Length of hysterotomy for fetal spina bifida repair is associated with prematurity risk.

OBJECTIVE: To investigate whether prenatal repair of spina bifida aperta through mini-hysterotomy results in less prematurity, as compared to standard hysterotomy, when adjusting for known prematurity risks. METHODS: We performed a bi-centric, propensity score matched, controlled study, that is, adjusting for factors earlier reported to result in premature delivery or membrane rupture, in consecutive women having prenatal repair either through stapled hysterotomy or sutured mini-hysterotomy (≤3.5 cm). Matches were pairwise compared and cox-regression analysis was performed to define the hazard ratio of delivery <37 weeks. RESULTS: Of 346 meeting the MOMS-criteria, 78 comparable pairs were available for matched-controlled analysis. Mini-hysterotomy patients were younger and had a higher BMI. Mini-hysterotomy was associated with a 1.67-lower risk of delivery <37 weeks (hazard ratio: 0.60; 95% CI: 0.42-0.85; p = 0.004) and 1.72 for delivery <34 + 6 weeks (hazard ratio: 0.58; 95% CI: 0.34-0.97; p = 0.037). The rate of intact uterine scar at birth (mini-hysterotomy: 98.7% vs. hysterotomy: 90.4%; p = 0.070), the rate of reversal of hindbrain herniation within 1 week after surgery (88.9% vs. 97.4%; p = 0.180) and the rate of cerebrospinal fluid leakage (0% vs. 2.7%; p = 0.50) were comparable. CONCLUSION: Prenatal spina bidifa repair through mini-hysterotomy was associated with a later gestational age at delivery and a comparable intact uterus rate without apparent compromise in neuroprotection.

Fetal open spinal dysraphism repair through a mini-hysterotomy: Influence of gestational age at surgery on the perinatal outcomes and postnatal shunt rates.

OBJECTIVE: To analyze the impact of gestational age (GA) at the time of fetal open spinal dysraphism (OSD) repair through a mini-hysterotomy on the perinatal outcomes and the infants' ventriculoperitoneal shunt rates. METHODS: Retrospective study of cases of fetal OSD correction performed from 2014 and 2019. RESULTS: One hundred and ninety women underwent fetal surgery for OSD through a mini-hysterotomy, and 176 (176/190:92.6%) have since delivered. Fetal OSD correction performed earlier in the gestational period, ranging from 19.7 to 26.9 weeks, was associated with lower rates of postnatal ventriculoperitoneal shunting (P: .049). Earlier fetal surgeries were associated with shorter surgical times (P: .01), smaller hysterotomy lengths (P < .001), higher frequencies of hindbrain herniation reversal (P: .003), and longer latencies from surgery to delivery (P < .001). Median GA at delivery was 35.3 weeks. Multivariate binary logistic regression showed that both fetal lateral ventricle-to-hemisphere ratio (%; P < .001; OR: 1.14 [95% CI: 1.09-1.21]) and GA at the time of fetal surgery (P: .016; OR: 1.37 [95% CI: 1.07-1.77]) were independent predictors of postnatal ventriculoperitoneal shunting. CONCLUSION: Fetuses with OSD who were operated on earlier in the gestational interval, which ranged from 19.7 to 26.9 weeks, were less prone to receiving postnatal ventriculoperitoneal shunts.

Feasibility and reproducibility of diffusion-weighted magnetic resonance imaging of the fetal brain in twin-twin transfusion syndrome.

OBJECTIVE: The aim of this study is to test the feasibility and reproducibility of diffusion-weighted magnetic resonance imaging (DW-MRI) evaluations of the fetal brains in cases of twin-twin transfusion syndrome (TTTS). METHOD: From May 2011 to June 2012, 24 patients with severe TTTS underwent MRI scans for evaluation of the fetal brains. Datasets were analyzed offline on axial DW images and apparent diffusion coefficient (ADC) maps by two radiologists. The subjective evaluation was described as the absence or presence of water diffusion restriction. The objective evaluation was performed by the placement of 20-mm(2) circular regions of interest on the DW image and ADC maps. Subjective interobserver agreement was assessed by the kappa correlation coefficient. Objective intraobserver and interobserver agreements were assessed by proportionate Bland-Altman tests. RESULTS: Seventy-four DW-MRI scans were performed. Sixty of them (81.1%) were considered to be of good quality. Agreement between the radiologists was 100% for the absence or presence of diffusion restriction of water. For both intraobserver and interobserver agreement of ADC measurements, proportionate Bland-Altman tests showed average percentage differences of less than 1.5% and 95% CI of less than 18% for all sites evaluated. CONCLUSION: Our data demonstrate that DW-MRI evaluation of the fetal brain in TTTS is feasible and reproducible.

