Showing papers in "Ultrasound in Obstetrics & Gynecology in 2014"

Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review

Abstract: Objective To review systematically the medical literature reporting on the prevalence of a niche at the site of a Cesarean section (CS) scar using various diagnostic methods, on potential risk factors for the development of a niche and on niche-related gynecological symptoms in non-pregnant women. Methods The PubMed and EMBASE databases were searched. All types of clinical study reporting on the prevalence, risk factors and/or symptoms of a niche in non-pregnant women with a history of CS were included, apart from case reports and case series. Results Twenty-one papers were selected for inclusion in the review. A wide range in the prevalence of a niche was found. Using contrast-enhanced sonohysterography in a random population of women with a history of CS, the prevalence was found to vary between 56% and 84%. Nine studies reported on risk factors and each study evaluated different factors, which made it difficult to compare studies. Risk factors could be classified into four categories: those related to closure technique, to development of the lower uterine segment or location of the incision or to wound healing, and miscellaneous factors. Probable risk factors are single-layer myometrium closure, multiple CSs and uterine retroflexion. Six out of eight studies that evaluated niche-related symptoms described an association between the presence of a niche and postmenstrual spotting. Conclusions The reported prevalence of a niche in non-pregnant women varies depending on the method of detection, the criteria used to define a niche and the study population. Potential risk factors can be categorized into four main categories, which may be useful for future research and meta-analyses. The predominant symptom associated with a niche is postmenstrual spotting. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Prenatal identification of invasive placentation using magnetic resonance imaging: systematic review and meta-analysis.

Abstract: Objective To assess systematically the performance of prenatal magnetic resonance imaging (MRI) in diagnos- ing the presence, degree and topography of disorders of invasive placentation and to explore the role of the differ- ent MRI signs in predicting these disorders. The diagnostic accuracy of ultrasound and MRI in the detection of inva- sive placentation was also compared. and 'magnetic resonance imaging'. Only prospective studies reporting a diagnosis of invasive placentation at the time of MRI and retrospective studies in which the radiologist was blinded to the final results were included in the analysis. The MRI signs explored were: uterine bulging, heterogeneous signal intensity, dark intraplacen- tal bands on T2 weighted sequences, focal interruption of the myometrium and tenting of the bladder. Summary estimates of sensitivity, specificity, positive and negative likelihood ratios (LR+, LR-) and diagnostic odds ratio (DOR) were based, depending on the number of studies, upon DerSimonian-Laird random-effect or hierarchical summary receiver-operating characteristics models. Results A total of 18 studies involving 1010 pregnancies at risk for invasive placentation were included. The over- all diagnostic accuracy of MRI in detecting the presence of invasive placentation was: sensitivity, 94.4% (95% CI, 86.0-97.9%); specificity, 84.0% (95% CI, 76.0-89.8%); LR+, 5.91 (95% CI, 3.73-9.39); LR-, 0.07 (95% CI, 0.02-0.18); DOR, 89.0 (95% CI, 22.8-348.1). MRI had

First-trimester uterine artery Doppler and adverse pregnancy outcome: a meta-analysis involving 55,974 women

Abstract: Objectives To determine the accuracy with which uterine artery Doppler in the first trimester of pregnancy predicts pre-eclampsia and fetal growth restriction, particularly early-onset disease. Methods We searched MEDLINE (1951–2012), EMBASE (1980–2012) and the Cochrane Library (2012) for relevant citations without language restrictions. Two reviewers independently selected studies that evaluated the accuracy of first-trimester uterine artery Doppler to predict adverse pregnancy outcome and performed data extraction to construct 2 × 2 tables. We synthesized sensitivity and specificity for various Doppler indices using a bivariate random-effects model. Results From 1866 citations, we identified 18 studies (55 974 women). The sensitivity and specificity of abnormal uterine artery flow velocity waveform (FVW) in the prediction of early-onset pre-eclampsia were 47.8% (95% CI: 39.0–56.8) and 92.1% (95% CI: 88.6–94.6), and in the prediction of early-onset fetal growth restriction were 39.2% (95% CI: 26.3–53.8) and 93.1% (95% CI: 90.6–95.0), respectively. The sensitivities for predicting any pre-eclampsia and fetal growth restriction were 26.4% (95% CI: 22.5–30.8) and 15.4% (95% CI: 12.4–18.9), respectively, and the specificities were 93.4% (95% CI: 90.4–95.5%) and 93.3% (95% CI: 90.9–95.1), respectively. The number needed to treat (NNT) with aspirin to prevent one case of early-onset pre-eclampsia fell from 1000 to 173 and from 2500 to 421 for background risks varying between 1% and 0.4%, respectively. Conclusions First-trimester uterine artery Doppler is a useful tool for predicting early-onset pre-eclampsia, as well as other adverse pregnancy outcomes. Based on the NNT, abnormal uterine artery Doppler in low-risk women achieves a sufficiently high performance to justify aspirin prophylaxis in those who test positive. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Cesarean scar pregnancy is a precursor of morbidly adherent placenta

Abstract: Objective To provide further sonographic, clinical and histological evidence that Cesarean scar pregnancy (CSP) is a precursor to and an early form of second- and third-trimester morbidly adherent placenta (MAP). Methods This is a report of 10 cases of CSP identified early, in which the patients decided to continue the pregnancy, following counseling that emphasized the possibility of both significant pregnancy complications and a need for hysterectomy. Pregnancies were followed at 2–4-week intervals with ultrasound scans and customary monitoring. The aim was for patients to reach near term or term and then undergo elective Cesarean delivery and, if necessary, hysterectomy. Charts, ultrasound images, operative reports and histopathological examinations of the placentae were reviewed. Results The ultrasound diagnosis of CSP was made before 10 weeks. By the second trimester, all patients exhibited sonographic signs of MAP. Nine of the 10 patients delivered liveborn neonates between 32 and 37 weeks. In the tenth pregnancy, progressive shortening of the cervix and intractable vaginal bleeding prompted termination, with hysterectomy, at 20 weeks. Two other patients in the cohort had antepartum complications (bleeding at 33 weeks in one case and contractions at 32 weeks in the other). All patients underwent hysterectomy at the time of Cesarean delivery, with total blood loss ranging from 300 to 6000 mL. Placenta percreta was the histopathological diagnosis in all 10 cases. Conclusion The cases in this series validate the hypothesis that CSP is a precursor of MAP, both sharing the same histopathology. Our findings provide evidence that can be used to counsel patients with CSP, to enable them to make an informed choice between first-trimester termination and continuation of the pregnancy, with its risk of premature delivery and loss of uterus and fertility. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd

Cesarean scar pregnancy and early placenta accreta share common histology

Abstract: Objective To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester. Methods The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined. Results Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93). Conclusions EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

International standards for early fetal size and pregnancy dating based on ultrasound measurement of crown-rump length in the first trimester of pregnancy.

