Short-Term Flow Changes in Monochorionic Survivor Twins after Ultrasound-Guided Umbilical Cord Occlusion.

OBJECTIVE: To determine hemodynamic changes by Doppler ultrasound of the living fetus during 24 h after umbilical cord occlusion (UCO) in monochorionic diamniotic (MCDA) twin pregnancies. METHOD: We conducted a prospective observational study on fetuses undergoing UCO from 2015 to 2017. Doppler parameters peak systolic velocity (PSV) and umbilical pulsatility index (PI) were obtained in the middle cerebral artery (MCA), umbilical artery (UA) and ductus venosus (DV) before and right after UCO, and at 1, 3, 6, 12, and 24 h after. We used multiple of the median (MoM) to adjust for gestational age. Spaghetti plots visualized flow changes over time. Mixed model adjusting for paired longitudinal data compared the values at different time points. RESULTS: A total of 16 women were included. MCA-PSV dropped within the first hour after surgery from 0.91 to 0.82 MoM (p = 0.08). MCA-PI and UA-PI increased in the first hour from 0.75 to 0.91 MoM (p = 0.02) and 0.94 to 0.98 MoM (p = 0.22), respectively. The DV-PIV increased to 1.14 MoM 3 h after surgery (p = 0.07). The spaghetti plots illustrated the small changes within the first hours and showed a stabilization of flow measurements near initial values 24 h after UCO. CONCLUSION: Within the first hours after UCO the circulation of the survivor twin undergoes small hemodynamic changes.

Magnetic Resonance Imaging: A New Tool to Optimize the Prediction of Fetal Anemia?

INTRODUCTION: The false-positive rate in the prediction of fetal anemia is 10-15%. We investigated if a new, noninvasive MRI method used as a supplement to ultrasound could improve the prediction. METHODS: Fetuses suspected of anemia and controls were scanned in a 1.5-tesla MRI scanner 1-4 times during pregnancy. Cases were scanned before and after intrauterine blood transfusion with a T1-mapping MRI sequence in a cross-section of the umbilical vein. RESULTS: Inclusion of 8 cases and 11 controls resulted in 10 case scans (2 cases were included twice) and 33 control scans. In controls, the T1 relaxation time was 1,005-1,391 ms; in cases with severe anemia, 1,505-1,595 ms, moderate anemia 1,503-1,525 ms, and no/mild anemia 1,245-1,410 ms. After blood transfusions, values dropped to 1,123-1,288 ms. The mean value in moderate and severe anemic cases was 275 ms higher than in controls (95% CI 210-341 ms, p < 0.0001), and after blood transfusion it was comparable to controls (3 ms, 95% CI -62 to 68 ms, p = 0.934). A 1,450-ms cut-off would have identified all cases in need of blood transfusion with no false-positive cases. CONCLUSIONS: Our findings indicate a potential for this new MRI method to improve the prediction of fetal anemia as a supplement to ultrasound.

Long-Term Neurodevelopmental Outcome of Monochorionic Twins after Laser Therapy or Umbilical Cord Occlusion for Twin-Twin Transfusion Syndrome.

INTRODUCTION: We sought to assess the incidence of severe neurodevelopmental impairment (NDI) in monochorionic twins treated for twin-twin transfusion syndrome (TTTS) and compare it to the incidence in uncomplicated monochorionic twins. MATERIAL AND METHODS: We included TTTS pregnancies treated by fetoscopic selective laser coagulation (FSLC) or umbilical cord occlusion (UCO) in 2004-2015. Primary outcome was severe NDI defined as cerebral palsy, bilateral blindness or bilateral deafness (ICD-10 diagnoses), and severe cognitive and/or motor delay (assessed by the Ages and Stages Questionnaires [ASQ]). RESULTS: A total of 124 children after TTTS and 98 controls were followed up at 25 months of age (SD 11.4). Severe NDI was found in 8.9% of the TTTS children (10.5% [9/86] after FSLC; 5.3% [2/38] after UCO) compared to 3.1% in the control group (p = 0.10). The odds ratio for severe NDI was 1.8 in cases versus controls (p = 0.37). The total ASQ score was significantly lower in the TTTS group than in controls (p = 0.03) after FSLC (p = 0.03) and after UCO (p = 0.14). DISCUSSION: Children after TTTS appear to have a higher risk of severe NDI and score significantly lower on the ASQ compared to monochorionic twins from uncomplicated pregnancies.

