Anatomic parameters of omphaloceles and their association with anatomic, genetic, or syndromic malformations: a retrospective study.

PURPOSE: This retrospective study aims to describe anatomical parameters of omphaloceles and to analyze their association with anatomical, genetic, or syndromic malformations. METHODS: Cases were selected from digital records of two university centers, a certified regional registry and personal records. Patients from 1998 to 2018 with omphalocele and live birth (LB), termination of pregnancy due to fetal anomaly (TOPFA) and fetal death (FD) were included. Cases born outside Western Switzerland and/or with upper or lower coelosomy were excluded. RESULTS: We analyzed 162 cases with the following distribution: 57 (35%) LB, 91 (56%) TOPFA and 14 (9%) FD. TOPFA was significantly more frequently performed in cases with non-isolated omphalocele, i.e., omphaloceles with associated major malformations (especially cardiovascular and genitourinary), genetic/chromosomal anomalies, or syndromes. For LB, associated anatomical malformations, genetic or chromosomal anomalies were not significantly associated with the size of the omphalocele or the liver involvement. CONCLUSIONS: The proportion of cases resulting in TOPFA was higher among fetuses with major malformations, genetic or chromosomal anomalies. Despite the large size of this cohort, and in contrary to previous publications, the size of the omphalocele and/or liver involvement does not allow for conclusions regarding the presence or number of associated malformations, genetic or chromosomal anomalies.

Predictors of fetal death, neonatal survival and neurological outcomes in severe twin-twin transfusion syndrome treated by laser ablation of placental vessels.

OBJECTIVES: To identify predictors of outcomes in severe twin oligo-polyhydramnios sequence (TOPS) with or without twin anemia-polycythemia sequence (TAPS) and/or selective fetal growth restriction (SFGR) treated by laser ablation of placental vessels (LAPV). METHODS: Analysis of cases treated from 2011 to 2022. Variables evaluated Prenatal predictors: stages of TOPS, presence of TAPS and/or SFGR; pre-LAPV fetal ultrasound parameters; peri-LAPV variables. Perinatal predictors: GA at birth; birthweight; Apgar scores; transfontanellar ultrasonography (TFUS). OUTCOME VARIABLES: fetal death, neonatal survival, infant's neurodevelopment. Binary logistic regression analyses were performed to detect predictors of outcomes. RESULTS: 265 cases were included. Predictors of post-LAPV donor fetus' death were delta EFW (p:0.045) and absent/reverse end-diastolic flow in the umbilical artery (AREDF-UA) (p < 0.001). The predictor of post-LAPV recipient fetus' death was hydrops (p:0.009). Predictors of neonatal survival were GA at birth and Apgar scores. Predictors of infant's neurodevelopment were TFUS and pre-LAPV middle cerebral artery Doppler (MCAD) for the donor twin; and pre-LAPV ductus venosus' flow and MCAD for the recipient twin. CONCLUSIONS: Prediction of fetal death, neonatal survival and infant's neurodevelopment is possible in cases of TOPS associated or not with SFGR and/or TAPS that were treated by LAPV.

Prenatal Risk Factors and Outcomes of Pseudoamniotic Band Sequence following Fetoscopic Laser Surgery: Systematic Review, and Meta-Analysis.

BACKGROUND: Pseudoamniotic band sequence (PABS) is a rare iatrogenic consequence of invasive fetal interventions, most commonly fetoscopic laser surgery (FLS) in monochorionic multiple pregnancies complicated by twin-to-twin transfusion syndrome (TTTS). OBJECTIVES: The aim of this study was to investigate prenatal risk factors and perinatal outcomes for pregnancies involving PABS after FLS for TTTS and compare outcomes between those undergoing fetoscopic band release versus not. METHOD: We conducted a systematic search of PubMed, Scopus, and Web of Science on studies reporting PABS following FLS for TTTS. A meta-analysis of pooled proportions was conducted. RESULTS: There were 16 studies covering 47 pregnancies complicated by PABS following FLS, mostly case series and case reports. The incidence of PABS was 2%, with the recipient twin affected in 94% of the cases. Pregnancies complicated by PABS were associated with inter-twin septostomy in 32% and chorioamniotic separation (CAS) in 90%. The mean gestational age (GA) at FLS and delivery were 17.7 and 30.9 weeks, respectively. Preterm premature rupture of membranes (PPROM) happened in 62% of pregnancies. The risk of preterm birth (PTB) <34 weeks, <32 weeks, and <28 weeks were 94%, 67%, and 31%, respectively. There were 41% fetal demises and 64% live births among the affected fetuses. Results of fetoscopic band release versus not were comparable, including GA at delivery, PPROM, and PTB at 32 weeks. It was noted that the likelihood of PTB by 28 weeks (67% vs. 23%) and fetal death (50% vs. 39%) were higher in the band release group. It was similar between groups in terms of postnatal amputation. CONCLUSIONS: PABS causes amputations or fetal death in more than one-third of cases. Pregnancies with an inter-twin septostomy, CAS, advanced TTTS staging, and early GA are more likely to experience PABS. In addition, more than a third of FLS-treated TTTS resulted in PTB and PPROM. PABS cases with prenatal band release showed higher rates of PTB and fetal death, but the data were from small, heterogeneous studies.

