Fetal reduction by bipolar cord coagulation in managing complicated monochorionic multiple pregnancies: preliminary experience in China.

BACKGROUND: Monochorionic multiple pregnancies (MMPs) are associated with higher rates of perinatal morbidity and mortality caused by interfetal vascular anastomoses in the monochorionic placenta, which can lead to fetal health interactions. In some circumstances, selective feticide of the affected fetus is necessary to save the healthy co-twin. We evaluated the effects and safety of our initial experiences using bipolar cord coagulation for the management of complicated MMPs. METHODS: Using ultrasound-guided bipolar cord coagulation, we performed selective feticide on 14 complicated MMPs (5 with twin-twin transfusion syndrome, 4 with acardia, 3 with discordant structural anomalies, and 2 with severe selective intrauterine growth restriction). One patient with monochorionic triplets received the procedure twice to terminate 2 affected fetuses for different indications. Data regarding the operations, complications and neonatal outcomes were analyzed. RESULTS: Cord occlusions were successfully performed in 13/14 (93%) cases. The failure happened in an acardiac fetus and the pregnancy was terminated by induction. The included cases delivered at a mean gestational age of 35.4 weeks with a perinatal survival rate of 11/13 (85%). Three operation-related complications occurred (21%), including membrane rupture of the terminated sac (1 case), preterm labor at 28 weeks gestation (1 case), and chorioamniotic membrane separation (1 case). Amnioinfusion was indicated in 11 procedures to expand the target sacs for entering the trocar and obtaining sufficient working space. However, in all 4 cases of acardia, the acardiac sacs showed extreme oligohydramnios and could not be well expanded by infusion; thus, the trocar had to be inserted from the sac of the preserved co-twin. CONCLUSIONS: The application of bipolar cord coagulation in complicated MMPs is safe and improves the prognosis. Amnioinfusion is useful in helping to expand the target sac when the working space is limited.

[Comparison between transabdominal and transcervical chorionic villus sampling in clinical application for prenatal diagnosis].

OBJECTIVE: To compare transabdominal and transcervical chorionic villus sampling (TC-CVS) in application for prenatal diagnosis, and to summarize the experience of transabdominal chorionic villus sampling (TA-CVS). METHODS: One hundred and nine TA-CVS between April 2005 and November 2007 and 69 TC-CVS between August 1999 and March 2005 were retrospectively analyzed. RESULTS: (1) The mean gestational age was (12.4 +/- 1.9) weeks at TA-CVS and (8.8 +/- 1.2) weeks at TC-CVS (P < 0.01). (2) Compared with TC-CVS, punctures were fewer (1.4 +/- 0.5) and (1.1 +/- 0.4) and specimen amount was more (9 +/- 5) mg and (17 +/- 5) mg in TA-CVS, and the success rate of one puncture (62.3% vs 87.2%) was higher in TA-CVS. (3) Among the cases followed up, the incidence of vaginal bleeding (TA-CVS: 2 cases, 2.0%; TC-CVS: 2 cases, 6.1%) and spontaneous abortion (TA-CVS: 4 cases, 4.0%; TC-CVS: 1 cases, 3.0%) were not significantly different between the two groups (P > 0.05). CONCLUSION: TA-CVS appears to be a good method for early prenatal diagnosis with a wide range of indications, high success rate and sufficient specimen.

[Prevalence of hypertension in the Guangxi Bai Ku Yao populations].

OBJECTIVE: To observe the prevalence of hypertension and associated risk factors in the Guangxi Bai Ku Yao populations. METHODS: A total of 1170 subjects of Bai Ku Yao aged 15 and over were surveyed by a stratified randomized cluster sampling. Blood pressure, body height, weight, waist circumference, serum lipid and apolipoprotein levels were measured, and body mass index (BMI) were calculated, matched 1173 subjects of Han Chinese from the same region served as control. RESULTS: The standardized prevalence of hypertension in Bai Ku Yao was significantly lower than that in Han (11.53% vs.16.79%, P < 0.01). The mean levels of systolic, diastolic blood pressure, and pulse pressure in Bai Ku Yao were also significantly lower than those in Han [(115.7 +/- 16.3) vs. (120.0 +/- 16.3) mm Hg (1 mm Hg = 0.133 kPa), P < 0.01; (74.1 +/- 9.4) vs. (75.9 +/- 10.4) mm Hg, P < 0.01; and (41.6 +/- 12.0) vs. (44.2 +/- 11.2) mm Hg, P < 0.01; respectively]. Hypertension was positively correlated with male, age, physical activity, BMI, waist circumference, and the intakes of total energy, total fat, and sodium, and negatively associated with education level in both ethnic groups (P < 0.05 - 0.01), but was positively associated with alcohol consumption only in Han. The rates of awareness, treatment and control of hypertension were significantly lower in Bai Ku Yao than those in Han population [(11.81% vs. 21.76%), P < 0.05; (5.51% vs. 12.95%), P < 0.05; and (2.36% vs. 8.29%), P < 0.05; respectively]. CONCLUSION: The prevalence of hypertension was significantly lower in Bai Ku Yao population than in Han population and diet, low sodium intake, life style, and genetic factors might be responsible for the lower hypertension prevalence in Bai Ku Yao population.

