Case of resuscitation from cardiac failure by intrauterine transfusion after single fetal death in monochorionic twin pregnancy.

In case of a single fetal death in monochorionic twin pregnancy, the surviving fetus is thought to become hypovolemic. However, there is no report of any evidence of fetal circulatory insufficiency in such cases. We present a case of a single fetal death in a monochorionic twin pregnancy with type III selective intrauterine growth restriction that involved low fractional shortening, high myocardial performance index, elevated pulsatility index in the middle cerebral artery and fetal ascites. After immediate intrauterine transfusion, each parameter improved promptly. The surviving baby grew up without cardiac and neurological complications. To the best of our knowledge, this is the first report on transient circulatory insufficiency and decreased cardiac function in the surviving fetus.

Amnioinfusion for variable decelerations caused by umbilical cord compression without oligohydramnios but with the sandwich sign as an early marker of deterioration.

We report prophylactic amnioinfusion (AI) for variable decelerations in umbilical cord compression without oligohydramnios as an early sign of deterioration. We performed a transabdominal AI in cases without oligohydramnios using the ultrasonography findings of umbilical cord compression (i.e. sandwich sign [SWS]) and variable decelerations (VD) in a foetal heart rate. Thirteen cases and 21 AIs were analysed. Nine (69%) cases were of a foetal growth restriction and 4 (31%) had umbilical hyper-coiled cords. VD frequency (p < .0001), umbilical artery pulsatility index (PI) (p < .01) and ductus venous PI (0.66 vs. 0.48; p < .05) significantly decreased, and an umbilical venous (UV) flow volume (121 vs. 197 ml/min/kg; p < .05) significantly increased after AI. The umbilical artery diastolic blood flow abnormalities and UV pulsation improved. In conclusion, AI improves the umbilical cord compression even without oligohydramnios. The SWS is an important marker of deterioration to severe oligohydramnios and latent foetal damage. IMPACT STATEMENT What is already known on this subject? Antepartum variable decelerations due to umbilical cord compression are significantly associated with the deceleration in labour. In particular, foetal hypoxia leads to other adverse events such as foetal distress, hypoxic-ischemic encephalopathy, and pulmonary arterial hypertension after birth. Amnioinfusion has been shown to be effective in patients who also have oligohydramnios. What do the results of this study add? Amnioinfusion may be effective in the cases with ultrasonography findings of umbilical cord compression (i.e. sandwich sign) and in cases with variable decelerations in foetal heart rate, but without oligohydramnios. What are the implications of these findings for clinical practice and/or further research? Amnioinfusion may be helpful to prevent adverse events including oligohydramnios and anhydroamnios.

Hypercoiled cord can cause a reversible abnormal Doppler in ductus venosus in cases of fetal growth restriction.

AIM: Although an absent or reversed a-wave in ductus venosus (DV-RAV) is reported to be the terminal finding of fetal growth restriction (FGR), we have seen DV-RAV that disappears within a short span of time in some FGR cases with a hypercoiled cord. The purpose of this study was to investigate the relationship between hypercoiled cord and reversible DV-RAV in FGR. METHODS: This was a retrospective study of 499 FGR cases, including 14 with DV-RAV. Transabdominal amnioinfusion (AI) was performed when oligohydramnios was severe (maximum vertical pocket <2 cm) and/or variable deceleration was detected. DV-RAV that disappeared quickly was defined as 'temporary DV-RAV'. DV-RAV that continued until delivery or fetal death (FD) was defined as 'persistent DV-RAV'. A hypercoiled cord was defined as one with an umbilical coiling index >0.6 antenatally or >0.3 postnatally. Clinical characteristics and clinical courses of the two types of DV-RAV were compared. RESULTS: DV-RAV disappeared after AI in all five cases in which temporary DV-RAV was identified. The incidence of a hypercoiled cord was significantly higher among temporary DV-RAV cases (100%) than among persistent DV-RAV cases (14.3%; P = 0.015). The time from detection of DV-RAV to delivery or FD was significantly longer among temporary DV-RAV cases (4.5 weeks) than among persistent DV-RAV cases (0.7 weeks; P = 0.027). CONCLUSION: Temporary DV-RAV is suspected to be related to the combination of a hypercoiled cord and oligohydramnios. DV-RAV may not be always be a terminal finding in FGR with a hypercoiled cord.

