Implementation of universal screening for preterm delivery by mid-trimester cervical-length measurement.

OBJECTIVE: To assess the feasibility and results of introducing a policy of universal screening for preterm delivery (PTD) by mid-trimester cervical-length (CL) measurement. METHODS: In this retrospective cross-sectional study of singleton pregnancies, transvaginal sonography for CL measurement was performed at 20-24 weeks of gestation. Vaginal progesterone therapy was offered to women with CL ≤ 15 mm. The incidence of spontaneous PTD (sPTD) according to CL and the distribution of CL measurements were assessed. Rate of PTD before implementation of screening was compared with that after. RESULTS: A total of 10 506 singleton pregnancies were assessed. The decline rate was 1.32%. sPTD < 32 weeks, < 34 weeks and < 37 weeks occurred in 0.51%, 0.82% and 3.90% of pregnancies, respectively. CL measurement was best described by a mixture model distribution comprising a 'short' and a 'long' component. The percentage of the two components varied between subgroups of PTD, with the short component being greater the earlier the birth. CL, history of miscarriage, smoking status and prior PTD were independent predictors in the construction of a model predictive of PTD < 34 weeks (area under the curve = 0.74, P < 0.001). The rate of sPTD < 34 weeks in women with CL ≤ 15 mm receiving progesterone treatment was 20.4%. In the progesterone-treated group, a plateau was observed in the increase in risk for PTD for CL 9-13 mm, whereas below 9 mm the risk increased exponentially. Following the introduction of mid-trimester CL measurement, there was a trend for reduction in the rate of any PTD < 34 weeks of about 20% in comparison with the prescreening period (odds ratio = 0.81; 95% CI, 0.59-1.13). CONCLUSIONS: Universal screening for PTD by transvaginal sonographic measurement of CL at 20-24 weeks is feasible and well accepted by pregnant women. This policy identifies a very high-risk group that may benefit from intervention. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Switching to ranibizumab in diabetic macular oedema refractory to bevacizumab treatment. / Cambio a ranibizumab en edema macular diabético refractario al tratamiento con bevacizumab.

AIM: To determine the efficacy of switching to ranibizumab in patients with diabetic macular oedema refractory to treatment with bevacizumab, and to evaluate the outcomes when switching back to bevacizumab. METHODS: A prospective study was conducted that included 43 eyes of 31 patients refractory to previous bevacizumab treatment. The patients were switched to ranibizumab, and optical coherence tomography was performed one month post-injection. Patients showing improvement (>10% reduction in central sub-field thickness) were switched back to bevacizumab, and optical coherence tomography was performed one month post-switch back. RESULTS: The 34 eyes switched to ranibizumab showed a statistically significant improvement in mean best corrected visual acuity from 0.67±0.39 logMAR to a mean of 0.55±0.36 logMAR (P<.05). In addition, there was a statistically significant decrease in central subfield thickness (CST) from a mean of 475.3±122.8 to a mean of 417.3±109.1 (P<.05). In the 21 eyes that were switched back to bevacizumab, there was no significant difference either in the change in CST or in the change in best corrected visual acuity post-switch back. CONCLUSION: Switching to ranibizumab in patients improves both the best corrected visual acuity and CST in diabetic patients refractory to previous bevacizumab treatment. This effect is pronounced in patients with increased CST prior to the switch. Switching back to bevacizumab adds no further improvement.

Aflibercept in age-related macular degeneration: evaluating its role as a primary therapeutic option.

