Vasa previa in singleton pregnancies: diagnosis and clinical management based on an international expert consensus.

BACKGROUND: There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. OBJECTIVE: This study aimed to systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions and a Delphi technique. STUDY DESIGN: A 4-round focus group discussion and a 3-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected on the basis of their publication record on vasa previa. First, we convened a focus group discussion panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A 3-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa, which the experts were asked to rate on a 5-point Likert scale (from "strongly disagree"=1 to "strongly agree"=5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of ≤3 were deemed to have had no consensus and were excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and nonconsensus statements were then aggregated. RESULTS: A total of 68 international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on 5 continents and have contributed to >80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, and 91% for the first, second, and third rounds, respectively, and 71% completed all 3 rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including the following: (1) although there is no agreement on the distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2-cm distance; (2) all pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; (3) when a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at approximately 32 weeks to rule out vasa previa; (4) outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; (5) asymptomatic patients with vasa previa should be delivered by scheduled cesarean delivery between 35 and 37 weeks of gestation; and (6) there was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. CONCLUSION: Through focus group discussion and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines.

Hysterosalpingo-foam sonography (HyFoSy): Tolerability, safety and the occurrence of pregnancy post-procedure.

BACKGROUND: Fallopian tube patency testing is an essential part of infertility evaluation. Hysterosalpingo-contrast sonography (HyCoSy) has been described as reliable, well tolerated and safe compared to other modalities such as laparoscopy and a dye test or hysterosalpingography. Limited availability of the previously used contrast has led to the introduction of a foam contrast agent as an alternative. AIMS: To assess the tolerability, safety and occurrence of pregnancy post-procedure of hysterosalpingo-foam sonography (HyFoSy). MATERIALS AND METHODS: A retrospective cohort study of women who had a HyFoSy at Queensland Ultrasound for Women from March 2013 to February 2015. A questionnaire was sent to their referring doctor to identify any complications or subsequent pregnancies with or without artificial reproductive technology (ART) within six months of the HyFoSy. RESULTS: Of 200 women, four cases were abandoned due to difficulty introducing the intracervical catheter, severe discomfort or a vasovagal episode. Response from referring doctors for 155 women reported no post-procedural complication. One hundred and eleven women were followed up for at least six months. Twenty-four out of 59 women (40.7%) who had ART and 24 out of 52 women (46.2%) who did not have ART conceived. Fifty percent of women who were nulligravida at the time of investigation, found to have at least one patent fallopian tube, whose partner had a normal semen analysis, spontaneously conceived within the time of follow up. CONCLUSIONS: HyFoSy is well tolerated and safe. A preponderance of pregnancies in the first month after HyFoSy suggests that a therapeutic effect may exist.

Future Directions in the Management of Twin-to-Twin Transfusion Syndrome.

Twin-to-twin transfusion syndrome (TTTS) is the major complication of monochorionic (MC) pregnancy. The outcomes of this condition have been significantly improved after the introduction and widespread uptake of fetoscopic laser ablation over the last decade. However, there is still a significant fetal loss rate and morbidity associated with this condition. Improvements in the management of TTTS will require improvements in many areas. They are likely to involve refinements in the prediction of the disease and clarification of the optimum frequency of surveillance and monitoring. Improvements in training for fetoscopic surgery as well as in the technique of fetoscopic laser ablation may lead to better outcomes. New technologies as well as a better understanding of the pathophysiology of TTTS may lead to adjuvant medical therapies that may also improve short- and long-term results.

Prenatal extra-abdominal bowel dilatation is a risk factor for intrapartum fetal compromise for fetuses with gastroschisis.

OBJECTIVE: The aim of this study was to investigate the prenatal ultrasound features that were associated with intrapartum fetal distress in fetuses with gastroschisis. METHODS: This was a retrospective observational study of all cases of gastroschisis referred to and delivering at the Mater Mothers' Hospital in Brisbane, Australia. Maternal demographics, prenatal ultrasound features including the presence of bowel dilatation, umbilical artery and middle cerebral artery Doppler indices and amniotic fluid volume as well as intrapartum outcome details were analysed using univariate and multivariate logistic regression to ascertain factors predictive of intrapartum compromise. RESULTS: The study cohort included 155 cases of gastroschisis over a 16-year period. The overall perinatal loss rate was 5.9% (four intrauterine fetal deaths, four neonatal deaths and one termination of pregnancy). The live birth rate was 96.8% (150/155). Fetal heart rate abnormalities occurred in 55.1% of cases. The overall caesarean section rate was 40.9% (63/154), of which 63.5% (40/63) was emergency procedures. Both univariate and multivariate analysis confirmed that only extra-abdominal bowel dilatation was a risk factor for intrapartum fetal compromise necessitating emergency delivery. CONCLUSIONS: Extra-abdominal bowel dilatation is a risk factor for intrapartum fetal compromise (OR 2.2; 95%CI 1.03-4.7) and emergent delivery.

