Successful Elective Thoracoscopic Resection of Complicate Extralobar Bronchopulmonary Sequestration after Intrafoetal Vascular Laser Ablation: The Paediatric Surgeon's Point of View.

Few reports of laser coagulation for foetal bronchopulmonary sequestration (BPS), a rare congenital malformation characterised by the absence of tracheobronchial connection and the presence of a systemic feeding artery, have been published. Additionally, very few of them focus also on the postnatal management, with results limited and controversial. Postnatal treatment of residual malformation remains debated, hence the need to share our experience of a combined pre- and postnatal approach to complicated extra-lobar BPS. We report the case of a female foetus with the diagnosis of a pulmonary lesion. Due to mediastinal shift, unilateral compressive hydrothorax, ascites, and hydrops, a foetal treatment with ultrasound-guided laser coagulation of the anomalous vessel was performed. At birth, due to the persistence of the malformation, an elective delayed thoracoscopical surgery was performed. Prenatal laser ablation for complicated BPS is a life-saving procedure not always resulting in lesion disappearance. Thoracoscopical surgical exploration in case of persistent lesions at birth offers the possibility of a minimally invasive sequestrectomy feasible and safe.

Prenatal diagnosis of an adrenal mature teratoma mimicking a neuroblastoma.

Teratomas are defined by the presence of cell types from different germ layers, they typically involve the gonads or the sacrococcygeal region and are rarely retroperitoneal. Prenatally detected adrenal teratomas are extremely uncommon. Aim of this paper is to share our experience with an adrenal antenatal mass initially diagnosed as a left adrenal neuroblastoma that turned out to be a mature teratoma after microscopical examination. We present the case of a male fetus with antenatal diagnosis of a left adrenal cystic image at the 22nd week of amenorrhea. The fetal magnetic resonance imaging showed a non-calcified cystic mass of the left adrenal gland, compatible with a neuroblastoma. At birth an ultrasound confirmed the presence of an anechogenic lesion of the left adrenal gland. The infant was closely monitored during his first year and in the absence of significant regression of the adrenal mass, it was decided to perform a laparoscopic left adrenalectomy. Unexpectedly, the final pathological diagnosis was mature cystic adrenal teratoma. In conclusion, an adrenal mass diagnosed antenatally is generally a hemorrhage or a neuroblastoma. Adrenal teratomas are very rare and those diagnosed antenatally even more. At present, we have no clinical, biological, or radiological evidence to suspect them before surgical removal. There are only two other cases of unexpected adrenal teratoma in infants described in Literature.

Severe Antenatal Hypertrophic Cardiomyopathy Secondary to ACAD9-Related Mitochondrial Complex I Deficiency.

Introduction: Antenatal presentation of hypertrophic cardiomyopathy (HCM) is rare. We describe familial recurrence of antenatal HCM associated with intrauterine growth restriction and the diagnostic process undertaken. Methods: Two pregnancies with antenatal HCM were followed up. Biological assessment including metabolic analyses, genetic analyses, and respiratory chain study was performed. We describe the clinical course of these two pregnancies, antenatal manifestations as well as specific histopathological findings, and review the literature. Results: The assessment revealed a deficiency in complex I of the respiratory chain and two likely pathogenic variations in the ACAD9 gene. Discussion and Conclusion: Antenatal HCM is rare and a diagnosis is not always made. In pregnancies presenting with cardiomyopathy and intrauterine growth restriction, ACAD9 deficiency should be considered as one of the potential underlying diagnoses, and ACAD9 molecular testing should be included among other prenatal investigations.

