Antenatal management and neonatal outcomes of monochorionic twin pregnancies in a tertiary teaching hospital: a 10-year review.

Monochorionic (MC) pregnancy is a high risk pregnancy with well-defined specific complications, such as twin-to-twin transfusion syndrome (TTTS) and twin anaemia-polycythaemia sequence (TAPS). Laser photocoagulation (LPC) is an effective treatment for both complications. In the current retrospective study, we determined the incidence of MC pregnancy complications in a tertiary care centre during a 10-year period. Single foetal death (FD) beyond 14 weeks' gestation was significantly higher when complicated by either TTTS, TAPS or selective foetal growth restriction (21.4%, 16.7% and 9.1% versus 1.6%, p<.001, p=.02 and p=.04, respectively). We also demonstrated that twins' weight discordance >20% is an independent risk factor for single or double FD after LPC. Consequently, prior to LPC, patients should be counselled that early diagnosis of TTTS, advanced Quintero stages and weight discordances >20% are potential risk factors for FD. Further studies are needed to identify additional risk factors for TTTS and TAPS outcome after LPC.Impact StatementWhat is already known on this subject? Monochorionic (MC) pregnancy is a high risk pregnancy with well-defined specific complications, such as twin-twin transfusion syndrome (TTTS) and twin anaemia-polycythaemia sequence (TAPS). Laser photocoagulation (LPC) is an effective treatment for both complications.What the results of this study add? The results of the current study determined the incidence of MC pregnancy complications in a tertiary care centre in Brussels, and identified that twins' weight discordance >20% is an independent risk factor for single or double foetal death after LPC.What the implications are of these findings for clinical practice and/or further research? Prior to laser coagulation, patients should be counselled that early diagnosis of TTTS, Quintero stages 3 or 4 and weight discordances >20% are potential risk factors for foetal demise. Further studies are needed to identify additional risk factors for TTTS and TAPS outcome after LPC.

Corpus luteum score, a simple Doppler examination to prognose early pregnancies.

OBJECTIVES: In early pregnancies, miscarriages and inconclusive ultrasound scans considering location and viability are very common. In several previous studies, serum progesterone levels predicted viability of pregnancy and, in recent ones, failed Pregnancies of Unknown Location (PUL), completion of miscarriage and complications. Corpus luteum, secreting progesterone in early pregnancy, was less studied. Some publications showed correlations between corpus luteum aspects and diagnosis of miscarriage but it was not evaluated for other outcomes in early pregnancy, such as failed PUL, completion of miscarriage or complications. We aimed to assess if Doppler examination of corpus luteum could also predict all these outcomes: failed PUL, diagnosis and completion of miscarriages and complications. STUDY DESIGN: A single operator prospectively described and/or collected pictures of Doppler signal in the wall of the corpus luteum at most consultations in our early pregnancy unit and established a three-level score. All suspected or confirmed non-viable pregnancies with this score or/and serum progesterone levels were registered retrospectively. With logistic regressions, AIC/BIC, likelihood ratios, ROC curves, Mann-Whitney and Fisher exact tests, we evaluated the ability of the score, alone, to predict failed PUL, diagnosis and completion of miscarriages and the complications, and, combined, to improve previously published predictions. RESULTS: From 277 included pregnancies, 186 (67.1 %) miscarried. Of these, 159/186 (85.5 %) fully evacuated without surgery: 114/186 (61.3 %) within 20 days after the first diagnosis and 45/186 (24.2 %) after more than 20 days. Twenty-seven patients (14.5 %) underwent surgical evacuation, including ten complications, five haemorrhages and five suspected infections. Logistic regression correlated strongly the corpus luteum score with failed PUL (p < 0.0001) and miscarriages (p < 0.0001). Moreover, rates of complications and swift non-surgical completions of miscarriage were respectively 0 % and 92 % with scores of 0, versus 6 % and 44 % with scores of 1, versus 16 % and 0 % with scores of 2. Combined with serum progesterone levels, this score improved most predictions. Adding parity or history of miscarriage in predictive models even increased these performances. CONCLUSIONS: Corpus luteum score, alone, can predict failed PUL, diagnosis and completion of miscarriages and their complications. Combining this score with other factors (mainly serum progesterone levels) improves most predictions.

