Mara Rosner

Long-term neurologic outcomes after common fetal interventions

OBJECTIVE Fetal interventions have clearly decreased mortality, but the neurological outcomes of survivors are of critical concern. Here we consolidated available data on long-term neurological outcomes after common fetal interventions to guide counseling, management, and future research. STUDY DESIGN Published studies assessing long-term neurological outcomes after common fetal interventions from 1990 through 2014 were collected. We included all studies with a cohort of more than 5 patients and with follow-up of 1 year or longer. We divided procedures into those performed for singletons and for multiples. Singleton procedures included amnioinfusion for preterm premature rupture of membranes, intrauterine transfusion for red cell alloimmunization-associated anemia, intrauterine transfusion for parvovirus-associated anemia, vesicoamniotic shunts, thoracoamniotic shunts, ventriculoamniotic shunts, fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia, and open fetal cases by myelomeningocele and others. Multiple procedures included those done for monochorionic twins including serial amnioreduction, selective fetoscopic laser photocoagulation, and selective termination. RESULTS Of 1341 studies identified, 28 met the inclusion criteria. We combined available literature for all procedures. Studies varied in their length of follow-up and method of assessing neurological status. Neurological outcome after intervention varied by procedure but was normal in 40-93%, mildly impaired in 3-33%, and severely impaired in 1-40%. Follow-up to school age was rare with the exception of procedures for monochorionic twins. CONCLUSION Fetal treatments have been successful in achieving survival in previously hopeless cases, but success should also be determined by the outcomes of survivors. Except for monochorionic twins, there is a dearth of reported long-term outcomes. Standardized reporting of long-term neurological sequelae is imperative so that meaningful analysis and study comparisons can be made.

Detection of genetic abnormalities by using CVS and FISH prior to fetal reduction in sonographically normal appearing fetuses

To examine the ability of chorionic villus sampling (CVS) and fluorescence in situ hybridization (FISH) to detect aneuploidy before first trimester fetal reduction (FR) in sonographically normal‐appearing fetuses.

Evolution of gender options in multiple pregnancy management

Fetal reduction (FR) in multiples dramatically improves outcomes. We prioritize FR decisions for health and historically declined to factor gender. As male preferences apparently diminished, our bioethicist encouraged a re‐evaluation.

Clinical Outcomes of Anterior Compared With Posterior Placenta Accreta

INTRODUCTION: The objective of this study was to evaluate the effect of placental location on maternal and gestational outcomes associated with placenta accreta. METHODS: We conducted a retrospective analysis of all cases of pathologically proven placenta accreta with delivery after 20 weeks of gestation at our institution over the past 10 years. Placental location was characterized as anterior or nonanterior. Central previa location was considered in the anterior group. Gestational age at delivery and maternal data were collected. Outcomes of patients diagnosed with anterior accretes were compared with those of patients diagnosed with nonanterior accretes. Composite maternal morbidity was defined as nonred blood cell product transfusion, disseminated intravascular coagulation, or intensive care unit admission or postpartum stay longer than 7 days. RESULTS: The overall incidence of placenta accreta was 1.2 per 1,000 deliveries with 51 confirmed cases. Thirty-one (60.8%) had anterior and 20 (39.2%) had nonanterior placentation. Patients with anterior accretes were more likely to be antenatally diagnosed (58% compared with 17%, P=.003), had a history of more cesarean deliveries (P=.04), and deeper invasion of chorionic villi (P=.004). Composite maternal morbidity was significantly higher (71% compared with 30%, P=.007) and mean gestational age at delivery was lower (33.3 compared with 36.6 weeks, P=.02) for patients with anterior placenta accreta. CONCLUSION: Nearly 40% of accreta cases at our academic institution had nonanterior location. These cases are more difficult to diagnose antenatally but also seem to have less associated morbidity. Anterior placenta accreta appears to be a more histologically and clinically severe disease than posterior placenta accreta with significantly higher maternal morbidity and preterm delivery despite improved antenatal detection.

Clinical outcomes and efficacy of antenatal diagnosis of placenta accreta using ultrasonography and magnetic resonance imaging.

