Michał Lipa

Comparison Between Monochorionic and Dichorionic Placentas With Special Attention to Vascular Anastomoses and Placental Share.

Placental vascular anastomoses in twins lead to a shared circulation and may subsequently enable the development of severe complications such as twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence (TAPS). The presence of vascular anastomoses has frequently and systematically been studied in monochorionic (MC) placentas, but only rarely in dichorionic (DC) placentas. The aim of this study was to compare the prevalence of vascular anastomoses and evaluate the sharing discordance in MC and DC placentas. All consecutive placentas of MC and DC twins delivered at the Leiden University Medical Center (the Netherlands) and Medical University of Warsaw (Poland) from 2012 to 2015 were routinely injected with colored dye and included in the study. We excluded twin pregnancies treated with fetoscopic laser surgery. A total of 258 placentas were analyzed in this study, including 134 MC placentas and 124 DC placentas. Vascular anastomoses were present in 99% (133/134) of MC placentas and 0% of DC placentas (p < .01). Placental share discordance between MC twins was significantly larger compared to DC twins, 19.8 (interquartile range [IQR] 8.1-33.3) and 10.8 (IQR 6.2-19.0), respectively (p < .01). Vascular anastomoses associated complications occurred in 16% (22/134) MC twins. Our findings show that vascular anastomoses are almost ubiquitous in MC placentas, but non-existent in DC placentas. In addition, unequal placental sharing appears to be more common in MC than in DC placentas.

Lipoxin A4 (LXA4) as a potential first trimester biochemical marker of intrauterine growth disorders

Abstract Objective: To evaluate first trimester maternal serum levels of lipoxin A4 (LXA4) in prediction of intrauterine fetal growth. Methods: Study group of 185 patients in singleton pregnancy was divided into three subgroups according to neonatal birthweight: ≤10th percentile (SGA), 11–89th percentile (AGA) and ≥90 percentile (LGA). Results: We observed decreased values of LXA4 concentrations, both in SGA- and LGA groups, when compared to AGA (68.91 ± 33.72 and 68.30 ± 23.49 versus 102.13 ± 121.90, respectively). Conclusions: Lipoxin A4 may become an biochemical marker in the prediction of intrauterine fetal growth disturbances; however, more studies need to be undertaken to investigate LXA4’s role in pregnancy.

Sudden Fetal Hematologic Changes as a Complication of Amnioreduction in Twin-Twin Transfusion Syndrome

We present the first case of a monochorionic twin pregnancy in which sudden hematologic changes occurred as a complication of the amnioreduction procedure for twin-twin transfusion syndrome (TTTS). At 33 weeks of gestation, 4 days after the amnioreduction, the recipient developed severe anemia while the donor developed severe polycythemia. Postnatal placental examination revealed several arteriovenous and venoarterial anastomoses, a pale placental mass of the recipient and a congested and plethoric placental mass of the donor. We speculate on the pathophysiologic changes and potential deleterious effects provoked by the decompressive amnioreduction. Decompression of the placenta and anastomoses after the amnioreduction may have led to an acute blood shift from recipient to donor (thus also a reversal of feto-fetal transfusion), resulting in anemia in the recipient and polycythemia in the donor twin. In the past 15 years, 13 TTTS cases with late presentation were treated with amnioreduction. This is the first time we encountered this severe complication, yielding an incidence of 8%. Although the optimal treatment in TTTS with late presentation is not known, perinatologists should be aware that treatment with amnioreduction can lead to sudden hematologic changes.

Prenatal diagnosis of dural sinus malformation in fetus presenting with edema

Dural sinus malformation (DSM) is an extremely rare, congenital dilatation of the dural sinus pouch. DSM cases associated with arteriovenous shunt (AV shunt) usually have a poor pregnancy outcome due to an excessive hemodynamic load and progressive cardiac failure.

Prenatal diagnosis of dural sinus malformation in a fetus presenting with general oedema

Dural sinus malformation (DSM) is an extremely rare, congenital dilatation of the dural sinus pouch. DSM cases associated with arteriovenous shunt (AV shunt) usually have a poor pregnancy outcome due to an excessive hemodynamic load and progressive cardiac failure.