Prominent cervical mucous and its impact on cervical length measurement: findings of a national survey.

INTRODUCTION: Cervical length measurement by transvaginal scanning (TVS) has been proposed by some as a universal screening test for preterm labour. The presence of prominent cervical mucous may affect assessment of the cervix; however, the exact technique to measure the cervix when there is prominent mucous or funnelling has not been described. We evaluated the level of agreement in cervical length measurements amongst Australian specialists and sonographers reporting on cervical assessment using an online survey. METHODS: We conducted an online survey with 11 images of the cervix to assess how obstetric sonographers and sonologists report on the cervix when there is prominent mucous or funnelling. They were asked five questions about the image of the cervix. A kappa coefficient was calculated from the responses. RESULTS: We had 151 complete responses to the online survey. For the images which showed funnelling or prominent cervical mucous, there was little agreement regarding the cervix being open or closed and regards the location of the internal os. The Kappa coefficient was 0.22 indicating a low level of agreement for the location of the internal os. CONCLUSION: There is lack of agreement amongst Australian specialists and sonographers reporting on cervical assessment when there is prominent mucous or funnelling seen in the cervix. We propose a method to standardise reporting on the cervix incorporating the chorioamniotic membrane for the identification of the inner cervical os when there is prominent mucous or funnelling.

Prenatal administration of progesterone for preventing preterm birth in women considered to be at risk of preterm birth.

BACKGROUND: Preterm birth is a major complication of pregnancy associated with perinatal mortality and morbidity. Progesterone for the prevention of preterm labour has been advocated. OBJECTIVES: To assess the benefits and harms of progesterone for the prevention of preterm birth for women considered to be at increased risk of preterm birth and their infants. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (14 January 2013) and reviewed the reference list of all articles. SELECTION CRITERIA: Randomised controlled trials, in which progesterone was given for preventing preterm birth. DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated trials for methodological quality and extracted data. MAIN RESULTS: Thirty-six randomised controlled trials (8523 women and 12,515 infants) were included. Progesterone versus placebo for women with a past history of spontaneous preterm birth Progesterone was associated with a statistically significant reduction in the risk of perinatal mortality (six studies; 1453 women; risk ratio (RR) 0.50, 95% confidence interval (CI) 0.33 to 0.75), preterm birth less than 34 weeks (five studies; 602 women; average RR 0.31, 95% CI 0.14 to 0.69), infant birthweight less than 2500 g (four studies; 692 infants; RR 0.58, 95% CI 0.42 to 0.79), use of assisted ventilation (three studies; 633 women; RR 0.40, 95% CI 0.18 to 0.90), necrotising enterocolitis (three studies; 1170 women; RR 0.30, 95% CI 0.10 to 0.89), neonatal death (six studies; 1453 women; RR 0.45, 95% CI 0.27 to 0.76), admission to neonatal intensive care unit (three studies; 389 women; RR 0.24, 95% CI 0.14 to 0.40), preterm birth less than 37 weeks (10 studies; 1750 women; average RR 0.55, 95% CI 0.42 to 0.74) and a statistically significant increase in pregnancy prolongation in weeks (one study; 148 women; mean difference (MD) 4.47, 95% CI 2.15 to 6.79). No differential effects in terms of route of administration, time of commencing therapy and dose of progesterone were observed for the majority of outcomes examined. Progesterone versus placebo for women with a short cervix identified on ultrasound Progesterone was associated with a statistically significant reduction in the risk of preterm birth less than 34 weeks (two studies; 438 women; RR 0.64, 95% CI 0.45 to 0.90), preterm birth at less than 28 weeks' gestation (two studies; 1115 women; RR 0.59, 95% CI 0.37 to 0.93) and increased risk of urticaria in women when compared with placebo (one study; 654 women; RR 5.03, 95% CI 1.11 to 22.78). It was not possible to assess the effect of route of progesterone administration, gestational age at commencing therapy, or total cumulative dose of medication. Progesterone versus placebo for women with a multiple pregnancy Progesterone was associated with no statistically significant differences for the reported outcomes. Progesterone versus no treatment/placebo for women following presentation with threatened preterm labour Progesterone, was associated with a statistically significant reduction in the risk of infant birthweight less than 2500 g (one study; 70 infants; RR 0.52, 95% CI 0.28 to 0.98). Progesterone versus placebo for women with 'other' risk factors for preterm birth Progesterone, was associated with a statistically significant reduction in the risk of infant birthweight less than 2500 g (three studies; 482 infants; RR 0.48, 95% CI 0.25 to 0.91). AUTHORS' CONCLUSIONS: The use of progesterone is associated with benefits in infant health following administration in women considered to be at increased risk of preterm birth due either to a prior preterm birth or where a short cervix has been identified on ultrasound examination. However, there is limited information available relating to longer-term infant and childhood outcomes, the assessment of which remains a priority.Further trials are required to assess the optimal timing, mode of administration and dose of administration of progesterone therapy when given to women considered to be at increased risk of early birth.