INTRODUCTION: The objective of this study was to evaluate the effect of antepartum diagnosis of placenta accreta on maternal and neonatal outcomes. Additionally, we evaluated the relative contribution of ultrasonography and magnetic resonance imaging (MRI) to antepartum diagnosis. METHODS: We conducted a retrospective analysis of pathologically proven placenta accreta with delivery after 20 weeks of gestation at our institution over the past 10 years. Characteristics and outcomes of patients with antepartum diagnosis were compared with those with intrapartum diagnosis. Referrals for MRI were per health care provider preference. Composite morbidity was defined as nonred blood cell product transfusion, disseminated intravascular coagulation, or intensive care unit admission or postpartum stay longer than 7 days. RESULTS: Twenty-one patients (41%) had antepartum diagnosis and 30 (59%) had intrapartum diagnosis. Antepartum diagnosis was more likely if the placental was previa (76% compared with 40%, P=.025), anterior (58% compared with 15%, P=.003), or both and was significantly associated with deeper invasion of chorionic villi (62% compared with 20%, P=.003), yet we found no difference in composite maternal morbidity. There was increased preterm delivery (P=.03) and lower average birth weights (P=.046) in patients with antepartum diagnosis. Sixty-six percent of antepartum diagnosis patients had MRI. When compared with ultrasonography, MRI was more consistent with the clinicopathologic findings in 7 of 14 (50%) and ultrasonography was more consistent in 7 of 14 (50%) of patients. CONCLUSION: The clinical presentation of placenta accreta is heterogenous and the majority of diagnoses are still made in the intrapartum period. Antepartum diagnosis is associated with higher disease burden and yet allows for equalization of maternal outcomes. Magnetic resonance imaging is of questionable benefit; however, it may be useful in select cases.

P16.03: 3-dimensional power Doppler (3DPD) “biopsy” of the Utero-Placental Circulation Space (UPCS): inter/intraobserver variability and reproducibility

Results: The shapes of the NPA of the targeted myoma were divided into 4 types: Type 1: No or little perfused area. Type 2: Perfused area near the posterior margin. Type 3: Perfused area near both anterior and posterior margins, or all around the margin. Type 4: Perfused area within the myoma including the area in type 3. The mean NPA of types 1, 2, 3 and 4 was 76.9 ± 12.3%, 57.3 ± 8.8%, 51.0 ± 10.2%, and 38.3 ± 16.7%, respectively (P < 0.01). The relation between the phases of the menstrual cycle and the shape of the NPA, or the rate of the TA, was not statistically significant. Conclusions: The menstrual cycle does not significantly affect the type of NPA or the rate of the TA of MRgFUS-treated uterine myoma, suggesting that the treatment of myoma with MRgFUS is not circumscribed by the menstrual cycle.

OP17.02: 2D Estimated Placental Volume (EPV) measurements in first trimester are reliable and correlate with measurements obtained by the 3D VOCAL™ technique

A 3D volume of the placenta was acquired at the time offirst trimester screening for aneuploidy (11 w0d-14w0d). Offlineevaluation of the volumes was performed independently by 2experienced operators (MR & JG) for EPV from a selected 2Dplane and for 3D volume using VOCAL. Intraclass correlation(ICC) was used to assess inter- and intraobserver variability forEPV. Correlation of mean placental volumes calculated by the EPVmethod to the volume obtained using VOCAL was also assessed.

OP10.05: Cerclage height is associated with risk of preterm delivery in patients with ultrasound‐indicated but not prophylactic cerclage

Objectives: Amniotic fluid ‘sludge’ (AFS) has been linked to intraamniotic infection, increased rates of spontaneous preterm delivery, PPROM and short interval from ultrasound diagnosis to delivery. This observational pilot study aims to determine if management with broad-spectrum antibiotics and progesterone initiated at diagnosis could delay delivery in patients incidentally found to have extremely premature cervical shortening and the presence of AFS. Methods: From 2008 to 2010, 42 patients were diagnosed with extremely premature cervical shortening (≤ 15 mm) at routine ultrasound between 18–24 weeks’ gestation. Ten patients were excluded because of multiple pregnancy or fetal anomaly. The presence of AFS was identified in 17 of the 32 patients and these women were managed uniformly with bed rest, broad-spectrum antibiotics and progesterone initiated at diagnosis and followed prospectively until delivery. Patients without AFS did not receive antibiotics. Results: Mean gestational (GA) at diagnosis was 21.4 ± 1.9 weeks. The mean GA at delivery was 31.9 ± 6.0 (range 23.0–40.6) for patients without AFS and 35.1 ± 6.9 (range 21.9–41.4) weeks for patients with AFS (P = 0.16). The median delay from ultrasound diagnosis to delivery was 9.8 ± 6.2 (range 1.14–19.0) for patients without AFS and 14.3 ± 6.6 weeks (range 1.9–17.7) for patients with AFS. Conclusions: Though limited by small sample size, it appears that the outcome for women with very premature cervical changes and AFS treated with antibiotics and progesterone does not differ from those women with premature cervical changes without ‘sludge’. Antibiotic and progesterone therapy may improve outcome in these women who have been shown to have a very poor prognosis when treated expectantly or with cerclage. Future studies involving multiple centers are needed to better answer this question.

