Twin-to-twin transfusion syndrome complicated with in utero limb ischemia of the donor twin - a case report.

BACKGROUND: In utero limb ischemia is a rare complication of the monochorionic twin pregnancies complicated with twin to twin transfusion syndrome (TTTS). The condition is more often seen in recipient twins. There are few theories of the pathogenesis including in utero venous thromboembolism, but the cause remains unclear. However, limb ischemia is thought to be unrelated with any prenatal intervention. CASE PRESENTATION: We present a case of a monochorionic twin pregnancy complicated with TTTS admitted to the Clinic for selective fetoscopic laser photocoagulation. The invasive procedure failed due to poor visibility. In the following weeks of pregnancy, amnioreduction procedures were performed. At 28 weeks of gestation due to twin anemia-polycythemia sequence diagnosis the patient was qualified for cesarean section. Postnatally, the donor twin was diagnosed with lower right limb ischemic necrosis. The extremity was amputated 2 days later with an uncomplicated recovery. After speculations of the potential pathogeneses it was suggested that the ischemic limb occurred as a complication of the main condition - TTTS. CONCLUSIONS: In literature, there have been no cases reported of TTTS stage I complicated with donor twin limb ischemia. The actual cause of the in utero limb ischemic necrosis in monochorionic twins remains unknown. Nevertheless, increased attention to the potential complication after failed invasive procedures or conservative treatment should be required.

Hemoglobin differences in twins are related to the time of cord clamping, not intertwin transfusion - a prospective cohort study.

BACKGROUND: Delayed cord clamping increases placental transfusion. In vaginal deliveries higher hemoglobin concentrations are found in the second-born twin. We hypothesized it is unrelated to intertwin transfusion but to the time of cord clamping. METHODS: It was a prospective cohort study of 202 women delivering twins > 32 weeks of gestation. Monoamniotic pregnancy, antenatal intertwin transfusions, fetal demise or major abnormalities were excluded from the study. The time of cord clamping depended on the obstetrician's decision. Hemoglobin, hematocrit, and reticulocyte count were measured at birth and during the second day of life. RESULTS: At birth, hemoglobin and hematocrit levels were significantly higher in the first-born twins delivered with delayed than with early cord clamping. Higher hemoglobin and hematocrit levels were observed during the second day of life in all twins delivered with delayed cord clamping. The lowest levels were observed in twins delivered with early cord clamping. Infants delivered with delayed cord clamping were at a lower risk of respiratory disorders and NICU hospitalization. CONCLUSION: The observed differences in Hgb concentrations between the infants in a twin pregnancy are related to cord clamping time.

Experience of 300 cases of prenatal fetoscopic open spina bifida repair: report of the International Fetoscopic Neural Tube Defect Repair Consortium.