Successful antenatal treatment of MAGED2-related Bartter syndrome and review of treatment options and efficacy.

A new form of transient antenatal Bartter syndrome (aBS) was recently identified that is associated with the X-linked MAGED2 variant. Case reports demonstrate that this variant leads to severe polyhydramnios that may result in preterm birth or pregnancy loss. There is limited but promising evidence that amnioreductions may improve fetal outcomes in this rare condition. We report a woman with two affected pregnancies. In the first pregnancy, the patient was diagnosed with mild-to-moderate polyhydramnios in the second trimester that ultimately resulted in preterm labor and delivery at 25 weeks with fetal demise. Whole exome sequencing of the amniotic fluid sample resulted after the pregnancy loss and revealed a c.1337G>A MAGED2 variant that was considered diagnostically. The subsequent pregnancy was confirmed by chorionic villi sampling to also be affected by this variant. The pregnancy was managed with frequent ultrasounds and three amnioreductions that resulted in spontaneous vaginal delivery at 37 weeks and 6 days of a viable newborn with no evidence of overt electrolyte abnormalities suggesting complete resolution. A detailed review of the published cases of MAGED2-related transient aBS is provided. Our review focuses on individuals who received antenatal treatment. A total of 31 unique cases of MAGED2-related transient aBS were compiled. Amnioreduction was performed in 23 cases and in 18 cases no amnioreduction was performed. The average gestational age at delivery was significantly lower in cases without serial amnioreduction (28.7 vs. 30.71 weeks, p = 0.03). Neonatal mortality was seen in 5/18 cases without serial amnioreduction, and no mortality was observed in the cases with serial amnioreduction. In cases of second trimester severe polyhydramnios without identifiable cause, whole exome sequencing should be considered. Intensive ultrasound surveillance and serial amnioreduction is recommended for the management of MAGED2-related transient aBS.

Hígado graso agudo del embarazo en una adulta joven / Acute fatty liver of pregnancy in a young adult woman i: en

Se presenta el caso clínico de una gestante de 20 años de edad, quien acudió al Cuerpo de Guardia del bloque materno del Hospital General Docente Dr. Juan Bruno Zayas Alfonso de Santiago de Cuba por presentar decaimiento, náuseas y malestar general. Durante la exploración física se encontró piel sudorosa y fría, taquicardia e ictericia. Se realizaron diversos exámenes complementarios y se constató alteración hepática, así como cifras bajas de glucemia. Se diagnosticó hígado graso agudo del embarazo. Luego de varios días de hospitalizada con una evolución desfavorable, hasta llegar al estado crítico, la paciente falleció por síndrome de disfunción multiorgánica.

The case report of a 20 years pregnant woman is presented, who went to the maternal block emergency room of Dr. Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba due to run-down, nausea and diffuse discomfort. During the physical exploration sweaty and cold skin, tachycardia and jaundice were found. Diverse complementary exams were carried out and a hepatic disorder was verified, as well as low figures of glycemia. Acute fatty liver of pregnancy was diagnosed. After several days hospitalized with an unfavorable clinical course until getting to the critical state, the patient died due to multiple organ dysfunction syndrome.

"Prevalence and secular trend of neural tube defects in fetal deaths in Argentina, 1994-2019".

BACKGROUND: Fetal deaths are a major source of information on the epidemiology of neural tube defects (NTDs; anencephaly and myelomeningocele). We analyzed NTDs prevalence and secular trend using fetal death records between 1994 and 2019 in Argentina. MATERIALS AND METHODS: Data were obtained from the Department of Statistics and Information of the Ministry of Health (DEIS). Using the number of fetal deaths due to anencephaly and myelomeningocele, we estimated the proportion of all fetal deaths due to anencephaly, myelomeningocele, and NTDs (anencephaly + myelomeningocele) during pre- and post-fortification period in Argentina. We also estimated the ratio of fetal deaths due to anencephaly, myelomeningocele, and NTDs (anencephaly + myelomeningocele) to 10,000 live births. Secular trend in the outcomes was analyzed using a Poisson model and Joinpoint regression analysis. RESULTS: In the entire period analyzed, the NTD proportion on fetal deaths was 1.32. In 1994, NTDs accounted for 34.7% of congenital malformations fetal deaths (CM) and 1.7% of all fetal deaths, whereas in 2019, these percentages were 9.4% and 0.5%, respectively. NTDs present a negative secular trend (p < .05). The risk of fetal death due to anencephaly and myelomeningocele decreases between 2005 and 2019 by 67% and 51% respectively (p < .05) in comparison to the period between 1994 and 2004 before the effective fortification of wheat flour used in the food industry destined for the domestic market. DISCUSSION AND CONCLUSION: We found a significant decrease in the risk of all fetal deaths due to NTDs, particularly anencephaly, in Argentina over the study period, with most reduction observed during the mandatory flour fortification era (introduced in Argentina in 2002). The inclusion of fetal deaths in NTD surveillance, coupled or uncoupled with other pregnancy outcomes, is essential for monitoring preventive supplementation measures.