The recent VIEW studies have demonstrated the non-inferiority of monthly and bi-monthly aflibercept in the management of wet age related macular degeneration (AMD) compared with ranibizumab. However, the current data are limited mainly to fixed dosing regimens with few studies looking at flexible dosing regimens of aflibercept in wet AMD. In addition, recent data from the VIEW 96 week extension has shown that patients being shifted from fixed dosing regimens to PRN have shown a drop in visual acuity and increase in central macular thickness. This is an indication that fixed dosing, a non-sustainable option, is only effective as long as it is continued. Regimens such as treat and extend (TAE) and pro-re nata (PRN) have been studied extensively in ranibizumab and bevacizumab and have shown to be effective options. With the presence of effective, established and less costly drugs such as ranibizumab and bevacizumab, the role of aflibercept as a primary treatment modality has yet to be clearly defined. The current review provides an analysis of the VIEW studies, as well as the extension phases. It also looks at post hoc analysis of predictors of response and outcomes. We have also conducted a search on studies comparing between PRN regimens using aflibercept and other anti-VEGF agents. This review also explores cheaper off label aflibercept; ziv-aflibercept in the treatment of wet AMD. The main purpose of the review is to delineate the role of aflibercept as a primary therapeutic option and if there are any significant advantages that would advocate its use over alternative anti-VEGF drugs. Finally, we propose a treatment algorithm for patients being started on aflibercept during the first year and thereafter.

Aflibercept in diabetic macular edema: evaluating efficacy as a primary and secondary therapeutic option.

The recent results of Protocol T have illustrated the efficacy of aflibercept in the treatment of diabetic macular edema. It also demonstrated that in patients with poor vision (<6/12), aflibercept offers anatomical and visual advantages over ranibizumab and bevacizumab in the first 12 months of treament. At 2 years, the difference between the three drugs decreased with patients with a better baseline VA (69-78) showing a statistically insignificant advantage for ranibizumab compared with aflibercept.These results were achieved using a pro-re nata (PRN) protocol, which was not previously studied in large phase 3 trials, VIVID and VISTA, that chose to compare the 2.0 mg dose in a monthly and bimonthly regimen. In this review article, we analyzed earlier studies such as DAVINCI and VIVID and VISTA to determine which treatment strategy offers the best results; monthly, bimonthly, or PRN. We also studied the different doses for aflibercept used in DAVINCI to determine which is more effective the 0.5 mg dose or the 2.0 mg dose. In addition, we analyzed the recent data from protocol T with regards to visual and anatomic outcomes to try to determine whether these results concur with previous studies. Finally, we discuss the role of aflibercept as a potential alternative to any diabetic macular edema regimen regardless what the primary drug used is.

Central retinal vein occlusion: modifying current treatment protocols.

Central retinal vein occlusion (CRVO) is a common retinal vascular disorder that can result in severe visual acuity loss. The randomized control study, CRUISE, helped establish anti-VEGFs as the standard of care in cases with CRVO. The extension studies for CRUISE; HORIZON and RETAIN showed that not all visual gains are maintained beyond the first year. In addition, patients showed different behavior patterns; with some patients showing complete response with few recurrences, whereas others showed partial or even no response with multiple recurrences. Long-term follow-up demonstrated that patients responding poorly to anti-VEGFs tended to do so early in the course of treatment. It also demonstrated the effectiveness of a pro re nata (PRN) protocol for improving vision and maintaining these gains over long-term follow-ups. The SHORE study further illustrated this point by demonstrating that there were minimal differences in visual outcomes between patients receiving monthly injections and patients being treated PRN. In this review we analyzed the data from the major randomized clinical trials (RCT) that looked at anti-VEGFs as the primary treatment modality in patients with CRVO (CRUISE and the extension studies HORIZON and RETAIN for ranibizumab as well as GALILEO and COPERNICUS for aflibercept). In addition, we looked at SCORE and GENEVA to help determine whether there is a place for steroids as a first line therapy in current treatment practice. We then explored alternative treatment regimens such as laser therapy and switching between anti-VEGF agents and/or steroids for non or partially responding patients. Finally, we propose a simplified modified treatment algorithm for patients with CRVO for better long-term outcomes in all types of responders.

Socioeconomic and psychological impact of treatment for unilateral intraocular retinoblastoma.