BACKGROUND: The multicenter randomized controlled trial Management of Myelomeningocele Study demonstrated that prenatal repair of open spina bifida by hysterotomy, compared with postnatal repair, decreases the need for ventriculoperitoneal shunting and increases the chances of independent ambulation. However, the hysterotomy approach is associated with risks that are inherent to the uterine incision. Fetal surgeons from around the world embarked on fetoscopic open spina bifida repair aiming to reduce maternal and fetal/neonatal risks while preserving the neurologic benefits of in utero surgery to the child. OBJECTIVE: This study aimed to report the main obstetrical, perinatal, and neurosurgical outcomes in the first 12 months of life of children undergoing prenatal fetoscopic repair of open spina bifida included in an international registry and to compare these with the results reported in the Management of Myelomeningocele Study and in a subsequent large cohort of patients who received an open fetal surgery repair. STUDY DESIGN: All known centers performing fetoscopic spina bifida repair were contacted and invited to participate in a Fetoscopic Myelomeningocele Repair Consortium and enroll their patients in a registry. Patient data entered into this fetoscopic registry were analyzed for this report. Fisher exact test was performed for comparison of categorical variables in the registry with both the Management of Myelomeningocele Study and a post-Management of Myelomeningocele Study cohort. Binary logistic regression analyses were used to assess the registry data for predictors of preterm birth at <30 weeks' gestation, preterm premature rupture of membranes, and need for postnatal cerebrospinal fluid diversion in the fetoscopic registry. RESULTS: There were 300 patients in the fetoscopic registry, 78 in the Management of Myelomeningocele Study, and 100 in the post-Management of Myelomeningocele Study cohort. The 3 data sets showed similar anatomic levels of the spinal lesion, mean gestational age at delivery, distribution of motor function compared with upper anatomic level of the lesion in the neonates, and perinatal death. In the Management of Myelomeningocele Study (26.16±1.6 weeks) and post-Management of Myelomeningocele Study cohort (23.3 [20.2-25.6] weeks), compared with the fetoscopic registry group (23.6±1.4 weeks), the gestational age at surgery was lower (comparing fetoscopic repair group with the Management of Myelomeningocele Study; P<.01). After open fetal surgery, all patients were delivered by cesarean delivery, whereas in the fetoscopic registry approximately one-third were delivered vaginally (P<.01). At cesarean delivery, areas of dehiscence or thinning in the scar were observed in 34% of cases in the Management of Myelomeningocele Study, in 49% in the post-Management of Myelomeningocele Study cohort, and in 0% in the fetoscopic registry (P<.01 for both comparisons). At 12 months of age, there was no significant difference in the number of patients requiring treatment for hydrocephalus between those in the fetoscopic registry and the Management of Myelomeningocele Study. CONCLUSION: Prenatal and postnatal outcomes up to 12 months of age after prenatal fetoscopic and open fetal surgery repair of open spina bifida are similar. Fetoscopic repair allows for having a vaginal delivery and eliminates the risk of uterine scar dehiscence, therefore protecting subsequent pregnancies of unnecessary maternal and fetal risks.

Sudden Fetal Hematologic Changes as a Complication of Amnioreduction in Twin-Twin Transfusion Syndrome.

We present the first case of a monochorionic twin pregnancy in which sudden hematologic changes occurred as a complication of the amnioreduction procedure for twin-twin transfusion syndrome (TTTS). At 33 weeks of gestation, 4 days after the amnioreduction, the recipient developed severe anemia while the donor developed severe polycythemia. Postnatal placental examination revealed several arteriovenous and venoarterial anastomoses, a pale placental mass of the recipient and a congested and plethoric placental mass of the donor. We speculate on the pathophysiologic changes and potential deleterious effects provoked by the decompressive amnioreduction. Decompression of the placenta and anastomoses after the amnioreduction may have led to an acute blood shift from recipient to donor (thus also a reversal of feto-fetal transfusion), resulting in anemia in the recipient and polycythemia in the donor twin. In the past 15 years, 13 TTTS cases with late presentation were treated with amnioreduction. This is the first time we encountered this severe complication, yielding an incidence of 8%. Although the optimal treatment in TTTS with late presentation is not known, perinatologists should be aware that treatment with amnioreduction can lead to sudden hematologic changes.

Contemporary management of prenatally diagnosed spina bifida aperta - an update.

Spina bifida aperta is a relatively common congenital defect that occurs in the general population. Once the disorder has been diagnosed, a discussion, that can be emotionally-charged, ensues about whether to treat it prenatally or to only offer surgery postnatally. Given that there are good arguments for and against both options, it is of paramount importance to gain a good understanding of the major advantages and disadvantages of the various surgical approaches. The aim of our paper is to summarize current knowledge about spina bifida and the potential benefits of prenatal surgery.

Placental examination with dye injections in post-delivery chorionicity assessment in dichorionic triplet pregnancy.

The incidence of spontaneous triplet pregnancy is approximately 1 in 7000 deliveries. Due to the fact that every presentation of a triplet and higher order pregnancy is associated with high rate of morbidity and preterm delivery, chorionicity and amnionicity remain significant predictive factors which determine specific management throughout the pregnancy. Ultrasound chorionicity assessment in triplet pregnancies is more complex than in twins, and in many cases it remains unknown. We present a case report of a 24-year-old primipara in a spontaneous dichorionic triplet pregnancy, qualified for a cesarean section at 33 weeks of gestation, with subsequent placental examination with dye injections and post-delivery chorionicity assessment.