Outcomes of monoamniotic twin pregnancies managed primarily in outpatient care-a Danish multicenter study.

INTRODUCTION: Monoamniotic twin pregnancies are high-risk pregnancies, and management by inpatient or frequent outpatient care is recommended. We report the outcomes of a national cohort of monoamniotic twin pregnancies managed primarily as outpatients. MATERIAL AND METHODS: We prospectively analyzed the recorded data from the Danish Fetal Medicine Database, local databases, and medical records of all monoamniotic twin pregnancies diagnosed at the first trimester scan or later, and managed at the six major fetal medicine centers in Denmark over a 10-year period. RESULTS: Sixty-one monoamniotic twin pregnancies were included. Thirteen pregnancies were terminated early. Of the remaining 48 pregnancies with a normal first trimester scan, there were 36 fetal losses (25 spontaneous miscarriages <22+0  weeks, 3 late terminations and 8 intrauterine deaths >22 weeks) and 60 liveborn children (62.5%), all of whom were delivered by cesarean delivery at a median gestational age of 33+0  weeks. Three children had minor malformations and there was 1 pregnancy with twin-to-twin transfusion syndrome. After 26+0  weeks, 78.8% were managed as outpatients. Intrauterine death occurred in 3.8% of outpatients and in 28.6% of inpatients (admitted due to complications). At weeks 32, 33 and 34, the prospective risk of intrauterine death was 6.9%, 4.2% and 5.9%, respectively. CONCLUSION: In this nationwide, unselected population, only 62.5% of fetuses with a normal first trimester scan were born alive. In contrast, the mortality was 3.8% after 26 weeks among the 78.8% of the cohort that was managed as outpatients. More knowledge is still needed to predict which pregnancies are at the highest risk of intrauterine death.

Ultrasound-Guided Bipolar Umbilical Cord Occlusion in Complicated Monochorionic Pregnancies: Is There a Learning Curve.

INTRODUCTION: Ultrasound-guided bipolar umbilical cord occlusion (UCO) is used in complicated monochorionic multiple pregnancies in Denmark. The aim of this study was to assess a learning curve in the procedure of UCO. MATERIALS AND METHODS: One hundred and two monochorionic pregnancies treated with UCO at Rigshospitalet, Denmark between 2004 and 2015 were included. The procedures were divided into period 1 (2004-2009) and period 2 (2010-2015) to determine a learning curve. Primary outcome measure was survival rate. Secondary outcome measures were time from operation to fetal loss and gestational age (GA) at delivery. RESULTS: Period 1 included 59 cases. The median GA at procedure was 19.9 weeks (range 16.7-25.9) and at delivery 34.7 weeks (range 24.3-40.3). Period 2 included 43 cases. The median GA at procedure was 20.7 weeks (range 16.7-27.6) and at delivery 37.3 weeks (range 29.1-40.3). Survival rate increased from 78% (period 1) to 95% (period 2) (p = 0.02). GA at delivery increased as well. Fetal death within 48 h after surgery decreased from 4 (period 1) to 0 (period 2). DISCUSSION: Our results suggest a learning curve in the procedure of UCO with improved outcome on all measures.

Stable fetal hemodynamics measured by Doppler flow after initiation of anti-hypertensive treatment with methyldopa in pregnant women with diabetes.

AIM: To evaluate whether initiation of anti-hypertensive treatment with methyldopa affects fetal hemodynamics in women with pregestational diabetes. METHODS: Prospective study of unselected singleton pregnant women with diabetes (seven type 1 and two type 2 diabetes), normal blood pressure and kidney function at pregnancy booking. Methyldopa treatment was initiated at blood pressure >135/85 mmHg and/or urinary albumin excretion (UAE) >300 mg/g creatinine. Pulsatility indices (PI) of the uterine, umbilical, middle cerebral arteries before and 1 week after initiation of methyldopa treatment (250 mg three times daily) was performed and the cerebro-placental ratio (CPR) was calculated. RESULTS: Methyldopa treatment was initiated at median 249 (range 192-260) gestational days, mainly due to gestational hypertension (n = 7). Blood pressure declined from 142 (112-156)/92 (76-103) mmHg before to 129 (108-144)/82 (75-90) mmHg after initiation of methyldopa treatment (p = 0.11 and 0.04 for systolic and diastolic blood pressure, respectively). There were no significant changes in the umbilical artery PI (0.82 (0.72-1.40) versus 0.87 (0.64-0.95), p = 0.62) or CPR (1.94 (0.96-2.33) versus 1.78 (1.44-2.76), (p = 0.73). Gestational age was 265 (240-270) d. Apgar scores were normal. CONCLUSIONS: Stable Doppler flow velocity waveforms were documented after initiation of methyldopa treatment for pregnancy-induced hypertensive disorders in this cohort of pregnant women with pregestational diabetes.