Retrospective Analysis of the Clinical Features and Pregnancy Outcomes in 124 Pregnant Patients with Non-Obstetric Acute Abdomen.

Objective: To retrospectively analyze the clinical characteristics and pregnancy outcomes of patients with the non-obstetric acute abdomen (AAD) during pregnancy. Methods: A total of 124 patients with non-obstetric AAD during pregnancy were selected, including acute gastroenteritis (n = 42), acute appendicitis (n = 24), pedicle torsion of ovarian tumor (n = 21), acute pancreatitis (n = 10), urinary stones (n = 8), acute cholecystitis (n = 5), ruptured ovarian cyst (n = 6), red degeneration of hysteromyoma (n = 4), pedicle torsion of subserosal hysteromyoma (n = 3) and intestinal obstruction (n = 1). The clinical data of included patients were collected, and their clinical manifestations, clinical diagnosis, treatment modalities, and pregnancy outcomes were analyzed. Results: Common clinical manifestations included abdominal pain, nausea, vomiting, fever, elevated leukocytes, and neutrophil count. Clinical diagnosis analysis revealed acute gastroenteritis (n = 42), acute appendicitis (n = 24), pedicle torsion of ovarian tumor (n = 21), acute pancreatitis (n = 10), urinary stones (n = 8), acute cholecystitis (n = 5), ruptured ovarian cyst (n = 6), red degeneration of hysteromyoma (n = 4), pedicle torsion of subserosal hysteromyoma (n = 3) and intestinal obstruction (n = 1) in patients. Surgery was performed for conditions such as acute appendicitis and ovarian tumor torsion, while conservative treatment was preferred for cases of acute gastroenteritis. 65 patients received surgery and 59 patients received conservative treatment. The pregnancy outcomes indicated 113 patients with full-term delivery, 5 with premature delivery, 6 with miscarriage and 1 with fetal death. Pregnancy outcomes varied, with 113 patients achieving full-term delivery, 5 experiencing premature delivery, 6 undergoing miscarriage, and 1 case of fetal death. Conclusion: Non-obstetric AAD during pregnancy manifests clinically as nausea and vomiting, abdominal pain, elevated body temperature, and leukocytes, all of which have pregnancy outcomes. Pregnant patients with non-obstetric AAD should be diagnosed according to their clinical manifestations, physical examinations, and relevant imaging examinations, and appropriate treatment modalities should be selected to achieve a better pregnancy outcome and ensure the safety of the mother and baby during the clinical diagnosis and treatment process. This study underscores the need for prompt and accurate diagnosis in pregnant patients with non-obstetric AAD, to optimize pregnancy outcomes and ensure maternal-fetal safety.

Maternal PlGF and umbilical Dopplers predict pregnancy outcomes at diagnosis of early-onset fetal growth restriction.

BACKGROUNDSevere, early-onset fetal growth restriction (FGR) causes significant fetal and neonatal mortality and morbidity. Predicting the outcome of affected pregnancies at the time of diagnosis is difficult, thus preventing accurate patient counseling. We investigated the use of maternal serum protein and ultrasound measurements at diagnosis to predict fetal or neonatal death and 3 secondary outcomes: fetal death or delivery at or before 28+0 weeks, development of abnormal umbilical artery (UmA) Doppler velocimetry, and slow fetal growth.METHODSWomen with singleton pregnancies (n = 142, estimated fetal weights [EFWs] below the third centile, less than 600 g, 20+0 to 26+6 weeks of gestation, no known chromosomal, genetic, or major structural abnormalities) were recruited from 4 European centers. Maternal serum from the discovery set (n = 63) was analyzed for 7 proteins linked to angiogenesis, 90 additional proteins associated with cardiovascular disease, and 5 proteins identified through pooled liquid chromatography and tandem mass spectrometry. Patient and clinician stakeholder priorities were used to select models tested in the validation set (n = 60), with final models calculated from combined data.RESULTSThe most discriminative model for fetal or neonatal death included the EFW z score (Hadlock 3 formula/Marsal chart), gestational age, and UmA Doppler category (AUC, 0.91; 95% CI, 0.86-0.97) but was less well calibrated than the model containing only the EFW z score (Hadlock 3/Marsal). The most discriminative model for fetal death or delivery at or before 28+0 weeks included maternal serum placental growth factor (PlGF) concentration and UmA Doppler category (AUC, 0.89; 95% CI, 0.83-0.94).CONCLUSIONUltrasound measurements and maternal serum PlGF concentration at diagnosis of severe, early-onset FGR predicted pregnancy outcomes of importance to patients and clinicians.TRIAL REGISTRATIONClinicalTrials.gov NCT02097667.FUNDINGThe European Union, Rosetrees Trust, Mitchell Charitable Trust.