Amnioinfusion before 26 weeks' gestation for severe fetal growth restriction with oligohydramnios: preliminary pilot study.

AIM: The prognosis for severe fetal growth restriction (FGR) with severe oligohydramnios before 26 weeks' gestation (WG) is currently poor; furthermore, its management is controversial. We report the innovative new management of FGR, such as therapeutic amnioinfusion and tocolysis. MATERIAL AND METHODS: For FGR and severe oligohydramnios before 26 WG complicated with absent or reversed umbilical artery end-diastolic flow velocity and/or deceleration by ultrasonography, we performed transabdominal amnioinfusion with tocolysis. Cases with multiple anomalies were excluded. Survival rate and long-term prognosis were analyzed. RESULTS: Among 570 FGR cases, 18 were included in the study. Mean diagnosis and delivery were at 22.6 ± 2.0 and 28.7 ± 3.3 WG. Median birthweight was 625 g (-4.2 standard deviation). Final survival rate was 11/13 (85%). There were five fetal deaths. In seven cases, oligohydramnios improved. Growth was detected in 10/18 fetuses. Furthermore, 8/8 decelerations, 4/12 cases of reversed umbilical artery end-diastolic flow velocity, 7/14 cases of brain-sparing effect, and 6/13 venous Doppler abnormalities were improved. When we detected umbilical cord compression, 8/10 cases were rescued. Eleven infants were followed up for an average of 5 years; one case of cerebral palsy with normal development and 10 cases with intact motor functions without major neurological handicap were confirmed. CONCLUSIONS: In cases of extremely severe FGR before 26 WG with oligohydramnios and circulatory failure, amnioinfusion might be a promising, innovative tool.

Umbilical cord length affects the efficacy of amnioinfusion for repetitive variable deceleration during labor.

OBJECTIVES: Although amnioinfusion (AI) for repetitive variable deceleration has been reported to reduce the frequency of variable deceleration and cesarean section (CS) rate, CS is sometimes unavoidable even after therapeutic AI. The purpose of this study was to investigate prenatal factors related to the efficacy of therapeutic AI during labor. METHODS: This retrospective study investigated 80 singleton pregnancies that underwent transcervical therapeutic AI for repetitive variable deceleration during labor. AI was performed with 500 mL of warmed saline through an intrauterine pressure catheter by gravity infusion. Prenatal factors related to emergency CS for fetal distress even after therapeutic AI were investigated. RESULTS: Emergency CS was performed for 12 of the 80 cases due to fetal distress. Z-score for umbilical cord length was significantly smaller in the CS group (-0.68 SD) than in the vaginal delivery group (0.15 SD, p < .001). No CSs were performed in cases with Z-score for umbilical cord length >-0.05 SD. No significant differences between CS and vaginal delivery groups were seen in gestational age at delivery, cervical dilatation at AI, birth weight, Z-score of birth weight, incidence of the nuchal cord or incidence of abnormal umbilical cord insertion. CONCLUSIONS: Therapeutic AI for repetitive variable deceleration was considered useful, in many cases avoiding emergency CS. Short umbilical cord length (lower Z-score) was related to emergency CS after therapeutic AI for repetitive variable deceleration. Umbilical cord length may offer an important factor for assessing the risk of fetal distress that is difficult to avoid, if methods to accurately determine umbilical cord length can be developed.

Transabdominal amnioinfusion: An evaluation of its adverse events.