Clinically relevant discordances identified after tertiary reassessment of fetuses with isolated congenital diaphragmatic hernia.

OBJECTIVE: Fetoscopic endoluminal tracheal occlusion (FETO) may improve outcome of severe isolated congenital diaphragmatic hernia (iCDH). We aimed to identify any discrepancy between initial assessment at the referring hospital and the evaluation at the fetal surgery center, and to document parental decisions following counseling for fetal surgery. DESIGN: Single center retrospective study on patients with presumed iCDH either referred for assessment and counseling or referred for fetal surgery. Discordant findings were defined as either a >10% difference in lung size, discordant liver position or associated anomalies. RESULTS: Outcomes from 129 consecutive assessments over 24 months were analyzed. Among fetal surgery referrals, 2% did not have CDH, and 10% had undiagnosed associated anomalies. Liver position was discordant in 7%. Thirty-three per cent had discordant lung size. Ninety-four per cent of patients eligible for surgery underwent FETO. In patients referred because of suspicion of CDH, associated anomalies were found in 14%. Fetal liver and lung assessments were discordant in 50% resp. 38%. Of those patients eligible for FETO, 26% requested termination. For three patients, the postnatal course was marked by a genetic or syndromic additional diagnosis. CONCLUSION: Discordances between initial assessment before referral and evaluation in our institution were frequent, some of them clinically relevant. © 2017 John Wiley & Sons, Ltd.

Primary maternal cytomegalovirus infections: accuracy of fetal ultrasound for predicting sequelae in offspring.

BACKGROUND: Cytomegalovirus infection is the most common perinatal viral infection that can lead to severe long-term medical conditions. Antenatal identification of maternal cytomegalovirus infections with proven fetal transmission and potential postnatal clinical sequelae remains a major challenge in perinatology. There is a need to improve the prenatal counseling offered to patients and guide future clinical management decisions in cases of proven primary cytomegalovirus infection. OBJECTIVE: We sought to evaluate the accuracy of fetal ultrasound for predicting sequelae in fetuses infected with congenital cytomegalovirus after maternal primary infection. STUDY DESIGN: We conducted a prospective observational study from 1996 through 2012 in pregnant women with serological evidence of primary cytomegalovirus infection and proven vertical transmission to the fetus, based on viral load in the amniotic fluid. Fetal ultrasound was performed in all patients. Pregnancy termination was presented as an option for infected fetuses. Hearing and neurological clinical assessments were performed for all neonates with cytomegalovirus-positive urine samples. RESULTS: A total of 67 patients (69 fetuses) with proven vertical transmission were included in this study, including 64 singleton and 3 twin pregnancies. Eight fetuses were lost to follow-up. Of the remaining 61 fetuses, termination of the pregnancy was performed for 26, including 11 with fetal ultrasound anomalies. Autopsy provided histological evidence of fetal cytomegalovirus infection in all cases. In the 15 terminated fetuses without ultrasound anomalies, histological evidence of damage caused by fetal infection was detected in 13 cases. Among the 35 live-born infants, 12 had fetal ultrasound anomalies suggestive of congenital infection. Of these 12 infants, 6 had normal clinical evaluations, whereas 6 presented with either hearing and/or neurological anomalies, classified as severe in 4 cases. Among the 23 live-born infants with normal prenatal ultrasound, 5 developed hearing impairments and 1 showed mild neurological developmental delay. CONCLUSION: Fetal ultrasound anomalies were detected in 37.7% of pregnant women with primary cytomegalovirus infection acquired in early pregnancy and proven fetal infection, and were confirmed by autopsy or postnatal clinical evaluation in 73.9%. Autopsy or postnatal clinical evaluation also detected cytomegalovirus-related anomalies in 55% of infants with normal fetal ultrasound evaluations.

Prediction of neonatal respiratory function and pulmonary hypertension in fetuses with isolated congenital diaphragmatic hernia in the fetal endoscopic tracleal occlusion era: a single-center study.

