features, Endoloop appears to be a suitable option for the laparoscopic management of IPs, both in elective and emergency settings.

Etiology and Prognosis of Severe Ventriculomegaly Diagnosed at Late Gestation

OBJECTIVES  We sought to assess the causes and outcomes of severe VM diagnosed de novo after 24 weeks of gestation where a mid-trimester anomaly scan was described as normal. METHODS  Multicenter retrospective study of five European fetal medicine centers. The inclusion criteria were normal anatomy at the mid-trimester scan, uni/bilateral finding of posterior ventricle measuring ≥ 15 mm after 24 weeks with neonatal and postnatal pediatric and/or neurological assessment data. RESULTS  Of 74 potentially eligible cases, 10 underwent termination, the outcome was missing in 19 cases and there was 1 neonatal death. Therefore, 44 formed the study cohort with a median gestation at diagnosis of 32 + 0 weeks (25 + 6 - 40 + 5). VM was unilateral in five cases. Agenesis of the corpus callosum (ACC) and grade III/IV intraventricular hemorrhage (IVH) accounted for 14 cases each. ACC was isolated in 9 fetuses. Obstructive abnormalities included 5 arachnoid and 1 cavum velum interpositum cyst. Four fetuses had an associated suspected or confirmed genetic condition, 2 congenital infections, 1 abnormal cortical development and the etiology was unknown in 3/44. Postnatal assessment at median 20 months (3 - 96) showed 22/44 (50 %) normal, 7 (16 %) mildly abnormal and 15 (34 %) severely abnormal neurodevelopmental outcomes. CONCLUSION  One half of babies with severe VM diagnosed after 24 weeks have normal infant outcome with ACC and IVH representing the most common causes. Etiology is the most important factor affecting the prognosis of fetuses with severe VM diagnosed at late gestation.

How often an isolated cardiac disproportion predicts a coarctation of the aorta? Single center experience and systematic review of the literature

Abstract Background: Cardiac disproportion is considered as an indirect sign of coarctation of the aorta (CoA). In this review, we have reassessed the positive predictive value (PPV) of such finding for a postnatal confirmation of CoA. Data sources: All cases of isolated cardiac disproportion diagnosed in the four-chamber and/or three-vessel/three-vessel and trachea views (right/left sections >1.5) were included. Postnatal cardiac findings were recorded. Additionally, a systematic literature search (PubMed, EMBASE, Cochrane library, and the reference lists of identified articles) regarding the association between antenatally detected cardiac disproportion and postnatal confirmation of CoA was performed. Data from our center were pooled with those derived from the literature. Results: Ten fetuses with isolated cardiac disproportion were selected from our center and 259 from the literature review. CoA was postnatally confirmed in 101/269 (PPV 38%). PPV of antenatal cardiac findings was significantly higher in earlier gestation (23/27, 85% <26+0 weeks versus 11/39, 28%≥26+0 weeks, p < .001). No significant difference was noticed comparing ventricular disproportion with combined ventricular and great vessels disproportion (86/230 versus 15/39, p  .89). Discussion: Isolated cardiac disproportion has an overall chance of one in three of heralding a CoA in the neonate. The specificity of these findings is significantly higher in the second trimester.

Correlation between umbilical vein-to-artery delta pH and type of intrapartum hypoxia in a cohort of acidemic neonates: A retrospective analysis of CTG findings

INTRODUCTION Umbilical artery blood analysis is assumed to give a picture of the acid-base balance of the infant at birth and is considered the gold standard to diagnose neonatal acidemia at birth. The evaluation of umbilical vein pH has been suggested as an adjunct in order to optimize the understanding of the pathophysiology of the hypoxic events in labor. The objective of this study was to assess the correlation between the Delta pH (vein-to-artery) on the umbilical cord and the intrapartum cardiotocography (CTG) patterns in a selected cohort of acidemic neonates. METHODS Retrospective analysis of all CTG traces from non-anomalous term neonates consecutively born with acidemia (pH < 7.05 on the arterial cord) at four European tertiary Maternity Units. Intrapartum CTG traces were collected and their characteristics were reviewed in consensus by three senior Obstetricians. Each case was assigned to one of these four types of intrapartum hypoxia according to the CTG features: acute hypoxia, subacute hypoxia, slowly evolving hypoxia, and chronic hypoxia. The relationship between the different categories of intrapartum hypoxia and the Delta pH on the umbilical cord were evaluated. RESULTS Overall, 83 acidemic neonates were included. Acute hypoxia, subacute hypoxia, slowly evolving hypoxia, and chronic hypoxia accounted for 19 (22.9%), 24 (28.9%), 24 (28.9%) and 16 (19.3%) cases, respectively. No difference of the Delta pH (p 0.61) was noted across the CTG subclasses, while significantly lower birthweight among cases with chronic hypoxia was found (p 0.03). The mean Delta pH did not vary at comparison between the cases with rapid onset hypoxia (acute + subacute hypoxia) and those with long lasting hypoxia (chronic + slowly evolving) (p 0.59). CONCLUSIONS Within a selected cohort of acidemic neonates, our data do not demonstrate an association between the different CTG patterns of intrapartum hypoxia and the artery-to-vein Delta pH on the umbilical cord.