Prenatal diagnosis of fetal pericardial rhabdomyoma resulting in fetal death.

We present a case of huge pericardial rhabdomyoma that progressed into the pericardial cavity, resulting in fetal death. Fetal ultrasound and neonatal echocardiography provide excellent diagnostic methods for fetal rhabdomyoma. When established, antenatal diagnosis enables a focused, specialized, and multidisciplinary approach with individual case management, potentially reducing perinatal morbidity and mortality.

Triple repeated fetal congenital heart disease linked to PLD1 mutation: a case report.

BACKGROUND: Congenital heart disease occurs in approximately 1 in 100 cases. Although sibling occurrence is high (3-9%), the causative genes for this disease are still being elucidated. PLD1 (Phospholipase D1) is a recently discovered gene; however, few case reports have been published on it. In this report, we describe a case of triplicate fetal congenital heart disease that was diagnosed as a PDL1 mutation. Our objective is to explore the clinical manifestations of PLD1 mutations in this particular case. CASE PRESENTATION: A 32-year-old Japanese woman (gravida, para 0) was introduced since fetus four chamber view was not clear and was diagnosed with ductus arteriosus-dependent left ventricular single ventricle and pulmonary atresia at 21 weeks and 1 day of gestation during her first pregnancy. Artificial abortion using Gemeprost was performed at 21 weeks and 5 days of gestation. The second pregnancy was diagnosed as pulmonary atresia with intact ventricular septum with cardiomegaly, a cardiothoracic area ratio of more than 35%, and a circulatory shunt at 13 weeks and 3 days of gestation. Subsequently, intrauterine fetal death was confirmed at 14 weeks and 3 days of gestation. Regarding the third pregnancy, fetal ultrasonography at 11 weeks and 5 days of gestation showed mild fetal hydrops and moderate tricuspid valve regurgitation. At 16 weeks and 5 days of gestation, the fetus was suspected to have a left ventricular-type single ventricle, trace right ventricle, pulmonary atresia with intact ventricular septum, or cardiomyopathy. Cardiac function gradually declined at 26 weeks of gestation, and intrauterine fetal death was confirmed at 27 weeks and 5 days of gestation. The fourth pregnancy resulted in a normal heart with good progression and no abnormal baby. We submitted the first and second fetuses' umbilical cord, third fetus' placenta, and the fourth fetus' blood to genetic testing using whole exome analysis with next generation sequencing. Genetic analysis identified hemizygous PLD1 mutations in the first, second, and third fetuses. The fourth fetus was heterozygous. In addition, the parents were heterozygous for PLD1. This case is based on three consecutive cases of homozygosity for the PLD1 gene in the sibling cases and the fetuses with recurrent right ventricular valve dysplasia. This will elucidate the cause of recurrent congenital heart disease and intrauterine fetal death and may serve as an indicator for screening the next fetus. To date, homozygous mutations in PLD1 that repeat three times in a row are not reported, only up to two times. The novelty of this report is that it was repeated three times, followed by a heterozygous live birth. CONCLUSIONS: This report is consistent with previous reports that mutations in PLD1 cause right ventricular valve dysplasia. However, there have been few case reports of PLD1 mutations, and we hope that this report will contribute to elucidate the causes of congenital heart disease, especially right ventricular valve dysplasia, and that the accumulation of such information will provide more detailed information on PLD1 mutations in heart disease.

Oxidative Stress Markers in Human Brain and Placenta May Reveal the Timing of Hypoxic-Ischemic Injury: Evidence from an Immunohistochemical Study.

During pregnancy, reactive oxygen species (ROS) serve as crucial signaling molecules for fetoplacental circulatory physiology. Oxidative stress is thought to sustain the pathogenesis and progression of hypoxic-ischemic encephalopathy (HIE). A retrospective study was performed on the brains and placentas of fetuses and newborns between 36-42 weeks of gestation (Group_1: Fetal intrauterine deaths, Group_2: Intrapartum deaths, Group_3: Post-partum deaths, Control group sudden neonatal death); all groups were further divided into two subgroups (Subgroup_B [brain] and Subgroup_P [placenta]), and the study was conducted through the immunohistochemical investigations of markers of oxidative stress (NOX2, 8-OHdG, NT, iNOS), IL-6, and only on the brain samples, AQP4. The results for the brain samples suggest that NOX2, 8-OHdG, NT, iNOS, and IL-6 were statistically significantly expressed above the controls. iNOS was more expressed in the fetal intrauterine death (Group_1) and less expressed in post-partum death (Group_3), while in intrapartum death (Group_2), the immunoreactivity was very low. IL-6 showed the highest expression in the brain cortex of the fetal intrauterine death (Group_1), while intrapartum death (Group_2) and post-partum death (Group_3) showed weak immunoreactivity. Post-partum death (Group_3) placentas showed the highest immunoreactivity to NOX2, which was almost double that of the fetal intrauterine death (Group_1) and intrapartum death (Group_2) placentas. Placental tissues of fetal intrauterine death (Group_1) and intrapartum death (Group_2) showed higher expression of iNOS than post-partum death (Group_3), while the IL-6 expression was higher in the fetal intrauterine death (Group_1) than the post-partum death (Group_3). The AQP4 was discarded as a possible marker because the immunohistochemical reaction in the three groups of cases and the control group was negative. The goal of this study, from the point of view of forensic pathology, is to provide scientific evidence in cases of medical liability in the Obstetric field to support the clinical data of the timing of HIE.

