Placental Location in Maternal-Fetal Surgery for Myelomeningocele.

INTRODUCTION: Uterine incision based on the placental location in open maternal-fetal surgery (OMFS) has never been evaluated in regard to maternal or fetal outcomes. OBJECTIVE: The aim of this study was to investigate whether an anterior placenta was associated with increased rates of intraoperative, perioperative, antepartum, obstetric, or neonatal complications in mothers and babies who underwent OMFS for fetal myelomeningocele (fMMC) closure. METHODS: Data from the international multicenter prospective registry of patients who underwent OMFS for fMMC closure (fMMC Consortium Registry, December 15, 2010-June 31, 2019) was used to compare fetal and maternal outcomes between anterior and posterior placental locations. RESULTS: The placental location for 623 patients was evenly distributed between anterior (51%) and posterior (49%) locations. Intraoperative fetal bradycardia (8.3% vs. 3.0%, p = 0.005) and performance of fetal resuscitation (3.6% vs. 1.0%, p = 0.034) occurred more frequently in cases with an anterior placenta when compared to those with a posterior placenta. Obstetric outcomes including membrane separation, placental abruption, and spontaneous rupture of membranes were not different among the 2 groups. However, thinning of the hysterotomy site (27.7% vs. 17.7%, p = 0.008) occurred more frequently in cases of an anterior placenta. Gestational age (GA) at delivery (p = 0.583) and length of stay in the neonatal intensive care unit (p = 0.655) were similar between the 2 groups. Fetal incision dehiscence and wound revision were not significantly different between groups. Critical clinical outcomes including fetal demise, perinatal death, and neonatal death were all infrequent occurrences and not associated with the placental location. CONCLUSIONS: An anterior placental location is associated with increased risk of intraoperative fetal resuscitation and increased thinning at the hysterotomy closure site. Individual institutional experiences may have varied, but the aggregate data from the fMMC Consortium did not show a significant impact on the GA at delivery or maternal or fetal clinical outcomes.

Ultrasound characteristics of early-stage high-grade serous ovarian cancer.

BACKGROUND: Survival from ovarian cancer is strongly dependent on the stage at diagnosis. Therefore, when confronted with a woman with an isolated adnexal mass, clinicians worry about missing the opportunity to detect cancer at an early stage. High-grade serous ovarian cancers account for 80% of ovarian cancer deaths, largely because of their tendency to be diagnosed at a late stage. Among adnexal masses, large size and the presence of solid areas on ultrasound examination have been found to be associated with cancer, but it is unclear whether these characteristics identify early-stage cases. OBJECTIVE: This study aimed to evaluate the ultrasound findings associated with clinically detected early-stage high-grade serous ovarian cancer. STUDY DESIGN: This was a retrospective cohort study of women diagnosed with stage I or II high-grade serous ovarian or fallopian tube cancer measuring at least 1 cm at pathology from 2007 to 2017. Preoperative ultrasound examinations were independently reviewed by 3 radiologists. Adnexal masses were scored for size and volume; overall appearance; presence, thickness, and vascularity of septations; morphology and vascularity of other solid components; and degree of ascites. Characteristics were compared between masses of <5 cm and larger masses and between stage I and stage II cases. Interobserver variability was assessed. RESULTS: Among 111 women identified, 4 had bilateral ovarian involvement, for a total of 115 adnexal masses characterized by ultrasound examination. The mean age at diagnosis was 61.8 years (range, 42-91 years). The median mass size was 9.6 cm (range, 2.2-23.6 cm) with 87% of cases having a mass size of ≥5 cm. A mixed cystic and solid appearance was most common (77.4%), but a completely solid appearance was more frequently seen for tumors of <5 cm compared with larger tumors (26.7% vs 13.0%). Solid components other than septations were seen in 97.4% of cases. The characteristics of stage I and II cases were similar other than ascites, which was more commonly seen in stage II cases (18.0% vs 3.1%, respectively). Interobserver concordance was high for size and volume measurements (correlation coefficients, 0.96-0.99), with moderate agreement observed across the other ultrasound characteristics (Fleiss kappa, 0.45-0.58). CONCLUSION: In this community-based cohort, early-stage high-grade serous cancers rarely presented as masses of <5 cm or masses without solid components other than septations. Our findings provide additional support for the observation of small masses without solid areas on ultrasound examination.