PURPOSE: To identify the socioeconomic and psychosocial impacts of clinical treatment decisions for advanced unilateral intraocular retinoblastoma. DESIGN: Retrospective observational case series. SETTING: institutional study at Alexandria Main University Hospital. STUDY POPULATION: records of 66 unilateral retinoblastoma cases treated from May 2005 to May 2013 were retrospectively reviewed. Sixty cases were eligible (International Intraocular Retinoblastoma Classification [IIRC] group C, D or E). PROCEDURES: two treatment groups were compared: enucleation vs. salvage treatment. Salvage treatment eyes were further subdivided based on IIRC group. Six socioeconomic parameters (financial burden, financial impact, psychological, social, medical and tumor impacts) were scored. Parameter scores ranged from 0 to 3, for overall score range 0 (no adverse impact) to 18 (severe adverse impact). MAIN OUTCOME MEASURES: derived Socioeconomic scores were correlated with treatment and outcomes. RESULTS: The enucleation group (28 eyes) had a median overall Socioeconomic score of 4/18, significantly lower than the salvage treatment group (32 eyes), median score 11/18 (P<0.01). Socioeconomic score varied with IIRC group. Attempted eye salvage failed in 25 children, due to uncontrolled tumor (44%) and socioeconomic impact of cumulative therapies (56%). Treatment duration and Socioeconomic score were higher for the 5 children in the salvage treatment group who developed metastatic disease compared to those without metastasis (P<0.01). CONCLUSIONS: The socioeconomic and psychosocial impacts of attempted ocular salvage for unilateral intraocular retinoblastoma are severe, in comparison to primary enucleation. Primary enucleation is a good treatment for unilateral retinoblastoma.

Cervical length in late second and third trimesters: a mixture model for predicting delivery.

OBJECTIVES: To examine the distribution of cervical length (CL) in the late second and third trimesters of pregnancy and construct survival models for spontaneous delivery. METHODS: This cross-sectional study included 647 women with a singleton pregnancy who had routine CL measurements taken by transvaginal ultrasonography between 24 and 40 weeks' gestation. Only one measurement per patient was included in the analysis. Exploratory data analysis revealed that the distribution of CL measurements was a mixture of two Gaussian distributions, and subsequently a mixture model was applied to describe the distribution of CL. Changes in CL in relation to gestational age were examined by regression analysis and measurements were converted to Z-scores. Survival analysis was applied to the subgroups identified, to describe the probability of delivery throughout gestation. RESULTS: CL was best described by a mixture model of two subgroups with Gaussian distribution, one including women with a long cervix (73.85% of the study population, mean CL of 28.2 ± 4.45 mm) and the other including women with a short cervix (26.15% of the study population, mean CL of 12.3 ± 5.14 mm). CL was dependent on gestational age (GA), therefore conversion to Z-scores was employed in the analysis. Women with a short cervix had a higher probability for spontaneous delivery (hazard ratio (HR), 1.807; P < 0.001) than did women with a long cervix, after adjustment for GA at the time of measurement (GA HR, 1.115; P < 0.001). In both subgroups, the probability of spontaneous delivery was predicted by the GA and CL Z-scores. Survival models for the prediction of spontaneous delivery were constructed separately for the short-cervix subgroup (GA HR, 1.085; P < 0.001 and CL Z-score HR, 0.819; P = 0.003) and the long-cervix subgroup (GA HR, 1.130; P < 0.001 and CL Z-score HR, 0.864; P = 0.005). CONCLUSIONS: CL follows a mixture of two Gaussian distributions, one for a short and one for a long cervix. Late second-trimester/third-trimester CL measurement may be of value in estimating the probability for spontaneous delivery at any given gestational age.

Performance of third-trimester ultrasound for prediction of small-for-gestational-age neonates and evaluation of contingency screening policies.