Three-dimensional neurosonography — a novel field in fetal medicine

Neurosonography is a promising technique for prenatal diagnosis, combining features of ultrasound imaging with fetal neurology. The brain is a three-dimensional structure, therefore observing brain structure in the three basic planes (sagittal, coronal and axial) is mandatory. The anterior fontanelle and sagittal suture may serve as acoustic ultrasound windows in the transvaginal brain scan, allowing to obtain high-resolution neuroimages of the intracranial structures. Furthermore, three-dimensional (3D) ultrasound combined with the transvaginal brain approach provides detailed and sophisticated neuroimages. Three orthogonal planes of the brain, tomographic ultrasound imaging (TUI) and other off-line approaches (e.g. volume contrast imaging (VCI) or HDlive silhouette imaging) may be obtained from a single 3D dataset. 3D Doppler ultrasound enables visualization of the intracerebral vascularity, allowing to obtain more precise information on cerebral perfusion. Various abnormal brain conditions, including ventriculomegaly, agenesis of the corpus callosum, posterior fossa abnormalities and others, can be well-demonstrated. Due to high rates of the associated anomalies and uncertain prognosis, any suspicion of CNS abnormalities shall imply detailed ultrasonographic evaluation of the fetal anatomy to exclude the associated anomalies. Despite a growing number of neuroimaging modalities, prenatal counselling remains a challenge as prediction of brain functionality and the neurological prognosis often remain uncertain. New investigations on the relations between various migration disorders and gene mutations, as well as recent clinical research on the relations between neuroimaging detection of local migration disorders using sophisticated imaging technologies and the postnatal neurological prognosis will contribute to the development of maternal-fetal medicine as well as pediatric neurology.

An experimental administration of pravastatin in patient with previous, multiple pregnancy losses

A 33-years old patient gravida 5 with chronic hypertension, hypothyroidism, polycystic ovarian syndrome with insuline resistance and obesity (BMI 32) was offered an experimental administration of pravastatin due to multiple pregnancy losses (fetal demise at 6, 8, 18 and 22 weeks) and preeclampsia in the last pregnancy. From the early first trimester methyldopa (750 mg/day), metformin (850 mg/day), L-thyroxine (50 μg/day), acetylsalicylic acid (150 mg/day) and enoxaparin (40 μg/day) were administered. First trimester risk assessment after combined test revealed low risk of chromosomal abnormalities with high risk of preeclampsia and fetal growth restriction: pregnancy associated plasma protein A (PAPP-A) serum level corresponding to 0.294 multiple of median (MoM) and high pulsatility indices in uterine arteries. At 17 weeks of gestation pravastatin (20 mg/day) was included to the treatment as a preventive modality from preeclampsia and intrauterine fetal demise (IUFD). Before administration of the pravastatin, patient gave written consent and this management was accepted by Ethical Comittee of Medical University of Warsaw. Anomaly scan did not reveal any abnormalities. At 27 weeks of gestation patient was admitted to the hospital due to cervical insufficiency with estimated fetal weight corresponding to 12th centile, normal volume of amniotic fluid and cerebroplacental ratio (CPR). Due to high risk of preterm delivery, cervical pessary and course of 24 mg betamethasone i.m. were administered. Throughout prental surveillance we observed fetal growth restriction (FGR) with decreasing volume of amniotic fluid, brain sparing and decreasing short time variability (STV) in cardiotocography (Figure 1). At 33 weeks of gestation, due to high risk of intrauterine fetal demise, the caesarean section was performed. A female newborn was delivered in good general condition (10 points in Apgar score) with birthweight 1545 grams. Postnatal placental examination revealed morphologically normal placenta with weight 245 grams (corresponding to 10th centile at this gestational age), three vessels umbilical cord and marginal cord insertion (Figure 2). Subsequently, newborn was transferred to Neonatal Intensive Care Unit (NICU). Due to transient respiratory adaptation problems a nasal continuonus positive airways pressure (nCPAP) was administered for 5 days. During the stay in NICU an anemia and increased thyroid stymulating hormone (TSH) concentration were detected. After Figure 1. Increased pulsatility index (PI) (> 95th centile) in umbilical artery at 33 weeks of gestation

Placental examination with dye injections in post-delivery chorionicity assessment in dichorionic triplet pregnancy.

The incidence of spontaneous triplet pregnancy is approximately 1 in 7000 deliveries. Due to the fact that every presentation of a triplet and higher order pregnancy is associated with high rate of morbidity and preterm delivery, chorionicity and amnionicity remain significant predictive factors which determine specific management throughout the pregnancy. Ultrasound chorionicity assessment in triplet pregnancies is more complex than in twins, and in many cases it remains unknown. We present a case report of a 24-year-old primipara in a spontaneous dichorionic triplet pregnancy, qualified for a cesarean section at 33 weeks of gestation, with subsequent placental examination with dye injections and post-delivery chorionicity assessment.