OBJECTIVE: To correlate prenatal indicators of pulmonary hypoplasia with neonatal lung function and pulmonary hypertension (PHT) in isolated congenital diaphragmatic hernia (iCDH). MATERIALS AND METHODS: Prospective single-center study on 40 fetuses with iCDH either expectantly managed (n = 13) or undergoing tracheal occlusion (n = 27). Prenatal predictors included observed/expected lung-head ratio (O/E LHR), observed/expected total fetal lung volume, fetal pulmonary reactivity to maternal O2 administration (Δpulsatility index, ΔPI) and liver-to-thorax ratio (LiTR) as measured in the second and third trimesters. Postnatal outcome measures included survival until discharge, best oxygenation index (OI) and alveolar-arterial oxygen gradient [D(A-a)O2] in the first 24 h of life and the occurrence of PHT in the first 28 days of life. RESULTS: Median gestational age (GA) at evaluations was 27.2 and 34.3 weeks. GA at delivery was 36.0 weeks, and overall survival was 55%. In the second trimester, measurement of lung size, LiTR and pulmonary reactivity were significantly related to survival and the best OI and D(A-a)O2.The occurrence of PHT was better predicted by ΔPI and LiTR. CONCLUSIONS: O/E LHR, LiTR and vascular reactivity correlate with ventilatory parameters in the first 24 h of life. Occurrence of PHT at ≥28 days was best predicted by LiTR and ΔPI, but not by lung size.

Psychosocial aspects of invasive fetal therapy as compared to prenatal diagnosis and risk assessment.

OBJECTIVE: To explore the psychosocial impact of invasive fetal therapy (FT). METHODS: We studied 100 consecutive patients scheduled for invasive FT. Contemporary controls were women undergoing (1) invasive prenatal diagnosis (AC/CVS) and (2) first trimester risk assessment of aneuploidy (NT), and (3) women who declined the latter (CTR). Prior to the procedure, participants completed the Beck Depression Inventory II, the State-Trait Anxiety Inventory, the Dyadic Adjustment Scale and a questionnaire specifically designed to evaluate the process preceding the intervention. RESULTS: Thirty-five percent of women in the FT group had mild to severe depressive symptoms, and 30% showed high levels of state anxiety. Mean state anxiety was significantly higher in women facing invasive as compared to non-invasive procedures. Trait anxiety levels and relationship scores were comparable across all groups. FT patients were more satisfied with the information and support given, whereas women in the NT group felt a greater degree of self-determination and contentedness with the choices they made. CONCLUSION: Pregnant women awaiting invasive prenatal diagnosis and FT face higher levels of state anxiety than women undergoing non-invasive procedures. Traits of depression and high state anxiety are found in at least one third of women undergoing FT.

Sonographic evaluation of vascular pulmonary reactivity following oxygen administration in fetuses with normal lung development.

OBJECTIVE: This study aimed to establish nomograms for sonographic assessment of fetal pulmonary vascular reactivity following maternal hyperoxygenation. STUDY DESIGN: Sixty-two healthy fetuses were assessed at four weekly intervals from 26 weeks onwards. Pulmonary reactivity was evaluated using Doppler ultrasound in the main pulmonary artery and in the first branch of this main pulmonary artery. The difference in pulsatility index (∆PI) during maternal inhalation of a mixture of room air and oxygen (9 L/min) for at least 10 min was expressed as a percentage. Nomograms were constructed, and Kaplan-Meier curves were used to express the occurrence of a reactive test (∆PI ≥ 20%) with advancing gestation. RESULTS: In the first branch, linear regression analysis revealed a significant correlation of ∆PI (%) with gestational age (r(2) = 0.04, p = 0.0057). Large inter-individual and intra-individual variability was noted. The ∆PI (%) in the main pulmonary artery remained constant throughout gestation (6.62 ± 17.83%). CONCLUSION: Vascular reactivity in the pulmonary circulation increases in the first branch of the pulmonary artery. Large individual variability is limiting its use as a management tool.