Phosphorylated IGFBP-1 in predicting successful vaginal delivery in post-term pregnancy.

PURPOSE: To estimate whether phosphorylated IGFBP-1 (phIGFBP-1) in cervical secretion in term and post-term pregnancies can predict spontaneous onset of labor or vaginal delivery. METHODS: A prospective cohort study of 167 women in singleton term and post-term pregnancies, was conducted at 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, between 2013 and 2014. phIGFBP-1 test (Actim Partus Medix Biochemica), ultrasound cervix assessment and Bishop score were analyzed in the study group. Spontaneous onset of labor was the primary and vaginal delivery was the secondary outcome. RESULTS: In 32.5 % of patients, spontaneous uterine contractions appeared. 67.5 % of women delivered vaginally, 32.5 % had cesarean section. phIGFBP-1 test predicted spontaneous onset of labor (sensitivity 0.69, specificity of 0.42) and successful vaginal delivery (0.67, 0.48). In the prediction of spontaneous delivery onset ultrasound cervical assessment and phIBFBP-1 had comparable sensitivity and in the prediction of successful vaginal birth all three tests had comparable sensitivity. The time from preinduction to spontaneous onset of delivery was significantly shorter in women with positive phIGFBP-1 test (13.65 ± 6.7 vs 20.75 ± 2.6 h; p = 0.006). CONCLUSION: A test for phIGFBP1 presence might be an additional tool for predicting both spontaneous onset of labor and successful vaginal delivery in post-term pregnancies.

Potential first trimester metabolomic biomarkers of abnormal birth weight in healthy pregnancies.

OBJECTIVE: Macrosomia and low birth weight (LBW) can be associated with pregnancy complications and may affect the long-term health of the child. The aim of this study was to evaluate the metabolomic serum profiles of healthy pregnant women to identify early biomarkers of macrosomia and LBW and to understand mechanisms leading to abnormal fetal growth not related to mother's body mass index or presence of gestational diabetes. METHOD: Serum samples from 770 women were collected between the 12th and 14th gestational week. Delivery samples were divided into three groups according to the infant birth weight as follows: low, <2500 g; normal, 2500-4000 g; and high >4000 g. Samples from women with any complications of pregnancy were excluded. Serum fingerprinting was performed by LC-QTOF-MS. RESULTS: Lower levels of phospholipids, lysophospholipids, and monoacylglycerols; low vitamin D3 metabolites; and increased bilirubin level were associated with macrosomia. Because most changes involved lipids, as a concept of validation, adipocyte fatty acid-binding protein (A-FABP) levels were measured and found correlated with the studied lipids and birth weight. CONCLUSION: Serum fingerprinting in early pregnancy can predict the risk of macrosomia. Serum levels of A-FABP and several lipids are promising prognostic markers for macrosomia in healthy pregnancies.

Suitable application of selected biochemical and biophysical markers during the first trimester screening.

Normal trophoblast growth is one of the more important stages of early pregnancy that has a deciding factor on its later development and normal outcome. Identifying pregnant women who have a high risk of complications connected to hypertension during pregnancy is currently one of the most important tasks of perinatal medicine. Abnormal placentation is related not only to the appearance of preeclampsia, but also to many other complications, such as premature placental abruption, intrauterine fetal demise, and intrauterine growth restriction. Preeclampsia and eclampsia are one of the major causes of maternal morbidity and mortality and appear in about 5% of all pregnancies. Clinical symptoms are a far-removed consequence of abnormal placentation. When they become visible, it is definitely too late for preventive action, and there is essentially no effective treatment. New research data suggests that a chance of prophylactic intervention might exist as early as in the first trimester of the pregnancy. One of the clinically documented possibilities is to apply low doses of acetylsalicylic acid before the 16th week of gestation. Despite the great importance of the placenta in the physiology of pregnancy, not much attention has been paid to the way it functions. This paper reviews selected biochemical and biophysical markers which are, or could be, used in clinical practice in the future.