Abstract: Objectives There are no international standards for relating fetal crown‐rump length (CRL) to gestational age (GA), and most existing charts have considerable methodological limitations. The INTERGROWTH-21 st Project aimed to produce the first international standards for early fetal size and ultrasound dating of pregnancy based on CRL measurement. Methods Urban areas in eight geographically diverse countries that met strict eligibility criteria were selected for the prospective, population-based recruitment, between 9 +0 and 13 +6weeks’ gestation, of healthy well-nourished women with singleton pregnancies at low risk of fetal growth impairment. GA was calculated on the basis of a certain last menstrual period, regular menstrual cycle and lack of hormonal medication or breastfeeding in the preceding 2 months. CRL was measured using strict protocols and quality-control measures. All women were followed up throughout pregnancy until delivery and hospital discharge. Cases of neonatal and fetal death, severe pregnancy complications and congenital abnormalities were excluded from the study.

Changes in fetal Doppler indices as a marker of failure to reach growth potential at term.

Abstract: Objective To evaluate whether changes in the middle cerebral artery (MCA), umbilical artery (UA) and cerebroplacental ratio (CPR) Doppler indices at term might be used to identify those appropriate-for-gestational-age (AGA) fetuses that are failing to reach their growth potential (FRGP). Methods This was a retrospective cohort study of data obtained in a single tertiary referral center over a 10-year period from 2002 to 2012. The UA pulsatility index (PI), MCA-PI and CPR were recorded between 37+0 and 41+6 weeks within 14 days before delivery. The Doppler parameters were converted into multiples of the median (MoM), adjusting for gestational age, and their correlation with birth-weight (BW) centiles was evaluated by means of regression analysis. Doppler indices were also grouped according to BW quartiles and compared using Kruskal–Wallis and Dunn's post-hoc tests. Results The study included 11 576 term fetuses, with 8645 (74.7%) classified as AGA. Within the AGA group, fetuses with lower BW had significantly higher UA-PI, lower MCA-PI and lower CPR MoM values. Large-for-gestational-age (LGA) fetuses were considered as the group least likely to be growth-restricted. The CPR MoM < 5th centile (0.6765 MoM) in these fetuses was used as a threshold for diagnosing FRGP. Using this definition, in the AGA pregnancies the percentage of fetuses with FRGP was 1% in the 75–90th BW centile group, 1.7% in the 50–75th centile group, 2.9% in the 25–50th centile group and 6.7% in the 10–25th centile group. Conclusion AGA pregnancies may present with fetal cerebral and placental blood flow redistribution indicative of fetal hypoxemia. Fetal Doppler assessment may be of value in detecting AGA pregnancies that are subject to placental insufficiency, fetal hypoxemia and FRGP. Future studies are needed to evaluate the appropriate threshold for the diagnosis of FRGP and the diagnostic performance of this new approach for the management of growth disorders. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd

Brain abnormalities and neurodevelopmental delay in congenital heart disease: systematic review and meta-analysis.

Abstract: Objectives Studies have demonstrated an association between congenital heart disease (CHD) and neurodevelopmental delay. Neuroimaging studies have also demonstrated a high incidence of preoperative brain abnormalities. The aim of this study was to perform a systematic review to quantify the non-surgical risk of brain abnormalities and of neurodevelopmental delay in infants with CHD. Methods MEDLINE, EMBASE and The Cochrane Library were searched electronically without language restrictions, utilizing combinations of the terms congenital heart, cardiac, neurologic, neurodevelopment, magnetic resonance imaging, ultrasound, neuroimaging, autopsy, preoperative and outcome. Reference lists of relevant articles and reviews were hand-searched for additional reports. Cohort and case–control studies were included. Studies reporting neurodevelopmental outcomes and/or brain lesions on neuroimaging in infants with CHD before heart surgery were included. Cases of chromosomal or genetic abnormalities, case reports and editorials were excluded. Between-study heterogeneity was assessed using the I2 test. Results The search yielded 9129 citations. Full text was retrieved for 119 and the following were included in the review: 13 studies (n = 425 cases) reporting on brain abnormalities either preoperatively or in those who did not undergo congenital cardiac surgery and nine (n = 512 cases) reporting preoperative data on neurodevelopmental assessment. The prevalence of brain lesions on neuroimaging was 34% (95% CI, 24–46; I2 = 0%) in transposition of the great arteries, 49% (95% CI, 25–72; I2 = 65%) in left-sided heart lesions and 46% (95% CI, 40–52; I2 = 18.1%) in mixed/unspecified cardiac lesions, while the prevalence of neurodevelopmental delay was 42% (95% CI, 34–51; I2 = 68.9). Conclusions In the absence of chromosomal or genetic abnormalities, infants with CHD are at increased risk of brain lesions as revealed by neuroimaging and of neurodevelopmental delay. These findings are independent of the surgical risk, but it is unclear whether the time of onset is fetal or postnatal. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Non-invasive prenatal testing for fetal chromosomal abnormalities by low-coverage whole-genome sequencing of maternal plasma DNA: review of 1982 consecutive cases in a single center

