P Klaritsch

Assessment of fetal cardiac function before and after therapy for twin-to-twin transfusion syndrome

OBJECTIVE We sought to assess fetal cardiac function in monochorionic twins before and after therapy for twin-to-twin transfusion syndrome (TTTS) and compare it with control subjects. STUDY DESIGN We conducted prospective longitudinal assessment of fetal cardiac function in cases undergoing curative fetal therapy for TTTS (n = 39) until 4 weeks postoperatively and in uncomplicated monochorionic twins (n = 23). Fetal cardiac function was assessed by the left and right ventricular myocardial performance index, atrioventricular valve flow pattern, ductus venosus a-wave, and umbilical vein pulsations. RESULTS Nomograms for the myocardial performance index were constructed. Fetal cardiac function was grossly abnormal in recipient twins of TTTS when compared with control subjects (P < .001 for all indices) but normalized by 4 weeks postoperatively. The donor developed abnormal ductus venosus flow and tricuspid regurgitation postoperatively that regressed within 4 weeks. CONCLUSION The cardiac dysfunction in the recipient twin of TTTS normalizes within 1 month after laser. The donor develops a transient impairment of cardiac function postoperatively.

Perinatal complications and long-term neurodevelopmental outcome of infants with intrauterine growth restriction

OBJECTIVE The objective of the study was to evaluate perinatal and long-term complications of fetuses with intrauterine growth restriction (IUGR) compared with constitutionally small for gestational age (SGA) ones. STUDY DESIGN The outcome of infants with IUGR and SGA born at the Medical University Graz (Austria) between 2003 and 2009 was retrospectively analyzed. Group assignment was based on birthweight, Doppler ultrasound, and placental morphology. The primary outcome was neurodevelopmental delay at 2 years corrected age. The secondary outcomes were perinatal complications. RESULTS We included 219 IUGR and 299 SGA infants for perinatal and 146 and 215 for long-term analysis. Fetuses with IUGR were delivered earlier (35 vs 38 weeks) and had higher rates of mortality (8% vs 1%; odds ratio [OR], 8.3) as well as perinatal complications (24.4% vs 1.0%; OR, 31.6). The long-term outcome was affected by increased risk for neurodevelopmental impairment (24.7% vs 5.6%; OR, 5.5) and growth delay (21.2% vs 7.4%; OR, 3.4). CONCLUSION IUGR infants are subject to an increased risk for adverse short- and long-term outcome compared with SGA children.

Prenatal diagnosis, prediction of outcome and in utero therapy of isolated congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) can be associated with genetic or structural anomalies with poor prognosis. In isolated cases, survival is dependent on the degree of lung hypoplasia and liver position. Cases should be referred in utero to tertiary care centers familiar with this condition both for prediction of outcome as well as timed delivery. The best validated prognostic indicator is the lung area to head circumference ratio. Ultrasound is used to measure the lung area of the index case, which is then expressed as a proportion of what is expected normally (observed/expected LHR). When O/E LHR is < 25% survival chances are < 15%. Prenatal intervention, aiming to stimulate lung growth, can be achieved by temporary fetal endoscopic tracheal occlusion (FETO). A balloon is percutaneously inserted into the trachea at 26–28 weeks, and reversal of occlusion is planned at 34 weeks. Growing experience has demonstrated the feasibility and safety of the technique with a survival rate of about 50%. The lung response to, and outcome after FETO, is dependent on pre‐existing lung size as well gestational age at birth. Early data show that FETO does not increase morbidity in survivors, when compared to historical controls. Several trials are currently under design. Copyright

The correlation between lung volume and liver herniation measurements by fetal MRI in isolated congenital diaphragmatic hernia: a systematic review and meta‐analysis of observational studies

We conducted a meta‐analysis to assess the correlation of lung volume and liver position measured by magnetic resonance imaging (MRI) with survival until discharge in fetuses with isolated congenital diaphragmatic hernia (CDH).

Instrumental requirements for minimal invasive fetal surgery

Minimal invasive intrauterine interventions have gained their place in fetal medicine. Interventions on the placenta, umbilical cord, fetal membranes or on the fetus require special endoscopes with their respective sheaths, cannulas and additional instruments. Instruments for fetal therapy are purpose designed for the procedure of interest and most gynaecologists are therefore not familiar with them. We review the currently available instrumentation used during operations for complicated monochorionic multiple pregnancies, congenital diaphragmatic hernia, amniotic band syndrome, urinary tract obstruction and hydrothorax.

Changes in haemodynamic and autonomous nervous system parameters measured non-invasively throughout normal pregnancy

OBJECTIVE To examine non-invasively haemodynamic and autonomous parameters throughout normal pregnancy. STUDY DESIGN We used the Task Force Monitor 3040i system to retrieve, record, and calculate haemodynamic as well as autonomous parameters. 20 healthy women were included and scheduled for longitudinal examinations throughout normal pregnancy. Heart rate (HR), blood pressure (BP), stroke volume (SV), cardiac output (CO), systemic vascular resistance (SVR), heart rate variability (HRV), blood pressure variability (BPV), and baroreceptor sensitivity (BRS) were measured. Measurements were performed at gestational week 10(+0)-13(+6), 15(+0)-18(+6), 20(+0)-22(+6), and >30(+0). RESULTS HR increased during gestation showing a significant increase at III versus I trimester (74 bpm vs. 88 bpm, P<.05). Mean arterial pressure remained stable until III trimester, when a significant increase compared to I trimester could be noted (78 mm Hg vs. 86 mm Hg, P<.05). SV and CO remained relatively stable in I and II trimester, and in III trimester significant decreases were observed. In contrast, SVR increased significantly at III trimester (P<.001). Whereas HRV and BPV did not change at different gestational ages, BRS was significantly lower in III trimester compared to I trimester values (P<.05). CONCLUSION The non-invasive determination of cardiovascular and autonomous parameters throughout pregnancy is possible and the results of this pilot study can serve as basic parameters for classifying and assessing cardiovascular and autonomous changes in pathological conditions in pregnancy such as hypertensive disorders.

