Romaine Robyr

Correlation between ultrasound and anatomical findings in fetuses with lower urinary tract obstruction in the first half of pregnancy

The prognosis of fetal lower urinary tract obstruction (LUTO) depends upon renal function and also upon the underlying etiology. Precise identification of the latter remains a challenge antenatally. Our objective was to examine the underlying pathology in male fetuses with sonographic evidence of severe and isolated LUTO.

Selective feticide in complicated monochorionic twin pregnancies using ultrasound-guided bipolar cord coagulation

Objective  To review our experience with selective feticide in complicated monochorionic (MC) twin pregnancies, using ultrasound‐guided cord coagulation with a bipolar forceps.

Fetal medicine: Intrauterine fetal demise following laser treatment in twin‐to‐twin transfusion syndrome

Objective  To evaluate the incidence, risk factors and consequences of intrauterine fetal demise (IUFD) of at least one twin in twin‐to‐twin transfusion syndrome (TTTS) treated by laser.

P09.15: Recurrence of twin–twin transfusion syndrome (TTTS) and feto‐fetal hemorrhage: two complications of laser treatment with distinct ultrasound features

Quintero’s stage 3 was sub-classified into two groups according to visible or non-visible donor bladder; Stage 3 atypical was defined as abnormal Doppler flow in either twin WITH visible donor bladder, Stage 3 classical as abnormal Doppler flow in either twin WITHOUT visible donor bladder. Results: Fifty-five cases (98%) was completed surgery (median gestational age 21.6 weeks and range 16.7 to 25.9, median operating time 85 minutes and range 34 to 210). Median gestational age at delivery was 32.1 weeks (range 18.0 to 38.6) and interval from procedure to delivery was 70 days (range 0 to 123). There were 90 of 112 survivors (80.4%) and 2 of 90 live infants had cystic periventricular leukomalacia (2.2%). There were 2 cases (3.6%) of miscarriage before 22 weeks gestation. Two survivors per mother were 87.5% in Stage 2, 64.9% in Stage 3 and 63.6% in Stage 4, however, 46.7% of two survivors in Stage 3 atypical in contrast to 77.3% in Stage 3 classical. There were 4.5% (1/22) of intrauterine fetal demise of donor in Stage 3 classical comparing to 46.7% (7/15) in Stage 3 atypical (p < 0.01). Conclusions: Our Japanese experience of FLP was almost as equal perinatal mortality and morbidity as previous report. Subclassification of Stage 3 with-/without donor bladder is considered reasonable and proper by means of perinatal outcome.

Maternal pseudo primary hyperaldosteronism in twin-to-twin transfusion syndrome

Objective  To monitor changes in the maternal renin–angiotensin–aldosterone system following laser therapy and amnioreduction in severe twin‐to‐twin transfusion syndrome (TTTS).

OC124: Intrauterine fetal demise (IUFD) following laser treatment in twin to twin transfusion syndrome (TTTS)

Objective: To evaluate the incidence, risk factors and consequences of intrauterine death of one twin, in TTTS treated by laser. Methods: All pregnancies with TTTS treated by laser coagulation of chorionic anastomoses between 1999 and 2004 with IUFD of one twin not related to PROM or preterm delivery were analysed. Staging of the disease, estimated fetal weight, fetal Doppler, placental insertion, interval from procedure to IUFD, surgical complications, intrauterine transfusions and neonatal outcomes were reviewed. Results: 120 cases of TTTS were treated by laser between 1999 and 2004. IUFD of one twin occurred in 45 cases (33%) 8 hours to 85 days after the procedure. These were 29 donors and 21 recipients. This occurred within 24 hours of the procedure in 60% of the cases and within a week in 75%. The second twin also died in utero in 5 cases (11%) within 24 hours following the death of the first twin. 17 of the 22 (77%) donors that died had severe IUGR and 14 of the 45 fetuses (31%) that died had abnormal ductus venosus and/or umbilical artery Doppler. Late miscarriage occurred in 2 cases (5%) within 2 weeks. Brain lesions developed in 2 survivors and termination of pregnancy was carried out. The surviving twin was anaemic and intrauterine transfusion was given in 5 cases within 24 hours of the death of one twin. There were 2 neonatal deaths. 2 babies had severe and moderate neurodevelopmental delay at 36 months and at 1 year of life respectively. 32 of 36 liveborn babies are neurologically normal at 1 to 44 months of life. Conclusion: IUFD of one or both twins occurred in 45 of 120 cases of severe TTTS treated by laser at a mean gestation of 20 weeks and 5 days. The prognosis of the co-twin was poor in 8/40 (20%) of the cases. Separation of the 2 placental circulations was incomplete in at least 10 cases (25%) where the co-twin either died, developed in utero cerebral lesions or was anaemic following the death of its co-twin.

OC9.05: Intertwin anastomoses in monochorionic placentas after fetoscopic laser coagulation for twin–twin transfusion syndrome: is there more than meets the eye?

