Ebstein anomaly: 3D virtual and physical models from obstetrical ultrasound data.

3D virtual and physical models from ultrasound scan data allow a 3D spatial view of congenital heart anomalies, interactive discussion among a multidisciplinary team, and improved parental counseling. To the best of our knowledge, this is the first description of 3D physical and virtual models of a fetal Ebstein anomaly.

Prevention of preterm birth in twin-to-twin transfusion syndrome: a systematic review and network meta-analysis.

OBJECTIVES: We aimed to perform a systematic review and network meta-analysis to evaluate the preventive strategies for preterm birth in twin-to-twin transfusion syndrome. METHODS: PubMed, Embase and Cochrane Central were searched from inception to December 2023 with no filters. Additionally, the reference lists of the included studies were manually examined to identify any supplementary studies. We selected randomized controlled trials and cohorts comparing interventions to prevent preterm birth in twin pregnancies complicated by twin-to-twin transfusion syndrome. A random-effects frequentist network meta-analysis was performed using RStudio version 4.3.1. Randomized controlled trials and cohorts were assessed respectively using the Risk of Bias in Non-randomized Studies of interventions tool and Cochrane Collaboration's tool for assessing risk of bias in randomized trials. RESULTS: In this systematic review and meta-analysis, we included eight studies comprising a total of 719 patients. Compared with expectant management, cerclage stood out as the only intervention associated with an increase in the survival of at least one twin (risk ratio 1.12; 95 % confidence interval 1.01-1.23). Our subgroup analysis based on different thresholds for short cervix demonstrated a significant reduction in the risk of preterm birth before 32 weeks with ultrasound-indicated cerclage using a 15 mm criterion (risk ratio 0.65; 95 % confidence interval 0.47-0.92). CONCLUSIONS: Our study suggests the potential benefit of cerclage as a preventive strategy for preterm birth in pregnancies complicated by twin-to-twin transfusion syndrome. These findings highlight the necessity for further investigation to corroborate our results and address the optimal threshold for ultrasound-indicated cerclage.

Prenatal Cardiac Ultrasound Markers of Outcomes in Ebstein's Anomaly: An International Multicenter Case Series.

This study aimed to analyze prenatal cardiac ultrasound markers of outcome in fetuses with Ebstein's anomaly (EA). From a retrospective database, 35 fetuses diagnosed with EA at fetal medicine centers in Brazil, Italy, and Poland were retrieved. The primary outcome was perinatal mortality. We analyzed prenatal cardiac ultrasound markers of outcomes and perinatal follow-up. Gestational age at diagnosis, extracardiac fetal anomalies, spontaneous fetal demise, and gestational age at each event were recorded. In postnatal survivors, data on cardiac surgery and short-term postoperative outcomes were collected. Our study included a cohort of 35 fetuses with EA (mean gestational age of 29.4 weeks), in which 6 fetuses were excluded due to termination of pregnancy (3), pregnancy still ongoing (2), and missed follow-up (1). Of the remaining 29 cases, severe tricuspid regurgitation and absence of anterograde pulmonary flow (pulmonary atresia) were observed in 88%. Significant cardiomegaly accounts for 58% of these data with a mean cardiothoracic ratio of 0.59. The cardiovascular profile (CVS) score ≤ 6 in six patients with one survival (4 fetal deaths, one stillbirth, and one survival). All fetuses with CVS score of 5 had intrauterine demise. Seventeen fetuses were born alive (53.1% of 29 cases). Of the remaining fetuses, one (1%) fetal was a stillbirth, six (20%) fetuses were neonatal deaths, and five (17%) fetuses were fetal deaths. Of the nineteen patients who underwent surgery to correct the cardiac defect, 17 survived after surgery. Among the survivors, biventricular cardiac repair was performed using the cone technique (da Silva's approach) in the majority of cases. We observed 2 abnormal karyotypes among in the remaining 29 fetuses. One of the patients with abnormal karyotype was a fetus with ascites and large for gestational age. The other patient with abnormal karyotype underwent cardiac surgery and progressed to neonatal death. Nine patients (25%) had extracardiac anomalies (genitourinary anomalies and single umbilical artery), being that 2 of them are alive and 4 died (2 had fetal and 2 neonatal death). Fetal EA is associated with high mortality. The most common prenatal marker associated with non-survival was CVP score ≤ 6. Fetuses that survived and underwent postnatal corrective surgery are significantly favorable outcomes.