Abstract: Objective To review the performance of non-invasive prenatal testing (NIPT) by low-coverage whole-genome sequencing of maternal plasma DNA at a single center. Methods The NIPT result and pregnancy outcome of 1982 consecutive cases were reviewed. NIPT was based on low coverage (0.1×) whole-genome sequencing of maternal plasma DNA. All subjects were contacted for pregnancy and fetal outcome. Results Of the 1982 NIPT tests, a repeat blood sample was required in 23 (1.16%). In one case, a conclusive report could not be issued, probably because of an abnormal vanished twin fetus. NIPT was positive for common trisomies in 29 cases (23 were trisomy 21, four were trisomy 18 and two were trisomy 13); all were confirmed by prenatal karyotyping (specificity = 100%). In addition, 11 cases were positive for sex-chromosomal abnormalities (SCA), and nine cases were positive for other aneuploidies or deletion/duplication. Fourteen of these 20 subjects agreed to undergo further investigations, and the abnormality was found to be of fetal origin in seven, confined placental mosaicism (CPM) in four, of maternal origin in two and not confirmed in one. Overall, 85.7% of the NIPT-suspected SCA were of fetal origin, and 66.7% of the other abnormalities were caused by CPM. Two of the six cases suspected or confirmed to have CPM were complicated by early-onset growth restriction requiring delivery before 34 weeks. Fetal outcome of the NIPT-negative cases was ascertained in 1645 (85.15%). Three chromosomal abnormalities were not detected by NIPT, including one case each of a balanced translocation, unbalanced translocation and triploidy. There were no known false negatives involving the common trisomies (sensitivity = 100%). Conclusions Low-coverage whole-genome sequencing of maternal plasma DNA was highly accurate in detecting common trisomies. It also enabled the detection of other aneuploidies and structural chromosomal abnormalities with high positive predictive value. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd

Additional value of prenatal genomic array testing in fetuses with isolated structural ultrasound abnormalities and a normal karyotype: A systematic review of the literature

Abstract: OBJECTIVE To establish the prevalence of submicroscopic genetic copy number variants (CNVs) in fetuses with a structural ultrasound anomaly (restricted to one anatomical system) and a normal karyotype. The aim was to determine the diagnostic and prognostic value of genomic array testing in these pregnancies. Methods Embase and PubMed databases were systematically searched for all relevant articles on prevalence of pathogenic submicroscopic CNVs in fetuses with ultrasound anomalies. Reported cases were sorted into groups according to anatomical site of the detected ultrasound anomaly. The prevalence of causative submicroscopic CNVs was calculated for each group. Results Combined data of the reviewed studies (n = 18) indicated that fetuses with an ultrasound anomaly restricted to one anatomical system (n = 2220) had a 3.1–7.9% chance of carrying a causative submicroscopic CNV, depending on the anatomical system affected. This chance increased to 9.1% for fetuses with multiple ultrasound anomalies (n = 1139). Conclusion This review indicates that 3.1–7.9% of fetuses with a structural ultrasound anomaly restricted to one anatomical system and a normal karyotype will show a submicroscopic CNV, which explains its phenotype and provides information for fetal prognosis. Therefore, we conclude that microarray has considerable diagnostic and prognostic value in these pregnancies. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Percutaneous minimally invasive fetoscopic surgery for spina bifida aperta. Part I: surgical technique and perioperative outcome.

Abstract: Objectives To analyze the current technical approach of percutaneous minimal-access fetoscopic closure of spina bifida aperta (SBA) and provide an overview of its development in ovine and human fetuses. Methods Minimal-access percutaneous fetoscopic closure of SBA was performed at the German Center for Fetal Surgery & Minimal-access Therapy (DZFT) in 51 human fetuses at 21.0–29.1 weeks of gestation (mean age, 23.7 weeks). Various parameters of surgical relevance for the success and safety of the procedure and the early perioperative outcome were analyzed retrospectively. In addition, information from the early clinical cases was examined to determine how this shaped development of the approach. Results Percutaneous minimal-access fetoscopic closure of SBA was performed with a high rate of technical success, regardless of placental or fetal position. All fetuses survived surgery, but there was one very early preterm delivery 1 week after the procedure and this neonate died immediately, from early postoperative chorioamnionitis. Of the 50 surviving fetuses, 44 (88%) were delivered at or beyond 30 weeks and 25 (50%) at or beyond 34 weeks of gestation. There was one neonatal death from an uinsuspected case of trisomy 13 and two infant deaths from Chiari-II malformation. Conclusions Following an adequate learning curve, minimal-access fetoscopic surgery for fetal spina bifida can be performed with a high rate of technical success, regardless of placental position. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Additional value of fetal magnetic resonance imaging in the prenatal diagnosis of central nervous system anomalies: a systematic review of the literature.

Abstract: Objectives To analyze literature on the additional value of fetal magnetic resonance imaging (MRI) in assessing central nervous system (CNS) anomalies suspected by ultrasound. Methods A search was performed of PubMed, EMBASE, Cochrane library and the reference lists of identified articles. Inclusion criteria were CNS anomalies suspected/diagnosed by ultrasound, MRI performed after ultrasound, and postmortem examination by autopsy or postnatal assessment. MOOSE guidelines were followed. Outcomes assessed were positive/negative agreement between ultrasound and MRI, additional information provided by MRI, and discordance between ultrasound and MRI. Pooled sensitivity and specificity of MRI were calculated using the DerSimonian‐Laird method. Postnatal/postmortemexaminationswereusedasthereference standard. Results We identified thirteen articles which included 710 fetuses undergoing both ultrasound and MRI. MRI confirmed ultrasound-positive findings in 65.4% of fetuses and provided additional information in 22.1%. MRI disclosed CNS anomalies in 18.4% of fetuses. In 2.0% of cases, ultrasound was more accurate than MRI. In 30% of fetuses, MRI was so different from ultrasound that the clinical management changed. Agreement was observed mainly for ventriculomegaly (51.3%). Disagreement was noted mainly for midline anomalies (48.6%). Pooled sensitivity of MRI was 97% (95% CI, 95‐98%) and pooled specificity was 70% (95% CI, 58‐81%). Conclusions MRI supplements the information provided by ultrasound. It should be considered in selected fetuses with CNS anomalies suspected on ultrasound. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Potential diagnostic consequences of applying non-invasive prenatal testing: population-based study from a country with existing first-trimester screening.