[Fetal hepatic artery flow assessment in prenatal diagnostics--a review of the literature]. / Ocena przeplywów w tetnicy watrobowej plodu w diagnostyce prenatalnej. Przeglad literatury.

Standards of screening tests for the most frequent fetal chromosomal defects in modern non-invasive prenatal diagnostics provide sensitivity of about 93-96%, with the false positive rate of 2.5%. During the first trimester scan, routinely performed between 11 and 13+6 week of pregnancy the calculation of the risk for chromosomal aberrations is based on maternal age (MA), nuchal translucency (NT), levels of free beta human chorionic gonadotropin (free beta-hCG), pregnancy associated plasma protein A (PAPP-A) in maternal blood, as well as the parameters from extended ultrasound examination like evaluation of the nasal bone (NB), blood flow in ductus venosus (DV), visualization of the tricuspid valve with potential regurgitation (TR) or measurement of the frontomaxillary facial angle (FMFA). The 100% detection rate remains unachievable at present, despite constantly improving guidelines for specialists, quality of imaging, and advancement in ultrasound technology Therefore, several studies have been undertaken to establish the group of 'additional markers' of chromosomal defects which, when combined with basic markers of routine screening tests, might increase the detection rate and approach it to 100%. Results of recent studies imply that evaluation of blood flow in fetal hepatic artery performed during the first trimester scan may become a new additional marker for chromosomal defects.

Reference values for placental growth factor (PlGF) concentration and uterine artery doppler pulsatility index (PI) at 11-13(+6) weeks of gestation in the Polish population.

OBJECTIVES: The aim of the study was to determine placental growth factor (PIGF) concentration and uterine artery (UtA) Doppler pulsatility index (PI) at 11-13(+6) weeks of gestation in the Polish population. MATERIAL AND METHODS: A prospective study was performed in pregnant women who underwent routine ultrasound scan at 11-13(+6) weeks of gestation. All participants completed a questionnaire about their medical history demographics and current pregnancy. Mean arterial pressure (MAP) was calculated. Gestational age was confirmed by CRL and mean UtA PI was calculated. Blood samples were taken to measure beta HCG, PAPP-A and P/GF concentrations. RESULTS: Out of the 577 analyzed participants, 60 (10.4%) were found to have abnormal placentation disorders (20 -hypertensive disorders and 40-IUGR). The patients were subdivided into two groups, depending on pregnancy outcome: unaffected (n = 517) and affected (n = 60). The study did not confirm the anticipated correlation between maternal BMI and PIGF, but the concentration of PIGF was significantly increased in smokers. UtA PI values were not statistically significantly different depending on maternal age, BMI, method of conception, smoking or parity The study confirms that both, UtA PI and PIGF concentrations are CRL-dependent. Median MoM values for PIGF and UtA PI were obtained for each set of CRL measurements. Median PIGF MoM was decreased in pregnancies complicated by hypertensive disorders and IUGR as compared to the unaffected group. CONCLUSIONS: The established reference ranges for UtA PI and PIGF at 11-13(+6) weeks of gestation may be of clinical value in predicting placenta-associated diseases in early stages of pregnancy in the Polish population.

First trimester ultrasound of the cerebral lateral ventricles in fetuses with open spina bifida: a retrospective cohort study.