EP22.04: Assessment of Caesarean section scar stiffness by ultrasound elastography

withdrawn EP22.06 Morphology of maternal structures in fetal MRI: a retrospective, clinical-anatomical data analysis A. Bahrami2, D. Prayer2, M. Weber2, G.M. Gruber1 1Department of Anatomy, Medical University of Vienna, Vienna, Austria; 2Department of Radiology, Medical University of Vienna, Vienna, Austria Objectives: Fetal MRI has become an important tool in prenatal diagnostics and is also capable of evaluating extrafetal and maternal structures. They are of significant relevance when it comes to obstetrical outcome. This study aims to investigate values for maternal cervical length and width (in case of depiction of a cervical mucus plug (CMP)) and width of the urinary tract in fetal MRI examinations. Correlation analysis between those values and gestational age (GA) was performed. Furthermore, filling degree of maternal urinary bladder and visually captured abnormalities of maternal structures were evaluated. Methods: 453 Fetal MRI examinations (1.5 Tesla and 3 Tesla) of singleton pregnancies performed in 2014 at Vienna General Hospital were evaluated. Subjects with unknown GA, cervical insufficiency or maternal kidney disease were excluded, resulting in a total of 348 included cases. Cervical length and width were measured on sagittal T2 sequences, width of renal pelvis and ureters were measured on axial T2 sequences and filling degree of the urinary bladder was scored using T2 sequences. Results: Mean cervical length was 41.5 millimetres (mm) ± 8.8, 36.7 mm ± 9.4 and 34.2 mm ± 8.7 for GA 18-21, 22-35 and 36-42 respectively. Statistical analysis showed significant (p < 10-2) correlation between GA and cervical length, latter decreasing along gestation. Although correlation between width of urinary tract structures and GA was not significant, trends of positive correlation between them were observed. Conclusions: Regarding the values of uterine cervix in MRI are in line with ultrasound-based studies while assessment of the urinary tract is often complicated by restricted field of view. Other parameters influencing cervical morphology (e.g. maternal age, height, ethnicity) have not been taken into account and should be subject of ongoing studies. Hence, the efficacy of fetal MRI when it comes to depicting maternal structures requires further investigation. EP22.07 Blood flow calculated in the uterine arteries based on the PixelFlux technique T. Andersen2, H. Arneberg2, T. Scholbach3, H. Torp4, L. Loraas1, T.M. Eggebø1 1National Centre for Fetal Medicine, St Olavs Hospital, Trondheim, Norway; 2Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway; 3Leipzig Ultrasound Institute, Leipzig, Germany; 4Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway

Intrapartum Sonographic Diagnosis of Compound Hand-Cephalic Presentation

Dear Editor, We have recently shown that intrapartum ultrasound is a useful tool in the diagnosis of fetal head malposition [1]. Compound presentation (CP) is a rare malpresentation occurring when an extremity prolapses alongside the presenting part, with both parts presenting simultaneously. We report herein the first case of compound hand-cephalic presentation diagnosed at intrapartum sonography. In a 42-year-old nullipara with an unfavorable Bishop score, labor was induced at 38 weeks by means of Dinoprostone pessary due to severe gestational hypertension. One day later oxytocin infusion was started as per protocol because of unchanged cervical findings. After eight hours, despite augmentation and amniotomy, no progression of cervical dilatation and a lack of fetal head descent were noted at clinical examination. At transabdominal suprapubic ultrasound, a right occiput anterior position with anterior spine was diagnosed and a hand of the fetus lying between the presenting part and the cervix was suspected (▶ Fig. 1, 2a). At transperineal ultrasound (▶ Fig. 2b), hand-cephalic CP with the right hand preceding the leading part of the fetal skull was documented. Given the persistently unfavorable Bishop score, manual resolution of the malpresentation could not be attempted and due to the lack of cervical changes despite adequate uterine contractions Cesarean delivery for failed induction was performed. CP occurs in approximately 1/700 deliveries [2]. Preterm delivery and external cephalic version are acknowledged as being among the predisposing factors, although most cases of CP occur in low-risk term cephalic presenting fetuses [2, 3]. The diagnosis of CP involves the palpation of a small part of the limb along with the major presenting part during vaginal examination. In early labor, the fetus may retract the extremity allowing for the spontaneous resolution of this malpresentation. On the other hand, if the extremity fails to retract spontaneously and prolapses below the fetal head, the correction of the malpresentation can be manually attempted by gently pushing the prolapsed arm upward and the head simultaneously downward by fundal pressure [2]. CP persisting despite multiple attempts of manual resolution should be closely observed given that the prolapsed limb may interfere with labor progression causing dystocia. The persistence of this malpresentation has been associated with a higher rate of obstetric intervention and a lack of fetal head descent during vacuumassisted delivery, with a greater number of pulls and higher traction force required to overcome the entrapment of the presenting part [2, 4]. Additionally, soft tissue injury with ischemic necrosis of the limb may occur if no intervention is undertaken [3]. By reporting this first case of sonographic diagnosis of CP, we have further demonstrated that intrapartum ultrasound represents a useful tool to disclose or clarify the underlying cause of dystocia in the case of labor arrest [1, 5]. This can reduce the likelihood of incorrect diagnosis, therefore improving overall intrapartum care.