OBJECTIVE: Transabdominal amnioinfusion is beneficial in oligohydramnios, which has high fetal mortality and does not improve with observation alone. However, there are few reports on the maternal adverse events of transabdominal amnioinfusion. This study aimed to evaluate the adverse events of amniocentesis with transabdominal amnioinfusion. STUDY DESIGN: This study is a retrospective cohort study at a single tertiary perinatal center in Japan. A total of 313 procedures in 126 patients who underwent amniocentesis for transabdominal amnioinfusion at our tertiary perinatal institution were evaluated using the Common Terminology Criteria for Adverse Events (CTCAE). Adverse events were retrospectively examined using a 5-grade evaluation based on the CTCAE. Procedurally, a 21-23-G percutaneous transhepatic cholangiography drainage (PTCD) needle was advanced under ultrasound guidance into the amniotic fluid cavity with a gravity-fed infusion of warm saline solution. RESULTS: No maternal deaths were recorded. Only two maternal/fetal adverse events occurred, and grade 4 fetal adverse events requiring pregnancy termination were observed in seven cases. Fetal death occurred in five cases, all with severe oligohydramnios and premature rupture of the membranes. No placental abruption or bleeding occurred before or after delivery. CONCLUSION: Adverse events during transabdominal amnioinfusion were successfully analyzed using CTCAE. We also provided new terminology for evaluating adverse events during amnioinfusion. Our results may encourage obstetricians to perform amnioinfusion in difficult situations, with less concern for severe maternal or fetal adverse events.

Changes in the Intra-Amniotic Pressure following Transabdominal Amnioinfusion during Pregnancy.

OBJECTIVE: The aim of the article was to investigate the changes in intra-amniotic pressure following transabdominal amnioinfusion during pregnancy. DESIGN: This retrospective study included 19 pregnant women who underwent transabdominal amnioinfusion during pregnancy to relieve umbilical cord compression and improve the intrauterine environment or to increase the accuracy of ultrasonography. MATERIALS AND METHODS: We measured and analyzed the changes in intra-amniotic pressure, single deepest pocket, and the amniotic fluid index before and after amnioinfusion. We also determined the incidence of maternal or fetal adverse events, such as preterm premature rupture of membranes, preterm delivery, fetal death within 48 h, placental abruption, infection, hemorrhage, and peripheral organ injury. RESULTS: A total of 41 amnioinfusion procedures were performed for 19 patients. The median gestational age during the procedure was 24.3 weeks. The median volume of the injected amniotic fluid was 250 mL. The median single deepest pocket and amniotic fluid index after amnioinfusion were significantly higher than those before amnioinfusion (4.0 cm vs. 2.65 cm; p < 0.001 and 13.4 cm vs. 6.0 cm; p < 0.001). However, the median (range) intra-amniotic pressure after amnioinfusion was not significantly different compared to that before amnioinfusion (11 mm Hg vs. 11 mm Hg; p = 0.134). Maternal or fetal adverse events were not observed following amnioinfusion. CONCLUSION: Intra-amniotic pressure remained unchanged following amnioinfusion. The complications associated with increased intra-amniotic pressure are not likely to develop if the amniotic fluid index and/or single deepest pocket remains within the normal range after amnioinfusion. Studies of groups with and without complications are warranted to clarify the relationship between the intra-amniotic pressure and incidence of complications.

Successful amnioinfusion for severe fetal growth restriction with umbilical cord complications: two case reports.

BACKGROUND: There is no established treatment for fetal growth restriction during pregnancy. We report two cases that represent an example of an amnioinfusion-based management strategy for severe fetal growth restriction with umbilical cord complications. CASE PRESENTATION: We encountered two cases of fetal growth restriction with abnormal fetal Doppler velocity. In one case, fetal ultrasound revealed a hypercoiled umbilical cord with a single umbilical artery and oligohydramnios, while fetal Doppler revealed a reversed end-diastolic flow in the umbilical artery and reversed a-waves of the ductus venosus. Umbilical cord compression was confirmed at 22 weeks and 2 days of gestation, and nine amnioinfusions were performed to relieve the umbilical cord compression. A cesarean section was performed at 31 weeks and 2 days of gestation because of severe preeclampsia. The Asian infant is now a normally developed 6-month-old. In another Asian case, fetal ultrasound revealed a hypercoiled cord, while fetal Doppler revealed a reversed end-diastolic flow in the umbilical artery and intermittent reversed a-waves of the ductus venosus. Umbilical cord compression was confirmed at 24 weeks and 5 days of gestation, and seven amnioinfusions were performed. A cesarean section was performed at 31 weeks and 1 day of gestation because of nonreassuring fetal status. At the age of 1 month, the Asian infant was stable on respiratory circulation. In both cases, fetal Doppler findings improved significantly following amnioinfusions. CONCLUSIONS: Amnioinfusion is a symptomatic treatment for umbilical cord compression. However, to determine the therapeutic effect of amnioinfusion, complete resolution of the umbilical cord compression should be ascertained by ultrasonography.

