Fetal monolateral urinoma and neonatal renal function outcome in posterior urethral valves obstruction: the pop-off mechanism.

The "fetal urinoma" is a clinical and diagnostic entity due to urinary extravasation, early diagnosed in fetal and/or neonatal period. Both urinoma and urinary ascites, whose pathogenesis is not clear, are recognized associations of uterero-pelvic junction obstruction (UPJO) and neonatal posterior urethral valves (PUV) related with a protected fetal and neonatal renal function. Clinical and experimental studies have demonstrated that fetal urinary tract obstruction results in severe renal parenchymal injury. The so called "pop-off" valve mechanism has been advocated to justify the upper tract function preservation. Protective "pop-off" mechanisms, such as a unilateral reflux and dysplasia, urinary extravasation and congenital bladder diverticula are present in about 30% of patients with PUV. Their presence correlates with better overall long-term renal function. This mechanism has been justified as a sort of self derivation, to explain the renal function preservation in fetal and neonatal period. In the last two years we observed three cases of fetal monolateral urinoma, prenatally detected in fetuses with diagnosis of PUV. All three cases did well for that concerning renal function despite some current opinions suggesting the necessity of a bilateral urinary extravasation in order to preserve upper urinary tract function.

Cystic anomalies of biliary tree in the fetus: is it possible to make a more specific prenatal diagnosis?

BACKGROUND/PURPOSE: Biliary tree cystic malformations (BCM) occur rarely. Current progress in ultrasonography makes it possible to identify them prenatally. The aim of this study was to analyze retrospectively prenatal ultrasound patterns of 5 consecutive subhepatic cysts in an effort to differentiate the BCM before birth and onset of symptoms. METHODS: The prenatal ultrasound patterns of 5 consecutive BCM were correlated with the postnatal diagnosis. RESULTS: Case 1 showed a hyperechogenic cyst that underwent enlargement during fetal life; the diagnosis at birth was an obstructed choledochal cyst (CC). In cases 2 and 3, an anechoic cyst with small, stable dimensions during pregnancy was identified; a biliary atresia (BA) type III-C was confirmed at birth. A slightly hyperechogenic cyst with no increase in size at repeated prenatal scans, was observed in cases 4 and 5; a CC and a cystic lesion at the confluence of the hepatic ducts (without obstruction) were diagnosed postnatally, respectively. CONCLUSIONS: The ultrasound scan pattern and size allow to make a prenatal differential diagnosis of BCM. Anechoic, small cyst in the hepatic hilum is highly suspicious for BA. Large, echoic or enlarging cyst is strongly suggestive of "obstructed" CC. Echoic, small and stable cyst is more suggestive of "unobstructed" CC.

Multidisciplinary management of fetal surgical anomalies: the impact on maternal anxiety.

AIM: To assess the impact on maternal anxiety of a multidisciplinary approach in prenatal management of fetal surgical anomalies. DESIGN: A case-control study was undertaken: Group A (cases) consisted of 16 couples receiving a prenatal multidisciplinary counselling, Group B (controls) was represented by 16 couples, who received diagnosis of the fetal anomaly and the relevant counselling by an obstetrician only. The fetuses were affected by the following gastrointestinal anomalies: gastroschisis, omphalocele, intestinal atresia. METHODS: The Italian version of the Spielberger State-Trait Anxiety Inventory was utilized to assess maternal anxiety. In Group A maternal anxiety level was assessed after the first antenatal counselling and at birth, whereas in Group B only at birth. RESULTS: At birth, Group A presented STAI-S scores significantly lower than after the first antenatal consultation with the team (Mean +/- SD = 39.87 +/- 6.46 versus 68.93 +/- 5.81; p < 0.01). At the end of the first day spent with the baby in the Neonatal Surgery Unit, Group A presented STAI-S scores significantly lower than Group B (Mean +/- SD = 39.87 +/- 6.46 versus 70.62 +/- 4.12; p < 0.01). CONCLUSIONS: This study provides evidence of the positive impact on maternal anxiety of a multidisciplinary approach in prenatal management of fetal surgical anomalies.

Prenatal measurement of testicular diameter by ultrasonography: development of fetal male gender and evaluation of testicular descent.

