S. Sarmento

Diagnosis of Heterotopic Pregnancy Using Ultrasound and Magnetic Resonance Imaging in the First Trimester of Pregnancy: A Case Report

Heterotopic pregnancy is a condition characterized by implantation of one or more viable embryos into the uterine cavity while another one is implanted ectopically, particularly into the uterine tube. Its occurrence has increased drastically over the last few years due to assisted reproduction procedures. In general, the diagnosis is made during the first trimester by using endovaginal two-dimensional ultrasound (2DUS), through observing a complex para- or retrouterine mass in association with a viable uterine pregnancy. However, under some conditions such as atypical ultrasonographic presentations, 2DUS does not clarify the situation whereas magnetic resonance imaging (MRI) of the pelvis is able to do so. We present the case of a pregnant woman in her fifth pregnancy, with a clinical condition of lower abdominal pain and pallor. Endovaginal 2DUS showed a complex voluminous mass in the left pelvic region in association with a viable intrauterine pregnancy. 2DUS in power Doppler mode showed “ring” vascularization, compatible with an ectopic gestational sac. MRI was of great importance in that it suggested that the mass had hematic content, which together with the clinical features, indicated that laparotomy should be performed. This surgical choice was essential for the woman to achieve a clinical improvement and for good continuation of the intrauterine pregnancy.

Microcirculation Approach in HELLP Syndrome Complicated by Posterior Reversible Encephalopathy Syndrome and Massive Hepatic Infarction

HELLP syndrome is a complication of severe forms of preeclampsia and occurs mainly in the third trimester of pregnancy. In extreme cases, it may evolve unfavorably and substantially increase maternal mortality. We present the case of an 18-year-old pregnant woman who was admitted to our emergency service in her 31st week, presenting with headache, visual disturbances, and epigastralgia, with progression to a severe condition of HELLP syndrome followed by posterior reversible encephalopathy syndrome (PRES) and hepatic infarction. We highlight the approach taken towards this patient and the case management, in which, in addition to the imaging examinations routinely available, we also used the sidestream dark field (SDF) technique to evaluate the systemic microcirculation.

Perinatal outcomes after open fetal surgery for myelomeningocele repair: a retrospective cohort study

Describe outcomes of open fetal surgery for myelomeningocele (MMC) repair in two Brazilian hospitals and the impact of surgical experience on outcome.

Guillain-Barré Syndrome after H1N1 Shot in Pregnancy: Maternal and Fetal Care in the Third Trimester—Case Report

Guillain-Barré syndrome is a rare neurological disease of progressive installation, usually following a previous acute infectious state, has a rare incidence, especially in pregnancy, and can induce major complications and high mortality risk. Its occurrence, after immunization to influenza during the last trimester pregnancy, has not been reported before. We presented a case of a 36-year-old pregnant woman that was immunized to H1N1 in the last trimester; 10 days later she developed shoulder and lumbar spines pain, limbs weakness and facial paralysis with unfavorable clinical evolution and was submitted to intensive therapy care. We described clinical and obstetrical approach, pointing out peculiarities involved in this pathology in pregnancy.

Fetal modified left myocardial performance index monitoring during open surgery for myelomeningocele repair

Fetal hemodynamic changes have already been described during open myelomeningocele repair. This study aimed to access fetal myocardial performance index (MPI) during this high‐complexity surgery.

Amniotic fluid lactic acid and matrix metalloproteinase‐8 levels at the time of fetal surgery for a spine defect: association with subsequent preterm prelabour rupture of membranes

In utero fetal surgery to correct incomplete closure of the spinal cord lessens the extent of permanent damage but is associated with preterm prelabour rupture of membranes (PPROM). We determined whether compounds in amniotic fluid collected at the time of surgery predicted subsequent development of PPROM.

P24.11: Fetal neurosonographic aspects of the Zika virus infection

Objectives: Zika virus epidemic occurred in Brazil in 2015 was associated with an increase in the number of cases of microcephaly. Currently, the association between fetal central nervous system (CNS) onset and congenital infection by zika virus is known. The aim of this study was to describe the main neurosonographic manifestations observed in cases of zika virus infection with fetal brain lesions followed up during 2016 in the fetal neurology sector of the Federal University of São Paulo and in the centro paulista de medicina fetal. Methods: 10 pregnant women with suspected changes in fetal brain morphology and diagnosed with zika virus infection were followed up during 2016. Maternal diagnosis was confirmed by serology or urine test. In all cases, a detailed examination of the fetal CNS morphology was performed by neurosonography to describe the main cerebral changes observed. Results: Main neurosonographic findings were: mild ventricumegaly 4 cases (40%); periventricular calcifications 6 cases (60%); calcifications in caudate nucleus 7 (70%); thalamic calcifications 3 cases (30%); polymicrogyria 2 cases (20%); schizencephaly 2 cases (20%); severe ventriculomegaly 6 (60%); cerebellar hypotrophy 5 cases (60%); corpus callosum dysgenesis 10 cases (100%); cerebral sulcation delay 10 (100%); increased subarachnoid space 4 (40%); microcephaly 4 (40%). Conclusions: Zika virus infection can lead to changes in the fetal CNS, although these manifestations are not specific for this infection. However, detailed assessment of brain morphology is very important to correct counselling and follow-up of these cases.