Abstract: Objectives Targeted non-invasive prenatal testing (NIPT) tests for trisomies 21, 18 and 13 and sex chromosome aneuploidies and could be an alternative to traditional karyotyping. The aim of this study was to determine the risk of missing other abnormal karyotypes of probable phenotypic significance by NIPT. Methods This was a retrospective population-based analysis of all singleton pregnancies booked for combined first-trimester screening (cFTS) in Denmark over a 4-year period. Data concerning maternal demographics, cFTS and prenatal or postnatal karyotypes were collected from the Danish Fetal Medicine database. Karyotypes were classified according to whether the chromosomal anomaly would have been detected by NIPT and whether it was likely to affect phenotype. Results cFTS was completed in 193638 pregnancies. 10205 (5.3%) had cytogenetic or molecular analysis performed. Of these, 1122 (11.0%) had an abnormal karyotype, of which 262 (23.4%) would have been missed by NIPT, but would probably have been clinically significant. The prevalence of such 'atypical abnormal karyotypes' was increased in women above 45 years of age, in pregnancies with increased nuchal translucency (NT) thickness (≥ 3.5 mm), with abnormal levels of free β-human chorionic gonadotropin ( Conclusions A significant proportion of karyotypic abnormalities will be missed by targeted NIPT. Women of advanced maternal age, or with increased fetal NT or abnormal biochemistry, have a higher risk of having a fetus affected by an atypical abnormal karyotype and need to be counseled accordingly when considering NIPT.

Fetal lung volume and quantification of liver herniation by magnetic resonance imaging in isolated congenital diaphragmatic hernia.

Abstract: Objective To determine associations between fetal lung and liver herniation volumes measured by magnetic resonance imaging (MRI) and mortality/need for extracorporeal membrane oxygenation (ECMO) in cases of isolated congenital diaphragmatic hernia (CDH). A secondary objective was to compare prenatal MRI parameters with two-dimensional ultrasound lung measurements. Methods A retrospective review of medical records of all fetuses with isolated CDH evaluated between January 2004 and July 2012 was performed. The following MRI parameters were measured at 20–32 weeks: observed/expected total fetal lung volume (o/e-TLV), predicted pulmonary volume (PPV), percentage of liver herniated into the fetal thorax (%LH) and the liver/thoracic volume ratio (LiTR). These were compared with the ultrasound-determined lung-to-head ratio (LHR) and the observed/expected LHR (o/e-LHR) in the same cohort. The predictive value of MRI and ultrasound parameters for mortality and the need for ECMO was evaluated by univariate, multivariate and factor analysis and by receiver–operating characteristics curves. Results Eighty fetuses with isolated CDH were evaluated. Overall mortality was 18/80 (22.5%). Two newborns died a few hours after birth. ECMO was performed in 29/78 (37.2%) newborns, with a survival rate of 48.3% (14/29). The side of the diaphragmatic defect was not associated with mortality (P = 0.99) or the need for ECMO (P = 0.48). Good correlation was observed among o/e-TLV, PPV, LHR and o/e-LHR as well as between %LH and LiTR (r = 0.89; P 0.05). All parameters were statistically associated with mortality or the need for ECMO. The best combination of measurements to predict mortality was o/e-TLV and %LH, with 83% accuracy. Conclusion Mortality and the need for ECMO in neonates with isolated CDH can be best predicted using a combination of MRI o/e-TLV and %LH. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

ISUOG consensus statement on the impact of non-invasive prenatal testing (NIPT) on prenatal ultrasound practice

Abstract: The emergence of effective cell-free fetal DNA-based techniques to screen for trisomy 21 and other aneuploidies has greatly expanded the range of prenatal tests available over the last few years. Non-invasive prenatal testing (NIPT) is rapidly being incorporated into prenatal care, thus changing the traditional approach to prenatal screening and diagnosis. However, although NIPT techniques are highly efficient, their role and performance must be considered alongside and combined with other screening modalities. The role of prenatal ultrasound in particular needs to be reassessed as NIPT becomes more widely available. It is important to emphasize that the main goal of prenatal screening is to provide accurate information that will facilitate the delivery of optimized antenatal care, with the best possible outcome for both mother and fetus. Women should be informed about prenatal screening performance by appropriately trained health professionals, allowing them to make an informed decision. It is the parent’s choice to undergo such procedures, and their wishes should be determined and respected. The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) has compiled the following Consensus Statement, which will be updated on a regular basis.

Neurodevelopmental outcome in isolated mild fetal ventriculomegaly: systematic review and meta-analysis.

Abstract: Objectives The finding of fetal ventriculomegaly is variably associated with other fetal abnormalities and, even when isolated, is thought to be linked to abnormal neurodevelopmental outcome. The aim of this study was to undertake a systematic review and meta-analysis of the current literature to assess the prevalence of neurodevelopmental delay in cases of isolated mild fetal ventriculomegaly, as well as the false-negative rate of prenatal imaging for the diagnosis of associated abnormalities in patients referred for isolated mild ventriculomegaly. Methods Studies that assessed neurodevelopmental outcome in isolated ventriculomegaly were identified from a search of scientific databases. Studies that did not check for karyotype or that excluded cases of bilateral ventriculomegaly were not included in the analysis. Ventriculomegaly was defined as mild when the width of the ventricular atrium was between 10 and 15 mm. Cases in which an associated abnormality (abnormal karyotype, structural abnormality or fetal infection) was observed either before or after birth were not considered as part of the isolated group. Neurodevelopmental delay was defined as an abnormal quotient score, according to the test used. Results The search yielded 961 possible citations; of these, 904 were excluded by review of the title or abstract as they did not meet the selection criteria. Full manuscripts were retrieved for 57 studies, and 20 were included in the review with a total of 699 cases of isolated mild ventriculomegaly. The overall prevalence of neurodevelopmental delay was 7.9% (95% CI, 4.7–11.1%). Of the 20 studies included in the systematic review, nine reported data on postnatal imaging, showing a prevalence of previously undiagnosed findings of 7.4% (95% CI, 3.1–11.8%). Conclusions The false-negative rate of prenatal imaging is 7.4% in apparently isolated fetal ventriculomegaly of ≤ 15 mm. The incidence of neurodevelopmental delay in truly isolated ventriculomegaly of ≤ 15 mm is 7.9%. As the latter rate is similar to that noted in the general population, large prospective cohort studies assessing the prevalence of childhood disability, rather than subtle neurodevelopmental delay, are required. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd

Uterine artery Doppler, birth weight and timing of onset of pre-eclampsia: providing insights into the dual etiology of late-onset pre-eclampsia.