Prenatal ultrasonography has evolved through advancements in imaging technology and observer experience. The purpose of the present study was to evaluate fetal testicular descent and diameter in relation to gestational age. A prospective cross-sectional study on 331 fetuses from an unselected population underwent a detailed assessment of testicular descent and diameter at 20-40 weeks' gestation by means of transabdominal sonography (91.2%) and transvaginal sonography (8.8%) when necessary. Fetal gender was identified in the transverse and sagittal planes and maximum testicular diameter was measured. The mean testicular diameter (in millimeters) per week and the 95% confidence interval (CI) were defined. Testicular descent was not observed prior to 23 weeks' gestation, with 6.6% of the fetuses having one testis descended at 23 weeks and 98.2% after 32 weeks. A linear relationship between testicular diameter and gestational age was observed. The present results chart the time course for testicular descent and provide a centile chart for fetal testicular diameter from 25 to 40 weeks' gestation. These findings may aid prenatal diagnosis of associated abnormal conditions as well as investigations into the clinical finding of abnormal testicular size.

Prenatal diagnosis of a bronchogenic cyst in an unusual site.

We report a rare case of a subdiaphragmatic cyst, diagnosed prenatally during routine ultrasound screening at 25 weeks' gestation. Serial ultrasonographic evaluation demonstrated a slight increase in the size of the cyst during pregnancy. On the basis of the anatomic site and the sonographic features of the lesion, four diagnostic hypotheses were postulated: cystic neuroblastoma, adrenal hemorrhage, duplication of the inferior third of the esophagus and retroperitoneal cystic lymphangioma. A healthy baby, weighing 3300 g and with Apgar scores of 8 and 9, was delivered vaginally at term. He underwent successful surgery at the age of 3 months. The post-operative course was uneventful and the baby is currently doing well. Histology revealed a bronchogenic cyst.

Cystic adenomatoid malformation of the lung: clinical evolution and management.

UNLABELLED: Cystic adenomatoid malformation of the lung (CAML) is a rare pulmonary maldevelopment resulting from an abnormal growth of the terminal bronchial structures. This study proposes a possible management of prenatally diagnosed CAML. A group of nine cases of CAML diagnosed prenatally between January 1990 and December 1995 was studied retrospectively. The evolution of lesions was followed in utero by serial ultrasound monitoring. Chest X-ray was performed at birth in all neonates and CT only in the symptomatic ones. CAML was macrocystic in three cases and microcystic in six. No polyhydramnios, hydrops or associated malformations were seen. In four cases, CAML was confirmed at birth and required surgery. The lesion decreased in size prenatally in five fetuses, of whom only one underwent surgery. In two further cases a prenatal diagnosis of CAML was changed to diaphragmatic hernia. CONCLUSION: Given the possible clinical disappearance or resolution of cystic adenomatoid malformation of the lung, we believe that surgery is justified at birth only in symptomatic and radiologically positive neonates. It could be safely delayed in those asymptomatic patients with either positive or negative chest X-ray. The former need computed tomography at birth, whereas, in the latter, it should be performed at 6 months of age for a more definitive assessment of the patient.

Persistent cloaca: are we ready for a correct prenatal diagnosis?

Cloacal malformations are rare and can present in variable aspects. The importance of ultrasound in detecting these anomalies is well known. Sonographic features vary in accordance with the type of malformation and the gestational age. A positive diagnosis is not possible because of the lack of specific ultrasound findings, which can show similar aspects to other abnormalities. We present 3 cases of prenatal diagnosis of this malformation, emphasizing that in the presence of a plurilobed cystic pelvic fetal mass with associated malformations, such as cardiac, renal, and vertebral anomalies, a persistent cloaca can reasonably be suspected.

Transplacental amniocentesis: is it really a higher-risk procedure?