Comparison of bilateral and unilateral umbilical artery diastolic blood flow abnormalities in monochorionic diamniotic twin pregnancies.

Aim: Our study aimed to clarify the prognosis of bilateral and unilateral umbilical artery end-diastolic blood flow abnormalities (BFAs) in monochorionic diamniotic twin pregnancies.Methods: Monochorionic diamniotic twin pregnancies were classified into bilateral (group 1), unilateral (group 2), and no (group 3) umbilical artery end-diastolic BFAs. After the usual obstetric management, short- and long-term prognoses were analyzed.Results: A total of 171 monochorionic diamniotic twins were analyzed and classified into group 1 (13 twins, 7.6%), 2 (12 twins, 7.0%), and 3 (146 twins, 85.4%). Gestational age at delivery was significantly lower in group 1 than in groups 2 and 3 (median, 29.3, 35.6, and 35.6 weeks, respectively; p < .01 and p < .001). The survival rate of fetuses with BFAs was significantly lower in group 1 than in group 2 (23.0% [3/13] versus 100% [12/12]; p < .001). However, the survival rate of the co-twin was not significantly different between groups 1 and 2 (84.6% [11/13] versus 100% [12/12]; p = .48). The survival rate of both fetuses was significantly lower in group 1 than in groups 2 and 3 (53.8% [14/26], 100% [24/24], and 98.6% [288/292], respectively; both p < .001). In cases with fetal therapy, the survival rate of both fetuses tended to be lower in group 1 than in group 2 (44.4% [8/18] versus 83.3% [10/12]; p = .05). In cases without fetal therapy, the gestational age at delivery tended to lower in group 1 than in group 2 and was significantly lower than in group 3 (median, 29.1, 35.6, 35.6 weeks, respectively; p = .05 and p < .05). The survival rate of fetuses with BFA tended to be lower in group 1 than in group 2 (50.0% [2/4] versus 100% [12/12]; p = .05). The survival rate of the co-twin was not significantly different between groups 1 and 2 (100% [4/4] versus 100% [12/12]; p = 1). The survival rate of both fetuses tended to be lower in group 1 than in group 2 and was significantly lower than in group 3 (75% [6/8], 100% [24/24], and 99.2% [278/280], respectively; p = .05 and p < .01).Conclusions: In monochorionic diamniotic twin pregnancies, bilateral umbilical artery end-diastolic BFAs demonstrated a poor prognosis. However, unilateral abnormalities exhibited a good prognosis similar to that in twins with normal umbilical artery blood flow. If such abnormalities are detected during a routine checkup, the umbilical artery pulse wave on the other side should be examined.

Cardiomegaly of the larger twin in monochorionic twin pregnancies warrants neonatal intensive care even without twin-to-twin transfusion syndrome.