Levothyroxine for subclinical hypothyroidism during pregnancy: an updated systematic review and meta-analysis of randomized controlled trials.

PURPOSE: We aimed to perform a systematic review and meta-analysis addressing the efficacy of levothyroxine therapy in pregnant women with subclinical hypothyroidism considering most recent evidence and subgroups of interest for clinical practice. METHODS: PubMed, Embase, and Cochrane Central were searched from inception for randomized controlled trials (RCTs) comparing levothyroxine with placebo or no intervention in pregnant women with subclinical hypothyroidism. We used a random-effects model and conducted subgroup analyses based on thyroid peroxidase antibody status, thyroid stimulating hormone levels, fertility treatment, and recurrent miscarriage. RESULTS: We included 11 RCTs comprising 2,749 pregnant women with subclinical hypothyroidism. Patients treated with levothyroxine (1,439; 52.3%) had significantly lower risk of pregnancy loss (risk ratio 0.69; 95% confidence interval 0.52-0.91; p < 0.01; 6 studies). However, there was no significant association between levothyroxine and live birth (risk ratio 1.01; 95% confidence interval 0.99-1.03; p = 0.29; 8 studies). No statistically significant interaction was observed across subgroups (p > 0.05). CONCLUSION: Levothyroxine replacement therapy for subclinical hypothyroidism during pregnancy may decrease pregnancy loss when early prescribed. Nevertheless, further investigation is needed in patients with thyroid stimulating hormone above four milliunits per liter, especially when associated with recurrent miscarriage or infertility.

Impact of overweight and obesity in the fetal cardiac function parameters in the second and third trimesters of pregnancy.

OBJECTIVE: To assess the impact of overweight and obesity in the second and third trimesters of pregnancy on fetal cardiac function parameters. METHODS: We performed a prospective cohort study of 374 singleton pregnant women between 20w0d and 36w6d divided into three groups: 154 controls (body mass index - BMI < 25 kg/m2), 140 overweight (BMI 25-30 kg/m2) and 80 obese (BMI ≥ 30 kg/m2). Fetal left ventricular (LV) modified myocardial performance index (Mod-MPI) was calculated according to the following formula: (isovolumetric contraction time + isovolumetric relaxation time)/ejection time. Spectral tissue Doppler was used to determine LV and right ventricular (RV) myocardial performance index (MPI'), peak myocardial velocity during systole (S'), early diastole (E'), and late diastole (A'). RESULTS: We found significant differences between the groups in maternal age (p < 0.001), maternal weight (p < 0.001), BMI (p < 0.001), number of pregnancies (p < 0.001), parity (p < 0.001), gestational age (p = 0.013), and estimated fetal weight (p = 0.003). Overweight pregnant women had higher LV Mod-MPI (0.046 versus 0.044 seconds, p = 0.009) and LV MPI' (0.50 versus 0.47 seconds, p < 0.001) than the control group. Obese pregnant women had higher RV E' than control (6.82 versus 6.33 cm/sec, p = 0.008) and overweight (6.82 versus 6.46 cm/sec, p = 0.047) groups. There were no differences in 5-min APGAR score < 7, neonatal intensive care unit admission, hypoglycemia and hyperglobulinemia between the groups. CONCLUSIONS: We observed fetal myocardial dysfunction in overweight and obese pregnant women with higher LV Mod-MPI, LV MPI' and RV E' compared to fetuses from normal weight pregnant women.

Placenta acrreta spectrum-first trimester, 2D and 3D ultrasound, and magnetic resonance imaging findings.