The outcome of isolated primary fetal hydrothorax: a 10-year review from a tertiary center.

INTRODUCTION: The management of primary fetal pleural effusion remains a challenge for clinicians given the paucity of clinical information to guide practice. MATERIALS AND METHODS: A retrospective descriptive study of cases referred for management to our fetal therapy center over a 10-year period. Survival to hospital discharge was evaluated against case characteristics and prenatal intervention. For this study, we categorized the severity of the pleural effusion at diagnosis as mild, moderate or severe, and the clinical course as regression, stable or progression. RESULTS: Forty-five of the 103 pregnancies complicated by fetal pleural effusions during the study period were managed for primary effusions. Termination of pregnancy was requested in 6 cases. Thirty-nine pregnancies continued management, with 14 undergoing prenatal intervention. The overall survival rate to hospital discharge was 51%, including 7 survivors after prenatal intervention. The rate of survival was low if the effusion was categorized as severe at diagnosis or if there was progression of the clinical course. CONCLUSIONS: Case characteristics at the time of diagnosis and clinical course can be used to guide patient counseling and decision-making regarding fetal therapy. Prenatal intervention may improve the chance of survival in cases with characteristics associated with a poor prognosis.

Absent ductus venosus--outcomes and implications from a tertiary centre.

BACKGROUND: Absent ductus venosus (ADV) has been reported as case reports and series with suggestions that the outcome is variable. The prognosis depended on the associated abnormalities with ADV and the type of umbilical venous drainage. METHODOLOGY: We performed a retrospective audit of all cases with ADV in our centre from 2004 to 2008 and prospectively collected cases from 2008 and analysed the associations and outcomes. To our 22 cases, we added 67 cases extracted from all the reported case series with isolated ADV in the English literature and analysed them together. RESULTS: Eight of the 22 cases in our centre had isolated ADV and all eight fetuses were live born with no adverse outcomes. This was similar when compiled with the 67 extracted cases. Of the 89 cases; 19 with isolated ADV had 100% survival. This was independent of the umbilical venous drainage in contrast to previous reports. The overall survival is 57% and 45% when there is an associated abnormality in the fetus. CONCLUSION: Isolated ADV has a favourable outcome regardless of the umbilical venous drainage.

Uptake of invasive prenatal tests in pregnancies conceived via assisted reproductive technologies: the experience in Queensland, Australia.

OBJECTIVE: Prenatal diagnosis of a chromosomal abnormality currently involves the use of an invasive procedure, which has a risk of fetal loss. The aim of this study was to identify whether pregnancies conceived via assisted reproductive technologies were more or less likely to be subjected to an invasive procedure compared with pregnancies that were conceived spontaneously. METHOD: Population data were collated from three private ultrasound clinics across southeast Queensland, Australia. RESULTS: Of the 15,032 spontaneously conceived pregnancies, 775 (5.2%) had invasive testing, while 95 (6.0%) of the 1581 pregnancies conceived through assisted reproductive technologies had invasive testing. When the uptake of testing is adjusted by the maternal age the assisted reproductive population was significantly less likely to pursue invasive testing (p = 0.003). Similarly when adjusted for the combined first trimester screen risk estimate, the assisted reproduction population is significantly less likely to undergo invasive testing than the spontaneous population (p = 0.005). CONCLUSION: Pregnancies conceived using assisted reproductive technologies are significantly less likely to be subjected to invasive testing than pregnancies conceived spontaneously in women of the same age and combined first trimester screen risk.