The correlation between lung volume and liver herniation measurements by fetal MRI in isolated congenital diaphragmatic hernia: a systematic review and meta-analysis of observational studies.

OBJECTIVE: We conducted a meta-analysis to assess the correlation of lung volume and liver position measured by magnetic resonance imaging (MRI) with survival until discharge in fetuses with isolated congenital diaphragmatic hernia (CDH). METHOD: Systematic searches of MEDLINE and EMBASE from 1 January 1980 to 10 December 2010 were performed. Studies correlating total fetal lung volumes (TFLV, observed/expected (O/E) TFLV) and/or liver position by fetal MRI to survival in expectantly managed fetuses with CDH were included. Data on the side of the defect, position of the liver, TFLV, O/E TFLV, gestational age (GA) at MRI, GA and weight at birth were collected. Odds ratio (OR) for dichotomous data, mean differences (MD) or standardized mean differences (SMD) for continuous variables were determined using RevMan 5.0 software. RESULTS: Nineteen studies (n = 602 fetuses) were included. Survival was associated with left-sided defects (OR 2.52; p = 0.01), "liver down" (OR 0.18; p < 0.00001), a higher TFLV (MD 9.63; p < 0.00001) and O/E TFLV (SMD 0.98; p < 0.00001) as well as higher birth weight (MD 146.60; p = 0.04). GA at MRI (MD 0.70) and GA at birth (MD 0.33) were not correlated with survival. CONCLUSIONS: MRI measurements of fetal lung volumes, liver position and side of the defect correlate well with neonatal survival in fetuses with isolated CDH.

Technical aspects of fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia.

In isolated congenital diaphragmatic hernia, prenatal prediction is made based on measurements of lung size and the presence of liver herniation into the thorax. A subset of fetuses likely to die in the postnatal period is eligible for fetal intervention that can promote lung growth. Rather than anatomical repair, this is now attempted by temporary fetal endoscopic tracheal occlusion (FETO). Herein we describe purpose-designed instruments that were developed thanks to a grant from the European Commission. The feasibility and safety of FETO have now been demonstrated in several active fetal surgery programs. The most frequent complication of the procedure is preterm premature rupture of the membranes, which is probably iatrogenic in nature. It does have an impact on gestational age at delivery and complicates balloon removal. FETO is associated with an apparent increase in survival compared with same severity controls, although this needs to be evaluated in a formal trial. The time has come to do so.

Prognostic value of pulmonary Doppler to predict response to tracheal occlusion in fetuses with congenital diaphragmatic hernia.

Pulmonary Doppler may play an important role in the prediction of survival and postnatal morbidity in fetuses with congenital diaphragmatic hernia treated with fetoscopic tracheal occlusion (FETO). Spectral Doppler indexes such as pulsatility index and peak early diastolic reversed flow could help to refine the selection of fetuses that might benefit from fetal therapy. When combined with lung-to-head ratio (LHR), these Doppler indices allow to discriminate cases with moderate-to-high survival rates from fetuses with extremely low chances to survive after FETO. In addition, they discriminate groups with a high or low risk of serious neonatal morbidity in surviving fetuses. After therapy, the combined evaluation of the relative increase of LHR with the increase in lung tissue perfusion by power Doppler seems to improve the prediction of fetal survival. In conclusion, while LHR remains the strongest predictive index, Doppler measurements allow to substantially improve the accuracy in the prediction of the chances of survival of fetuses with congenital diaphragmatic hernia treated with FETO.

Examining the relationship between the lung-to-head ratio measured on ultrasound and lung volumetry by magnetic resonance in fetuses with isolated congenital diaphragmatic hernia.