BACKGROUND: The term placenta accreta spectrum (PAS) is commonly used to describe abnormal trophoblastic invasion of the myometrium, serosa, or organs adjacent to the uterus. It is of great obstetric importance because of its high morbidity, risk of hemorrhage, admission to the intensive care unit, risk of hysterectomy, and high risk of iatrogenic pelvic lesions and even death. These risks are minimized when prenatal diagnosis is performed. Prenatal diagnosis of PAS is based on imaging findings suggestive of abnormal and pathologically adherent placentation, including placental lacunae (intraplacental sonolucent spaces), disruption of the bladder-uterine serosa interface, turbulent flow on color Doppler, and bridging vessels. OBJECTIVE: In this article, we review the major prenatal imaging features of PAS using diagnostic modalities (first trimester, two-dimensional ultrasound, three-dimensional ultrasound, and magnetic resonance imaging) for the diagnosis of PAS.

Heterotopic twin pregnancy in unicornuate uterus and non-communicating rudimentary horn with survival of both fetuses: Magnetic resonance imaging and 3D reconstructions findings.

We reported a case of heterotopic twin pregnancy in a unicornuate uterus with a non-communicating rudimentary horn with survival of both fetuses. The diagnosis was made late at 28 weeks of gestation, with suspicion raised by ultrasound and confirmed by magnetic resonance imaging (MRI). During hospitalization, obstetric ultrasound with color Doppler was performed every 2 days to assess fetal well-being and myometrial thickness, which was determined by measurements of the uterine wall at the accessory horn. Elective cesarean section was performed at 33 + 5 weeks of gestation. Delivery started with the fetus in the rudimentary horn, with subsequent extraction of the fetus in the unicornate uterus. Three-dimensional virtual reconstruction allowed a spatial view of the both uterus and fetuses with better understanding of the obstetrical condition by the parents and interactive discussion by the multidisciplinary medical team.

Is there a role for magnetic resonance imaging in cesarean scar pregnancy after the first trimester?

Magnetic resonance imaging (MRI) can provide additional information in cases of cesarean scar pregnancy beyond the first trimester. MRI and 3D reconstructions can demonstrate the relationships between the uterus, cervix, bladder, and placenta, improving the spatial perspective of the pelvic anatomy in cases requiring surgical management. MRI and 3D reconstructions can also provide more comprehensive images for parental counseling, virtual and face-to-face multidisciplinary team discussion, and medical record storage.

Fetal cervical sarcoma: Comparison between virtual and real fetal bronchoscopy.

Fetal cervical tumors are a life-threatening condition if proper diagnosis and perinatal care are inadequate. The most common causes of fetal cervical masses are teratomas and lymphangiomas. Less common tumors may obstruct the fetal airway due to cervical compression. In this case report, a fetus with a cervical sarcoma was evaluated by ultrasound and MRI. The prenatal imaging characteristics of the tumor were described, virtual navigation of the fetal airway was performed and compared with fetal bronchoscopy to evaluate the consistency of the tumor. Neonatal outcome was also described.

Focal dermal hypoplasia: The conflicting characteristics of prenatal and long-term follow-up images of skin anomalies.

To the best of our knowledge, this case presents the first prenatal magnetic resonance imaging diagnosis of focal dermal hypoplasia with long-term follow-up, with important discordance between the prenatal and postnatal imaging characteristics of the skin malformation.

Fetal tetralogy of Fallot: Three-dimensional virtual and physical models from ultrasound scan data findings.

Three-dimensional reconstructions provide a spatial view of the congenital heart disease with a better understanding of the pathology for parents and allow interactive discussion among the medical team (maternal-fetal medicine specialist, neonatology, pediatric cardiology, and cardiovascular surgeon) and improve both objective knowledge and learner satisfaction for medical students.

Available evidence on fetal liver changes detected by ultrasound in pregnant women with gestational diabetes mellitus: Systematic review.

