W. J. Hisaba

Reversible constriction of the fetal ductus arteriosus after maternal use of topical diclofenac and methyl salicylate

A 33-year-old physician in her second pregnancy underwent fetal echocardiography at 35 weeks’ gestation. She decided to present at this late gestational age due to anxiety. Cardiac anatomy was normal, as were color Doppler velocimetry assessments of the foramen ovale, mitral valve, pulmonary artery and aortic arch. Slight tricuspid regurgitation was observed (Figure 1) and systolic and diastolic ductal velocities were 2.2 m/s and 0.42 m/s, respectively (Figure 2), indicating ductal constriction (normal values being < 1.40 m/s and 0.35 m/s). The patient did not smoke, had no history of preterm labor requiring prostaglandin inhibitors or steroids and denied use of any medication throughout her pregnancy. However, she did mention that for the last two nights, due to severe musculoskeletal pain, she had been massaging her shoulders and neck with a diclofenac gel (Cataflam Emulgel @ Novartis, São Paulo, Brazil). After rubbing in the gel she covered the painful area overnight with an adhesive patch containing methyl salicylate, l-menthol and dl-camphor (Salonpas @ Hisamitsu, São Paulo, Brazil). On the second night she repeated both topical treatments and also took a 50-mg tablet of tramadol (Tramal @ Searle, São Paulo, Brazil), a centrally acting synthetic analgesic, analogous to codeine. All medication was self-prescribed and purchased by the patient, without the knowledge of her obstetrician. She was advised to discontinue all medication and return within a week. Five days later repeat echocardiography (Figure 3) revealed normal ductal velocities (systolic, 1.1 m/s; diastolic, 0.27 m/s). An uneventful delivery occurred 1 month later and, after a neonatal echocardiogram showed no abnormalities, the infant was discharged on the 3rd day. The fetal ductus arteriosus is patent throughout gestation due to low oxygen tension and circulating prostaglandins. This patency allows the majority of right ventricular output to bypass the high-resistance pulmonary vessels. Rare cases of spontaneous ductus arteriosus constriction have been reported and some have been attributed to an anatomical distortion of the ductal arch2. More frequently, ductal constriction is caused by maternal use of non-steroidal anti-inflammatory drugs (NSAIDs) that enter the fetal circulation, block cyclooxygenase enzymes and inhibit prostaglandin synthesis. Fetuses become more susceptible to NSAIDs with advancing gestational age. Individual susceptibility also influences fetal response. Demandt et al.3 reported a case in which only one twin developed ductal constriction after maternal exposure to indomethacin. Although specific Figure 1 Echocardiography at 35 weeks’ gestation revealed slight tricuspid regurgitation (TR). RA, right atrium; RV, right ventricle.

Improvement of motor function and decreased need for postnatal shunting in children who had undergone intrauterine myelomeningocele repair

OBJECTIVE To compare neuromotor development between patients who did and those who did not undergo intrauterine myelomeningocele repair. METHODS Children with myelomeningocele aged between 3.5 and 6 years who did undergo intrauterine repair (Group A, n=6) or not (Group B; n=7) were assessed for neuromotor development at both anatomical and functional levels, need for orthoses, and cognitive function. RESULTS Intrauterine myelomeningocele repair significantly improved motor function. The functional level was higher than the anatomical level by 2 or more spinal segments in all children in Group A and 2 children in Group B, with a significant statistical difference between groups (p<0.05). Five children in Group A and one in Group B were community ambulators. CONCLUSION Despite the small sample, it was observed that an improvement of motor function and decreased need for postnatal shunting in the 6 children who had undergone intrauterine myelomeningocele repair.

Fetal brain tumors: Prenatal diagnosis by ultrasound and magnetic resonance imaging.

Congenital central nervous system tumors diagnosed during pregnancy are rare, and often have a poor prognosis. The most frequent type is the teratoma. Use of ultrasound and magnetic resonance image allows the suspicion of brain tumors during pregnancy. However, the definitive diagnosis is only confirmed after birth by histology. The purpose of this mini-review article is to describe the general clinical aspects of intracranial tumors and describe the main fetal brain tumors.