OBJECTIVES: Some monochorionic twin pregnancies need intensive cardiac management even in the absence of twin-to-twin transfusion syndrome after birth. The purpose of this study was to investigate risk factors related to persistent hypotension requiring cardiotonic agent use among monochorionic twin pregnancies without twin-to-twin transfusion syndrome. STUDY DESIGN: This was a retrospective study of 316 monochorionic twin pregnancies without twin-to-twin transfusion syndrome (632 babies). All cases were treated in the neonatal intensive care unit. Hypotension was defined as mean arterial blood pressure below the norm for gestational age. Decreased left ventricular ejection fraction was defined as a value <60%. Dopamine, dobutamine and phosphodiesterase III inhibitor were used as cardiotonic agents for hypotension persisting even after adequate infusion. RESULTS: Among the 632 cases, 33 (5.2%) needed cardiotonic agents for persistent hypotension. The frequency of persistent hypotension with decreased left ventricular ejection fraction was significantly higher among larger twins (4.4%) than among smaller twins (0.6%, p = 0.0038). In larger twins, multivariate analysis showed that Z-score for cardiothoracic area ratio (odds ratio, 2.31; p < 0.001), tricuspid regurgitation (odds ratio, 6.34; p = 0.015) and gestational age at delivery (odds ratio, 0.66; p < 0.001) correlated with persistent hypotension. In smaller twins, univariate analysis showed gestational age at delivery, birth weight, Z-score for birth weight and Z-score for cardiothoracic area ratio of the larger twin were related to persistent hypotension. Concentration of brain natriuretic peptide in the umbilical vein in larger and smaller twins were significantly correlated (coefficient of correlation = 0.792, p < 0.001). CONCLUSIONS: In monochorionic twin pregnancies, attention needs to be given to cardiac size along with amniotic fluid and fetal growth. Both larger and smaller twins carry risks of persistent hypotension after birth. Close observation is needed, especially in cases where the larger twin displays cardiomegaly despite absence of twin-to-twin transfusion syndrome.

Relationship between higher intra-amniotic pressures in polyhydramnios and maternal symptoms.

OBJECTIVES: Our study aimed to analyze the differences in intra-amniotic pressures in patients with polyhydramnios with and without symptoms. STUDY DESIGN: We recruited patients with pregnancies in which amnioreduction was performed for polyhydramnios in the Department of Fetal-Maternal Medicine at Nagara Medical Center between April 2017 and August 2018. Amnioreduction was performed for severe polyhydramnios with maternal symptoms [symptomatic group] or polyhydramnios without maternal symptoms [asymptomatic group] such as abdominal distension, dyspnea, or threatened premature labor. We measured the intra-amniotic pressure after every 200 ml volume reduction during the amnioreduction. RESULTS: A total of 27 patients who underwent amnioreduction were classified into symptomatic (66.7%, 18/27) and asymptomatic (33.3%, 9/27) groups. Gestational age, amniotic fluid index at the time of amnioreduction, and the volume of amniotic fluid removed were not significantly different between the symptomatic and asymptomatic groups [median 32.4 weeks vs. 33.1 weeks, median 38.0 cm vs. 39.0 cm, and median 1500 ml vs. 2500 ml, respectively]. However; the intra-amniotic pressure before amnioreduction was significantly higher in the symptomatic group than in the asymptomatic group [median 15.0 mmHg (range, 10-27) vs. 10.0 mmHg (range, 6.0-13); p < 0.005]. After amnioreduction, these pressures decreased significantly to median 9.0 mmHg (range, 5.0-13) (p < 0.001) in the symptomatic and 7.0 mmHg (range, 4.0-11) (p < 0.05) in the asymptomatic group. The median intra-amniotic pressure gradually decreased and reached a plateau during the amnioreductions in both groups. CONCLUSIONS: With polyhydramnios, the intra-amniotic pressure was significantly higher in the symptomatic group than in the asymptomatic group. Therefore, uterine pressure tolerance might vary according to the individual. In addition, intra-amniotic pressure monitoring might enhance the safety during amnioreduction procedures to avoid drastic and potentially harmful pressure changes.

Ultrasonic identification of pump twin by dual-gate Doppler in a monochorionic-triamniotic triplet twin reversed arterial perfusion sequence before preventative radiofrequency ablation: a case report.