The aim of this systematic review was to examine the available scientific literature on ultrasound-detected fetal liver changes in pregnant women with gestational diabetes mellitus (GDM) and to explore the potential of these markers to inform clinical management and improve outcomes. A total of four articles investigating fetal liver changes in GDM pregnancies were selected. The studies varied in methodology, gestational age studied, and diagnostic criteria for GDM. Fetal liver indices, such as fetal liver length and fetal liver volume, emerged as potential markers for identifying GDM and predicting adverse outcomes. Studies suggest an association between fetal liver changes and GDM, with implications for both maternal glycemic control and fetal metabolic adaptation. Variability in study methodology highlights the need for standardized approaches to assess fetal hepatic indices and their correlation with GDM outcomes.

Three-dimensional navigation inside a normal fetal heart in a virtual reality environment.

Three-dimensional navigation allows in a virtual reality environment across the fetal heart structures using glasses and joysticks. This technology allows virtual interactive discussions among multidisciplinary teams providing new perspectives on diagnosis and planning possible surgical corrections.

Cervical length measurement between 11 and 13 + 6 weeks of pregnancy: Comparison of maternal and ultrasonographic characteristics between term and preterm deliveries.

OBJECTIVE: The aim of this study was to evaluate the maternal and ultrasonographic characteristics of pregnant women who underwent cervical length (CL) measurement by transvaginal ultrasound between 11 and 13 + 6 weeks of gestation and who delivered at term or preterm. METHODS: A retrospective cohort study was carried out between March 2013 and December 2018 by analyzing ultrasound data of singleton pregnant women who underwent CL measurement by transvaginal ultrasound during the first trimester scan. CL was compared between the two groups (full-term and preterm birth [PB]) using Student's t-test. RESULTS: A total of 5097 pregnant women were enrolled, of whom 5061 (99.3%) had term and 36 (0.7%) had PB < 34 weeks. CL measurements did not differ between the term and preterm groups (36.62 vs. 37.83 mm, p = 0.08). Maternal age showed a significant and linear association with CL (r = 0.034, p = 0.012) and CRL (r = 0.086, p < 0.001). Smoking status was associated with shorter CL (36.64 vs. 35.09 mm, p = 0.003). When we analyzed the CL of the pregnant women in the term and preterm groups, according to the gestational age cut-offs for prematurity (28, 30, 32, and 34 weeks), we found that there was no significant difference between the measurements in all groups (p > 0.05). CONCLUSION: We observed no significant differences between CL measurements between 11 and 13 + 6 weeks in pregnant women who had preterm and term deliveries. Gestational age and CRL showed a significant and linear association with CL measurement.

Prenatal diagnosis of fetal left ventricular diverticulum: 3D virtual and physical reconstruction models.

Congenital diverticulum is a very rare congenital heart disease. 3D virtual and physical models from ultrasound scan data provide a spatial visualization and better understanding of congenital heart disease to the parents and support possible surgical procedures.

Elastographic and vascular findings of uterine myomas assessed by ultrasound.

OBJECTIVE: The objectives of this study were to evaluate the vascularization pattern of uterine myoma (UM) by ultrasonography using Superb Microvascular Imaging (SMI) and tissue stiffness elastography. METHOD: A prospective and cross-sectional study was carried out between March 2020 and December 2022 among women with clinical and ultrasound diagnosis of UM who would subsequently undergo radiofrequency ablation. Ultrasound examination was performed using both transvaginal and transabdominal routes. UM vascularization pattern was assessed by power Doppler (PD) and SMI, while elastographic pattern was assessed by shear wave (SWE) and strain (STE). FIGO classification, location, and measurement of the largest UM were also described. RESULTS: A total of 21 women diagnosed with UM were evaluated. There was a predominance of nulliparous women and 20 women (95.2%) reported desire for pregnancy. Of the 18 women with abnormal uterine bleeding, 15 (83.3%) had abdominal cramping. As far as previous treatment, 7 (33.3%) had undergone myomectomy for other UM. The mean uterine and UM volumes were 341.9 cm3 (90-730) and 126.52 cm3 (6.0-430), respectively. There was a predominance of hypoechogenic lesions (90.5%). There was also preponderance of UM in the FIGO 2-5 classification (n = 9; 42.9%). Vascularization patter was mostly moderate (score 2) in 9 cases (42.9%). The majority of UM were considered to have intermediate stiffness (n = 10; 47.6%). CONCLUSION: The majority of UM showed vascularization and moderate stiffness. A relationship was observed between the stiffness of the UM assessed by elastography and its FIGO classification.