Neurodevelopmental outcome and risk factors for disability for twin-twin transfusion syndrome treated with laser surgery.

OBJECTIVE: This study was performed to report the neurodevelopmental outcome of survivors of twin-twin transfusion syndrome (TTTS) treated with laser surgery and to determine the risk factors for neurodevelopmental disability. STUDY DESIGN: A prospective study of TTTS cases treated with laser was performed. Survivors were assessed at 2 years corrected for prematurity. Neurodevelopmental disability was defined as the presence of cerebral palsy, deafness, blindness, or cognitive impairment with a developmental score >2 SDs below the mean. RESULTS: A total of 75 TTTS pregnancies were treated with a perinatal survival rate of 79.3%. A total of 113 survivors were assessed. The rate of cerebral palsy was 4.4% and cognitive impairment was 8%, with a neurodevelopmental disability rate of 12.4%. Quintero stage was the only independent risk factor for neurodevelopmental disability. CONCLUSION: The incidence of neurodevelopmental disability in TTTS survivors treated with laser is considerable, with Quintero stage being an independent risk factor.

Selective fetoscopic laser ablation in 100 consecutive pregnancies with severe twin-twin transfusion syndrome.

AIMS: To report the perinatal outcomes of a large series of twin pregnancies with severe twin-twin transfusion syndrome (TTTS) managed with laser ablation surgery in an Australian tertiary perinatal centre and to compare the outcome with other large cohorts. METHODS: The outcomes of 100 consecutive pregnancies with severe TTTS managed with selective fetoscopic laser ablation from March 2002 to June 2007 were examined. Survival and neonatal morbidity were analysed. Comparisons were made with the results from other studies of laser surgery with at least 100 pregnancies. RESULTS: There were 100 women with TTTS treated with laser ablation; 34 stage II, 44 stage III and 22 at stage IV. Median gestation at time of laser was 21 weeks (range 18-28) and median gestation at delivery was 31 weeks (range 20-39). Overall perinatal survival rate was 151 of 200 (75.5%). Eighty five per cent had one or more surviving twins. The survival rate for stage IV TTTS was 88.6%, significantly better than for stage II (69.1%) and stage III (73.9%) pregnancies. The perinatal mortality rate for donors (30%) was not significantly different from recipients (19%), but the fetal death rate for donors was significantly greater than that for recipients (P = 0.03). Severe cerebral abnormalities were present in only 2.8% of newborns. The overall survival rate was comparable to other large series. CONCLUSIONS: These results for the management of severe TTTS are comparable to the best reported international series. Long-term follow-up is required and more research needs to be undertaken to further improve these results.

Progesterone for the prevention of preterm birth: a systematic review.

OBJECTIVE: We performed a systematic review to assess the benefits and harms of progesterone administration for the prevention of preterm birth in women and their infants. DATA SOURCES: The Cochrane Controlled Trials Register was searched, and reference lists of retrieved studies were searched by hand. No date or language restrictions were placed. METHODS OF STUDY SELECTION: Randomized trials comparing antenatal progesterone for women at risk of preterm birth were considered. Studies were evaluated for inclusion and methodological quality. Primary outcomes were perinatal death, preterm birth before 34 weeks, and neurodevelopmental handicap. TABULATION, INTEGRATION AND RESULTS: Eleven randomized controlled trials (2,425 women and 3,187 infants) were included. For women with a history of spontaneous preterm birth, progesterone was associated with a significant reduction in preterm birth before 34 weeks (one study, 142 women, RR 0.15, 95% CI 0.04-0.64, number needed to treat 7, 95% CI 4-17), but no statistically significant differences were identified for the outcome of perinatal death. For women with a short cervix identified on ultrasound, progesterone was not associated with a significant difference in perinatal death (one study, 274 participants, RR 0.38, 95% CI 0.10-1.40), but there was a significant reduction in preterm birth before 34 weeks (one study, 250 women, RR 0.58, 95% CI 0.38-0.87, number needed to treat 7, 95% CI 4-25). For women with a multiple pregnancy, progesterone was associated with no significant difference in perinatal death (one study, 154 participants, RR 1.95, 95% CI 0.37-10.33). For women presenting after threatened preterm labor, no primary outcomes were reported. For women with "other" risk factors for preterm birth, progesterone was not associated with a significant difference in perinatal death (two studies, 264 participants, RR 1.10, 95% CI 0.23-5.29). CONCLUSION: Progesterone is associated with some beneficial effects in pregnancy outcome for some women at increased risk of preterm birth.