The Almodin–Moron Trocar for Uterine Entry during Fetal Surgery

Objective: Compare the use of a newly designed and reusable metal trocar for initial uterine entry with the disposable Tulipan–Bruner trocar in creation of a hysterotomy for fetal surgery. Methods: Six consecutive patientsundergoing hysterotomy for intrauterine repair of myelomeningocele were randomized to uterine entry either with the Tulipan–Bruner trocar or with the Almodin–Moron trocar. Blood loss was estimated by the primary surgeon. Results: There was no statistically significant difference in the uterine entry times between the trocars. Blood loss was estimated to be approximately the same. The Almodin–Moron trocar was judged to provide easy handling with good safety. Conclusions: The Almodin–Moron trocar provides a uterine entry during creation of a hysterotomy that is as quick and causes as little trauma as the Tulipan–Bruner trocar.

P06.13: Conservative management of acardiac twins: report of two cases

K. Ishii1, K. Tanaka1, T. Murakoshi2, H. Sago3, S. Hayashi3, M. Nakata4 1The Department of Obstetrics and Gynecology Niigata University Graduate School of Medical and Dental Sciences, Japan, 2Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Japan, 3Division of Fetal Medicine, National Center for Child Health and Development, Japan, 4Perinatal Care Center, Yamaguchi University Hospital, Japan

The Role of Fetal Neurosurgery in Spina Bifida

Myelomeningocele (MMC) is a nonlethal form of neural tube defect (NTD) that results from failure of the neural tube to fuse during early embryogenesis. The lesion is characterized by protrusion of the meninges through a midline bony defect of the spine, a sac containing cerebrospinal fluid and dysplastic neural tissue not covered by skin. MMC represents an important congenital defect of the brain and spinal cord that affects approximately one in 2,000 live births and about 23% of pregnancies that end in elective abortion [1, 2]. MMC leads to lifelong and significant physical disabilities including paraplegia, hydrocephalus, bladder and fecal incontinence, sexual dysfunction, skeletal deformation and mental impairment [3]. The mortality rate, which can be as high as 47% on long-term followup, is principally attributable to the hindbrain herniation observed in Chiari malformation and to the renal failure observed in neurogenic bladder dysfunction [4].

Contagem de corpos lamelares versus teste de Clements na avaliação da maturidade pulmonar fetal em gestantes diabéticas

PURPOSE: to assess the performance of lamellar body count compared to the shake (Clements) test in the prediction of fetal lung maturity in diabetics. METHODS: prospective study of 62 patients who underwent amniocentesis between the 26th and 39th week of pregnancy. Immediately after collection, the amniotic fluid sample was submitted to the shake test and lamellar body count. Deliveries occurred within three days of amniocentesis. Immature test results (absence of a complete bubble ring in the third tube for the shake test and less than 50,000 lamellar bodies) were confronted with the occurrence of pulmonary immaturity in the neonate (respiratory distress syndrome). The performance of both tests was compared using the c2 test and p<0.05 was considered to be significant. RESULTS: seven infants had respiratory distress syndrome (11.3%). The lamellar body count and shake test were similar regarding sensitivity (100 vs 71.4%, respectively) and negative predictive value (100 vs 93.5%). Lamellar body count was superior as regards specificity (87.3 vs 52.7%, p=0.0001), positive predictive value (50 vs 16.1%, p=0.017), and accuracy (88.7 vs 54.8%, p<0.001). CONCLUSIONS: lamellar body count is a simple and accurate method of assessing fetal lung maturity. It performs slightly better than the shake test in terms of specificity, positive predictive value and accuracy, with the advantage of not requiring manipulation or reagents. Similar to the shake test, lamellar body count has a high-negative predictive value: mature results (50,000 or more) indicate thar the infant will not have hyaline membrane.