Constrictive amniotic band syndrome, when the embryo gets caught.

Constrictive amniotic band syndrome (CABS) is a rare condition which occurs sporadically and should not be compared with a syndrome as it is known from genetics. However, since the pathogenesis is not yet fully understood, some theories suggest genetics playing a role. Even though CABS is rare it is associated with a high risk of foetal death as seen in 1/70 of these cases. The diagnostics start with ultrasound of the pregnant woman, and if this leads to suspicion of CABS it is possible to supplement with 3D ultrasound or MRI to verify. The treatment involves either in utero or postnatal surgery depending on the case, as argued in this review.

Comparison of the effect of vaginal misoprostol and evening primrose oil capsule with misoprostol alone on the consequences of abortion in women with intrauterine fetal death: a randomized clinical trial.

BACKGROUND: Misoprostol is the choice drug for inducing an abortion with intrauterine fetal death, but it has several side effects that increase with accumulating the dose received. Induction abortion with cheap and non-invasive methods with minimal complications is essential. This study aimed to compare the effect vaginal misoprostol plus vaginal evening primrose oil capsule with vaginal misoprostol alone on the consequences of abortion in pregnant women with intrauterine fetal death at 12-20 weeks of pregnancy. METHODS: This study is a randomized, triple-blind clinical trial with two parallel groups at a ratio of 1:1. We randomized 82 women with indications of termination of pregnancy due to intrauterine fetal death into two groups. The experimental group (n = 42) received 200 mcg of misoprostol tablet with 1000 mg evening primrose oil capsule intravaginal. The control group (n = 40) received 200 mcg of misoprostol tablet with 1000 mg evening primrose oil placebo capsule intravaginal. Both groups received the drugs every 4 h for up to five doses. The primary outcome was the mean induction-to-fetal expulsion interval. Secondary outcomes were the mean dose of misoprostol, the highest pain intensity in the induction-to-fetal expulsion interval, the frequency of participants requiring blood transfusion, curettage, and the frequency of side effects of misoprostol or evening primrose oil. Pain intensity was measured through the Visual Analog Scale. RESULTS: The mean age of the experimental group was 32.30 ± 6.19 years, and the control group was 30.27 ± 7.68 years. The mean gestational age of the experimental group was 15.29 ± 2.26 weeks, and the control group was 15.10 ± 1.89 weeks. The mean induction-to-fetal expulsion interval in the experimental group (3.12 ± 2.17 h) was significantly lower than that in the control group (8.40 ± 4.1 h) (p < 0.001). The mean dose of misoprostol received in the experimental group (271.42 ± 115.39 mcg) was significantly lower than that in the control group (520 ± 201.53 mcg) (p < 0.001). Also, the mean pain intensity in the experimental group (5.02 ± 0.60) was significantly lower than that in the control group (8.65 ± 1.001) (p < 0.001). The two groups were not significantly different in the frequency of blood transfusion requirements, analgesia and drug side effects. The need for curettage in the experimental group (4.8%) was significantly lower than that in the control group (47.5%) (p < 0.001). CONCLUSIONS: Vaginal administration of evening primrose oil with misoprostol reduced duration of time of fetal expulsion, pain intensity, mean dose of misoprostol received, and the need for curettage in participants. Therefore, we suggest this method for induced abortion in women with intrauterine fetal death. TRIAL REGISTRATION: IRCT20181207041873N3. Dated 16/2/2021 prospectively registered https://en.irct.ir/user/trial/53681/view .

Management of large placental chorioangioma: two-port laser approach for fetal intervention.