Abstract: Objective To investigate the relationship between uterine artery Doppler ultrasound indices and birth weight in women with early-, intermediate- and late-onset pre-eclampsia as compared with women with uneventful pregnancy outcome. Methods In a retrospective, observational cohort study, uterine artery Doppler assessment was carried out at 18 + 0 to 23 + 6 weeks' gestation in 26 893 women attending for routine antenatal care in a tertiary care center. The mean resistance index (RI) and its relationship to the outcome of pregnancy and birth-weight centiles were evaluated. Results Uterine artery RI showed a significant, negative correlation with birth weight (r = −0.20, P < 0.0001). Patients with early-onset pre-eclampsia had an increased prevalence of high uterine artery mean RI, above the 90th centile, corresponding to an increased proportion of small-for-gestational age (SGA) neonates with a birth weight below the 10th centile. In late-onset pre-eclampsia, however, there was an unexpectedly higher proportion of large-for-gestational-age (LGA) neonates with a birth weight above the 90th centile without a concurrent increase in the prevalence of low uterine artery mean RI below the 10th centile. Conclusions The finding of a bimodal skewed distribution of birth weight, with neonates exhibiting a higher prevalence of both LGA and SGA with late-onset pre-eclampsia, indicates that there are two types of late-onset pre-eclampsia. These findings explain the poor performance of mid-trimester uterine artery Doppler in predicting pre-eclampsia at term and provide insights into the placental origins of the early and late forms of pre-eclampsia. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd

Percutaneous minimal-access fetoscopic surgery for spina bifida aperta. Part II: maternal management and outcome.

Abstract: Objective To assess maternal morbidity and outcome in women undergoing minimal-access fetoscopic surgery for spina bifida aperta. Methods This was a retrospective study of 51 women undergoing minimal-access fetoscopic surgery to improve postnatal neurological outcome of spina bifida aperta, at a mean gestational age of 24 weeks, at our center between July 2010 and June 2013. We analyzed various perioperative complications of surgery, namely: maternal and fetal death, need for maternal blood transfusion, placental abruption, pulmonary edema, spontaneous labor, oligohydramnios, chorioamnionitis, chorioamniotic membrane separation, duration of hospitalization, amniotic fluid leakage, gestational age at delivery and status of hysterotomy site. Results In none of the 51 women was there maternal demise, spontaneous labor, placental abruption or a need for maternal blood transfusion in the perioperative period. Chorioamniotic membrane separation occurred in one patient, mild pulmonary edema occurred in one and oligohydramnios occurred in seven. All fetuses survived surgery, but there was one very early preterm delivery 1 week after the procedure and this neonate died immediately, from early postoperative chorioamnionitis. Amniotic fluid leakage occurred in 43 patients, at a mean gestational age of 29.7 (range, 22.6–37.3) weeks; two of these patients developed chorioamnionitis. Duration of maternal hospitalization after surgery was 7.2 (range, 4–12) days. Mean gestational age at delivery was 33 (range, 24.6–38.1) weeks. All abdominal and uterine trocar insertion sites healed well. Conclusion Minimal-access fetoscopic surgery for spina bifida aperta is apparently safe for most maternal patients. Despite the common occurrence of amniotic leakage, the majority of women deliver beyond 32 weeks of gestation. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis.

Abstract: Objective To evaluate whether the presence or severity of endometriosis affects the outcome of assisted reproductive techniques (ART). Methods In this systematic review, all studies comparing the outcome of ART in women with and those without endometriosis, or at different stages of the disease, were considered eligible. We used either risk ratio (RR) or mean difference (MD) and their 95% CIs for comparisons. The primary outcome was live birth; the secondary outcome was clinical pregnancy. Miscarriage and the number of oocytes retrieved were examined as additional outcomes. Results We included 92 studies in the review and 78 in the meta-analysis: 20 167 women with endometriosis were compared with 121 931 women without endometriosis, and 1703 women with Stage-III/IV endometriosis were compared with 2227 women with Stage-I/II endometriosis. The following results were observed for the comparison of women with endometriosis vs women without endometriosis: live birth, RR = 0.99 (95% CI, 0.92–1.06); clinical pregnancy, RR = 0.95 (95% CI, 0.89–1.02); miscarriage, RR = 1.31 (95% CI, 1.07–1.59); number of oocytes retrieved, MD = –1.56 (95% CI, –2.05 to –1.08). The following results were observed for the comparison of women with Stage-III/IV vs Stage-I/II endometriosis: live birth, RR = 0.94 (95% CI, 0.80–1.11); clinical pregnancy, RR = 0.90 (95% CI, 0.82–1.00); miscarriage, RR = 0.99 (95% CI, 0.73–1.36); number of oocytes retrieved, MD = –1.03 (95% CI, –1.67 to –0.39). Conclusions Women with endometriosis undergoing ART have practically the same chance of achieving clinical pregnancy and live birth as do women with other causes of infertility. No relevant difference was observed in the chance of achieving clinical pregnancy and live birth following ART when comparing Stage-III/IV with Stage-I/II endometriosis. The quality of the evidence for the additional examined outcomes was very low, not allowing meaningful conclusions to be drawn. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd

Use of IOTA simple rules for diagnosis of ovarian cancer: meta-analysis

Abstract: Objectives To present data on prospective evaluation of the International Ovarian Tumor Analysis (IOTA) ‘simple-rules’ tool for the diagnosis of ovarian cancer and to perform a meta-analysis of studies that utilized the same diagnostic method. Methods In the present study a level-II ultrasound operator systematically assessed the tumors of women with an ultrasound diagnosis of adnexal tumor(s) according to the IOTA simple-rules protocol to determine the risk of the tumor being malignant. The results of simple rules were compared with the ‘pattern recognition’ method and with histological findings. This validation study was included in the subsequent meta-analysis, for which we searched MEDLINE, EMBASE and Cochrane from the publication of the first study in 2008. The terms used were ‘simple rules’, ‘simple rules ovarian’, ‘ovar tumor’ and ‘ultrasound’. Quality assessment was performed using the modified Quality Assessment of the Diagnostic Accuracy of Studies (QUADAS-2) checklist. Random effects meta-analysis was used to calculate pooled estimates of sensitivity and specificity for the simple-rules tool, and meta-regression was used to investigate heterogeneity across the studies. Results Three hundred and three women were included in the validation study with 168 (55.4%) benign, 19 (6.3%) borderline and 116 (38.3%) malignant tumors on histological examination. The rules were applicable in 237 (78.2%) of the tumors and for these tumors, sensitivity was 96.2% (95% CI, 90.5–99.0%) and specificity was 88.6% (95% CI, 82.0–93.5%). Six of the 88 discovered studies were included in the meta-analysis along with the current validation study, which resulted in inclusion of a total of 3568 patients. When the meta-analysis was performed the pooled sensitivity (when the rules were applicable) was 93% (95% CI, 90–96%) (I2 = 32.1%) and the pooled specificity was 95% (95% CI, 93–97%) (I2 = 78.1%). Heterogeneity was observed across the studies. Sensitivity was higher and specificity lower in the study populations in which the prevalence of malignant tumors was greatest. Conclusion The simple rules protocol could be used in 76–89% of tumors and is an accurate test for the diagnosis of ovarian cancer. Assessment by an ultrasound expert is required when the protocol cannot be applied. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Estimation of shear wave speed in the human uterine cervix

Abstract: Objectives To explore spatial variability within the cervix and the sensitivity of shear wave speed (SWS) to assess softness/stiffness differences in ripened (softened) vs unripened tissue. Methods We obtained SWS estimates from hysterectomy specimens (n = 22), a subset of which were ripened (n = 13). Multiple measurements were made longitudinally along the cervical canal on both the anterior and posterior sides of the cervix. Statistical tests of differences in the proximal vs distal, anterior vs posterior and ripened vs unripened cervix were performed with individual two-sample t-tests and a linear mixed model. Results Estimates of SWS increase monotonically from distal to proximal longitudinally along the cervix, they vary in the anterior compared to the posterior cervix and they are significantly different in ripened vs unripened cervical tissue. Specifically, the mid position SWS estimates for the unripened group were 3.45 ± 0.95 m/s (anterior; mean ± SD) and 3.56 ± 0.92 m/s (posterior), and 2.11 ± 0.45 m/s (anterior) and 2.68 ± 0.57 m/s (posterior) for the ripened group (P < 0.001). Conclusions We propose that SWS estimation may be a valuable research and, ultimately, diagnostic tool for objective quantification of cervical stiffness/softness. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Comparison of ultrasound and magnetic resonance imaging parameters in predicting survival in isolated left-sided congenital diaphragmatic hernia.

Abstract: Objective To compare test characteristics of ultrasound- and magnetic resonance imaging (MRI)-derived parameters in predicting newborn survival in cases of isolated left-sided congenital diaphragmatic hernia (CDH). Methods This was a retrospective study involving 85 fetuses with an isolated left CDH. All had detailed prenatal evaluation, prenatal care, delivery and postnatal care at a single institution. Ultrasound images were reviewed to allow calculation of the lung-to-head ratio (LHR) and the observed/expected LHR (O/E-LHR), and MRI images were reviewed to determine the observed/expected total lung volume (O/E-TLV) and the percent herniated liver (%HL). Univariable logistic regression was used to evaluate each parameter for its ability to predict survival. Receiver–operating characteristics (ROC) curves were constructed and test characteristics were determined for each parameter as a predictor of survival. Results The overall survival for all fetuses included was 65%. Pseudo-R2 values for all parameters were similar and were statistically significant as predictors of survival, with %HL having the highest pseudo-R2, of 0.28. ROC curve analysis showed ultrasound-determined parameters (LHR and O/E-LHR) to have a similar area under the curve (AUC), of 0.70, whilst MRI parameters (O/E-TLV and %HL) had AUC values of 0.82 and 0.84, respectively. At ROC-curve-determined cut-off values, MRI parameters had better test characteristics than did ultrasound parameters. At a standardized 5% false-positive rate, %HL performed best, with a sensitivity of 0.54 and a specificity of 0.95. At clinically employed cut-off values, sensitivity was similar for all parameters but MRI parameters provided the best combination of sensitivity and specificity, as evidenced by better likelihood ratios. Conclusions A variety of measures have been proposed as antenatal predictors of survival in CDH. Ultrasound parameters function at a similar level, whereas MRI-determined parameters appear to offer better predictive value. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Sonographic prediction of vaginal delivery in prolonged labor: a two-center study

Abstract: Objective To investigate whether head-perineum distance (HPD) measured by transperineal ultrasound is predictive of vaginal delivery and time remaining in labor in nulliparous women with prolonged first stage of labor and to compare the predictive value with that of angle of progression (AoP). Methods This was a prospective observational study at Stavanger University Hospital, Norway and Addenbrooke's Hospital, Cambridge, UK from January 2012 to April 2013, of nulliparous women with singleton pregnancies with cephalic presentation at term with prolonged first stage of labor. We used transperineal ultrasound to measure HPD (shortest distance between the outer bony limit of the fetal skull and the perineum) and AoP (angle between a line through the long axis of the symphysis and the tangent to the fetal head) and transabdominal ultrasound to classify fetal head position. The main outcomes were vaginal delivery and time remaining in labor. Results Of 150 women enrolled, 39 underwent delivery by Cesarean section. The area under the receiver-operating characteristics curve for the prediction of vaginal delivery was 81% (95% CI, 73-89%) using HPD as the test variable and 72% (95% CI, 63-82%) using AoP. HPD was 40 mm in the other 66 (44%) women, of whom 34 (52%; 95% CI, 40-63%) delivered vaginally. AoP was >= 110 degrees in 84 of the 145 (58%) in whom this was available and, of these, 74 (88%; 95% CI, 79-93%) delivered vaginally. AoP was = 110 degrees (OR, 3.11; 95% CI, 1.01-9.56), non-occiput posterior position (OR, 3.36; 95% CI, 1.24-9.12) and spontaneous onset of labor (OR, 4.44; 95% CI, 1.42-13.89) were independent predictors for vaginal delivery. Both ultrasound methods were predictive for the time remaining in labor. Conclusion Transperineal ultrasound measurement of HPD and AoP provide important information about the likelihood of vaginal delivery and the time remaining in labor in nulliparous women with prolonged labor. Copyright (C) 2013 ISUOG. Published by John Wiley & Sons Ltd. (Less)