Endoscopic laser dichorionization of the placenta in the treatment of severe twin-twin transfusion syndrome.

OBJECTIVES: To describe the results of a technique of laser ablation of placental vessels in the treatment of severe twin-twin transfusion syndrome (TTTS), which is characterized by separation of the fetoplacental vascular territories and dichorionization of the placenta. PATIENTS AND METHODS: Descriptive analysis of TTTS cases treated with the endoscopic laser dichorionization of the placenta (ELDP) procedure. The variables evaluated were the occurrence of reversal of the donor-recipient phenotype, persistence of TTTS or twin anemia-polycythemia sequence (TAPS); gestational age at delivery; discharge from the hospital of at least 1 or 2 live neonates, and incidence of neurological alterations among survivors. RESULTS: 67 patients were treated with the ELDP procedure. There was no persistence of TTTS, reversal of the donor-recipient phenotype or TAPS. The median gestational age at delivery was 33.0 (23.6-37.7) weeks. The rate of discharge from the hospital of at least 1 or 2 live neonates was 88.2% (67/76) and 71.1% (54/76), respectively. Among survivors, 17 (17/121 = 14.0%) children presented with neurodevelopmental alterations during clinical follow-up. CONCLUSIONS: The major contribution of this study was the demonstration that the ELDP technique appears to be associated with a low risk of persistence or recurrence of TTTS and TAPS.

Fetal lung volume after endoscopic tracheal occlusion in the prediction of postnatal outcome.

OBJECTIVE: The objective of the study was to investigate the volume response of the contralateral lung in the prediction of postnatal outcome in fetuses with congenital diaphragmatic hernia (CDH) treated by fetoscopic endotracheal occlusion (FETO). STUDY DESIGN: In 30 fetuses with isolated severe CDH that underwent FETO, the volume of the contralateral lung was measured by 3-dimensional ultrasound the day before and 2 and 7 days after FETO. The measurements of fetuses that subsequently died were compared to those who survived. RESULTS: In all fetuses before FETO, the lung volume was below the 2.5th percentile of the normal range for gestation (60%). Within 2 days after FETO, the lung volume increased to above the 2.5th percentile in 14/21 (66%) that survived, compared with 1/9 (11%) that died. The respective percentages at 7 days after FETO were 95% and 11%, respectively. CONCLUSION: In fetuses with CDH, the lung responsiveness within 2 and 7 days after FETO provides useful prediction of subsequent survival.

Lung volumes in fetuses with congenital diaphragmatic hernia: comparison of 3D US and MR imaging assessments.

PURPOSE: To prospectively compare three-dimensional (3D) ultrasonography (US) and magnetic resonance (MR) imaging in the assessment of lung volumes in fetuses with congenital diaphragmatic hernia. MATERIALS AND METHODS: Informed consent was obtained for this ethics committee-approved study. Left and right lung volumes were measured by using the 30 degrees virtual organ computer-aided analysis 3D US technique and a transverse multiplanar T2-weighted MR imaging technique in 43 fetuses with isolated congenital diaphragmatic hernia. Regression analysis was used to determine the significance of the association between the two methods. RESULTS: The 43 fetuses were assessed in a total of 78 examinations. Median gestational age at the examinations was 28 weeks (range, 18-38 weeks). In all examinations, it was possible to visualize and measure both the ipsilateral and the contralateral lungs with MR imaging. In contrast, with 3D US, the contralateral lung could be measured in all examinations, but the ipsilateral lung could be measured in only 44 (56%) examinations. For the contralateral lungs, there was a significant association between 3D US and MR imaging measurements (r = 0.86, P < .001). Although the mean lung volume measured with 3D US was 25% lower than that measured with MR imaging, the ratio of observed volume to expected normal mean volume for gestation was not significantly different between the two methods (3D US, 0.48; MR imaging, 0.52). In the 44 examinations in which the ipsilateral lung could be measured with both methods, 3D US volumes were not significantly different from MR imaging volumes, and the association was weaker (r = 0.39, P < .05) in the ipsilateral lungs than in the contralateral lungs. CONCLUSION: For congenital diaphragmatic hernia, 3D US provides a reliable measurement of the contralateral but not the ipsilateral lung.