Fetal hemodynamics and placental histopathology in Down syndrome.

OBJECTIVE: To evaluate the association between Doppler patterns in fetuses with Down syndrome (DS) and their placental histopathologic findings. METHODS: A retrospective cross-sectional study was performed by collecting data from medical records of singleton pregnancies between January 2014 and January 2022, whose fetuses had a confirmed diagnosis of DS either prenatally or postnatally. Placental histopathology, maternal characteristics, and prenatal ultrasound (biometric parameters and umbilical artery [UA] Doppler) were evaluated. RESULTS: Of 69 eligible pregnant women, 61 met the inclusion and exclusion criteria. In the sample, 15 fetuses had an estimated fetal weight < 10th percentile for gestational age (GA) and were considered small for gestational age (SGA). Thirty-eight fetuses had increased resistance on the UA Doppler. Histologic changes were detected in 100% of the placentas, the most common being delayed villous maturation, alterations associated with poor fetal vascular perfusion, and villous dysmorphism. More than 50% of the placentas showed alterations related to placental insufficiency. We did not observe a statistically significant association between UA Doppler examination and placental alterations. All placentas analyzed in the SGA subgroup showed findings compatible with placental insufficiency. CONCLUSION: We found no statistically significant association between placental histopathologic findings and UA Doppler abnormalities in fetuses with DS. The placental alterations identified were delayed villous maturation, alterations associated with poor fetal vascular perfusion, and villous dysmorphism.

Fetal ductus arteriosus constriction associated with citronella maternal use.

Constriction of the fetal ductus arteriosus is a condition that narrows the ductus arteriosus and can lead to death, so the importance of prior diagnosis. Citronella, due to its anti-inflammatory properties, should be avoided during pregnancy as it may cause constriction of the fetal duct.

Asymptomatic acute massive abruptio placenta at 30 weeks' gestation in a primigravida with no risk factors - clinical presentation and management.

Abruptio placenta can be a catastrophic event with a high association with adverse maternal and fetal outcomes. We present a case of massive abruptio placenta occurring in a young asymptomatic mother at 30 weeks' gestation. Although electronic fetal monitoring and ultrasound allowed a prompt diagnosis of an 8 × 5 cm retroplacental hematoma, the fetus died at the time of emergency cesarean section. The fetus was intubated, but could not be resuscitated. Histologic examination of the placenta documented thinning and stacked hypercapillarized villi, with syncytial buds and foci of fibrinoid necrosis in the presence of hyaline streaks on both the maternal and fetal sides.

Occult invasive cervical cancer, FIGO stage III, with a negative Pap smear test - clinical presentation and brief review of the literature.

Occult cervical cancer is rare and is diagnosed incidentally after a simple hysterectomy. The staging upon histological examination is usually International Federation of Gynecology and Obstetrics (FIGO) stage I, rarely higher with negative preoperative diagnostic tests such as a Pap smear. The clinical case in question is a rare case of cervical carcinoma diagnosed at the time of hysterectomy with a negative exo-endocervical Pap smear, diagnostic tests including transvaginal ultrasound, abdominal magnetic resonance imaging and abdominal computed tomography with a diagnosis of degenerating myoma or suspected sarcoma. In the operating theatre, the surgical radicality was modified and the operation was completed with removal of the parameters, vaginal collar and bilateral pelvic lymphadenectomy. The final histological examination indicated FIGO stage III, for which the patient underwent radiotherapy and chemotherapy.