Parenting stress and psychosocial health in mothers with twin-twin transfusion syndrome managed with laser surgery: a preliminary study.

Twin-twin transfusion syndrome (TTTS) is a severe complication of twin pregnancies with high risk for perinatal mortality and long-term morbidity. This cross-sectional cohort study aimed to determine parenting stress and psychosocial health in mothers with a pregnancy complicated by TTTS that had been managed with laser ablation of communicating placental vessels. Questionnaires were sent to the mothers for completion: Parenting Stress Index (PSI), Edinburgh Postnatal Depression Scale (EPDS) and a semi-structured questionnaire related to mental health problems and support received from health professionals. Thirty-seven mothers were sent questionnaires with 32 being returned. The results showed that 47% of women had total scores equal to or greater than the 85th percentile on the PSI, which is considered abnormally high. Twenty-six per cent of mothers had evidence of depression on the EPDS. Mothers of children with prolonged medical conditions or neurological problems had significantly higher scores (p =.011). Parenting stress was not associated with high scores on the EPDS. Medical and midwifery staff were considered to provide high levels of support, with social work providing none or low levels of support. In conclusion, women whose TTTS pregnancy was managed by laser surgery have high levels of parenting stress. As the results showed that parenting stress cannot be predicted at the time of hospitalization, it is suggested that more support should be provided in hospital with further follow-up after discharge.

Vasa Previa Diagnosis, Clinical Practice, and Outcomes in Australia.

OBJECTIVE: To estimate the incidence of women with vasa previa in Australia and to describe risk factors, timing of diagnosis, clinical practice, and perinatal outcomes. METHODS: A prospective population-based cohort study was undertaken using the Australasian Maternity Outcomes Surveillance System between May 1, 2013, and April 30, 2014, in hospitals in Australia with greater than 50 births per year. Women were included if they were diagnosed with vasa previa during pregnancy or childbirth, confirmed by clinical examination or placental pathology. The main outcome measures included stillbirth, neonatal death, cesarean delivery, and preterm birth. RESULTS: Sixty-three women had a confirmed diagnosis of vasa previa. The estimated incidence was 2.1 per 10,000 women giving birth (95% CI 1.7-2.7). Fifty-eight women were diagnosed prenatally and all had a cesarean delivery. Fifty-five (95%) of the 58 women had at least one risk factor for vasa previa with velamentous cord insertion (62%) and low-lying placenta (60%) the most prevalent. There were no perinatal deaths in women diagnosed prenatally. For the five women with vasa previa not diagnosed prenatally, there were two perinatal deaths with a case fatality rate of 40%. One woman had an antepartum stillbirth and delivered vaginally and the other four women had cesarean deliveries categorized as urgent threat to the life of a fetus with one neonatal death. The overall perinatal case fatality rate was 3.1% (95% CI 0.8-10.5). Two thirds (68%) of the 65 neonates were preterm and 29% were low birth weight. CONCLUSION: The outcomes for neonates in which vasa previa was not diagnosed prenatally were inferior with higher rates of perinatal morbidity and mortality. Our study shows a high rate of prenatal diagnosis of vasa previa in Australia and associated good outcomes.

Perinatal outcomes with laser surgery for twin-twin transfusion syndrome.

The aim of this tertiary hospital-based cohort study was to determine and compare perinatal outcome and neonatal morbidities of pregnancies with twin-twin transfusion syndrome (TTTS) before and after the introduction of a treatment program with laser ablation of placental communicating vessels. Twenty-seven pregnancies with Stage II-IV TTTS treated with amnioreduction were identified (amnioreduction group). The data were compared with that obtained from the first 31 pregnancies with Stage II-IV TTTS managed with laser ablation of placental communicating vessels (laser group). Comparisons were made for perinatal survival and neonatal morbidities including abnormalities on brain imaging. The median gestation at therapy was similar between the two groups (20 vs. 21 weeks, p = .24), while the median gestation at delivery was significantly greater in the laser treated group (34 vs. 28 weeks, p = .002). The perinatal survival rate was higher in the laser group (77.4% vs. 59.3%, p = .03). Neonatal morbidities including acute respiratory distress, chronic lung disease, requirement for ventilatory assistance, patent ductus arteriosus, hypotension, and oliguric renal failure had a lower incidence in the laser group. On brain imaging, ischemic brain injury was seen in 12% of the amnioreduction group and none of the laser group of infants (p = .01). In conclusion, these findings indicate that perinatal outcomes are improved with less neonatal morbidity for monochorionic pregnancies with severe TTTS treated by laser ablation of communicating placental vessels when compared to treatment by amnioreduction.