OP23.01: Trends in the timing and rate of diagnosis of major congenital anomalies after introduction of the routine first trimester screen (FTS)

Objectives: To determine the angle between the four-chamber view and left ventricular outflow tract (LVOT) using live xPlane imaging and to study the reproducibility of this technique. Methods: Live xPlane is a technology available on xMatrix transducers that allows simultaneous imaging of two different planes of section of the same structure, in real time and with the same twodimensional resolution. We attempted real time visualization of the LVOT in the second imaging plane by rotating a reference line along the Y-axis from 0◦ at a step of 5◦ while the 4-chamber view was being imaged in the primary imaging plane. We recorded the rotation angle necessary to begin visualizing the LVOT (first appearance angle) as well as the rotation angle at which, with continuing rotation of the secondary plane, the LVOT was no longer visualized (last appearance angle). The difference between these two angles was denominated ‘angle span’ of the LVOT. Results: Of 100 fetuses being examined at 11–37 weeks’ gestation (by ultrasound), 30 had cardiac defects. Postnatal outcomes were known in 85 of them. The mean ± SD maternal body mass index was 21.8 ± 2.9 kg/m2. Using xPlane imaging, the LVOT was visualized at a rate of 95.1% after 14 weeks. Both intraand inter-class correlation coefficients for the first and last appearance angles were high (0.876–0.980). These angles significantly varied with the cardiac position (P = 0.001 and < 0.001). The first appearance angle was smaller when the normal fetal heart was examined using the subcostal approach than the apical view (25◦ vs 60; P = 0.001). Besides, there was a significant difference in the last appearance angle and the angle span between fetuses with and without LVOT abnormality (P = 0.038 and 0.010). Conclusions: We described a novel method of using xPlane imaging to examine the angle between the four-chamber and LVOT. The results of present and future studies may lead to improved methods for standardizing 4D examinations of the fetal heart.

OP23.03: Early prenatal diagnosis of major anomalies is associated with increased pregnancy termination

Objectives: To determine the angle between the four-chamber view and left ventricular outflow tract (LVOT) using live xPlane imaging and to study the reproducibility of this technique. Methods: Live xPlane is a technology available on xMatrix transducers that allows simultaneous imaging of two different planes of section of the same structure, in real time and with the same twodimensional resolution. We attempted real time visualization of the LVOT in the second imaging plane by rotating a reference line along the Y-axis from 0◦ at a step of 5◦ while the 4-chamber view was being imaged in the primary imaging plane. We recorded the rotation angle necessary to begin visualizing the LVOT (first appearance angle) as well as the rotation angle at which, with continuing rotation of the secondary plane, the LVOT was no longer visualized (last appearance angle). The difference between these two angles was denominated ‘angle span’ of the LVOT. Results: Of 100 fetuses being examined at 11–37 weeks’ gestation (by ultrasound), 30 had cardiac defects. Postnatal outcomes were known in 85 of them. The mean ± SD maternal body mass index was 21.8 ± 2.9 kg/m2. Using xPlane imaging, the LVOT was visualized at a rate of 95.1% after 14 weeks. Both intraand inter-class correlation coefficients for the first and last appearance angles were high (0.876–0.980). These angles significantly varied with the cardiac position (P = 0.001 and < 0.001). The first appearance angle was smaller when the normal fetal heart was examined using the subcostal approach than the apical view (25◦ vs 60; P = 0.001). Besides, there was a significant difference in the last appearance angle and the angle span between fetuses with and without LVOT abnormality (P = 0.038 and 0.010). Conclusions: We described a novel method of using xPlane imaging to examine the angle between the four-chamber and LVOT. The results of present and future studies may lead to improved methods for standardizing 4D examinations of the fetal heart.