Placenta accreta spectrum: value of placental bulge as a sign of myometrial invasion on MR imaging.

PURPOSE: To evaluate correlation of "placental bulge sign" with myometrial invasion in placenta accreta spectrum (PAS) disorders. Placental bulge is defined as deviation of external uterine contour from expected plane caused by abnormal outward bulge of placental tissue. MATERIALS AND METHODS: In this IRB-approved, retrospective study, all patients undergoing MRI for PAS disorders between March 2014 and 2018 were included. Patients who delivered elsewhere were excluded. Imaging was reviewed by 2 independent readers. Surgical pathology from Cesarean hysterectomy or pathology of the delivered placenta was used as reference standard. Fisher's exact and kappa tests were used for statistical analysis. RESULTS: Sixty-one patients underwent MRI for PAS disorders. Two excluded patients delivered elsewhere. Placental bulge was present in 32 of 34 cases with myometrial invasion [True positive 32/34 = 94% (95% CI 0.80-0.99)]. Placental bulge was absent in 24 of 25 cases of normal placenta or placenta accreta without myometrial invasion [True negative = 24/25, 96% (95% CI 80-99.8%)]. Positive and negative predictive values were 97% and 96%, respectively. Placental bulge in conjunction with other findings of PAS disorder was 100% indicative of myometrial invasion (p < 0.01). Kappa value of 0.87 signified excellent inter-reader concordance. In 1 false positive, placenta itself was normal but the bulge was present. Surgical pathology revealed markedly thinned, fibrotic myometrium without accreta. One false-negative case was imaged at 16 weeks and may have been imaged too early. CONCLUSIONS: Placental bulge in conjunction with other findings of invasive placenta is 100% predictive of myometrial invasion. Using the bulge alone without other signs can lead to false-positive results.

Fetal Congenital Pulmonary Airway Malformation: The Role of an Objective Measurement of Cardiomediastinal Shift.

OBJECTIVE: To examine the relationship between cardiomediastinal shift angle (CMSA) and adverse perinatal outcomes and hydrops in cases of congenital pulmonary airway malformation (CPAM). STUDY DESIGN: This retrospective study evaluated CPAM cases referred to our institution from 2008 to 2015. The primary outcome was a composite score for adverse perinatal outcome. CMSA was measured for each case and evaluated for its association with the primary outcome. The prediction accuracy of CMSA for adverse perinatal outcome was assessed using receiver operator characteristic (ROC) curves. RESULTS: Eighteen (21.2%) of the 85 cases experienced an adverse perinatal outcome. Increases in CMSA were associated with adverse perinatal outcomes and hydrops in bivariate analyses. Adjusted analyses found each 10-degree increase in CMSA to be associated with increased odds of an adverse perinatal outcome (adjusted odds ratio [aOR] 2.2, 95% confidence interval [CI]: 1.4-3.3) and hydrops (aOR 3.0, 95% CI: 1.5-6.1). CMSA performed well and was comparable to CPAM volume ratio in predicting adverse perinatal outcomes (area under the curve 0.81 and 0.84, respectively). CONCLUSION: We describe a novel measurement of mediastinal shift in cases of CPAM and its relationship with adverse perinatal outcomes and hydrops. These findings may shape the evaluation and management of CPAMs, improve our understanding of their prognosis, and influence patient counseling.

Distal Forearm Fracture Open Reduction-Internal Fixation: Sonographic Detection of Hardware Malalignment and Associated Tendon Injuries Missed by Radiography.