BACKGROUND: Beyond 18 weeks of gestation an increased size of the fetal lateral ventricles is reported in the majority of fetuses with open spina bifida. At 1st trimester, the definition of ventriculomegaly is based on the ratio between the size of the choroid plexus and that of the ventricular space or of the entire fetal head. However, contrary to what is seen from midtrimester, in most fetuses with open spina bifida at 11-13 weeks the amount of fluid in the ventricular system seems to be reduced rather than increased. OBJECTIVE: To compare the biometry of the lateral ventricles at 11+0-13+6 weeks between normal fetuses and those with a confirmed open spina bifida. STUDY DESIGN: Retrospective cohort study including all cases of isolated open spina bifida detected at 11+0-13+6 weeks of gestation over a period of 5 years and a group of structurally normal fetuses attending at our Centre over a period of 1 year for the aneuploidies screening as controls. The transventricular axial views of the fetal brain obtained among cases and controls were extracted from the archive for post-hoc measurement of the cerebral ventricles. The ratios between choroid plexus and lateral ventricle lenghts (CPVLr) and areas (CPVAr), the ratio between the sum of both choroid plexus areas and fetal head area (CPHAr) and the ratio between the mean of choroid plexus lengths and occipito-frontal diameter (CPHLr) were calculated for both groups. Measurements obtained from the two groups were compared, and the association of each parameter with open spina bifida was investigated. RESULTS: Ten fetuses with open spina bifida were compared with 358 controls, showing significantly smaller size of the cerebral ventricles measurements as expressed by larger values of CPVAr (0.72 vs 0.49, p<0.001), CPVLr (0.79 vs 0.70, p<0.001), CPHAr (0.33 vs 0.28, p=0.006) and CPHLr (0.60 vs 0.52, p<0.001) compared with controls. CPVAr was found to be the most accurate predictor of OSB showing an area under the curve of 0.88 with a sensitivity of 90% and a specificity of 82%. CONCLUSIONS: At 11+0-13+6 weeks' gestation open spina bifida is consistently associated with a reduced amount of fluid in the lateral cerebral ventricles of the fetus, as witnessed by significantly increased CPVLr, CPVAr, CPHAr and CPHLr.

Is the sFlt-1/PlGF ratio efficient in predicting adverse neonatal outcomes in small-for-gestational-age newborns? A prospective observational multicenter cohort study.

Introduction: Fetuses with growth abnormalities are at an increased risk of adverse neonatal outcomes. The aim of this study was to investigate if placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), or the sFlt-1/PlGF ratio were efficient predictive factors of adverse neonatal outcomes in small-for-gestational-age (SGA) newborns. Methods: A prospective observational multicenter cohort study was performed between 2020 and 2023. At the time of the SGA fetus diagnosis, serum angiogenic biomarker measurements were performed. The primary outcome was an adverse neonatal outcome, diagnosed in the case of any of the following: <34 weeks of gestation: mechanical ventilation, sepsis, necrotizing enterocolitis, intraventricular hemorrhage grade III or IV, and neonatal death before discharge; ≥34 weeks of gestation: Neonatal Intensive Care Unit hospitalization, mechanical ventilation, continuous positive airway pressure, sepsis, necrotizing enterocolitis, intraventricular hemorrhage grade III or IV, and neonatal death before discharge. Results: In total, 192 women who delivered SGA newborns were included in the study. The serum concentrations of PlGF were lower, leading to a higher sFlt-1/PlGF ratio in the adverse outcome group. No significant differences in sFlt-1 levels were observed between the groups. Both PlGF and sFlt-1 had a moderate correlation with adverse neonatal outcomes (PlGF: R - 0.5, p < 0.001; sFlt-1: 0.5, p < 0.001). The sFlt-1/PlGF ratio showed a correlation of 0.6 (p < 0.001) with adverse outcomes. The uterine artery pulsatility index (PI) and the sFlt-1/PlGF ratio were identified as the only independent risk factors for adverse outcomes. An sFlt-1/PlGF ratio of 19.1 exhibited high sensitivity (85.1%) but low specificity (35.9%) in predicting adverse outcomes and had the strongest correlation with them. This ratio allowed the risk of adverse outcomes to be assessed as low with approximately 80% certainty. Discussion: The sFlt-1/PlGF ratio seems to be an efficient predictive tool in adverse outcome risk assessment. More studies on large cohorts of SGA-complicated pregnancies with and without preeclampsia are needed to develop an optimal and detailed formula for the risk assessment of adverse outcomes in SGA newborns.

The chorionic bump associated with acrania--case report.

