P. Glosemeyer

The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of severe postpartum hemorrhage.

OBJECTIVE To evaluate intrauterine balloon tamponade with or without B-Lynch sutures in avoiding postpartum hysterectomy in cases with severe postpartum hemorrhage. STUDY DESIGN Retrospective analysis using all women delivering between January 2005 and July 2010 in our center. Prevention of hysterectomy was the main outcome studied. RESULTS Twenty-four cases of severe postpartum hemorrhage occurred in which medical treatment alone failed. In 20 cases, the Bakri balloon was the first choice to stop hemorrhage. Sixty percent (n = 12) of these were successfully treated with the balloon alone, 30% (n = 6) with the balloon and the B-Lynch suture. Therefore, 90% (n = 18) were successfully treated with the balloon as part of the treatment. The balloon tamponade was not successful in 2 cases. Four cases were treated with emergency hysterectomy a priori. CONCLUSION The Bakri balloon with or without B-Lynch sutures in a stepwise approach is an effective option for the treatment of severe PPH.

Intrauterine Surgery—Choices and Limitations

BACKGROUND The past decade has seen much progress in intrauterine surgery. Randomized trials have documented the benefit of some procedures of this type for the unborn child. METHOD Selective literature review RESULTS Randomized trials have demonstrated the benefit of fetoscopic laser coagulation of placental anastomoses in twin-to-twin transfusion syndrome (TTTS) and of intrauterine surgery via hysterotomy for the repair of spina bifida. Other fetoscopic procedures have yielded promising initial results but are not yet supported by findings from randomized trials. Some intrauterine surgical procedures must still be considered experimental in view of the lack of randomized trials and the rarity of the conditions they are designed to treat. Fetoscopic laser coagulation for TTTS is by far the most common procedure in fetal surgery; TTTS arises in roughly 1 in 2500 pregnancies. The other procedures discussed in this article are performed much less often and for rarer indications. In general, intrauterine surgery is indicated only to treat conditions that would otherwise lead to intrauterine death or irreversible prenatal damage. CONCLUSION Intrauterine surgery is a rapidly developing field. Prenatal intervention by laser coagulation is indicated to treat severe TTTS, as its benefit has been shown in a randomized trial. Not enough evidence is yet available for the possible benefit of intrauterine surgery to treat myelomeningocele and congenital diaphragmatic hernia. Other indications are experimental. When an indication for intrauterine surgery exists, the parents should be informed and, depending on their wishes, referred to a center where it can be performed.

Laser therapy of twin-to-twin transfusion syndrome in triplet pregnancies

Laser coagulation of placental anastomoses in twin pregnancies complicated by severe twin‐to‐twin transfusion syndrome (TTTS) has been shown to be superior to serial amniodrainage, and has emerged as the standard therapy for this condition. We report the outcome of triplet pregnancies treated with laser therapy for severe TTTS.

Time‐interval analysis of ductus venosus flow velocity waveforms in twin‐to‐twin transfusion syndrome treated with laser surgery

To investigate time‐interval variables of ductus venosus (DV) flow velocity waveforms (FVWs) in twin‐to‐twin transfusion syndrome (TTTS), comparing the results with reference ranges from normal singleton fetuses. The impact of laser surgery and the effect of prognostic factors were also evaluated.

Umbilical venous volume flow in twin–twin transfusion syndrome

To examine umbilical venous volume flow (UVF) dynamics by twin status and disease severity in untreated twin–twin transfusion syndrome (TTTS).

Changes in umbilical venous volume flow after fetoscopic laser occlusion of placental vascular anastomoses in twin-to-twin transfusion syndrome