PURPOSE: In fetuses with isolated congenital diaphragmatic hernia (CDH), lung development can be measured by the lung-to-head ratio (LHR) using ultrasound as well as by lung volumetry determined by fetal magnetic resonance imaging (MRI). We aimed to investigate their relationship as well as to analyze the factors that may have an impact on it. MATERIAL AND METHODS: In 153 consecutive fetuses with isolated CDH, both the LHR and total fetal lung volume (TFLV) were measured. The observed LHR was calculated by dividing the lung area by the head circumference. On MRI, planimetric measurements of ipsilateral, contralateral and TFLV were performed on T(2)-HASTE (half-Fourier acquisition single-shot turbo spin echo) sequences in transverse as well as coronal or sagittal planes. All values were expressed as a ratio of what was observed over what is expected in a gestational age-matched normal fetus. Secondary analyses were performed for right- versus left-sided hernia and for measurements made prior to 25 weeks' gestation. A multivariate linear regression approach was used to determine the influence of the independent variables such as observed/expected (O/E) LHR, gestational age, liver position and CDH side on the dependent variables O/E TFLV and O/E contralateral FLV, and to determine the optimal formulas for calculation of the O/E TFLV as well as contralateral FLV. RESULTS: In total, 200 pairs of measurements were obtained between 20 and 37 weeks' gestation (median 26+6). There was a significant association between the O/E contralateral FLV and O/E LHR (R(2) = 0.44; p < 0.001) as well as between the O/E TFLV and the O/E LHR (R(2) = 0.37; p < 0.001). After adding the independent variables that were first shown to be significant on univariate analysis, the multiple regression analysis demonstrated that gestational age (p = 0.017) and side of the defect (p < 0.001) were predictive of O/E LHR (p < 0.001) and strongly improved the estimation of O/E TFLV (R(2) = 0.43 instead of 0.37 when using O/E LHR only). In terms of estimating O/E contralateral FLV, only the O/E LHR was a significant (p < 0.001) independent predictor (R(2) = 0.44). These correlations also applied when considering only left-sided CDH cases. For measurements done prior to the third trimester, the O/E LHR (p = 0.034), gestational age (p = 0.035) as well as liver herniation (p = 0.029) were significantly correlated to the O/E TFLV (R(2) = 0.33). In terms of predicting the O/E contralateral FLV (R(2) = 0.25), only O/E LHR (p = 0.008) and gestational age (p = 0.037) were useful predictors. CONCLUSION: Measurement of the O/E LHR on ultrasound allows a good estimation of the O/E contralateral FLV as well as TFLV as measured by MRI. Whereas the additional parameters such as gestational age, liver position and side of the defect did not improve the estimation of the contralateral FLV, they did so for estimating the TFLV.

Changes in lung tissue perfusion in the prediction of survival in fetuses with congenital diaphragmatic hernia treated with fetal endoscopic tracheal occlusion.

OBJECTIVE: To assess the impact of lung perfusion by fractional moving blood volume (FMBV) for the prediction of survival in fetuses with congenital diaphragmatic hernia (CDH) treated with fetal endoscopic tracheal occlusion (FETO). STUDY DESIGN: Lung perfusion by FMBV (%) and the observed/expected lung-to-head ratio (o/e LHR) were evaluated 1 day before and 7-14 days after FETO in a cohort of 62 CDH fetuses, and their isolated and combined values to predict survival was assessed. RESULTS: Preoperative lung perfusion did not show association with survival. However, after FETO, an increase in 30% of the preoperative lung FMBV and an increase in 50% of the LHR was significantly associated with the probability of survival. A model combining the changes in FMBV and o/e LHR after therapy allowed discrimination of cases with poor (10% survival), moderate (40-70% survival) and very good prognosis (100% survival). CONCLUSION: Changes in lung tissue perfusion, evaluated by FMBV after FETO, improved the prediction of survival in fetuses with CDH.

Twin anemia polycythemia sequence from a prenatal perspective.

OBJECTIVES: To describe the prevalence, management and outcome of spontaneous twin anemia polycythemia sequence (TAPS) diagnosed in the prenatal period. METHOD: Retrospective analysis of 142 consecutive monochorionic twin pregnancies not diagnosed with twin to twin transfusion syndrome. TAPS cases were identified based on the presence of discordant middle cerebral artery peak systolic velocity (MCA-PSV) measurements and signs suggestive of a chronic intertwin transfusion imbalance: either an elevated reticulocyte count in the anemic twin or the presence of few small unidirectional anastomoses during fetoscopy or at postnatal placental examination. RESULTS: Three cases were identified, giving an estimated prevalence of 2%. Prenatal interventions were tailored to the characteristics of each case and consisted of intrauterine transfusion and interruption of the shared circulation by cord coagulation or laser separation. CONCLUSION: In monochorionic twin pregnancies, TAPS is an uncommon prenatal finding. Nonetheless, its incidence seems high enough to recommend screening for this disease by MCA-PSV measurements.

