Nurit Zosmer

Clinical and echographic features of in utero cardiac dysfunction in the recipient twin in twin-twin transfusion syndrome.

OBJECTIVE--Fetal twin-twin transfusion syndrome (TTTS) presenting in the second trimester has been associated with almost no perinatal survival until recently, when serial drainage of amniotic fluid has improved the prognosis to 70%-80%. Most recipient twins now survive but develop cardiac dysfunction. The study was undertaken to evaluate the abnormal echocardiographic features and clinical complications of cardiac disease in the recipient twin of TTTS. DESIGN--Antenatal and postnatal echocardiographic and clinical observational study. SETTING--Antenatal studies in a tertiary referral centre. Postnatal management and follow up were performed by the same paediatric cardiologist, either at the obstetric hospital or at the regional referral centre. PATIENTS--Twin pregnancies complicated by TTTS with severe polyhydramnios diagnosed earlier than 25 weeks that proceeded until viability (n = 5). INTERVENTION--Serial fetal echocardiography with colour Doppler. Postnatal echocardiography in the first week and between two and seven months. Serial amnioreduction was performed in all pregnancies. Digoxin treatment, pericardiocentesis, paracentesis, or laser ablation of placental anastomoses was undertaken when there was hydrops. RESULTS--Increased cardiothoracic ratio and tricuspid regurgitation were seen in all recipient twins. High pulmonary artery velocities developed in three. One recipient twin died a week after delivery of endocardial fibroelastosis and infundibular pulmonary stenosis. Two other had balloon dilatation for pulmonary stenosis, one shortly after birth and one at four months. A further twin has apical thickening of the right ventricle at six months. The remaining recipient twin had normal echocardiographic findings at follow up. CONCLUSION--This report characterises for the first time a cardiac disease acquired in utero in the recipient twin in pregnancies complicated by TTTS. Clinical manifestations in utero range from mild to critical pulmonary stenosis or lethal cardiomyopathy. Although perinatal prognosis seems to be related to the severity of dysfunction when first diagnosed in utero, follow up in infancy is recommended in view of the possibility of progressive pulmonary stenosis.

Umbilical cord cysts in early pregnancy

Objective To assess the prevalence, morphologic characteristics, and natural history of umbilical cord cysts detected by ultrasound in the first trimester of pregnancy. Methods This was an ultrasound screening study for the presence of umbilical cord cysts in 859 pregnant women with singleton live fetuses at 7–13 weeks gestation. In all cases of cord cysts the scan was repeated fortnightly until the cyst resolved or a fetal abnormality was detected. All patients with ongoing pregnancies had detailed scans at 20 weeks. Infants and umbilical cords were examined after delivery for the presence of structural abnormalities. Results Umbilical cord cysts were present in 29 (3.4%) of the 859 pregnancies. Fetal abnormalities were found in seven (26%) of the 27 cases with ongoing pregnancies. The fetus was more likely to be abnormal if the cyst was located near the placental or fetal extremity of the cord (relative risk [RR] 3.3; 95% confidence interval [CI] 1.3, 8.5) or paraxially (RR 3.8; 95% CI 1.2, 12.0) or if it persisted beyond 12 weeks gestation (RR 7.7; 95% CI 3.2, 18.6). Conclusions The prevalence of umbilical cord cysts at 7–13 weeks gestation is approximately 3%, and in more than 20% of cases there are fetal chromosomal or structural defects.

Selection and identification of standard cardiac views from three-dimensional volume scans of the fetal thorax.

The feasibility of fetal echocardiographic examination using three-dimensional ultrasonography was investigated in 54 healthy pregnant women with uncomplicated pregnancies between 17 and 37 weeks of gestation. In 46 cases (85.2%), good quality three-dimensional volumes of the fetal heart were obtained from both apical and lateral four-chamber views. By reslicing apical volumes, the reformatted sections of the long axis view of the left ventricle and the aortic crest were seen in 40 (87%) and 38 (83%) of 46 cases, respectively. The short axis was seen in 26 (57%) and ductal arch in 30 (65%) cases. The examination of lateral volumes was much less successful. The short axis was seen in 11 (24%) cases, and the aortic crest in 22 (48%), whereas the analysis of the longitudinal views was not possible. The best results were obtained at a gestational age between 22 and 27 weeks. Three-dimensional fetal echocardiography allowed the examination of the four chambers of the heart and left outflow tract during the late second trimester. The technique may become useful for the screening and diagnosis of congenital cardiac defects in the future.

Natural history of early first‐trimester pregnancies implanted in Cesarean scars

To describe the ultrasound findings and natural history of pregnancies implanted within or on Cesarean section scars in the first trimester of pregnancy.

Amiodarone given by three routes to terminate fetal atrial flutter associated with severe hydrops

Background: We describe the concurrent administration of amiodarone using three different routes in order to provide: 1) rapid and adequate fetal loading without giving unduly high doses to the mother, and 2) a maintenance dose to the fetus without risking repeated invasive procedures.

DIRECT FETAL ADMINISTRATION OF IMMUNOGLOBULINS - ANOTHER DISAPPOINTING THERAPY IN ALLOIMMUNE THROMBOCYTOPENIA

Current management strategies to prevent fetal intracranial haemorrhage in perinatal alloimmune thrombocytopenia (PAIT) include serial platelet transfusion and/or maternal high-dose intravenous immunoglobulin (IVIG) administration. The former involves multiple invasive procedures, while the latter is both expensive and of questionable efficacy. We report the use of direct fetal IVIG in 2 fetuses with PAIT, undergoing serial intrauterine platelet transfusions. Fetal IVIG had no effect on fetal platelet count. We conclude that direct fetal IVIG administration does not appear to have a role in the management of PAIT, and that current management strategies remain far from ideal.

Fetal blood sampling from intrahepatic vein versus cord insertion: effect on PH and blood gases

Objective: To determine whether venous pH, base excess, and blood gas values collected by antenatal ultrasoundguided sampling from the fetal intrahepatic vein (intraabdominal umbilical vein, portal sinus, or portal vein) differ from those obtained from the placental cord insertion. Methods: Retrospective analysis was done of 1053 clinically indicated fetal blood sampling procedures performed between 1988‐1992. One hundred sixty‐eight appropriate for gestational age (AGA) singleton fetuses were identified after exclusion of those with conditions believed likely to have impaired fetal blood gas status. Fetal venous pH, carbon dioxide pressure, oxygen pressure, and base excess from 52 samplings at the intrahepatic vein were compared crosssectionally to those from 116 samplings at the placental cord insertion, using analysis of covariance to correct for gestational age. Results: There was no systematic difference in the blood gas or acid‐base values between the two sites of fetal venous blood sampling. Conclusions: Acid‐base and blood gas status in AGA fetuses is not affected by the site of sampling. Values obtained at the intrahepatic vein may be interpreted using reference ranges derived from sampling at the placental cord insertion. (Obstet Gynecol 1993;82:504‐8)

Screening for morbidly adherent placenta in early pregnancy: Morbidly adherent placenta

To estimate the diagnostic accuracy of a two‐stage strategy for early prediction of morbidly adherent placenta (MAP). In the first stage, at 11–13u2009weeks gestation, women with low‐lying placenta and history of uterine surgery are classified as being at high risk for MAP and, in the second stage, at 12–16u2009weeks, these high‐risk pregnancies are assessed at a specialist MAP clinic.