OBJECTIVES: To assess the performance of third-trimester fetal biometry and fetal Doppler studies for the prediction of small-for-gestational-age (SGA) neonates, and to explore contingency strategies using a first-trimester prediction model based on maternal and fetal parameters and third-trimester ultrasound. METHODS: This was an observational cross-sectional study of uncomplicated singleton pregnancies. Risk assessment for chromosomal abnormality was carried out in 4702 pregnancies using a combination of ultrasound markers (fetal nuchal translucency thickness (NT) and nasal bone assessment) and biochemistry (free beta-human chorionic gonadotropin (ß-hCG) and pregnancy-associated plasma protein-A (PAPP-A)) at 11 to 13 + 6 weeks. Maternal demographic characteristics and method of conception were recorded. Third-trimester (30-34 weeks) fetal biometry (biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL)) and umbilical artery (UA) and middle cerebral artery Doppler studies were performed routinely in a subgroup (n = 2310). Reference ranges for birth weight were constructed using the cohort of 4702 women, and neonates were classified as small (SGA, ≤ 5th centile) or appropriate (AGA) for gestational age. First-trimester, third-trimester and integrated first- and third-trimester prediction models for SGA were constructed using regression analysis and three different contingency strategies of rescanning in the third trimester were investigated. RESULTS: According to the areas under the receiver-operating characteristics curves (AUCs), AC (AUC = 0.85) and ultrasound-estimated fetal weight (EFW, AUC = 0.87) were equally good predictors of SGA. The model was marginally improved by the addition of UA Doppler, smoking status and first-trimester indices (free ß-hCG and PAPP-A multiples of the median) (combined model, AUC = 0.88), but the difference was not statistically significant. A contingency strategy of rescanning 50% of the population in the third trimester according to the risk estimated by a first-trimester prediction model yielded a detection rate of 79% for a 25% screen-positive rate. CONCLUSION: Third-trimester ultrasound is effective in screening for SGA in uncomplicated pregnancies. The use of a contingency screening policy can reduce the need for unnecessary examinations.

Fetal intracranial translucency and cisterna magna at 11 to 14 weeks : reference ranges and correlation with chromosomal abnormalities.

OBJECTIVE: To measure the intracranial translucency (IT) and the cisterna magna (CM), to produce reference ranges and to examine the interobserver and intraobserver variability of those measurements. To examine the possible association of IT with chromosomal abnormalities. METHODS: Prospective study on pregnancies assessed at 11 to 14 weeks. IT was measured retrospectively in 17 cases with aneuploidy. RESULTS: To produce reference ranges, 465 fetuses were used. IT and CM correlated linearly with crown-rump-length (CRL) and were independent of maternal demographic characteristics and biochemical indices. IT had a weak positive correlation with nuchal translucency. For IT the intraclass correlation coefficient was 0.88 for intraobserver variability and 0.83 for interobserver variability. For CM the intraclass correlation coefficient was 0.95 for intraobserver variability and 0.84 for interobserver variability. The IT multiple of the median was significantly increased in the chromosomally abnormal fetuses (1.02 for the normal and 1.28 for the chromosomally abnormal fetuses, Mann Whitney p < 0.001). IT multiple of the median was a significant predictor of chromosomal abnormality (Receiver Operator Characteristic curve analysis: Area under the curve = 0.86, CI=0.76-0.96, p<0.001). CONCLUSION: Intracranial translucency and CM can be measured reliably at the 11 to 14 weeks examination and the measurements are highly reproducible. IT appears to be increased in fetuses with chromosomal abnormalities.

A predictive model of short cervix at 20-24 weeks using first-trimester cervical length measurement and maternal history.