Tendon injury is a known complication of distal radius fracture plate and screw fixation. Targeted musculoskeletal sonography is uniquely capable of assessing both tendon integrity and hardware abnormalities not recognized on radiographs. Each of the 3 patients described presented with pain after an open reduction-internal fixation following a distal forearm fracture. In each patient, radiographic findings, specifically the hardware position, were interpreted as normal. Important radiographically occult observations were subsequently made with sonography, including 3 proud screws and tendon injuries, all of which required surgical treatment. This case series demonstrates the clinical utility of musculoskeletal sonography in symptomatic patients after distal radius open reduction-internal fixation with negative radiographic findings. In our practice, sonography has been the most useful modality for precluding missing or delaying the diagnosis and treatment of these hardware complications. We advocate its use as an adjunct in any department performing musculoskeletal imaging.

Ultrasonography versus computed tomography for suspected nephrolithiasis.

BACKGROUND: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography. METHODS: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy. RESULTS: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P<0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups. CONCLUSIONS: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.).

Risk of thyroid cancer based on thyroid ultrasound imaging characteristics: results of a population-based study.

IMPORTANCE: There is wide variation in the management of thyroid nodules identified on ultrasound imaging. OBJECTIVE: To quantify the risk of thyroid cancer associated with thyroid nodules based on ultrasound imaging characteristics. METHODS: Retrospective case-control study of patients who underwent thyroid ultrasound imaging from January 1, 2000, through March 30, 2005. Thyroid cancers were identified through linkage with the California Cancer Registry. RESULTS: A total of 8806 patients underwent 11,618 thyroid ultrasound examinations during the study period, including 105 subsequently diagnosed as having thyroid cancer. Thyroid nodules were common in patients diagnosed as having cancer (96.9%) and patients not diagnosed as having thyroid cancer (56.4%). Three ultrasound nodule characteristics--microcalcifications (odds ratio [OR], 8.1; 95% CI, 3.8-17.3), size greater than 2 cm (OR, 3.6; 95% CI, 1.7-7.6), and an entirely solid composition (OR, 4.0; 95% CI, 1.7-9.2)--were the only findings associated with the risk of thyroid cancer. If 1 characteristic is used as an indication for biopsy, most cases of thyroid cancer would be detected (sensitivity, 0.88; 95% CI, 0.80-0.94), with a high false-positive rate (0.44; 95% CI, 0.43-0.45) and a low positive likelihood ratio (2.0; 95% CI, 1.8-2.2), and 56 biopsies will be performed per cancer diagnosed. If 2 characteristics were required for biopsy, the sensitivity and false-positive rates would be lower (sensitivity, 0.52; 95% CI, 0.42-0.62; false-positive rate, 0.07; 95% CI, 0.07-0.08), the positive likelihood ratio would be higher (7.1; 95% CI, 6.2-8.2), and only 16 biopsies will be performed per cancer diagnosed. Compared with performing biopsy of all thyroid nodules larger than 5 mm, adoption of this more stringent rule requiring 2 abnormal nodule characteristics to prompt biopsy would reduce unnecessary biopsies by 90% while maintaining a low risk of cancer (5 per 1000 patients for whom biopsy is deferred). CONCLUSIONS AND RELEVANCE: Thyroid ultrasound imaging could be used to identify patients who have a low risk of cancer for whom biopsy could be deferred. On the basis of these results, these findings should be validated in a large prospective cohort.

Pseudo gallbladder sign in biliary atresia--an imaging pitfall.