Prospective assessment of fetal cardiac function with speckle tracking in healthy fetuses and recipient fetuses of twin-to-twin transfusion syndrome.

BACKGROUND: The aim of this study was to assess speckle tracking-derived fetal cardiac function in a normal population and in recipient fetuses of twin-to-twin transfusion syndrome (TTTS). METHODS: A case-control study was conducted of 59 uncomplicated singleton pregnancies and 17 recipient fetuses of TTTS. Peak systolic strain, strain rate, velocity, and displacement were calculated, corrected for gestational age, and compared between patients with TTTS and controls. RESULTS: The feasibility of speckle tracking was 83% in controls but only 61% in patients with TTTS. Myocardial velocity and displacement increased over gestation, and regional differences were present within each wall and between walls. Strain and strain rate were stable within each wall but were higher in the right ventricle than in the left ventricle and septum. Right ventricular strain was decreased in patients with TTTS compared with controls (0.75+/-0.34 vs 1.00+/-0.37 multiples of the median, P=.04). CONCLUSION: The feasibility of speckle tracking is low when imaging conditions are challenging, but it can identify right ventricular failure in selected patients with TTTS.

Injectable candidate sealants for fetal membrane repair: bonding and toxicity in vitro.

OBJECTIVE: This study was undertaken to test injectable surgical sealants that are biocompatible with fetal membranes and that are to be used eventually for the closure of iatrogenic membrane defects. STUDY DESIGN: Dermabond (Ethicon Inc, Norderstedt, Germany), Histoacryl (B. Braun GmbH, Tuttlingen, Germany), and Tissucol (Baxter AG, Volketwil, Switzerland) fibrin glue, and 3 types of in situ forming poly(ethylene glycol)-based polymer hydrogels were tested for acute toxicity on direct contact with fetal membranes for 24 hours. For the determination of elution toxicity, extracts of sealants were incubated on amnion cell cultures for 72 hours. Bonding and toxicity was assessed through morphologic and/or biochemical analysis. RESULTS: Extracts of all adhesives were nontoxic for cultured cells. However, only Tissucol and 1 type of poly(ethylene glycol)-based hydrogel, which is a mussel-mimetic tissue adhesive, showed efficient, nondisruptive, nontoxic bonding to fetal membranes. Mussel-mimetic tissue adhesive that was applied over membrane defects that were created with a 3.5-mm trocar accomplished leak-proof closure that withstood membrane stretch in an in vitro model. CONCLUSION: A synthetic hydrogel-type tissue adhesive that merits further evaluation in vivo emerged as a potential sealing modality for iatrogenic membrane defects.

Amniotic fluid markers of fetal cardiac dysfunction in twin-to-twin transfusion syndrome.

OBJECTIVE: The objective of the study was to determine whether cardiac troponin T (cTnT) and natriuretic peptides can be isolated from the amniotic fluid (AF) of pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) and whether they correlate with fetal echocardiographic findings and recipient survival. STUDY DESIGN: AF samples from the recipient sac were obtained in 52 TTTS cases and 16 controls. Samples were assayed for cTnT and natriuretic peptides. Prior to fetoscopic laser therapy, 34 recipient twins underwent assessment of atrioventricular flow patterns, myocardial performance index (MPI), and precordial venous Dopplers. Fetal survival was assessed 48 hours postoperatively. RESULTS: AF B-type natriuretic peptide and cTnT levels were elevated in TTTS and correlated with functional echocardiographic findings. Postoperative recipient survival was 72% when both AF-cTnT and left ventricular MPI were increased. If 1 of both markers was normal, survival was 100% (P = .046). CONCLUSION: Combining ultrasound and AF-cTnT measurements allows the identification of fetuses at risk of postoperative demise.