OBJECTIVES: To develop a model for the prediction of short cervix ( ≤ 15 mm) at 20-24 weeks by combining maternal history and transvaginal ultrasonographic measurement of cervical length at 11-14 weeks. To explore the value of an additional ultrasound examination of the cervix at about 17 weeks. METHODS: Longitudinal prospective study in 800 unselected pregnant women presenting for first-trimester ultrasound assessment by nuchal translucency and serum biochemistry. Cervical length was evaluated transvaginally between 11 weeks and 13 weeks and 6 days (cx1), at 16-19 weeks (cx2) and 20-24 weeks (cx3). Backward multiple logistic regression analysis with cx3 ≤ 15 mm as the dependent variable was used to identify the predictors of a short cervix at 20-24 weeks. RESULTS: Cx1 and history of preterm delivery were significant independent contributors of a short cervix at 20-24 weeks [area under the curve (AUC 0.808, p < 0.001, Model) 1]. Furthermore, the cx1/cx2 ratio was a significant independent predictor of a short cervix at 20-24 weeks (odds ratio = 58.325 p = 0.012). The addition of the cx1/cx2 ratio improved the model (AUC = 0.878, p < 0.001, Model 2). CONCLUSIONS: A short cervix at 20-24 weeks can be predicted at the 11-14 weeks scan. The addition of a cervical measurement at about 17 weeks can improve the prediction model.

Attitudes of pregnant women regarding termination of pregnancy for fetal abnormality.

OBJECTIVE: To study the attitudes of pregnant women towards termination of pregnancy for fetal abnormality. MATERIALS AND METHODS: A questionnaire was completed by all pregnant women attending routine ultrasound scan. They were asked whether they would opt for termination of the pregnancy in case the fetus was diagnosed with one of the following abnormalities: lethal anomaly, anomaly causing developmental delay, anomaly causing physical handicap, anomaly causing disfigurement and severe anomaly diagnosed after 24 weeks of pregnancy. Logistic regression analysis was used to examine the effect of a variety of demographic and socio-economic characteristics in their choices. RESULTS: A total of 533 women completed the questionnaire out of which 447 (86%) would terminate the pregnancy in case of lethal fetal anomaly. The corresponding figures for anomaly causing developmental delay, anomaly causing physical handicap and anomaly causing disfigurement were 396 (77.8%), 332 (65.9%) and 228 (45.2%). A total of 313 (64.7%) would request late termination owing to severe anomaly. The only two statistically significant factors that influenced the maternal decision on pregnancy termination were religious beliefs and the frequency of practicing religious duties (p < 0.001). CONCLUSION: The majority of pregnant women would terminate pregnancy for lethal fetal anomaly and for an anomaly causing mental or physical handicap, even in late pregnancy.

Screening for pre-eclampsia and fetal growth restriction by uterine artery Doppler and PAPP-A at 11-14 weeks' gestation.

OBJECTIVE: To assess the role of maternal demographic characteristics, uterine artery Doppler velocimetry, maternal serum pregnancy-associated plasma protein-A (PAPP-A) and their combination in screening for pre-eclampsia and small-for-gestational age (SGA) fetuses at 11-14 weeks. METHODS: This was a prospective study of 878 consecutive women presenting for a routine prenatal ultrasound examination at 11-14 weeks. Pulsed wave Doppler was then used to obtain uterine artery flow velocity waveforms and the mean pulsatility index (PI) of the uterine arteries was calculated. Maternal serum samples for PAPP-A were assayed. Along with maternal history, these measurements were compared in their ability to predict adverse outcome, defined as pre-eclampsia and/or SGA and/or placental abruption. RESULTS: Mean uterine artery PI > or = 95(th) centile and PAPP-A < or = 10(th) centile each predicted 23% of the women that developed pre-eclampsia and 43% of cases of placental abruption. For SGA < or = 5(th) centile, mean uterine artery PI > or = 95(th) centile predicted 23% of cases and PAPP-A < or = 10(th) centile predicted 34%. Independent predictors for subsequent development of pre-eclampsia were increased mean uterine artery PI > or = 95(th) centile (OR, 2.76; 95% CI, 1.11-6.81) and maternal history of pre-eclampsia/hypertension (OR, 50.54; 95% CI, 10.52-242.73). The predicting factors for SGA < or = 5(th) centile were increased mean uterine artery PI > or = 95(th) centile (OR, 2.0; 95% CI, 1.07-3.74) and low PAPP-A (OR, 0.43; 95% CI, 0.20-0.93). Increased uterine artery PI was the only independent factor in the prediction of placental abruption (OR, 8.49; 95% CI, 2.78-25.94). The combination of uterine artery PI and maternal history of pre-eclampsia/hypertension was better than was using uterine artery Doppler alone in predicting pre-eclampsia. Similarly, for the prediction of SGA < or = 5(th) centile, combining uterine artery Doppler and maternal serum PAPP-A was better than was uterine artery Doppler alone. In both cases, the difference approached statistical significance. CONCLUSIONS: The combination of maternal history with abnormal uterine artery Doppler and low PAPP-A level at 11-14 weeks achieves better results than does either test alone in the prediction of pre-eclampsia and SGA.