First-trimester prediction of pre-eclampsia: external validity of algorithms in a prospectively enrolled cohort

Abstract: Objective To evaluate the performance of published first-trimester prediction algorithms for pre-eclampsia (PE) in a prospectively enrolled cohort of women. Method A MEDLINE search identified first-trimester screening-prediction algorithms for early-onset (requiring delivery < 34 weeks) and late-onset (requiring delivery ≥ 34 weeks) PE. Maternal variables, ultrasound parameters and biomarkers were determined prospectively in singleton pregnancies enrolled between 9 and 14 weeks. Prediction algorithms were applied to this population to calculate predicted probabilities for PE. The performance of the prediction algorithms was compared with that in the original publication and evaluated for factors explaining differences in prediction. Results Six early and two late PE prediction algorithms were applicable to 871–2962 women, depending on the variables required. The prevalence of early PE was 1.0–1.2% and of late PE was 4.1–5.0% in these patient subsets. One early PE prediction algorithm performed better than in the original publication (80% detection rate (DR) of early PE for 10% false-positive rate (FPR)); the remaining five prediction algorithms underperformed (29–53% DR). Prediction algorithms for late PE also underperformed (18–31% DR, 10% FPR). Applying the screening cut-offs based on the highest Youden index probability scores correctly detected 40–80% of women developing early PE and 71–82% who developed late PE. Exclusion of patients on first-trimester aspirin resulted in DRs of 40–83% and 65–82% for early and late PE, respectively. Conclusion First-trimester prediction algorithms for PE share a high negative predictive value if applied to an external population but underperform in their ability to correctly identify women who develop PE. Further research is required to determine the factors responsible for the suboptimal external validity. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd

Assessment of performance measures and learning curves for use of a virtual-reality ultrasound simulator in transvaginal ultrasound examination.

Abstract: Objective To assess the validity and reliability of performance measures, develop credible performance standards and explore learning curves for a virtual-reality simulator designed for transvaginal gynecological ultrasound examination. Methods A group of 16 ultrasound novices, along with a group of 12 obstetrics/gynecology (Ob/Gyn) consultants, were included in this experimental study. The first two performances of the two groups on seven selected modules on a high-fidelity ultrasound simulator were used to identify valid and reliable metrics. Performance standards were determined and novices were instructed to continue practicing until they attained the performance level of an expert subgroup (n = 4). Results All 28 participants completed the selected modules twice and all novices reached the expert performance level. Of 153 metrics, 48 were able to be used to discriminate between the two groups' performance. The ultrasound novices scored a median of 43.8% (range, 17.9–68.9%) and the Ob/Gyn consultants scored a median of 82.8% (range, 60.4–91.7%) of the maximum sum score (P < 0.001). The ultrasound novices reached the expert level (88.4%) within a median of five iterations (range, 5–6), corresponding to an average of 219 min (range, 150–251 min) of training. The test/retest reliability was high, with an intraclass correlation coefficient of 0.93. Conclusions Competence in the performance of gynecological ultrasound examination can be assessed in a valid and reliable way using virtual-reality simulation. The novices' performance improved with practice and their learning curves plateaued at the level of expert performance, following between 3 and 4 h of simulator training. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Successful induction of labor: prediction by preinduction cervical length, angle of progression and cervical elastography

Abstract: Objective To examine the potential value of preinduction cervical length, cervical elastography and angle of progression (AOP) in prediction of successful vaginal delivery and induction-to-delivery interval. Methods This was a prospective study in 99 women with singleton pregnancy undergoing preinduction ultrasound assessment at 35–42 weeks' gestation. Cervical length, elastographic score at the internal os and AOP were determined. Regression analysis was used to assess the relationship between cervical length and both AOP and elastographic score. Logistic regression analysis was used to determine which of the maternal characteristics (cervical length, AOP, elastographic score) were significant predictors of vaginal delivery and induction-to-delivery interval. Results Vaginal delivery occurred in 66 (66.7%) cases and Cesarean delivery was performed in 33 (33.3%) cases. There were significant correlations between cervical length and both AOP (r = − 0.319) and elastographic score (r = 0.368). Significant independent prediction of vaginal delivery and induction-to-delivery interval was provided by nulliparity and cervical length, with no additional significant contribution from electrographic score or AOP. Conclusions In women undergoing induction of labor, AOP and elastographic score at the internal os are unlikely to be useful in prediction of vaginal delivery and induction-to-delivery interval. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Association of Doppler parameters with placental signs of underperfusion in late‐onset small‐for‐gestational‐age pregnancies

Abstract: Objective To elucidate the association between Doppler parameters and histological signs of placental underperfusion in late-onset small-for-gestational-age (SGA) babies. Methods Umbilical, fetal middle cerebral and uterine artery pulsatility indices and umbilical vein blood flow (UVBF), which had been recorded within 7 days prior to delivery, were analyzed from a cohort of SGA singleton pregnancies delivered after 34 weeks' gestation and confirmed as having a birth weight < 10th percentile by local standards. In each case, the placenta was histologically evaluated for signs of placental underperfusion using a hierarchical and standardized classification system. The independent association of the Doppler parameters with placental underperfusion was evaluated using logistic regression and decision tree analysis. Results In 51 cases (53.7%), there were 61 placental histological findings indicative of placental underperfusion. These cases had a significantly higher incidence of Cesarean section for non-reassuring fetal status (52.1% vs 11.9%; P 82 mL/min/kg (risk 31.3%), normalized UVBF ≤ 82 mL/min/kg and mean UtA-PI ≤ 95th percentile (risk 65.5%), and normalized UVBF ≤ 82 mL/min/kg and UtA-PI > 95th percentile (risk 94.4%). Conclusions In late-onset SGA pregnancies, uterine Doppler and UVBF are surrogates for placental underperfusion. These findings facilitate phenotypic profiling of cases of fetal growth restriction among the general population of late-onset SGA babies. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd

Accuracy of neurosonography and MRI in clinical management of fetuses referred with central nervous system abnormalities.