OBJECTIVE To examine effects of fetoscopic laser occlusion of placental vascular anastomoses on umbilical venous volume flow in twin-to-twin transfusion syndrome. STUDY DESIGN Absolute umbilical venous volume flow, measured preoperatively and 48 hours after fetoscopic laser occlusion was related to Doppler studies, bladder filling in donors, and anastomoses. RESULTS Among 45 patients, recipients had decreased ductus venosus pulsatility index (ductus venosus-pulsatility index for veins, 1.16 vs 1.01; P < .001) and unchanged umbilical venous volume flow after fetoscopic laser occlusion (74.7 vs 74.5 mL; P = .407). Donors had decreased umbilical artery pulsatility (1.34 vs 1.11; P = .008), increased ductus venous-pulsatility index for veins (0.75 vs 0.91; P < .014), and significantly increased umbilical venous volume flow per kilogram by 52.3% (136.6 vs 208.0 mL/Kg/min; P < .001). Donor bladder filling occurred at higher umbilical venous volume flow per kilogram (142.7 vs 221.4 mL/Kg/min; P < .012). Increase in umbilical venous volume flow per kilogram correlated with the net difference in arteriovenous anastomoses (Pearson r = 0.403, P = .006). CONCLUSION Fetoscopic laser occlusion in twin-to-twin transfusion syndrome corrects intertwin differences in umbilical venous volume flow by predominant effects in the donor. Reappearance of donor bladder filling correlates with correction of volume flow.

OP06.02: Development of survival rates after intrauterine laser therapy for severe mid-trimester twin–twin transfusion syndrome: experience with 600 cases

Methods: Women who had a fetus with spina bifida and had first admission after the 30th week of gestation were analyzed between the October 2009 and April 2010. Volumes were acquired starting from a midsagittal plan. The upper level of spina bifida was identified in multiplanar mode and maximum mode by comparing axial and sagittal views, using as reference either the last rib (corresponding to T12) or the sacroiliac joint (corresponding to S1). Images obtained on MRI were mainly evaluated on sagittal view. Promontorium was used as a reference point on the determination of S1. Results: Seven fetuses were found to be eligible and the mean gestational age at examination was 34.75 ± 3.53 (30–39) weeks. Five fetuses had lumbar defect and the remaining two had sacral or thoracal defects. All but two had Arnold-Chiari malformation and clubfoot deformity. Sonographically detected levels were identical with MRI findings in five (71.43%). In the two remaining the difference between the two modalities was within one segment (28.57%). Conclusions: Dorsoposterior position of the fetus was the most impeding factor to get an appropriate image on 3D. On the other hand MRI permits to evaluate fetal spine regardless to the fetal lie. Additionally, images obtained on MRI are more comprehensible for parents which permit them to see the entire spine in one image. However, the outcomes of this small group indicate that 3D sonography and MRI are both appropriate in the determination of the upper pole of open spina bifida during the third trimester.

Prediction of adverse perinatal outcome by cerebroplacental ratio adjusted for estimated fetal weight

To evaluate the relationship between cerebroplacental ratio (CPR) and estimated fetal weight (EFW) in low‐ and high‐risk singleton pregnancies. Furthermore, we evaluated the role of CPR in the prediction of adverse perinatal outcome and whether CPR measurements adjusted for EFW improve its predictive value.

Quantified discordant placental echogenicity in twin anemia–polycythemia sequence (TAPS) and middle cerebral artery peak systolic velocity

To quantify sonographic placental echogenicity in twin anemia–polycythemia sequence (TAPS) and to correlate it with middle cerebral artery peak systolic velocity (MCA‐PSV) measurements.

P21.03: Assessment of atrio-ventricular valve opening and closure time intervals in normal fetuses

Objectives: To analyze the duration of the atrio-ventricular valve (AVV) opening time and closure time in normal fetal hearts. Methods: This cross-sectional study included 67 normal fetuses aged 18 to 38 weeks’ gestation. The following time intervals were taken: Rt-AVV-O; from the opening of right AVV to its closure, Rt-AVVC; from the closure of right AVV to its opening, Lt-AVV-O; from the opening of left AVV to its closure, Lt-AVV-C; from the closure of left AVV to its opening. These variables were correlated with gestational age and fetal heart rate in normal fetuses. Results: All of the variables except Lt-AVV-C showed positive correlation with gestational age (Spearman’s rank correlation coefficient: Rt-AVV-O; 0.423, Lt-AVV-O; 0.674 and Rt-AVV-C; 0.389). In regard of fetal heart rate, negative correlation were found in all of the variables (Rt-AVV-O: −0.689, Lt-AVV-O: −0.789, Rt-AVV-C: −0.425 and Lt-AVV-C: −0.259). Conclusions: This study firstly showed gestational changes of time interval of AVV-O and AVV-C in uncomplicated fetuses. In addition, different evolution in right and left heart was suggested in fetal life.