The chorionic bump is a rare abnormality of the gestational sac, presenting as a convex bulge from the choriodecidual surface into the sac, correlated with poor prognosis for the pregnancy We report a case of a 36-year-old pregnant woman, with a history of spontaneous abortion, who presented for an early scan a 6 weeks and 4 days of gestation. The pregnancy was spontaneous and unplanned. The patient conceived in less than 3 months after discontinuing oral contraceptives. No folic acid was taken before or in the pregnancy An ultrasound scan revealed a chorionic bump with a hypoechoic center and echogenic border, measuring 18.3 x 14.7 x 21.9 mm. No motion within the chorionic bump was detected upon color and power Doppler examination. The second scan was performed a week later at 7+4 wks. The chorionic bump had not changed in terms of size and sonographic appearance. An acranial fetus of CRL 45.5 mm was diagnosed at 11 + 2 wks. The concentration of free beta-hCG was 17.2 IU/L, corresponding to 0.37 MoM and PAPP-A levels were 1.31 IU/L, corresponding to 0.82 MoM. After counseling the patient opted for termination of pregnancy Very few cases of chorionic bumps have been described so far and, to the best of our knowledge, its coexistence with neural tube defects has been reported for the first time. We postulate a possibility of an underlying pathological mechanism for such coexistence. The chorionic bump is a focal convex bulge with irregular borders, protruding from the choriodecidual surface into the gestational sac and with different degrees of echogenicity usually a hypoechoic middle and echogenic border The chorionic bump might represent the following: a hematoma, an area of hemorrhage, a non-embryonic gestation, or a demise of an embryo in a twin pregnancy The presence of the bump is associated with a four-fold increase in the spontaneous abortion rate as compared with the general population. Decreased folate levels increase the incidence of neural tube defects. Oxidative stress resulting from folic acid deficiency may be responsible for neural tube defects through impairment of factors inhibiting apoptosis in the neuroepithelium. Fetuses with neural tube defects are at an increased risk of being aborted spontaneously Furthermore, women who deliver children with neural tube defects frequently have a history of miscarriage. Our patient did not take any folic acid and also had a history of spontaneous miscarriage. In the case we herein presented, the coexistence of acrania and placental pathology could be attributed to folate deficiency Such coexistence is described for the first time and could be accidental, but there is possible theoretical association between these two pathologies.

Maternal SARS-CoV-2 Infection at Delivery Increases IL-6 Concentration in Umbilical Cord Blood.

BACKGROUND: SARS-CoV-2 infection in pregnant women may induce inflammation within the amniotic cavity and/or an increase in proinflammatory cytokines in fetal circulation. The aim was to investigate levels of IL-6 in maternal blood, umbilical cord blood, and amniotic fluid in pregnant women infected with SARS-CoV-2 at delivery. METHODS: A single-center prospective observational case-control study of pregnant women diagnosed with SARS-CoV-2 infection at delivery was conducted. A total of 48 infected and 42 healthy women had IL-6 concentrations measured in their blood, amniotic fluid, and umbilical cord blood. RESULTS: The concentrations of IL-6 in maternal blood and amniotic fluid were similar in the study and control groups, while umbilical cord blood concentrations were significantly higher in SARS-CoV-2-positive women. The umbilical cord blood IL-6 concentration was related to composite neonatal morbidity. CONCLUSIONS: Maternal SARS-CoV-2 infection in pregnant women at delivery increases umbilical cord blood IL-6 concentration. The correlation between maternal and umbilical blood concentrations indicates a possibility of passage of IL-6 through the placenta. Perinatal alterations resulting from maternal SARS-CoV-2 infection at delivery carry a risk of impacting the health of infants even in asymptomatic course of infection.

BabyNet＋＋: Fetal birth weight prediction using biometry multimodal data acquired less than 24 hours before delivery.