Severe placental lesions due to maternal SARS-CoV-2 infection associated to intrauterine fetal death.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can cause severe placental lesions leading rapidly to intrauterine fetal death (IUFD). From August 2020 to September 2021, in the pathology department of Toulouse Oncopole, we analyzed 50 placentas from COVID-19-positive unvaccinated mothers. The purpose of our study is to describe the clinicopathological characteristics of these placental damages and to understand the pathophysiology. Ten of them (20%) showed placental lesions with positive immunohistochemistry for SARS-CoV-2 in villous trophoblasts. In five cases (10%), we observed massive placental damage associating trophoblastic necrosis, fibrinous deposits, intervillositis, as well as extensive hemorrhagic changes due to SARS-CoV-2 infection probably responsible of IUFD by functional placental insufficiency. In five other cases, we found similar placental lesions but with a focal distribution that did not lead to IUFD but live birth. These lesions are independent of maternal clinical severity of COVID-19 infection because they occur despite mild maternal symptoms and are therefore difficult to predict. In our cases, they occurred 1-3 weeks after positive SARS-CoV-2 maternal real-time polymerase chain reaction testing and were observed in the 2nd and 3rd trimesters of pregnancies. When these lesions are focal, they do not lead to IUFD and can be involved in intrauterine growth restriction. Our findings, together with recent observations, suggest that future pregnancy guidance should include stricter pandemic precautions such as screening for a wider array of COVID-19 symptoms, enhanced ultrasound monitoring, as well as newborn medical surveillance.

Predicting the risk of respiratory distress in newborns with congenital pulmonary malformations.

OBJECTIVES: Most children with prenatally diagnosed congenital pulmonary malformations (CPMs) are asymptomatic at birth. We aimed to develop a parsimonious prognostic model for predicting the risk of neonatal respiratory distress (NRD) in preterm and term infants with CPM, based on the prenatal attributes of the malformation. METHODS: MALFPULM is a prospective population-based nationally representative cohort including 436 pregnant women. The main predictive variable was the CPM volume ratio (CVR) measured at diagnosis (CVR first) and the highest CVR measured (CVR max). Separate models were estimated for preterm and term infants and were validated by bootstrapping. RESULTS: In total, 67 of the 383 neonates studied (17%) had NRD. For infants born at term (>37 weeks, n=351), the most parsimonious model included CVR max as the only predictive variable (receiver operating characteristic (ROC) curve area: 0.70±0.04, negative predictive value: 0.91). The probability of NRD increased linearly with increasing CVR max and remained below 10% for CVR max <0.4. In preterm infants (n=32), both CVR max and gestational age were important predictors of the risk of NRD (ROC: 0.85±0.07). Models based on CVR first had a similar predictive ability. CONCLUSIONS: Predictive models based exclusively on CVR measurements had a high negative predictive value in infants born at term. Our study results could contribute to the individualised general risk assessment to guide decisions about the need for newborns with prenatally diagnosed CPM to be delivered at specialised centres.

Cyproterone acetate and meningioma: a nationwide-wide population based study.

BACKGROUND: The study the characteristics of surgical meningiomas in female patients who took CPA and to compare this population to a non-CPA control group. MATERIALS AND METHODS: We processed the French Système National des Données de Santé (SNDS) database to retrieve appropriate cases operated between 2007 and 2017. RESULTS: 1 101 female patients (3.8%) who used to take CPA and underwent a meningioma surgery were extracted from a nationwide population based cohort of 28 924 patients. Median age at CPA prescription was 42 years IQR[36.7-48.9]. The median time between CPA start and surgery was 5.5 years IQR[3.1-7.9]. The median age at surgery was significantly lower in patients who were treated by CPA (47 years, IQR[42-54) compared to the non-CPA population (61 years, IQR[51-70], p < 0.001). Median CPA dose was 40 g, IQR[19-72]. There was a strong correlation between CPA dose and duration (r = 0.58, 95%CI[0.54-0.62], p < 0.001). Middle skull base was the most common (39%) location with a anterior skull base insertion being also far more common compared to the usual population with 21.9% of the tumour. This skull base predominance of CPA-associated meningioma is highly significant (p < 0.001). Increased CPA dose raised the risk of having multiple meningioma surgeries (p < 0.001) and multiple meningioma locations (p < 0.001). Tumour grading was not modified by CPA treatment (p = 0.603). Benign or grade I meningioma accounting for 92%, atypical or grade II for 6.1% and malignant or grade III for 1.9%. CONCLUSION: In the past 10 years, a significant number of CPA-induced meningiomas have been removed, modifying the global pyramid of age at surgery for female patients. These tumours occur well before the usual age and are preferentially located on the anterior and middle skull base.