The aim of this study was to compare transplacental with non-transplacental amniocentesis in terms of related complications. Between January 1991 and December 1992, 4564 genetic amniocenteses were performed in 4527 patients (4491 singleton, 35 twin, and one triplet pregnancy) at 15-16 weeks of gestation. All the procedures were ultrasound-guided and performed by the same operator. In 1487 cases, an anterior placenta was traversed with the needle, whereas in 3077 cases, the needle was inserted directly into the amniotic cavity without traversing the placenta. After the exclusion of patients in whom amniotic cell culture failed or in whom an abnormal karyotype was obtained, and of patients lost to follow-up, a total of 4454 patients (98 per cent) were followed for 30 days after amniocentesis. Two spontaneous abortions occurred after a transplacental procedure, and five after a nontransplacental procedure (P = not significant). There were no episodes of amniotic fluid leakage in the first group, whereas 16 ruptures of the membranes that resolved spontaneously occurred in the second group (P < 0.01). Our data suggest that transplacental amniocentesis carries a similar abortive risk to and a lower risk of transient rupture of the membranes than non-transplacental amniocentesis and may therefore be preferred at the gestational period examined (15-16 weeks). However, the risk of feto-maternal haemorrhage, which is reported to be higher for a transplacental procedure, must be considered in the case of an anterior placenta.

Antenatal ultrasonographic diagnosis and management of fetal ovarian cysts.

OBJECTIVES: The aim of the present study was to evaluate the outcome of fetal ovarian cysts in relation to their ultrasonic appearance and size. METHODS: Forty-two fetal ovarian cysts were diagnosed in 41 fetuses and followed with serial ultrasonograms in utero and after birth until spontaneous or surgical resolution. RESULTS: Twelve fetal ovarian cysts that were echogenic at diagnosis and six that were anechoic at diagnosis but became echogenic at subsequent prenatal sonograms were all submitted to postnatal surgery. Of the remaining 24 cysts, all anechoic, four were successfully aspirated in utero, 11 resolved spontaneously after birth, and nine underwent postnatal surgery for complication. The outcome of cysts that were anechoic at diagnosis was significantly correlated with size (P = 0.01). CONCLUSIONS: Echogenic fetal ovarian cysts should be always surgically removed. The outcome of anechoic cysts depends on the size at diagnosis, and serial ultrasonographic assessment is recommended; although not randomized, the present series suggests that in utero aspiration of cysts > 5 cm may prevent complication and subsequent oophorectomy.

Prenatal diagnosis and clinical outcome of ovarian cysts.

Technical refinements of ultrasound (US) have greatly affected the antenatal diagnosis and treatment of ovarian cysts. From 1985 to 1990 25 consecutive fetuses with ovarian cysts were followed-up by US both during pregnancy and postnatally. All cases were diagnosed between the 28th and 39th weeks of gestation. Deliveries were all at term; cesarean section was required only for obstetric complications. Eight fetuses (32%) showed US patterns of cyst torsion, a finding confirmed at surgery in all. In five patients US patterns suggested complications postnatally that were also confirmed at operation. In six cases cysts increased or remained unchanged in size after 15 days of life: in 50% of these surgery showed ovarian torsion. In the remaining six cases spontaneous resolution occurred within 1 to 4 months. One patient required intrauterine needle aspiration. There were two cases of intestinal obstruction. To date, more than 60% of newborns with ovarian cysts require oophorectomy; however, different treatments (cystectomy, needle aspiration, uncapping) combined with a close US follow-up are likely to reduce this percentage.

Incidence of genital tuberculosis in infertile patients submitted to diagnostic laparoscopy: recent experience in an Italian university hospital.

The incidence of genital tuberculosis is decreasing in industrialized countries. The authors report their experience in 254 patients with primary or secondary infertility. Out of 101 patients with a tubal factor of infertility, two patients were diagnosed as having tuberculosis by both endometrial biopsy and endometrial culture. In a third patient, even in the presence of laparoscopic findings suggesting genital tuberculosis Mycobacterium tuberculosis was isolated only from the urine.

Successful intrauterine therapy of a large fetal ovarian cyst.

Fetal ovarian cysts can be managed in different ways, depending upon their size and clinical course: conservatively, by open surgery or by postnatal transabdominal puncture. However, in cases of large cysts detected antenatally and affecting the ongoing pregnancy, in utero transabdominal puncture can be undertaken, without increase of risk. A case of such a puncture at 30 weeks gestation is reported.