We performed a dual-gate Doppler examination for a twin reversed arterial perfusion (TRAP) sequence in a monochorionic-triamniotic triplet pregnancy at 16 weeks of gestation and were able to identify the pump twin by arterial pulse rate synchronicity. We performed radiofrequency ablation to coagulate blood flow in the acardius at 16 weeks of gestation without any postoperative complication. At 29 weeks of gestation, we performed a cesarean section due to preterm rupture of the membranes and the patient delivered 1167/1237-g female neonates and a macerated acardius. Examination of the placenta revealed two thickened vessels from the pump twin to the acardius, which had been prenatally identified by dual-gate Doppler. This new technology launches the new field of noninvasive fetal identification for triplet TRAP sequence.

Changes in Intra-Amniotic, Fetal Intrathoracic, and Intraperitoneal Pressures with Uterine Contraction: A Report of Three Cases.

Intra-amniotic, fetal intrathoracic, and intraperitoneal pressures during pregnancy have been previously investigated. However, to our knowledge, changes in these pressures during uterine contractions have not been reported. Herein, we present three cases of polyhydramnios, fetal pleural effusion, and fetal ascites, in which intra-amniotic, fetal intrathoracic, intraperitoneal pressures increased with uterine contractions. These pressure increases may affect the fetal circulation. We suggest that managing potential premature delivery (e.g., with tocolysis) is important in cases with polyhydramnios and excess fluid in fetal body areas, such as the thorax, abdomen, and heart. The results of this preliminary study on intrafetal pressure measurements will be useful in performing fetal and neonatal surgeries in the future.

Prenatal diagnosis of funisitis: two case reports.

Acute funisitis is characterized by the infiltration of fetal neutrophils from the umbilical vessels into Wharton's jelly and presents as fetal inflammation. However, no reports about its prenatal diagnosis using ultrasonography have been published. We encountered one case of oligohydramnios at 26 weeks and another case of threatened premature delivery at 27 weeks of gestation with ultrasonographic findings of non-uniform thickening of Wharton's jelly, a heterogeneous internal echo, and a high echoic line of the umbilical vessel wall. Acute funisitis was diagnosed, and the postpartum histopathological examination revealed severe funisitis in both cases. To our knowledge, this is the first case report of prenatal diagnosis of funisitis determined using ultrasonography. When we find such ultrasonographic features under the circumstances of intrauterine infection, severe funisitis should be included in the differential diagnosis.

Preliminary preventive protocol from first trimester of pregnancy to reduce preterm birth rate for dichorionic-diamniotic twins.

OBJECTIVE: The preterm birth rate of twins is reportedly higher than that of single pregnancies. We performed preliminary preventive interventions at our center focused on evaluating the risk of each case before 14 weeks of gestation to reduce the spontaneous preterm birth rate. MATERIALS AND METHODS: The participants included 184 dichorionic-diamniotic twins delivered at our center during the 8 years from 2006. We evaluated each patient regarding high-risk status (at least 1 additional factor as follows: threatened abortion, history of chorioamnionitis, cervicitis, and bacterial vaginosis), based on available evidence; patients deemed high risk gave their informed consent and underwent treatment for cervicitis and cerclage if indicated. We divided the patients into two groups depending on whether the management was initiated before (Group A) or after (Group B) 14 weeks. We further divided Group A into three: Group 1 underwent treatment for cervicitis, Group 2 underwent cervical cerclage in addition to treatment for cervicitis, and Group 3 did not undergo preventive treatment. We retrospectively compared the preterm birth rates of the two groups, and we also compared them between the higher-risk group (Group 1 + 2) and the no additional risk group (Group 3) in Group A. RESULTS: The spontaneous preterm birth rate < 36 weeks was significantly lower in Group A (4/90; 4.4%) than in Group B (18/94; 19.1%) (p=0.001). However, there were no significant differences between Group 1 + 2 and Group 3 (2/42 vs. 2/46). Focusing on the spontaneous preterm birth rate < 34 weeks, Group A had a lower rate than Group B (2/90; 2.2% vs. 13/94; 13.8%, p=0.0012). CONCLUSION: Even though this was a preliminary study, the results are promising, and we propose custom-made management for dichorionic-diamniotic twins: (1) earlier management from before 14 weeks; (2) high-risk selection for cervicitis and a short cervix; and (3) intervention with anti-inflammatory agents and cerclage if indicated.