BACKGROUND: Ultrasound (US) is used to identify causes of neonatal cholestasis. We describe a potential sonographic pitfall, the "pseudo gallbladder," in biliary atresia (BA). OBJECTIVE: To describe the Pseudo Gallbladder sign (PsGB sign). MATERIALS AND METHODS: Sonograms/clinical records of 20 confirmed BA infants and 20 non-BA cases were reviewed retrospectively. For the BA group, preoperative sonography and surgical and pathological findings were examined. For the non-BA group, sonographic features and pathological findings were examined. The PsGB sign is defined as a fluid-filled structure, located in the expected region of the gallbladder, measuring ≤ 15 mm in length but without a well-defined or normal-appearing gallbladder wall. RESULTS: A recognizable gallbladder and normal gallbladder wall were present in all non-BA infants. However, none of the BA infants had a sonographically normal gallbladder. Seventy-three percent of BA patients had a PsGB, and in 27% no gallbladder or gallbladder-like structure was detected. CONCLUSION: A gallbladder-like structure in BA is common and can be misinterpreted as a normal gallbladder, delaying diagnosis and therapy. Recognition of this imaging pitfall, described here as the pseudo gallbladder sign, will help avoid this error.

Cerebellar hemorrhage on magnetic resonance imaging in preterm newborns associated with abnormal neurologic outcome.

OBJECTIVE: To investigate the relationship between cerebellar hemorrhage in preterm infants seen on magnetic resonance imaging (MRI), but not on ultrasonography, and neurodevelopmental outcome. STUDY DESIGN: Images from a cohort study of MRI in preterm newborns were reviewed for cerebellar hemorrhage. The children were assessed at a mean age of 4.8 years with neurologic examination and developmental testing using the Wechsler Preschool and Primary Scale of Intelligence, Third Edition. RESULTS: Cerebellar hemorrhage was detected on both ultrasonography and MRI in 3 of the 131 preterm newborns evaluated, whereas smaller hemorrhages were seen only on MRI in 10 newborns (total incidence, 10%). Adjusting for gestational age at birth, intraventricular hemorrhage, and white matter injury, cerebellar hemorrhage detectable solely by MRI was associated with a 5-fold increased odds of abnormal neurologic examination compared with newborns without cerebellar hemorrhage (outcome data in 74%). No association with the Wechsler Preschool and Primary Scale of Intelligence, Third Edition score was found. CONCLUSIONS: Cerebellar hemorrhage is not uncommon in preterm newborns. Although associated with neurologic abnormalities, hemorrhage seen only on MRI is associated with much more optimistic outcomes than that visible on ultrasonography.

Prenatal steroids for microcystic congenital cystic adenomatoid malformations.

OBJECTIVE: The purpose of this study is to evaluate the effect of prenatal steroid treatment in fetuses with sonographically diagnosed congenital cystic adenomatoid malformations (CCAMs). METHODS: This was an institutional review board-approved retrospective review of 372 patients referred to the University of California, San Francisco (UCSF), for fetal CCAM. Inclusion criteria were (1) a predominately microcystic CCAM lesion sonographically diagnosed at our institution, (2) maternal administration of a single course of prenatal corticosteroids (betamethasone), and (3) no fetal surgery. CCAM volume-to-head ratio (CVR), presence of hydrops, mediastinal shift, and diaphragm eversion were assessed before and after administration of betamethasone. The primary end points were survival to birth and neonatal discharge. RESULTS: Sixteen patients with predominantly microcystic CCAMs were treated with prenatal steroids. Three were excluded because of lack of follow-up information. All remaining fetuses (13/13) survived to delivery and 11/13 (84.6%) survived to neonatal discharge. At the time of steroid administration, all patients had CVR greater than 1.6, and 9 (69.2%) also had nonimmune hydrops fetalis. After a course of steroids, CVR decreased in 8 (61.5%) of the 13 patients, and hydrops resolved in 7 (77.8%) of the 9 patients with hydrops. The 2 patients whose hydrops did not resolve with steroid treatment did not survive to discharge. CONCLUSION: In high-risk fetal patients with predominantly microcystic CCAM lesions, betamethasone is an effective treatment. This series is a pilot study for a prospective randomized trial comparing treatment of CCAM with betamethasone to placebo.

Supratentorial abnormalities in the Chiari II malformation, IV: the too-far-back ventricle.