OBJECTIVES: There is a paucity of literature providing evidence-based guidelines for the management of large placental chorioangioma (≥ 4 cm in diameter). The objectives of this study were to compare outcomes between patients managed expectantly and those undergoing in-utero intervention and to describe the different in-utero techniques used for cessation of blood flow to the tumor and the associated outcome. METHODS: This was a retrospective cohort study of 34 patients referred for the management of large placental chorioangioma in a single center between January 2011 and December 2022, who were managed expectantly or underwent in-utero intervention. In-utero intervention was performed when the fetus developed any signs of impending compromise, including high combined cardiac output (CCO), worsening polyhydramnios or abnormal fetal Doppler velocimetry findings. Interventions included radiofrequency ablation (RFA), interstitial laser ablation (ILA) and single-port or two-port fetoscopic laser photocoagulation (FLP). Treatment selection was dependent on the proximity of the tumor to the umbilical cord insertion (UCI) and placental location. The two-port technique was performed in patients with a chorioangioma with large feeding vessels (≥ 3 mm) located in the posterior placenta, in which one port was used for occlusion using bipolar forceps and the other port was used for laser photocoagulation of the feeding vessels downstream. The single-port technique was used for chorioangioma with small feeding vessels (< 3 mm) located in the posterior placenta. ILA or RFA was performed in cases with an anterior placenta. Supportive treatments, including amnioreduction and intrauterine transfusion (IUT), were performed for worsening polyhydramnios and suspected fetal anemia based on middle cerebral artery Doppler flow studies, respectively. Comparative statistical analysis between cases undergoing expectant management vs in-utero intervention was performed. Descriptive details were provided for patients who underwent in-utero intervention. RESULTS: Thirty-four cases of large chorioangioma were evaluated, of which 25 (73.5%) were managed expectantly and nine (26.5%) underwent intervention. The frequency of polyhydramnios was significantly higher in the intervention group compared with the expectant-management group (66.7% vs 8.0%, P < 0.001). The live-birth rate among expectantly managed cases with large chorioangioma was significantly higher compared with that in cases that underwent in-utero intervention (96.0% vs 62.5%, P = 0.01). In the intervention group, preoperative CCO was elevated in all cases with available information and preoperative hydrops was present in 33.3% (3/9) of cases. One patient experienced fetal demise following IUT prior to planned FLP. Among the remaining eight patients, four underwent two-port FLP, two underwent single-port FLP, one underwent ILA and one underwent both ILA and RFA. All three cases in which hydrops was present at the time of intervention resulted in fetal demise. CONCLUSIONS: In-utero interventions aimed at cessation of blood flow in the feeding vessels are a therapeutic option for the management of cases with large chorioangioma. The two-port percutaneous technique appears to improve the efficiency of FLP when a large chorioangioma with large feeding vessels is located in the posterior placenta. We propose that in-utero interventions for large chorioangioma should be initiated prior to the development of fetal hydrops. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Characteristics and outcomes of patients undergoing second-trimester dilation and evacuation for intrauterine fetal demise vs induced abortion.

OBJECTIVES: Patients with intrauterine fetal demise (IUFD) are at higher risk of complications when undergoing dilation and evacuation (D&E) compared to patients undergoing abortion for other indications. We aimed to compare baseline characteristics and describe outcomes, including frequencies of complications such as disseminated intravascular coagulation (DIC) and hemorrhage, in patients undergoing D&E for IUFD vs induced abortion, with a goal of identifying associated risk factors for complications. STUDY DESIGN: We conducted a retrospective matched cohort study of patients undergoing nonemergent D&Es for singleton ≥14-0/7-week IUFD January 1, 2019 to May 31, 2021, matched with two patients undergoing induced second-trimester D&Es by cesarean delivery history, patient age, and gestational age (GA). We collected demographics, history, GA, coagulation studies, quantitative blood loss (QBL), and complications. We calculated descriptive statistics and tested for association using chi-square, Fisher's exact, t, and Wilcoxon's rank sum tests. RESULTS: Of 1390 procedures, 64 patients with IUFD met inclusion criteria and were matched with 128 patients undergoing induced D&E. Eight (12.5%) patients with IUFD and six (4.7%) undergoing induced D&E had hemorrhage (odds ratio [OR] = 2.90, 95% confidence interval [0.96, 8.77]). Six (9.4%) patients with IUFD and none undergoing induced D&E had DIC (OR = 28.56 [1.58, 515.38]). Median QBL was 75.0 mL (50, 162.5) for patients with IUFD vs 110.0 mL (50, 200) for those undergoing induced D&E (p = 0.083). Twelve (18.8%) patients with IUFD vs seven (5.5%) undergoing induced D&E received at least one intervention due to bleeding complications (p = 0.004). CONCLUSIONS: We found a higher DIC frequency but no significant difference in hemorrhage or QBL in IUFD D&E compared to induced abortion. Our IUFD D&E complication frequency is higher than those previously published. IMPLICATIONS: Our results affirm current standards of care for D&E in patients with IUFD. Large referral centers may have higher proportions of complications compared to other sites.

Fetal Mortality: United States, 2021.