Identification of nucleated red blood cells in maternal circulation: a second step in screening for fetal aneuploidies and pregnancy complications.

BACKGROUND: Identification of fetal nucleated red blood cells (NRBCs) in maternal circulation can facilitate non-invasive prenatal diagnosis, but technical difficulties still exist. An increase in the number of circulating NRBCs, however, could indicate fetal aneuploidies or pregnancy complications. MATERIALS AND METHODS: The number of NRBCs was determined from 20 mL peripheral blood in 351 women in the second trimester of pregnancy after isolation by magnetic cell sorting (MACS) with anti-CD71 antibody and identification with May-Grunwald/Giemsa staining. RESULTS: An average of eight NRBCs (range 1-12) were identified among 282 women with chromosomally normal fetuses. In cases known to carry aneuploid fetuses the mean number was 35 (range 7-113), but when the fetus had trisomy 21 (n = 17) an average of 71 NRBCs were identified. Among 26 carriers of beta-thalassemia, 42 NRBCs (range 22-158) were isolated. In pregnancies with abnormal Doppler findings in both uterine arteries (n = 20), 15 NRBCs (range 2-75) were isolated. CONCLUSION: Determining the number of NRBCs in maternal circulation could represent an additional screening step for fetal aneuploidies, as long as the anemic status of the mother is taken into consideration. However, more cases with abnormal Doppler results must be investigated before this test is used for in the prediction of pregnancy complications.

Short-rib-polydactyly syndrome presenting with increased nuchal translucency in a high-risk family.

Short-rib-polydactyly syndrome represents a group of rare, autosomal recessive, lethal skeletal dysplasias characterized by hypoplastic thorax, short ribs, short limbs, polydactyly, and visceral abnormalities. We describe an affected fetus from a high-risk family presenting with increased nuchal translucency at 13 weeks of pregnancy. The diagnosis was established in the 2nd trimester.

Embryo reduction versus expectant management in triplet pregnancies.

OBJECTIVE: In triplet pregnancies, to compare pregnancy outcome of expectant management with that after embryo reduction to twins. METHODS: Retrospective study of 255 trichorionic triplet pregnancies, of which 185 had embryo reduction to twins (reduced group) and 70 were managed expectantly (non-reduced group). RESULTS: Median birth weight was higher by about 500 g and gestation prolonged by about 3 weeks in the reduced pregnancies compared with the expectantly managed pregnancies (2300 vs. 1760 g; 36 vs. 33 weeks). The rates of preterm delivery were significantly lower in the reduced group (11.17 vs. 36.76% for delivery at < or = 32 weeks and 40.58 vs. 83.82% for delivery at < or = 35 weeks, reduced vs. non-reduced group). The percentage of infants born with low birth weight was significantly higher in the expectantly managed triplets (10.98 vs. 28.44% for birth weight < or = 1500 g and 68.55 vs. 92.89% for birth weight < or = 2500 g, reduced vs. non-reduced group). Total fetal loss was significantly higher in the reduced group than in the non-reduced group (15.41 and 4.76%, respectively) and the difference was mainly due to the higher miscarriage rate in the reduced group (8.11 vs. 2.86% in the non-reduced group). With the expected rates of handicap in preterm infants, we would anticipate 0.63% of severely handicapped children due to extreme prematurity in the reduced group and 1.64% in the non-reduced group. CONCLUSION: In triplet pregnancies, embryo reduction to twins significantly reduces the risk of severe preterm delivery and very low birth weight by about one-third, at the expense of a significant increase in total fetal loss, by about one-quarter. The procedure is likely to reduce the risk of having a severely handicapped child due to extreme prematurity.