Invasive treatment in complicated monochorionic twin pregnancies: indications and outcome of 120 consecutively treated pregnancies.

OBJECTIVE: Monochorionic twin pregnancies are associated with increased risk of severe complications. Umbilical cord occlusion (UCO) and fetoscopic selective laser coagulation (FSLC) are used as invasive treatment. The study aim was to document treatment indications and pregnancy outcome where UCO and FSLC were used for treating fetal discrepancies and twin-to-twin transfusion syndrome (TTTS). DESIGN: Cohort study of all consecutively treated monochorionic twin pregnancies 2004-2010. SETTING: Tertiary care center. POPULATION: One hundred and twenty pregnancies treated by FSLC (55) or UCO (65). Umbilical cord occlusion was undertaken in 49 TTTS cases, in four cases with fetal abnormality and TTTS and in 12 cases because of fetal anomaly only. MAIN OUTCOME MEASURES: Overall survival per fetus, survival per pregnancy of at least one fetus and further survival according to the Quintero stages. Infant survival until at least one week after birth. RESULTS: Of the pregnancies studied, 84% had TTTS, 13% had a fetal malformation and 3% had both. Of TTTS cases, 69% were Quintero stage 3 and 4. In the UCO group with TTTS, 87% were in stage 3 and 4. Survival in the UCO group was 82%. In the laser group, the survival of at least one fetus was 85%. Overall survival per fetus was 60%. CONCLUSIONS: By far the most common indication for invasive treatment was TTTS in Quintero stage 3. Outcome by means of survival after FSLC and UCO were similar to what has been reported elsewhere. Cord occlusion was an acceptable treatment alternative to fetoscopic selective laser coagulation in severe TTTS cases.

Implications of a first trimester Down syndrome screening program on timing of malformation detection.

OBJECTIVE: To determine the impact which introduction of the 11-14 week scan has had on the gestational age at which fetal malformations are detected by ultrasound in an unselected population of pregnant women. DESIGN: Retrospective study. SETTING: University hospital, Copenhagen, Denmark, covering the period 1 January 2003 to 30 June 2007. POPULATION: All pregnant women who chose a nuchal translucency scan at 11-14 weeks for Down syndrome risk estimate, and a scan at 18-20 weeks to screen for fetal malformations. METHODS: Review of cases detected ante- and postnatally. MAIN OUTCOME MEASURES: Detection rates at 11-14 weeks relative to all malformations in the population. RESULTS: A total of 216 anomalies were detected in 200 fetuses among the 9 324 fetuses included, while 70 anomalies were diagnosed in 59 infants postnatally. The prevalence of fetuses with anomalies was 2.8% (259 of 9 324). After excluding cases of pyelectasis (127), which may be considered physiological and transitory changes, the prevalence of malformed fetuses was 1.4% (132 of 9 324). Of the malformations detected antenatally, 25.8% were detected before week 15 and 59.6% in weeks 16-22. The remaining 14.6% of malformations were discovered after week 22. Among the lethal malformations, 50% were diagnosed before week 15. CONCLUSIONS: Although the purpose of the first trimester scan is to screen for Down syndrome and not for malformations, the introduction of the 11-14 week scan has resulted in the detection of approximately 26% of fetal malformations.

[Prenatal diagnosed hydronephrosis and other urological anomalies]. / Praenatalt diagnosticeret hydronefrose og andre urologiske anomalier.

By renal ultrasound examination, urological anomalies may be demonstrated in 1-2% of fetuses and in about 0.5% of newborns. Boys have about twice the frequency of girls. Surgical treatment is indicated in about one fourth of these urological anomalies. If all pregnant women in Denmark were to have fetal ultrasound examination of the kidneys and the urinary tract, about 70 children would be born each year with a prenatally diagnosed urological anomaly for which surgical procedure is or will be indicated. This paper provides Danish guidelines for prenatal diagnosis, follow-up and intervention in cases of urological anomalies and guidelines for post-natal diagnosis, follow-up and treatment of these anomalies, especially hydronephrosis.