Abstract: Objective To assess the accuracy of expert neurosonography (two- and three-dimensional NSG) in the characterization of major fetal central nervous system (CNS) anomalies seen at a tertiary referral center and to report the differential clinical usefulness of magnetic resonance imaging (MRI) used as a second-line diagnostic procedure in the same cohort. Methods This was a retrospective analysis of all 773 fetuses with confirmed CNS abnormalities referred to our center between 2005 and 2012. The following variables were analyzed: gestational age at NSG and MRI, NSG and MRI diagnoses, indication for MRI (confirmation of NSG findings; diagnostic doubt; search for possible additional brain anomalies), association with other malformations, diagnostic accuracy of NSG vs MRI (no additional clinical value for either MRI or NSG; additional information with clinical/prognostic significance on MRI relative to NSG; additional information with clinical/prognostic significance on NSG relative to MRI, NSG and MRI concordant but incorrect) and final diagnosis, which was made at autopsy or postnatal MRI/surgery. Results CNS malformations were associated with other anomalies in 372/773 (48.1%) cases and were isolated in the remaining 401 (51.9%) cases. NSG alone was able to establish the diagnosis in 647/773 (83.7%) cases. MRI was performed in 126 (16.3%) cases. The indication for MRI was: confirmation of NSG diagnosis in 59 (46.8%) cases; diagnostic query (in the case of inconclusive or uncertain finding on NSG) in 20 (15.9%) cases; search for possible additional brain anomalies in 47 (37.3%) cases. NSG and MRI were concordant and correct in 109/126 (86.5%) cases. Clinically relevant findings were evident on MRI alone in 10/126 (7.9%) cases (1.3% of the whole population) and on NSG alone in 6/126 (4.8%) cases; in all six of these cases, MRI had been performed at < 24 weeks of gestation. In one case, both NSG and MRI diagnoses were incorrect. The main type of malformation in which MRI played an important diagnostic role was space-occupying lesions, MRI identifying clinically relevant findings in 42.9% (3/7) of these cases. Conclusions (1) In a tertiary referral center with good NSG expertise in the assessment of fetal CNS malformations, MRI is likely to be of help in a limited proportion of cases; (2) MRI is more useful after 24 weeks of gestation; (3) the lesions whose diagnosis is most likely to benefit from MRI are gross space-occupying lesions. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd

Real‐time elastography for assessment of uterine disorders

Abstract: Objectives Sonoelastography is an ultrasound-imaging technique that measures tissue strain. The aim of this study was to define, in a systematic manner, specific sonoelastographic characteristics of the myometrium, fibroids and adenomyosis, to evaluate the feasibility of sonoelastography in patients with suspected gynecological pathology and to compare the results with histology and/or magnetic resonance imaging (MRI)-based diagnoses. Methods We performed a prospective observational cohort study between 2009 and 2011. Two-hundred and eighteen women with suspected gynecological pathology underwent routine transvaginal ultrasound and additional real-time sonographic elastography. Sixty-nine of the 218 women underwent MRI and/or histological examination and were included in the final analysis. Acquisition of elastographic images was standardized. We analyzed the elastographic characteristics of myometrium, fibroids and adenomyosis. An independent observer, unaware of clinical, histological or MRI findings, evaluated the recorded elastographic images and cineloops. These elastographic-based diagnoses were compared with histology and/or MRI diagnoses. Results With elastography, the uterus was well delineated from the surrounding bowel. The myometrium was uniform in color in 49% of the cases, with a main color of purple or dark blue, indicating stiffer tissue. Fibroids and adenomyosis had different elastographic characteristics and different color patterns. In general, fibroids were darker and adenomyosis was brighter than adjacent myometrium. The agreement between elastography-based diagnosis of fibroids and adenomyosis with MRI-based diagnosis was excellent; with histology-based diagnosis, agreement was substantial for fibroids and adenomyosis. Conclusions Elastography is able to identify clear discriminating characteristics of the uterus, fibroids and adenomyosis, and elastography-based diagnoses are in excellent agreement with those of MRI. Agreement between elastography-based diagnosis of adenomyosis and histology is substantial but not optimal. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Minimally invasive therapy for fetal sacrococcygeal teratoma: case series and systematic review of the literature

Abstract: Objective Large solid sacrococcygeal teratomas (SCT) can cause high-output cardiac failure and fetal or neonatal death. The aim of this study was to describe the outcomes of minimally invasive antenatal procedures for the treatment of fetal SCT. Methods A case review was performed of five fetuses with a large SCT treated antenatally using minimally invasive techniques, and a systematic literature review on fetal therapy for solid SCTs was carried out. Results Five women were referred between 17 + 5 and 26 + 4 weeks' gestation for a large fetal SCT with evidence of fetal cardiac failure. Vascular flow to the tumors was interrupted by fetoscopic laser ablation (n = 1), radiofrequency ablation (RFA; n = 2) or interstitial laser ablation ± vascular coiling (n = 2). There were two intrauterine fetal deaths. The other three cases resulted in preterm labor within 10 days of surgery. One neonate died. Two survived without procedure-related complications but had long-term morbidity related to prematurity. The systematic literature review revealed 16 SCTs treated minimally invasively for (early) hydrops. Including our cases, six of 20 hydropic fetuses survived after minimally invasive therapy (30%). Survival after RFA or interstitial laser ablation was 45% (5/11). Of 12 fetuses treated for SCT without obvious hydrops and for which perinatal survival data were available, eight (67%) survived. Mean gestational age at delivery after minimally invasive therapy was 29.7 ± 4.0 weeks. Survival after open fetal surgery in hydropic fetuses was 6/11 (55%), with a mean gestational age at delivery of 29.8 ± 2.9 weeks. Conclusions Fetal therapy can potentially improve perinatal outcomes for hydropic fetuses with a solid SCT, but is often complicated by intrauterine death and preterm birth. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.