OBJECTIVE: The sonographic diagnosis of fetal myelomeningocele (MMC) has improved mainly because the diagnostic focus has shifted from observation of the spinal abnormality to observation of cranial abnormalities. We describe an abnormality in the position of the occipital horn in fetuses with MMC. The occipital horn appears to be too posterior in location when compared to healthy fetuses. METHODS: We searched for all cases in which fetal MMC was sonographically detected from 1999 to 2009. Random controls from normal pregnancies were identified. We then measured the shortest distance of the edge of the occipital horn to the occipital bone in fetuses with MMC compared to healthy fetuses. Only fetuses with MMC who had normal-size ventricles were included. RESULTS: A total of 91 fetuses with MMC were identified. Twenty-six fetuses had a normal ventricle size. The gestational age range in this cohort was 18 weeks 5 days to 30 weeks 0 days. The comparison group of 39 healthy fetuses all had normal ventricles and had a gestational age range of 18 weeks 3 days to 35 weeks 2 days. After adjusting for gestational age, the statistical analysis showed that fetuses with MMC had significantly shorter measured distances from the posterior edge of the occipital horn to the occipital bone than healthy fetuses (P = .003). CONCLUSIONS: The occipital horn both appears to be and measures closer to the occipital bone in fetuses with MMC compared to healthy fetuses.

Prenatal intraabdominal bowel dilation is associated with postnatal gastrointestinal complications in fetuses with gastroschisis.

OBJECTIVE: The purpose of this study was to determine whether prenatal intraabdominal bowel dilation (IBD) is associated with increased postnatal complications in fetuses with gastroschisis. STUDY DESIGN: A retrospective review was performed on all maternal-fetus pairs with prenatally diagnosed gastroschisis that was treated at the University of California San Francisco from 2002-2008. Postnatal outcomes were compared between fetuses with and without IBD. RESULTS: Forty-three of 61 maternal-fetal pairs met the criteria for inclusion. Sixteen fetuses (37%) had evidence of IBD. Fetuses with IBD were significantly more likely to have postnatal bowel complications (38% vs 7%; P = .037). The presence of multiple loops of IBD (n = 6) as opposed to a single loop (n = 10) was associated highly with bowel complications and increased time to full enteral feeding and length of hospital stay (100% vs 0% [P = .001]; 44 vs 23 days [P = .034]; 69 vs 27 days [P = .001], respectively). CONCLUSION: IBD is associated with increased postnatal complications in infants with prenatally diagnosed gastroschisis; however, this association seems to be limited to those with multiple loops of dilated intraabdominal bowel.

Decidualized endometrioma during pregnancy: recognizing an imaging mimic of ovarian malignancy.

OBJECTIVE: To present the ultrasound and magnetic resonance imaging findings that may allow for a prospective diagnosis and expectant management of decidualized endometriomas because the rare occurrence of decidualization in the ectopic endometrial stroma of an endometrioma during pregnancy can mimic ovarian cancer at imaging. CASE REPORT: Smooth lobulated mural nodules with prominent internal vascularity were noted in an apparent right ovarian endometrioma on serial ultrasound studies in a 34-year-old woman at 12, 21, 27, and 30 weeks of gestation. Magnetic resonance imaging demonstrated the nodules to be strikingly similar in intensity and texture to the decidualized endometrium in the uterus on T2-weighted sequences. A provisional diagnosis of decidualized endometrioma allowed for expectant management with immediate postpartum resection and confirmation of the diagnosis. CONCLUSIONS: Decidualized endometrioma can mimic ovarian malignancy during pregnancy, but a prospective diagnosis may be possible when solid smoothly lobulated nodules with prominent internal vascularity within an endometrioma are seen from early in pregnancy, and the nodules demonstrate marked similarity in signal intensity and texture with the decidualized endometrium in the uterus at magnetic resonance imaging.

Does congenital diaphragmatic hernia associated with bronchopulmonary sequestration portend a better prognosis?