Unusual fetal ascites and spontaneous bladder rupture in a female fetus: a case report.

BACKGROUND: Fetal bladder rupture causing urinary ascites is uncommon. It is generally related to invasive fetal medicine procedures or obstructive disorders such as in posterior urethral valves in male fetuses. An exceptional case of spontaneous bladder rupture in a female fetus occurred in a pregnant woman treated with high doses of opiates in an intensive care unit. This unusual obstetric situation leads to discussion of the possible causes of fetal bladder rupture, its management, and the pediatric prognosis. CASE PRESENTATION: We report the case of a 30-year-old nulliparous black woman with a history of mesenteric cystic lymphangioma and multiple bowel resections leading to chronic malabsorption. During her pregnancy, our patient presented with an occlusive syndrome and major bilateral renal dilation. Urinary derivation resulted in iatrogenic bilateral ureteral perforation. Our patient thus presented with major uroperitoneum, bilateral pleural effusion and acute renal failure, treated by thoracic drainage and bilateral nephrostomy. Postoperative pain required treatment with level III analgesics. In this context, 5 days after morphine treatment introduction an enlarged fetal bladder was observed, followed 3 days later by voluminous fetal ascites. The diagnosis of spontaneous bladder rupture was suspected. After multidisciplinary discussion, expectant management was decided. At 31 weeks and 4 days gestation, our patient went into spontaneous labor with a subsequent vaginal delivery. The infant required resuscitation and paracentesis of ascites at birth. Her neonatal course was favorable with a simple urethral bladder drainage. Cystography at day 9 was normal. At 2 years of follow-up, the mother and the child have a normal course. CONCLUSIONS: An iatrogenic origin of megacystis in a female fetus must be evoked in the event of maternal administration of high doses of opiates in the second part of her pregnancy. In our case, the megacystis was followed by spontaneous bladder rupture at 30 weeks of gestation, with a favorable maternal fetal issue.

Selective feticide as a treatment of severe preeclampsia in discordant twins.

Multifetal gestation is often complicated by the development of preeclampsia. In some twin gestations, preeclampsia develops in association with restricted fetal growth of only one fetus. Instead of termination of the entire pregnancy, we investigated an alternative approach to the management of such pregnancies that might allow unharmed survival of the normal twin. We present a case of preeclampsia in twin discordance with severe fetal growth restriction at 25 weeks of gestation. Preeclampsia was linked to a lethal condition in one twin and was treated with selective feticide in an effort to reverse preeclampsia. Inasmuch as the fetal prognosis was extremely poor for the abnormal fetus, selective feticide was a reasonable therapeutic option. Maternal symptoms resolved, allowing continuation of the pregnancy for 4 weeks before delivery of the healthy fetus. We maintain that selective termination induced a decrease in the release of substances involved in the physiopathology of preeclampsia, which allowed the continuation of the pregnancy with close follow-up. This report highlights the link between placental pathology and the disease process of preeclampsia and further supports selective termination as a reasonable management strategy in carefully selected cases of discordant twins.

Apparent diffusion coefficient measurements of the fetal brain during the third trimester of pregnancy: how reliable are they in clinical practice?