Assessment of fetal anatomy at the 11-14-week ultrasound examination.

OBJECTIVE: To assess the feasibility of examining cardiac and non-cardiac fetal anatomy in a low-risk population in the setting of the routine 11-14-week ultrasound scan. METHODS: This was a prospective study of 1144 women with viable, singleton pregnancies at 11-14 weeks of gestation. The ultrasound examination was performed transabdominally and transvaginally and fetal anatomy assessment included visualization of the skull, brain, face, spine, four-chamber and three-vessel views of the heart, stomach, abdominal wall, kidneys, bladder and extremities. RESULTS: Complete examination of the fetal anatomy was achieved in 48% of the fetuses, whereas non-cardiac anatomy was examined successfully in 86% of the fetuses. The use of the transvaginal approach increased successful examination of the fetal anatomy from 72% to 86% of the fetuses and transvaginal scanning was particularly helpful in examining the face, kidneys and bladder. Non-cardiac anatomy visualization increased from 65% for fetuses with a crown-rump length of 45-54 mm, to 84%, 93% and 96% for fetuses with a crown-rump length of 55-64 mm, 65-74 mm and more than 74 mm, respectively. In the same groups the four-chamber view was seen in 67%, 86%, 93% and 97% of fetuses, and the three-vessel view was seen in 25%, 46%, 58% and 67% of fetuses, respectively. Maternal habitus and crown-rump length were found to be statistically significant contributors to the rate of successful examination of fetal anatomy. CONCLUSION: Examination of fetal anatomy is feasible during the routine 11-14-week scan. The optimal gestational age for examining both cardiac and non-cardiac anatomy is from the beginning of the 12th week to the end of the 13th week of gestation. Access to the transvaginal approach is important for completeness of the examination.

Pregnancy outcome after multifetal pregnancy reduction.

OBJECTIVE: To study the effects of multifetal pregnancy reduction (MFPR) as a means to reduce the adverse outcome of multiple gestations. METHODS: This was a retrospective study evaluating the outcome of 334 multiple pregnancies after embryo reduction. RESULTS: In 313 multiple pregnancies in which MFPR was performed before 15 weeks, the rates of miscarriage, preterm delivery <33 weeks, preterm delivery <36 weeks and total fetal loss were 9.12%, 13.33%, 38.60% and 16.25%, respectively, and median gestational age at delivery was 35 weeks. There was a significant correlation between miscarriage and the finishing number of fetuses. In 185 triplets reduced to twins, miscarriage, preterm delivery <33 weeks, preterm delivery <36 weeks and total fetal loss occurred in 8.25%, 11.18%, 40.59% and 15.41% of cases, respectively, and median gestational age at delivery was 36 weeks. In the subgroup of 32 reduced triplet pregnancies that also had second-trimester amniocentesis, the risk of miscarriage (3.13%) was not significantly different from that in the rest of the group. Among 21 twin pregnancies that had selective termination at or after 15 weeks, the risk of preterm delivery <33 weeks was three times higher than in the group of 22 twin pregnancies with first-trimester procedures. CONCLUSION: MFPR resulted in at least one live neonate in 83.75% of cases and was effective in reducing the risks of pregnancy loss and severe prematurity in quadruplets and higher-order pregnancies. The risk of miscarriage increased with increasing finishing number of fetuses. In reduced triplets gestation was prolonged in comparison with average figures reported in the literature. In twin pregnancies selective termination in the first trimester carries a lower risk of severe preterm delivery and this emphasizes the need for first-trimester diagnosis.