Vasa praevia: ultrasound diagnosis at the mid-trimester scan.

Background: Vasa praevia is a condition in which fetal vessels, unsupported by the umbilical cord or placenta, run on the fetal membranes in the lower uterine segment near the cervix. Rupture of these vessels prior to or at the time of delivery is associated with a very high perinatal mortality rate. Antenatal diagnosis of this condition with ultrasound is readily available, alters management and significantly decreases the risk of fetal loss. Materials and methods: We describe our experience of diagnosing vasa praevia at a tertiary referral ultrasound centre. The ultrasound characteristics that led to the diagnosis of vasa praevia and associated risk factors will be discussed. A guide to aid sonographers when performing an obstetric examination to help screen for this condition has been included. Conclusions: Where suspicion of vasa praevia is raised, and cannot be ruled out on transvaginal ultrasound, a third trimester scan is required.

Twin pregnancy with a coexisting hydatiform mole and liveborn infant: complicated by maternal hyperthyroidism and neonatal hypothyroidism.

A twin pregnancy with a coexisting complete hydatiform mole and a healthy fetus is rare. Associated with this condition are potentially serious maternal and fetal complications. We describe a case of a woman, 23/40 pregnant, who was diagnosed with a twin pregnancy complicated by a hydatiform mole, vaginal bleeding, hyperthyroidism and preterm labour at 26/40. Her hyperthyroidism was successfully treated with propylthiouracil. The preterm labour resulted in the livebirth of a healthy male infant. The baby developed biochemical hypothyroidism post-natally. The baby's thyroid function tests were unexpected, revealing a low T4 and a low-normal thyroid stimulating hormone. This is the first case reported in the literature to describe an infant's clinical and biochemical thyroid status after gestational trophoblastic disease complicated by hyperthyroidism.

Progesterone supplementation for preventing preterm birth: a systematic review and meta-analysis.

AIM: The aim of this study is to assess the role of progesterone in preterm birth prevention. METHODS: A MEDLINE search (from 1966 to the present; date of last search January 2005) was performed - using the key words progesterone, pregnancy, preterm birth, preterm labor, and randomized, controlled trial - in order to identify randomized, controlled trials in which progesterone (either intramuscular or vaginal administration) was compared with placebo or no treatment. Data were extracted and a meta-analysis was performed. RESULTS: Seven randomized, controlled trials were identified. Women who received progesterone were statistically significantly less likely to give birth before 37 weeks (seven studies, 1020 women, RR = 0.58, 95% CI = 0.48-0.70), to have an infant with birth weight of < or =2.5 kg (six studies, 872 infants, RR = 0.62, 95% CI = 0.49-0.78), or to have an infant diagnosed with intraventricular hemorrhage (one study, 458 infants, RR = 0.25, 95% CI = 0.08-0.82). CONCLUSIONS: For progesterone supplementation to be advocated for women at the risk of preterm birth, the prolongation of gestation demonstrated in this meta-analysis must translate into improved infant outcomes, including a reduction in mortality. There is currently insufficient information to allow recommendations regarding the optimal dose, route, and timing of administration of progesterone supplementation.

Limb constriction as a complication of intra-uterine vesico-amniotic shunt: fetoscopic release.

Complete fetal bladder outlet obstruction was first diagnosed in a fetus at 13.5 weeks. After sequential vesicocentesis had shown good renal function, a vesico-amniotic shunt was inserted at 17 weeks with a Rodeck catheter. The procedure was successful and amniotic fluid volume re-accumulated to normal levels. A detailed scan at 20 weeks showed that the distal free end of the catheter was wound round the left fetal thigh. As the fetus grew, there was progressive constriction of the fetal thigh by the catheter. By 29 weeks, Doppler blood flow changes to the left leg were apparent. Fetoscopic surgery was performed at 30 weeks to release the constriction. The catheter was divided successfully, but the divided end of the shunt subsequently retracted into the fetal abdomen, producing urinary ascites, bilateral hydroureter and hydronephrosis. The baby was delivered at 31.5 weeks in good condition. Endoscopic resection of anterior and posterior urethral valves was performed at 6 months of age. At 2 years, the child has normal renal function, growth parameters and developmental milestones. Mild indentation of the left thigh was still apparent, although there was no functional impairment.