Accurate prediction of fetal weight at birth is essential for effective perinatal care, particularly in the context of antenatal management, which involves determining the timing and mode of delivery. The current standard of care involves performing a prenatal ultrasound 24 hours prior to delivery. However, this task presents challenges as it requires acquiring high-quality images, which becomes difficult during advanced pregnancy due to the lack of amniotic fluid. In this paper, we present a novel method that automatically predicts fetal birth weight by using fetal ultrasound video scans and clinical data. Our proposed method is based on a Transformer-based approach that combines a Residual Transformer Module with a Dynamic Affine Feature Map Transform. This method leverages tabular clinical data to evaluate 2D+t spatio-temporal features in fetal ultrasound video scans. Development and evaluation were carried out on a clinical set comprising 582 2D fetal ultrasound videos and clinical records of pregnancies from 194 patients performed less than 24 hours before delivery. Our results show that our method outperforms several state-of-the-art automatic methods and estimates fetal birth weight with an accuracy comparable to human experts. Hence, automatic measurements obtained by our method can reduce the risk of errors inherent in manual measurements. Observer studies suggest that our approach may be used as an aid for less experienced clinicians to predict fetal birth weight before delivery, optimizing perinatal care regardless of the available expertise.

Deep learning for estimation of fetal weight throughout the pregnancy from fetal abdominal ultrasound.

BACKGROUND: Fetal weight is currently estimated from fetal biometry parameters using heuristic mathematical formulas. Fetal biometry requires measurements of the fetal head, abdomen, and femur. However, this examination is prone to inter- and intraobserver variability because of factors, such as the experience of the operator, image quality, maternal characteristics, or fetal movements. Our study tested the hypothesis that a deep learning method can estimate fetal weight based on a video scan of the fetal abdomen and gestational age with similar performance to the full biometry-based estimations provided by clinical experts. OBJECTIVE: This study aimed to develop and test a deep learning method to automatically estimate fetal weight from fetal abdominal ultrasound video scans. STUDY DESIGN: A dataset of 900 routine fetal ultrasound examinations was used. Among those examinations, 800 retrospective ultrasound video scans of the fetal abdomen from 700 pregnant women between 15 6/7 and 41 0/7 weeks of gestation were used to train the deep learning model. After the training phase, the model was evaluated on an external prospectively acquired test set of 100 scans from 100 pregnant women between 16 2/7 and 38 0/7 weeks of gestation. The deep learning model was trained to directly estimate fetal weight from ultrasound video scans of the fetal abdomen. The deep learning estimations were compared with manual measurements on the test set made by 6 human readers with varying levels of expertise. Human readers used standard 3 measurements made on the standard planes of the head, abdomen, and femur and heuristic formula to estimate fetal weight. The Bland-Altman analysis, mean absolute percentage error, and intraclass correlation coefficient were used to evaluate the performance and robustness of the deep learning method and were compared with human readers. RESULTS: Bland-Altman analysis did not show systematic deviations between readers and deep learning. The mean and standard deviation of the mean absolute percentage error between 6 human readers and the deep learning approach was 3.75%±2.00%. Excluding junior readers (residents), the mean absolute percentage error between 4 experts and the deep learning approach was 2.59%±1.11%. The intraclass correlation coefficients reflected excellent reliability and varied between 0.9761 and 0.9865. CONCLUSION: This study reports the use of deep learning to estimate fetal weight using only ultrasound video of the fetal abdomen from fetal biometry scans. Our experiments demonstrated similar performance of human measurements and deep learning on prospectively acquired test data. Deep learning is a promising approach to directly estimate fetal weight using ultrasound video scans of the fetal abdomen.

Emergency cerclage using double-level versus single-level suture in the management of cervical insufficiency (Cervical Occlusion double-level Stitch Application, COSA): study protocol for a multicentre, non-blinded, randomised controlled trial.