Assessment of fetal cardiac function before and after therapy for twin-to-twin transfusion syndrome.

OBJECTIVE: We sought to assess fetal cardiac function in monochorionic twins before and after therapy for twin-to-twin transfusion syndrome (TTTS) and compare it with control subjects. STUDY DESIGN: We conducted prospective longitudinal assessment of fetal cardiac function in cases undergoing curative fetal therapy for TTTS (n = 39) until 4 weeks postoperatively and in uncomplicated monochorionic twins (n = 23). Fetal cardiac function was assessed by the left and right ventricular myocardial performance index, atrioventricular valve flow pattern, ductus venosus a-wave, and umbilical vein pulsations. RESULTS: Nomograms for the myocardial performance index were constructed. Fetal cardiac function was grossly abnormal in recipient twins of TTTS when compared with control subjects (P < .001 for all indices) but normalized by 4 weeks postoperatively. The donor developed abnormal ductus venosus flow and tricuspid regurgitation postoperatively that regressed within 4 weeks. CONCLUSION: The cardiac dysfunction in the recipient twin of TTTS normalizes within 1 month after laser. The donor develops a transient impairment of cardiac function postoperatively.

Ultrasound prediction of intertwin birth weight discordance in monochorionic diamniotic twin pregnancies.

OBJECTIVES: To estimate the accuracy of ultrasound to predict birth weight (BW) and BW discordance in monochorionic diamniotic (MCDA) twin pregnancies. METHODS: A prospective series of MCDA twin pregnancies was subjected to ultrasound fetal weight estimations (EFW) at 16, 20, and 26 weeks of gestation and within 2 weeks of birth. Intertwin weight discordance (DeltaEFW and DeltaBW) was calculated. The correlation between DeltaEFW, DeltaBW, EFW, and BW was assessed (Pearson) and least square regression analysis was performed. Positive and negative predictive values of ultrasound to detect severe DeltaBW were calculated. Receiver-operating characteristics (ROC) curves were constructed to predict DeltaBW >25% at different time points of gestation. RESULTS: Sixty pregnancies were included. Median DeltaBW was 9.98%. Ten(16,7%), 8(13,3%) and 5(8,3%) twin pairs had a DeltaBW >20%, >25% and >30%, respectively. BW and EFW (r = 0.96; p < 0.001) as well as DeltaBW and DeltaEFW were well correlated with each other (r = 0.75; p < 0.001). Bland-Altman analysis showed that ultrasound evaluation overestimated DeltaBW if >20%. Negative predictive value of ultrasound for DeltaBW >25% was 98%. The area under the curve (AUC) to predict a DeltaBW >25% at 16, 20, and 26 weeks and <2 weeks before birth was 0.79, 0.87, 0.93, and 0.95, respectively. CONCLUSIONS: Ultrasound estimations of BW and DeltaBW are highly correlated with actual BW and DeltaBW in MCDA twin pregnancies.

Prenatal diagnosis, prediction of outcome and in utero therapy of isolated congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) can be associated with genetic or structural anomalies with poor prognosis. In isolated cases, survival is dependent on the degree of lung hypoplasia and liver position. Cases should be referred in utero to tertiary care centers familiar with this condition both for prediction of outcome as well as timed delivery. The best validated prognostic indicator is the lung area to head circumference ratio. Ultrasound is used to measure the lung area of the index case, which is then expressed as a proportion of what is expected normally (observed/expected LHR). When O/E LHR is < 25% survival chances are < 15%. Prenatal intervention, aiming to stimulate lung growth, can be achieved by temporary fetal endoscopic tracheal occlusion (FETO). A balloon is percutaneously inserted into the trachea at 26-28 weeks, and reversal of occlusion is planned at 34 weeks. Growing experience has demonstrated the feasibility and safety of the technique with a survival rate of about 50%. The lung response to, and outcome after FETO, is dependent on pre-existing lung size as well gestational age at birth. Early data show that FETO does not increase morbidity in survivors, when compared to historical controls. Several trials are currently under design.