P08.21: Analysis of the fetal ear position by three dimensional rendering mode using a novel method: the ear index—preliminary results

Objectives: To stablish normal ranges of Ear Index (EI) between 18 and 24 weeks of pregnancy, using three dimensional (3D) rendered mode sonography. Methods: This cross-sectional study involved 143 pregnant women with gestational age (GA) between 18 and 24 weeks. Voluson 730 Expert equipped with transabdominal transducer was used. Mean maternal age was 33.2 years (SD 10.2), 68 fetus were female and 75 male. A two dimensional coronal view of the ear was performed to make 3D reconstruction. Using rendered mode, a dotted line was traced through the comissure of the eye dividing the ear in two parts. The superior measurement divided by inferior was considered the EI (fig1). For analysis, Pearson Coefficient (r) was calculated. Results: No significant correlation between GA and EI was determined (r = 0.001), however, between 18 to 24 weeks, it could be considered a normal EI from 0.23 to 1.02. Percentiles of EI are shown in Table1. Conclusions: There is no correlation between GA and EI, but acceptable normal values could be observed within a normal range between 18 to 24 weeks (0.23 to 1.02). These values could be important as a new marker for chromosomal abnormalities. Further studies are needed for more conclusive data.

P28.06: Correlation between fetal ear position, analyzed by three‐dimensional rendered mode sonography, and biometric parameters: preliminary results

Objectives: The pituitary gland is critically important in the function of the endocrine axis. So far, antenatal demonstration of the pituitary gland was possible only by using Magnetic Resonance Imaging (MRI) modality. The objective of our study was to describe antenatal visualization of the pituitary gland using two and three dimensional ultrasound modality. Methods: Using a Voluson E-8 (E8 systems, GE Medical Systems, Zipf, Austria) ultrasound machine, equipped with transabdominal multifrequency 4–8-MHz probe, during the third trimester of pregnancy, two dimensional images and three dimensional volume acquisition were taken. Results: We identified the unique shape of the pituitary gland using two and three dimensional ultrasound modality, on axial plane of the skull, parallel to and slightly below the biparietal diameter plane, showing the circle of Willis. Four manipulated steps from the native volume were needed for 3D reconstruction of the gland using transabdominal sonography. The insertion of the stalk to the posterior part of the gland can be seen. The circle of Willis was found to be an excellent marker for the gland location. Conclusions: This is the first report to date indicating that prenatal visualization of the pituitary gland using ultrasound imaging is feasible. In cases with midline anomalies of the brain, face or cranium, the demonstration of the pituitary gland, which is an essential endocrine gland, is recommended.

P27.14: Normal ranges of anterior bregma angle using three dimensional rendered mode—preliminary results

Objectives: 2D bar coding is one of the methods to enable the health /medical data portability for prior and existing health care record system. Several field trial of PHR (Personal Health Record) project has been carried out in Japan. For standardize CTG digital record for PHR, we proposed MFER for CTG and data expression by 2D bar code (QR code). Methods: 1) Digital CTG recording signal was formatted adding a special profile header for MFER. 2) Two types of waveform data description format for MFER ware proposed, row data mode and compressed mode. 3) Row mode contained 2ch of FHR signals at 250msec and 1ch of tocogram signals at 1 sec whereas compressed mode contained FHR of 1 sec and tocogram of 2 sec. 4) QR code format v.15 (cell size 77 × 77) of error correction level M was applied for this trial. 5) Based on the MFER proposal, experimental system of CTG QR code generator and viewer was developed. ref: QR code http://www.denso-wave.com/qrcode/index-e.html MFER http://219.127.129.30/ikiw/index.php?en Results: Using level v15 format QR code, 600 bytes of data were encoded to one cell. One cell of QR code included 113 sec of recording. Using consecutive 16 QR cells could handle 30.2 min of serial CTG recording. Using iPad, QR coded CTG was successfully replayed. Conclusions: CTG recording format for EHR/PHR by MFER was proposed. Further study was required to confirm clinical feasibility, QR code format of CTG should be one of the cost beneficial way for PHR/EHR.