INTRODUCTION: Congenital diaphragmatic hernia (CDH) continues to be a devastating disease in the newborn population, with well-documented morbidity and mortality. Bronchopulmonary sequestration is a separate congenital defect that has been associated with CDH. While the association of sequestration with CDH has been reported to be as high as 30-40%, the prognosis associated with the two simultaneous defects is unknown. We reviewed our experience to evaluate if prognosis was better in the CDH infants with associated bronchopulmonary sequestration. METHODS: Institutional approval was obtained. Our institutional database was examined from August 1995 to August 2005, identifying all mothers carrying fetuses with pulmonary masses and/or CDH and all neonates treated with bronchopulmonary sequestration and/or CDH. Patients who had both CDH and sequestration were identified by prenatal ultrasound reports, postnatal radiographs, and operative and pathology reports. RESULTS: 16 patients were identified in the fetal or neonatal period with concomitant diagnoses of CDH and bronchopulmonary sequestration. Of those proceeding to delivery, 6 expired and 6 survived. The presence of liver herniation and low lung-to-head ratio on antenatal ultrasound correlated with mortality. However, 2 patients survived with very low lung-to-head ratio that would usually be associated with 100% mortality at our institution. Two diagnoses of bronchopulmonary sequestration were reversed after final pathology revealed liver tissue. CONCLUSION: Given the limited series, we cannot conclude that bronchopulmonary sequestration confers an anatomic advantage to patients that have CDH. We did observe survivors in this group that, given their antenatal predictors of CDH severity, would ordinarily have dismal prognosis. The presence of a sequestration may be protective in a subset of patients with severe CDH, or may confound our antenatal predictors of disease severity in these patients.

Role of sonography in the recognition, assessment, and treatment of cesarean scar ectopic pregnancies.

OBJECTIVE: Cesarean scar ectopic pregnancies (CSEPs) are rare but may have serious adverse consequences and are therefore important to promptly recognize on sonography. We aim to describe the typical sonographic appearances. Potential treatments are discussed, including sonographic guidance for transcervical injection of methotrexate (MTX) into the gestational sac. METHODS: Two patients with CSEPs were treated with systemic and intra-amniotic administration of MTX under sonographic guidance. RESULTS: Both patients were followed clinically after medical treatment, resulting in low maternal morbidity and mortality. CONCLUSIONS: Considering the increasing rate of cesarean delivery and the increased risk of CSEPs, sonologists should be familiar with the sonographic appearances of a pregnancy implanted into the cesarean scar. We show how to correctly diagnose scar implantation and describe how to perform sonographically guided transcervical injection of MTX.

Characteristics of congenital cystic adenomatoid malformations associated with nonimmune hydrops and outcome.

BACKGROUND/PURPOSE: In fetuses with congenital cystic adenomatoid malformations of the lung (CCAMs), hydrops fetalis and large masses are associated with poor outcomes. This study attempts to (1) determine sonographic features (in addition to large size) that correlate with hydrops and (2) characterize the features that correlate with outcome among hydropic fetuses. METHOD: Charts and sonograms of fetuses with large, unilateral CCAMs were retrospectively reviewed. Mass features evaluated included laterality, macrocystic/microcystic, cystic/solid predominance, degree of mediastinal shift, retrocardiac component, diaphragm eversion, polyhydramnios, and mass-thorax ratio (MTR). Features of hydrops included degree of ascites, scalp and integumentary edema, pleural/pericardial effusion, and placentomegaly. RESULTS: Thirty-six fetuses with large CCAMs were studied: 27 with and 9 without hydrops. Three sonographic features were significantly associated with hydrops: MTR of at least 0.56, cystic predominance of mass, and eversion of hemidiaphragm. Of 27 fetuses with hydrops, 10 (37%) demonstrated all 3 features compared with none in those without hydrops (P = .04). All 9 nonhydropic fetuses were expectantly managed, and 100% survived. In the hydropic group, none of the expectantly managed fetuses survived, and 10 (43%) of the 21 fetuses who underwent fetal intervention survived. CONCLUSION: Three features of large CCAMs were significantly associated with hydrops: MTR, cystic predominance, and diaphragm eversion. Identification of these features will allow clinicians to accurately predict which fetuses may warrant closer follow-up and possible treatment.