Objective: Selective intrauterine growth restriction (IUGR) affects up to 25% of all monochorionic twins. Absent end-diastolic velocity of the umbilical artery (AEDV) is present in a subset of these patients. Expectant management in these cases is associated with an increased risk of spontaneous fetal demise of the IUGR twin, with attendant co-morbidity or mortality of the healthy twin. We have previously reported on performing selective laser photocoagulation of communicating vessels (SLPCV) in monochorionic diamniotic twins (MCDA) with selective IUGR. Preliminary data showed no improvement in perinatal survival after SLPCV over expectant management, but did show a tendency for decreased neurological morbidity. We have launched a randomized clinical trial to compare expectant management versus SLPCV in MCDA twins with selective IUGR. Methods: Inclusion criteria: MCDA twins, estimated fetal weight of one of the twins < 10th percentile with AEDV, normal karyotype, absence of major congenital anomalies, no evidence of twin-twin transfusion syndrome (maximum vertical pockets (MVP) = > 8 cm < 2 cm, combined), gestational age 16–26 weeks, no sonographic evidence of neurological damage. Criteria for qualification as a laser center: experience with laser treatment of twin-twin transfusion syndrome with ability to treat anterior placentas percutaneously and > 75% survival of at least one twin. Primary outcome will be neurological morbidity at one month of age. Secondary outcome will include perinatal survival of at least one twin. Results: Approximately fifty-eight patients will be required in each arm to demonstrate a difference of 20% with a power of 80% in terms of neurological morbidity. Conclusions: The study is ongoing. All experienced laser centers and interested colleagues and institutions are welcome to participate.

OC101: Selective feticide in complicated monochorionic twin pregnancies using ultrasound guided bipolar cord coagulation. Experience with 46 cases

the median interval between the procedure and delivery was 18.1 (1.1–25.7) weeks. Median birth-weight was 2720 g (540–3840). PPROM occurred in 19% (11/59) at a median of 62 (1–102) days after the procedure. However, only 3% delivered within 28 days of the procedure. Conclusions: Fetoscopic laser coagulation is an effective treatment of TRAP sequence with 67% of pregnancies with surviving fetuses going to term (> 36 weeks) without further complications.

P14.81: Correlation between ultrasound and anatomical findings in fetuses presenting with megacystis in the first half of pregnancy

Objective: To examine the underlying pathology in male fetuses with sonographic evidence of severe and isolated LUTO. Methods: Detailed postmortem examination was carried out after termination of pregnancy in 24 male fetuses presenting before 25 weeks of gestation with ultrasound evidence of isolated severe low urinary tract obstruction. Results: Gender was male in all cases. There was megacystis and hyperechogenic kidneys in all cases. There was anhydramnios/oligohydramnios and pelvicalyceal dilatation in 20 and 15 cases respectively. Prenatal diagnosis of the underlying condition was erroneous in 2/3 of the cases. Urethral atresia was never suspected antenatally. Examination of the urethra demonstrated atresia in 6 cases, severe stenosis in 8 cases, posterior urethral valves in 9 cases and an apparently normal urethra in one. Renal dysplasia was found in all cases but one. Urethral atresia was the most common urethral anomaly at 12–17 weeks. Hydronephrosis was more frequent in cases with PUV (8/9) and urethral stenosis (6/8) than with urethral atresia (1/6). In LUTO presenting before 25 weeks hyperechogenic kidneys was predictive of renal dysplasia in 95% of the cases. The association of a bladder larger diameter of more than 40 mm and hydronephrosis in a male fetus before 25 weeks was predictive of PUV with a PPV and NPV of 44% and 100% respectively. Absence of hydronephrosis and a bladder larger diameter of less (or equal) than 40 mm were predictive of urethral atresia or stenosis with a PPV and NPV of 83% and 57% respectively. Conclusion: LUTO presenting with megacystis in a male fetus in the first and second trimester can correspond to urethral atresia or stenosis more often than posterior urethral valves. Since the formers carry a poor prognosis size of the bladder and the presence of hydronephrosis could be the most discriminant association to improve prenatal counselling.

OC119: Prognostic factors for preterm delivery in twin‐to‐twin transfusion syndrome (TTTS) treated by laser coagulation

Background: Monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome at midgestation can be treated by either serial amnioreduction (removal of large volumes of amniotic fluid) or by selective fetoscopic laser coagulation of the communicating vessels on the chorionic plate. We conducted a randomized trial to compare the efficacy and safety of these two methods of treatment. Methods: Pregnant women with severe twin-to-twin transfusion syndrome before 26 weeks of gestation were randomly assigned to laser therapy or amnioreduction. We assessed perinatal survival of at least one twin (a prespecified primary outcome), survival of at least one twin at 6 months of age, and survival without neurologic morbidity at 6 months of age. Results: The study was concluded early, after randomization of 72 women to the laser group and 70 to the amnioreduction group, based on results of a planned interim analysis demonstrating a significant benefit in the laser group. As compared with the amnioreduction group, the laser group had a higher likelihood of survival of at least one twin both in the perinatal period (76.4 percent vs. 55.7 percent; relative risk = 1.37 [95 percent confidence interval: 1.07–1.75]; P = 0.009) and at 6 months of age (P = 0.002). As compared with the amnioreduction group, infants in the laser group had a lower incidence of periventricular leukomalacia (5.6 percent vs. 14.3 percent; P = 0.02), and were more likely to be alive without neurological morbidity at 6 months (52.1 percent vs. 31.4 percent; P = 0.003). Conclusion: Endoscopic laser coagulation of anastomoses is a more effective first-line treatment of severe twin-to-twin transfusion syndrome diagnosed before 26 weeks’ of gestation than serial amnioreduction.