Objectives-This report presents 2021 fetal mortality data by maternal race and Hispanic origin, age, tobacco use during pregnancy, and state of residence, as well as by plurality, sex, gestational age, birthweight, and selected causes of death. Trends in fetal mortality are also examined. Methods-Descriptive tabulations of data are presented and interpreted for all fetal deaths reported for the United States for 2021 with a stated or presumed period of gestation of 20 weeks or more. Cause-of-fetal-death data are restricted to residents of the 41 states and the District of Columbia, where cause of death was based on the 2003 fetal death report revision and less than 50% of deaths were attributed to Fetal death of unspecified cause (P95). Results-A total of 21,105 fetal deaths at 20 weeks of gestation or more were reported in the United States in 2021. The 2021 U.S. fetal mortality rate was 5.73 fetal deaths at 20 weeks of gestation or more per 1,000 live births and fetal deaths, which was essentially unchanged from the rate of 5.74 in 2020. The fetal mortality rate in 2021 for deaths occurring at 20-27 weeks of gestation was 2.95, essentially unchanged from 2020 (2.97). For deaths occurring at 28 weeks of gestation or more, the rate in 2021 (2.80) was not significantly different from 2020 (2.78). In 2021, the fetal mortality rate ranged from 3.94 for non-Hispanic, single-race Asian women to 9.89 for non-Hispanic, single-race Black women. Fetal mortality rates were highest for females under age 15 and aged 40 and over, for women who smoked during pregnancy, and for women with multiple gestation pregnancies. Five selected causes accounted for 89.9% of fetal deaths in the 41-state and District of Columbia reporting area.

Cervical Pessary for Prevention of Preterm Birth in Individuals With a Short Cervix: The TOPS Randomized Clinical Trial.

Importance: A short cervix as assessed by transvaginal ultrasound is an established risk factor for preterm birth. Study findings for a cervical pessary to prevent preterm delivery in singleton pregnancies with transvaginal ultrasound evidence of a short cervix have been conflicting. Objective: To determine if cervical pessary placement decreases the risk of preterm birth or fetal death prior to 37 weeks among individuals with a short cervix. Design, Setting, and Participants: We performed a multicenter, randomized, unmasked trial comparing a cervical pessary vs usual care from February 2017 through November 5, 2021, at 12 centers in the US. Study participants were nonlaboring individuals with a singleton pregnancy and a transvaginal ultrasound cervical length of 20 mm or less at gestations of 16 weeks 0 days through 23 weeks 6 days. Individuals with a prior spontaneous preterm birth were excluded. Interventions: Participants were randomized 1:1 to receive either a cervical pessary placed by a trained clinician (n = 280) or usual care (n = 264). Use of vaginal progesterone was at the discretion of treating clinicians. Main Outcome and Measures: The primary outcome was delivery or fetal death prior to 37 weeks. Results: A total of 544 participants (64%) of a planned sample size of 850 were enrolled in the study (mean age, 29.5 years [SD, 6 years]). Following the third interim analysis, study recruitment was stopped due to concern for fetal or neonatal/infant death as well as for futility. Baseline characteristics were balanced between participants randomized to pessary and those randomized to usual care; 98.9% received vaginal progesterone. In an as-randomized analysis, the primary outcome occurred in 127 participants (45.5%) randomized to pessary and 127 (45.6%) randomized to usual care (relative risk, 1.00; 95% CI, 0.83-1.20). Fetal or neonatal/infant death occurred in 13.3% of those randomized to receive a pessary and in 6.8% of those randomized to receive usual care (relative risk, 1.94; 95% CI, 1.13-3.32). Conclusions and Relevance: Cervical pessary in nonlaboring individuals with a singleton gestation and with a cervical length of 20 mm or less did not decrease the risk of preterm birth and was associated with a higher rate of fetal or neonatal/infant mortality. Trial Registration: ClinicalTrials.gov Identifier: NCT02901626.

Manejo de Disminución de Movimientos Fetales en pacientes del Área de Urgencias Obstétricas / Management of Decreased Fetal Movements in patients in the Obstetric Emergency Area

Los movimientos fetales son uno de los primeros signos de vitalidad fetal. Durante la gestación, éstos van apareciendo progresivamente. La adecuada adquisición y mantenimiento de los mismos durante la gestación indica un correcto desarrollo neuromuscular, así como de bienestar fetal1. La percepción materna de una Disminución de los Movimientos Fetales (DMF) constituye un motivo de consulta frecuente en los Servicios de Urgencias Obstétricas; toda paciente embarazada debe vigilar los movimientos fetales, mediante un conteo subjetivo de los movimientos del feto, a partir de las 24 semanas de gestación. La DMF constituye el 5 ­ 15% de motivos de consulta en los servicios de Urgencias en el tercer trimestre del embarazo. Hasta un 25% de fetos que presentan una DMF presentarán alguna complicación perinatal (malformaciones, retraso de crecimiento, parto prematuro, hemorragia fetomaterna, y éxitus fetal) incluso en población de bajo riesgo. El manejo inadecuado de la DMF representa un 10-15% de las muertes evitables a término1-3. Es por esto que ninguna paciente que consulte por Disminución de Movimientos Fetales debe ser dada de alta sin asegurarse del adecuado bienestar fetal.