INTRODUCTION: Cervical insufficiency accounts for 15% of recurrent pregnancy losses between 16 and 28 weeks of gestation. The aim of the study is to verify the effectiveness of emergency double-level cerclage with vaginal progesterone in cervical insufficiency treatment in terms of the prevention of preterm delivery before 34 weeks of gestation. METHODS AND ANALYSIS: This trial is a multicentre, non-blinded, randomised study with 1:1 allocation ratio. The study is conducted at tertiary perinatal care departments in Poland. It will include patients with cervical insufficiency with the fetal membranes visible in the open cervical canal or protruding into the vagina between 16+0 and 23+6 weeks of pregnancy. They will be randomised into two arms: emergency single-level cerclage with vaginal progesterone or double-level cerclage with vaginal progesterone. All will be administered antibiotics and indomethacin. The primary outcome is the rate of deliveries below 34+0 weeks of gestation, while secondary outcomes include gestational age at delivery, neonatal outcomes, maternal outcomes according to the Core Outcome Set for Evaluation of Interventions to Prevent Preterm Birth and cerclage procedure complications. The planned number of participants according to the power analysis is 78. ETHICS AND DISSEMINATION: The study protocol was written in accordance with the Standard Protocol Items: Recommendations for Interventional Trials statement. It was created according to the requirements of the Declaration of Helsinki for Medical Research involving Human Subject. Ethical approval was obtained from the Ethics Committee of the Centre of Postgraduate Medical Education (no. 1/2022). The study protocol was approved and published by ClinicalTrials.gov (posted on 24 February 2022). All participants gave a written informed consent. After completion of the study its results will be published in a peer-reviewed English language journal. TRIAL REGISTRATION: NCT05268640.

Maternal serum vitamin D at 11-13 weeks in pregnancies delivering small for gestational age neonates.

OBJECTIVES: To determine if maternal serum levels of 25(OH)D at 11-13 weeks' gestation are altered in pregnancies that subsequently deliver small for gestational age (SGA) neonates and whether the levels are related to placental function reflected in serum concentration of pregnancy-associated plasma protein-A (PAPP-A). METHODS: Serum 25(OH)D and PAPP-A were measured at 11-13 weeks in 150 singleton pregnancies that delivered SGA neonates and 1,000 appropriate for gestational age (AGA) controls. The median 25(OH)D and PAPP-A multiple of the unaffected median (MoM) in the outcome groups were compared. RESULTS: In the SGA, the median serum 25(OH)D and PAPP-A were significantly decreased (0.78 vs. 1.00 MoM, p < 0.0001 and 0.78 vs. 1.00 MoM, p < 0.0001, respectively). The incidence of 25(OH)D levels below the 10th percentile was significantly higher in the SGA than the AGA group in Caucasian women (p = 0.002) but not in those of African racial origin (p = 0.183). There was no significant association between 25(OH)D MoM and PAPPA MoM in either the SGA or the AGA groups. CONCLUSION: Serum 25(OH)D levels at 11-13 weeks are decreased in pregnancies of Caucasian women that deliver SGA neonates but not in those of African racial origin. The decrease in 25(OH)D levels is unrelated to placental function.

Effective treatment of cervical incompetence in a monochorionic monoamniotic twin pregnancy with a rescue cervical cerclage and pessary--a case report and review of literature.

A monochorionic monoamniotic (MCMA) twin pregnancy is the rarest form of twin gestation, accounting for around 1:10000 to 1:20000 of all deliveries regardless of the region of the world. All multiple gestations have a higher risk of preterm delivery due to either preterm uterine contractions or asymptomatic cervical shortening (cervical incompetence). A case of a 28-year-old primigravida in MCMA twin pregnancy with cervical incompetence diagnosed at 22 weeks of gestation is presented. After obtaining cervical swabs, negative laboratory infection parameters and confirming concordant gestational age on ultrasound scan with no structural abnormalities of both fetuses, the patient was qualified for an emergency cervical cerclage according to Wurm-Hefner method. Five days after the procedure, a cervical pessary was additionally inserted. She was administered antibiotics and steroids. The wellbeing of both fetuses was strictly monitored by means of cardiotocography tracing and ultrasound examinations, on which they were both eutrophic, with no abnormalities in Doppler blood flow patterns. Spontaneous premature rupture of membranes took place at 32 weeks of gestation, a cesarean section was performed and two female fetuses of 1740 g and 1760 g were delivered. They both required antibiotics because of congenital pneumonia, but no respiratory support was necessary The twins were discharged from the hospital 22 days after birth in good general condition. This case of a rescue cervical cerclage and pessary used simultaneously can be an example of an effective method of cervical incompetence treatment in twin pregnancies.