EP20.06: Initial experience of a fetal medicine service in the accomplishment of fetoscopy for the treatment of feto-fetal transfusion syndrome

Objectives: To examine the diagnostic indices of fetal middle cerebral artery peak systolic velocity (MCA PSV) above 1.55 multiples of the median(MoM) Doppler velocimetry for the identification of fetal severe anemia in monochorionic diamniotic (MCDA) twin pregnancies. Methods: Study population consisted of 178 MCDA twin fetuses who underwent MCA PSV Doppler velocimetry within 7 days of delivery between gestational age (GA) of 24 and 38 weeks at Seoul National University Hospital between 2005 and February 2017. Fetuses with chromosomal abnormalities, major congenital anomalies or intrauterine demise were excluded. We examined the frequency of severe fetal anemia according to the presence of an increased fetal MCA PSV (≥1.55 MoM). Severe anemia was defined in the presence of hemoglobin concentration < 0.55 MoM in umbilical cord blood at the time of delivery. Results: An increased MCA PSV (≥1.55 MoM) was present in 8.4% of study population and severe anemia was present in 2.2%. Diagnostic indices of an increased MCA PSV (≥1.55 MoM) for the identification of severe anemia were as follows: sensitivity 100% (4/4), specificity 93.7% (163/14), positive predictive value (PPV) 26.7% (4/15) and negative predictive value 100% (163/163). However, PPV at GA 30 weeks or more was only 12.5%, while that at GA less than 30 weeks was 42.9%. Conclusions: The sensitivity and specificity of an increased MCA PSV (≥1.55 MoM) for the identification of severe anemia in MCDA twin pregnancies are very high. However, PPV of that is much lower in cases with GA 30 weeks or more than in those with GA less than less than 30 weeks among MCDA twin pregnancies.

P01.05: Relationship between fetal thymus size and cervical length in the second trimester of pregnancy and the risk of preterm birth

Objectives: Fetal adrenal gland receives rising awareness as a predictor of spontaneous preterm birth. Previous studies focused on cross-sectional assessments. We first aimed for longitudinally analysis and evaluated trajectories for term and preterm born neonates separately. Methods: Analyses were based on data from a population-based low-risk prospective pregnancy cohort. For this analyses, complete adrenal gland measurements had to be available, which we assessed at 24, 29 and 36 wks (n= 298 for analyses regarding total adrenal gland, n= 227 for adrenal mark). Median (25th, 75th percentile) values were calculated for adrenal gland volume corrected for estimated fetal weight and the ratio of adrenal mark width/total adrenal width (w/W). Continuous Friedman test was used for differences across pregnancy, Mann-Whitney-U test for comparisons between term and preterm. Results: Absolute adrenal volume increased with gestational age (p<0.0001). Regarding the ratio w/W, we observed a decrease over the course of pregnancy (p<0.0001). When stratifying our study sample into term and preterm born neonates, we only considered those neonates with complete data at all three time points. Hence, for those preterm neonates an ultrasound measurement was available at 36 wks and birth occurred shortly afterwards. While we observed similar trajectories regarding total adrenal gland volume (pfor difference ≥0.2), ratio w/W trajectories for term and preterm neonates differed particularly at 29 wks (pfor difference =0.3, 0.007, and 0.08 at 24, 29, and 36 wks, respectively). Compared to term born neonates, preterm ones had a lower ratio at 24, 29 and a higher at 36 wks, with a median increase from 0.43 to 0.49. Conclusions: Our study adds important longitudinal data on the fetal adrenal gland and supports the hypothesis that the adrenal mark enlarges prior to preterm birth and that this occurs already in the second trimester.

OC16.04: Intrauterine open fetal surgery for correction of isolated occipital encephalocele

83 to 450 minutes. A total of 42 cases already delivered (4 uneventful vaginal), no uterine dehiscence observed. PPROM occurred in 34/42 (81%) cases. Fetuses remained in utero on average for 6,1w (5d to 13w). Mean GA at delivery was 32,6w, only 16,7% below 30w, mean birthweight was 1906g (890 to 2960g). No intrauterine demise occurred. Two neonatal deaths due to sepsis occurred. VP shunt was placed in 42% cases and two infants died due to shunt related infection. Long-term follow up was obtained in 38 cases, mean 8,9 months. The functional level of the lesion was assessed in total 23 cases and was found to be one or more levels better than the anatomical level in 70%. Conclusions: Entirely percutaneous fetoscopic correction is feasible and safer than open fetal approach; however, it is associated with an increased risk of PPROM. Fetoscopic correction can be used in cases were open surgery cannot. The CECAM technique statistically significantly improves motor outcome, when compared to MOMS trial results, so it is not only safer for mothers but also better for babies.