Reliability of the lung-to-head ratio as a predictor of outcome in fetuses with isolated left congenital diaphragmatic hernia at gestation outside 24-26 weeks.

OBJECTIVE: The purpose of this study was to investigate the relationship between lung-to-head ratio (LHR) and gestational age (GA) in fetuses with isolated left congenital diaphragmatic hernia and to determine the applicability and reliability of LHR to predict postnatal outcome beyond 24-26 weeks of gestation. STUDY DESIGN: The institutional review board approved this retrospective review of the University of California, San Francisco, Fetal Treatment Center database for cases with left congenital diaphragmatic hernia who were referred between March 1995 and June 2004. LHR was determined at the initial evaluation. One hundred seven live-born fetuses at 20-34 weeks of gestation (excluding cases that were lost to follow-up, with factors that potentially could influence the LHR measurement or postnatal outcome, or that were terminated electively). RESULTS: The median GA at LHR measurement was 25.6 weeks; the median LHR was 1.01; the median GA at birth was 37.7 weeks; and the overall survival rate was 59% (64/107). The median LHR of nonsurvivors was significantly lower than that of survivors, but neither GA at LHR measurement nor at delivery was significantly different between the groups. Multiple logistic regression analysis confirmed LHR to be an independent predictor of postnatal survival, and receiver-operator characteristic curve analysis demonstrated that an LHR of > or = 0.97 has the highest performance in predicting postnatal survival. When fetuses were grouped by GA at initial LHR measurement to determine reliability of LHR, specifically with respect to GA, in the 26-34 and 24-26 weeks of gestation groups, median LHR of survivors was significantly higher than that of nonsurvivors, and receiver-operator characteristic curve analysis confirmed LHR to be a reliable predictor of postnatal survival. However, for fetuses at 20-24 weeks of gestation, there was a trend toward a higher LHR in survivors, although this did not reach statistical significance. CONCLUSION: A significant positive linear relationship exists between LHR and GA at the time of measurement, such that LHR reliably predicts postnatal survival in fetuses with left congenital diaphragmatic hernia at 24-34 weeks of gestation and less reliable at 20-24 weeks. However, given the limitations of a retrospective, cross-sectional study, further prospective longitudinal studies that will investigate the change of LHR with GA and its association with fetal outcome are necessary.

Efficacy of radiofrequency ablation for twin-reversed arterial perfusion sequence.

OBJECTIVE: We report our experience in the treatment of patients with twin-reversed arterial perfusion (TRAP) sequence using radiofrequency ablation to stop perfusion to the acardiac twin and protect the pump twin. STUDY DESIGN: An IRB approved retrospective review of all patients (n = 29) who underwent percutaneous radiofrequency ablation of an acardiac twin, using ultrasound guidance and either a 14 or 17 gauge radiofrequency needle for twin-reversed arterial perfusion sequence, from 1998 to 2005, was performed by review of hospital and outpatient medical records. RESULTS: The outcomes of all 29 of the patients treated with radiofrequency ablation are known. Twenty-six of the patients had monochorionic-diamniotic pregnancies, whereas 2 had monochorionic-monoamniotic pregnancies. One patient had a triplet pregnancy with a monochorionic-diamniotic pair with TRAP sequence. Overall, 25 of 29 pump twins survived (86%), delivering at a mean gestational age of 34.6 weeks. Survival was 24 of 26 (92%) in monochorionic-diamniotic pregnancies with a mean gestational age of 35.6 weeks. Two women in our early experience sustained thermal injuries from the site of grounding pads. CONCLUSION: Radiofrequency ablation of the acardiac twin effectively protects the pump twin from high-output cardiac failure and death. Greater than 90% survival can be achieved in monochorionic-diamniotic pregnancies complicated by TRAP sequence with a mean gestation age at time of delivery close to term. Our limited experience in cases of monochorionic-monoamniotic TRAP sequence does not allow the determination of efficacy in this group.