[Bipolar coagulation used in selective feticide of monochorionic twins with one twin anomaly].

OBJECTIVE: To summarize our preliminary experience of selective feticide with bipolar coagulation in complicated monochorionic twins (MCT), and discuss the clinical application of feticide in discordant MCT. METHODS: Three MCT with one twin anomaly, in which 2 had severe twin-twin transfusion syndrome (TTTS), stage IV, and 1 had acardiac twin, were identified in the second trimester of pregnancy. To terminate the abnormal twin and isolate the co-twin's circulation completely, selective feticide was performed by umbilical cord occlusion with bipolar coagulation under guidance of ultrasound and fetoscopy. After each invasive procedure, serial monitoring was performed, including procedural complications, Doppler of fetal middle cerebral artery and umbilical artery. Pregnancies were followed up every 2 weeks for fetal growth until delivery. After birth the placentas and the terminated fetuses were examined. RESULT: Cord occlusion was successfully accomplished in all 3 targeted fetuses, at 21, 22 and 24 weeks of gestation respectively. One case with TTTS was complicated with rupture of the membrane in the terminated fetus the 7th day after the procedure, and a healthy baby was born at 32 weeks. The other case with TTTS delivered a boy by cesarean section at 38 weeks. The third case with TRAP is at 35 weeks of gestations and under regular follow-up. Monochorionicity was confirmed by placental examination after delivery, and the effects of bipolar coagulation were observed at the cord of terminated fetuses. CONCLUSIONS: Umbilical cord occlusion with bipolar coagulation is an effective procedure for selective feticide in MCT with one twin anomaly. The outcome of normal fetus can be favorable.

[Clinical study and prenatal diagnosis of fetus with shortened long bones].

OBJECTIVE: To investigate the manifestations and prenatal diagnosis of the fetus with shortened long bones. METHODS: Ultrasonography was conducted on 57 fetuses with shortened long bones and 62 normal fetuses. Percutaneous umbilical blood sampling was performed on the 57 cases to undergo examination of karyotype and mutation in exon 10 of fibroblast growth factor receptor (FGFR)3 gene. Fetal radiography and autopsy were performed in 30 abnormal induced fetuses. RESULTS: Among the 57 fetuses of the shortened long bones group 21 (37%) were diagnosed as with specific skeletal dysplasia postnatally, abnormal chromosome were found in 8 (14%), 4 (7%) were with fetal growth restriction, and 24 (42%) were with unknown etiology. Prenatal ultrasonography showed that in the fetuses with skeletal dysplasia the value of standard deviation score (SD) for femur length and/or humerus length fell to -4 SD of the corresponding pregnancy week, and increase of biparietal diameter was often found; in the fetuses with abnormal chromosome and fetal growth restriction (FGR) the degree of bone shortening was between -2 SD to -4 SD; and in the fetuses with lethal skeletal dysplasia the long bones were shortened at the degree more than -8 SD. When the ratio of femur length to abdominal circumference was less than 0.16, the sensitivity and specificity for predicting narrow thorax were 100% and 85.7% respectively. CONCLUSION: The causes of fetus with shortened long bones include abnormal chromosome, skeletal dysplasia, and FGR. Femur length and/or humerus length falls below -4SD is almost an indication for skeletal abnormality. When the SD is between -2SD and -4SD, chromosome analysis is necessary and regular ultrasonography is recommended. When the femur length and/or humerus length is below -8SD and femur length/abdominal circumference (FL/AC) is less than 0.16, lethal skeletal dysplasia is suspected.