OBJECTIVE: The objective of this study was to determine the reproducibility, the inter-hemispheric difference and the reference apparent diffusion coefficient (ADC) values of the fetal brain according to gestational age. METHOD: One hundred and one normal fetal brain (29.4-38.4 weeks) were analysed with diffusion-weighted MR imaging. ADC was measured in frontal white matter (FWM), occipital white matter (OWM), centrum semi-ovale (CSO), basal ganglia (BG), cerebellar hemisphere (CBM) and pons. ADC ratios (fronto-occipital, fronto-cerebellar and occipito-cerebellar) were calculated. Inter-observer reproducibility was assessed on 27 studies, using intra-class correlation coefficient and Bland-Altman plot. Inter-hemispheric difference was evaluated with Bland-Altman plot. Gestation-specific reference intervals were estimated for each brain region. RESULTS: Inter-observer bias was near zero. Limits of agreement (LOA) were clinically acceptable (-0.17; 0.20 to -0.38; 0.31 × 10(-3) mm(2) /s) for all brain regions except for CSO and pons. Inter-hemispheric bias was near zero. Smallest LOA were for FWM (±0.09 mm(2) /s) and BG (±0.019 mm(2) /s). ADC values decreased, whereas ADC ratio increased with gestational age, reflecting normal maturation. Fronto-occipital, fronto-cerebellar and occipito-cerebellar ratios were consistently above 0.8, 1 and 1, respectively. CONCLUSION: The fetal brain regions with the highest reproducibility and smallest inter-hemispheric differences are the frontal, occipital, cerebellar white matter and BG. ADC ratio could be useful to assess differential temporo-spatial maturation.

Pulmonary and intestinal congenital anomalies masquerading as cystic suprarenal masses.

OBJECTIVES: The prenatal finding of a cystic suprarenal mass (CSM) presents a wide differential diagnosis. The aim of this study was to present the natural course and outcome of antenatally diagnosed CSMs. METHODS: We reviewed the medical records of patients with prenatally detected CSMs that were assessed between January 1998 and December 2011. Retrospective data collection included the age at the time of diagnosis, the size of the mass, and the sonographic evolution of the mass. Surgical treatment was indicated in cases of malignant tumors and symptoms or when size increased. RESULTS: The observation period ranged from 1 month to 10 years. The data of 21 patients were analyzed. The median length of follow-up was 32 months (ranging from 2 to 131 months). A total of 13 masses were detected on the left side and 8 on the right side. In 13 patients, the lesions disappeared after a median of 7 months (ranging from 0 to 37 months). Surgery was performed in two neonates: one for a teratoma at 10 days postpartum, and one for a neuroblastoma at 17 days postpartum. Six patients had an extralobar pulmonary sequestration (ELPS), and in four patients, surgical resection was performed at an average of 9.2 months (ranging from 1 to 20 months) postpartum, because of an infection or increase in ELPS size. Histological examination confirmed the pulmonary sequestration. An association with congenital cystic adenomatoid malformation (CCAM) was found in one patient, and ectopic pancreatic tissue was discovered in another patient. Two patients conservatively managed remain under observation. CONCLUSIONS: During the neonatal period, the accurate assessment of CSMs is necessary to exclude the presence of malignant tumors. Most patients can be conservatively managed, with close follow-up, including radiological assessment. If the mass persists after 1 year of age, ELPS should be considered as a probable diagnosis, and minimally invasive laparoscopic surgery can be performed, as it provides both definitive diagnosis and treatment.

The surgical management and outcome of congenital mediastinal malformations.

We reviewed our institutional experience with congenital mediastinal masses and compared the postnatal management and outcome of patients with or without prenatal diagnosis. Between January 1997 and August 2011, 24 patients underwent surgical procedures for congenital mediastinal mass. For eight patients, the mass was detected by prenatal ultrasonography at 27 weeks of gestation (range 22-35). Postnatal management consisted in open surgery for seven patients at a mean age of 9 months (range 1 day-20 months) and sclerotherapy for one lymphangioma at 5 months of life. Sixteen patients had postnatal diagnosis at 137 months (±194) of median age. Eight bronchogenic cysts, seven bronchopulmonary foregut malformations, five teratomas, three lymphangiomas and one haemangioma were operated on. The median age at resection was 28 months (1 day-15 years). There were four emergency procedures and no surgical mortality. The median follow-up was 45 months (3-144). The duration of mechanical ventilation and hospital stay was, respectively, 4.6 h and 7.5 days for antenatal patients and 24.3 h and 14.3 days for postnatal diagnosed patients. Prenatal diagnosis allows early management of congenital mediastinal malformations. Early resection can be performed prior to the occurrence of symptoms ∼1 year of life and is associated with an excellent outcome and less morbidity.