Reference ranges for middle cerebral artery peak systolic velocity in monochorionic diamniotic twins: a longitudinal study

The role of middle cerebral artery (MCA) peak systolic velocity (PSV) has become established in the management of fetal anemia. To date, singleton reference ranges have also been used in twin pregnancies. However, in monochorionic twin pregnancies, normal ranges for cerebral blood flow may differ from those in singletons owing to intertwin blood exchange. We aimed to establish gestational age‐specific reference ranges for MCA‐PSV in monochorionic diamniotic (MCDA) twin pregnancies, to compare them with previously reported singleton reference ranges, and to establish terms for calculating conditional reference intervals appropriate for individual serial measurements.

Rupture of endometriotic ovarian cyst causes acute hemoperitoneum in twin pregnancy

OBJECTIVE To present a case of an acute hemoperitoneum caused by a ruptured ovarian cyst in a late twin pregnancy. DESIGN Case report study. SETTING Department of Obstetrics and Gynecology, Medical University of Graz, Austria. PATIENT(S) A woman with a history of surgery for endometriosis and currently pregnant with dichorionic twins after IVF presented with acute abdominal pain. INTERVENTION(S) Serial ultrasound assessment revealed a massive hemoperitoneum that was caused by a ruptured endometriotic ovarian cyst. Emergency laparotomy was performed. MAIN OUTCOME MEASURE(S) Hemostasis. RESULT(S) Laparotomy led to operative hemostasis and preterm cesarean section of healthy twins at 27 weeks of gestation. CONCLUSION(S) Endometriosis occurs in about 10% of women of reproductive age and carries an infertility rate of up to 50%. Severe endometriosis used to be a rare event in patients with spontaneously conceived pregnancies. However, during the last decade, the increased use of assisted reproductive technologies has led to higher fertility rates in patients with endometriosis and to a higher incidence of multiple gestations. Therefore, the number of pregnant women with endometriosis and associated complications may rise.

Spontaneous Intrauterine Umbilical Artery Thrombosis Leading to Severe Fetal Growth Restriction

Intrauterine thrombosis of umbilical cord vessels is a rare event (2.5-4.5/10,000) and usually followed by poor fetal outcome. We present the rare case of spontaneous intrauterine thrombosis of an umbilical artery leading to severe intrauterine growth restriction (IUGR) and provide clinical and pathological findings. A 28-year-old nulliparous third gravida was referred to our institution because of IUGR at 32+4 weeks of gestation. Fetal growth had been appropriate until the 31st week of gestation and had stopped thereafter. There were no signs of abruption of the placenta and no structural abnormalities except an absent paravesical colour Doppler flow in the region of the right umbilical artery. Other Doppler measurements, karyotype and TORCH serology were normal. Intermittent non-reassuring fetal heart rate led to cesarean section at 34+3 weeks of gestation. A healthy girl with measurements on the 3rd centile was born (weight of 1,590 g, length of 41 cm and head circumference of 29 cm). Gross examination displayed an elongated, highly twisted umbilical cord with a length of 70 cm, central insertion and three umbilical vessels. Microscopic examination confirmed the diagnosis of umbilical artery thrombosis along the entire length of the umbilical cord. Calcification within the thrombus and microcalcification in occluded chorionic vessels were observed as well as hemorrhagic endovasculitis and endangiopathia obliterans in the stem villi arteries. This fetal thrombotic vasculopathy (FTV) comprised about 40% of the parenchyma. The coagulation parameters and blood counts of the mother and the infant were normal apart from transient neonatal thrombocytopenia. The reason for thrombosis remained unclear but could be attributed to the elongated and highly twisted umbilical cord. Intrauterine arterial thrombosis may cause severe IUGR. This condition might be detectable by ultrasound in the course of an IUGR workup, especially when no other reasons can be found.

Impact of smoking during pregnancy on peripheral tissue oxygenation in term neonates.

Background: Smoking during pregnancy is associated with higher blood pressure in neonates. Objective: To analyze whether smoking during pregnancy has an influence on peripheral tissue oxygenation in healthy term neonates within the first days after delivery. Methods: In a prospective cohort study, 15 healthy term neonates of mothers who had smoked during pregnancy (smoking group) were matched for gestational age, actual weight and postnatal age to 15 healthy term neonates of mothers who had not smoked during pregnancy (non-smoking group). Peripheral oxygenation was measured by near-infrared spectroscopy in combination with the venous occlusion method on the left forearm. Measurements were performed within the first 2 days after delivery. Tissue oxygenation index (TOI), fractional oxygen extraction (FOE), oxygen delivery (DO2) and oxygen consumption (VO2) were analyzed. Results: In neonates measured within the first day after delivery, TOI was significantly lower and FOE was significantly higher (63.5 ± 5.5; 0.37 ± 0.04) in the smoking group compared to the non-smoking group (69.2 ± 2.9; 0.30 ± 0.04). DO2 tended to be lower and VO2 tended to be higher in the smoking group. In neonates measured on the second day after delivery, no significant differences were observed between the groups. Conclusions: Smoking during pregnancy reduced TOI and increased FOE in otherwise healthy neonates on the first day of life with normalization on the second day of life.