Fetal movements are one of the first signs of fetal vitality. During gestation, they appear progressively. Adequate acquisition and maintenance of fetal movements during gestation indicates correct neuromuscular development, as well as fetal well-being1. Maternal perception of decreased fetal movements (DMP) is a frequent reason for consultation in Obstetric Emergency Departments; every pregnant patient should monitor fetal movements by subjectively counting fetal movements, starting at 24 weeks of gestation. FMD constitutes 5-15% of the reasons for consultation in the emergency department in the third trimester of pregnancy. Up to 25% of fetuses with FMD will present some perinatal complication (malformations, growth retardation, premature delivery, fetomaternal hemorrhage, and fetal death) even in low-risk populations. Inadequate management of FMD accounts for 10-15% of preventable deaths at term1-3. This is why no patient who consults for decreased fetal movements should be discharged without ensuring adequate fetal well-being.

Factores de riesgo maternos asociados con la muerte fetal tardía en el contexto santaclareño / Maternal risk factors associated with late fetal death in the Santa Clara context

Introducción: La muerte fetal es uno de los accidentes obstétricos más difíciles de enfrentar, tanto para la paciente y su familia como para el personal de salud que atiende a la gestante. Objetivo: Identificar los factores de riesgo maternos asociados con la muerte fetal tardía en el contexto santaclareño. Métodos: Se realizó un estudio descriptivo, longitudinal y retrospectivo en el municipio Santa Clara, provincia Villa Clara, en el período comprendido de enero de 2015 a diciembre de 2019. La población estuvo conformada por 71 gestantes con fetos muertos en una etapa tardía y sus productos; en el análisis y procesamiento de los datos, se usó el software SPSS versión 20 para Windows. Resultados: Existió predominio de gestantes multíparas (56,3 %), en edad reproductiva óptima (69 %) y con uno a tres factores de riesgo (71,8 %). Conclusiones: Los factores maternos asociados con mayor frecuencia a la muerte fetal tardía pueden agruparse en: los vinculados a las enfermedades crónicas, en primer lugar la hipertensión arterial y en segundo el hipotiroidismo, y los relacionados con las afecciones del tracto genital, entre las que prevalece la vaginitis.

Introduction: fetal death is one of the most difficult obstetric accidents to face, both for patients and their families as well as for the health personnel who take care of the pregnant women. Objective: to identify the maternal risk factors associated with late fetal death in the Santa Clara context. Methods: a descriptive, longitudinal and retrospective study was carried out in Santa Clara municipality, Villa Clara province, from January 2015 to December 2019. The population consisted of 71 pregnant women with late fetal demise and their products; the SPSS software version 20.0 for Windows was used in the data processing and analysis. Results: multiparous pregnant women predominated (56.3%), in optimal reproductive age (69%) and from one to three risk factors (71.8%). Conclusions: the most frequently maternal factors associated with late fetal death can be grouped into those that were linked to chronic diseases, firstly arterial hypertension and secondly hypothyroidism, and those related to disorders of the genital tract, among which vaginitis prevails.

Global Policy and Practice for Intrauterine Fetal Resuscitation During Fetal Surgery for Open Spina Bifida Repair.

Importance: Globally accepted recommendations suggest that a woman should be between 19 weeks and 25 weeks plus 6 days of pregnancy to be considered eligible for fetal closure of open spina bifida. A fetus requiring emergency delivery during surgery is therefore potentially considered viable and thus eligible for resuscitation. There is little evidence, however, to support how this scenario is addressed in clinical practice. Objective: To explore current policy and practice for fetal resuscitation during fetal surgery for open spina bifida in centers undertaking fetal surgery. Design, Setting, and Participants: An online survey was designed to identify current policies and practices in place to support fetal surgery for open spina bifida, exploring experiences and management of emergency fetal delivery and fetal death during surgery. The survey was emailed to 47 fetal surgery centers in 11 countries where fetal spina bifida repair is currently performed. These centers were identified through the literature, the International Society for Prenatal Diagnosis center repository, and an internet search. Centers were contacted between January 15 and May 31, 2021. Individuals volunteered participation through choosing to complete the survey. Main Outcomes and Measures: The survey comprised 33 questions of mixed multiple choice, option selection, and open-ended formats. Questions explored policy and practice supporting fetal and neonatal resuscitation during fetal surgery for open spina bifida. Results: Responses were obtained from 28 of 47 centers (60%) in 11 countries. Twenty cases of fetal resuscitation during fetal surgery during the last 5 years were reported across 10 centers. Four cases of emergency delivery during fetal surgery after maternal and/or fetal complications during the last 5 years were reported across 3 centers. Fewer than half the 28 centers (n = 12 [43%]) had policies in place to support practice in the event of either imminent fetal death (during or after fetal surgery) or the need for emergency fetal delivery during fetal surgery. Twenty of 24 centers (83%) reported preoperative parental counseling on the potential need for fetal resuscitation prior to fetal surgery. The gestational age at which centers would attempt neonatal resuscitation after emergency delivery varied from 22 weeks and 0 days to more than 28 weeks. Conclusions: In this global survey study of 28 fetal surgical centers, there was no standard practice about how fetal resuscitation or subsequent neonatal resuscitation was managed during open spina bifida repair. Further collaboration between professionals and parents is required to ensure sharing of information to support knowledge development in this area.