Comparison of management options for twin pregnancies with cervical shortening.

OBJECTIVE: To compare the effectiveness of expectant management (EM), cervical cerclage (CC) and vaginal progesterone (VP) in decreasing the rate of spontaneous preterm birth in twin gestations with midtrimester cervical shortening. STUDY DESIGN: This is a retrospective cohort study comparing pregnancy outcomes of twin gestations with midtrimester cervical shortening, defined as a cervical length (CL) on routine transvaginal ultrasound between 15 weeks 0 days and 24 weeks 6 days gestation of <2.5 cm, managed with either EM, CC or VP. Women were categorized by final management strategy. Primary outcome was gestational age at delivery. Secondary outcomes included latency period (defined as number of weeks between a diagnosis of cervical shortening and delivery), gestational age at delivery <32 weeks, mode of delivery, perinatal death, neonatal birthweight and rate of chorioamnionitis. Subanalysis of women with a CL < 1.5 cm was also performed. Logistic regression was used to identify predictors of delivery <32 weeks, controlling for potential confounders. RESULTS: Between January 2006 and July 2016, 64 pairs of twins with midtrimester cervical shortening were identified, 18 managed with EM (28.1%), 29 CC (45.3%), and 17 VP (26.6%), 52 of which had information regarding delivery outcomes. 90.4% of women delivered prematurely (<37 weeks). Women in the CC group were diagnosed with cervical shortening at a significantly earlier mean gestational age (CC 20.6 ± 1.7 weeks versus EM 22.2 ± 2.9 weeks and VP 22.2 ± 2.0 weeks, p = .02) and had a shorter mean cervical length at the time of diagnosis (CC 1.18 ± 0.7 cm vs. EM 1.56 ± 0.7 and VP 1.95 ± 0.6, p = .002), as compared to those in the EM and VP groups. There was no difference in gestational age at delivery (EM 30.9 ± 5.2 weeks, CC 30.4 ± 4.9 weeks and VP 32.4 ± 4.1 weeks, respectively) or any of the secondary outcomes listed above. Women with a CL <1.5 cm delivered significantly earlier than those with a cervical length ≥1.5 cm (28.4 ± 4.7 weeks vs. 33.2 ± 3.6 weeks, p = .0001). After adjusting for potential confounders, cervical length <1.5 cm, not the management strategy, was the predictor of PTB before 32 weeks in this twin population [AOR 6.56 (95% CI 1.78, 24.20), p = .005]. CONCLUSION: Twin pregnancies with midtrimester cervical shortening are at high risk for preterm delivery, and outcomes were similar regardless of management strategy. Large prospective trials are needed to evaluate the effect of different management strategies for cervical shortening in twins.

The natural history of an umbilical cord hemangioma.

Umbilical cord hemangiomas are rare, and the natural history is poorly understood. We present a case where the clinical course was complicated by distal umbilical cord edema, episodes of proximal obstruction of umbilical artery blood flow, transient fetal pleural and pericardial effusions, and position-dependent abnormal fetal heart rate monitoring with periods of sustained fetal tachycardia. Delivery was performed for fetal growth restriction with abnormal fetal surveillance. This case highlights possible mechanisms for fetal decompensation as well as the importance of a multifaceted approach to the management of an umbilical cord mass using multiple tools for fetal assessment. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:455-458, 2016.

Fetal cardiocentesis: a review of indications, risks, applications and technique.

OBJECTIVES: To review the indications, applications and technique of fetal cardiocentesis. METHODS: Review of published case reports and case series of fetal cardiocentesis utilizing the PubMed search engine of the National Library of Medicine. RESULTS: Case reports and case series demonstrate that fetal cardiocentesis may be an alternative method by which to facilitate prenatal diagnosis, intravascular therapy, multifetal and selective fetal reduction and in utero therapy of congenital heart disease. However, procedure-associated risk is higher than with cordocentesis and may limit use of this procedure. CONCLUSIONS: Fetal cardiocentesis may be a reasonable option to obtain fetal intravascular access and facilitate therapeutic interventions when cordocentesis fails or is not feasible. However, expected benefit must clearly outweigh the procedure-associated risk.

Emergent fetal intracardiac transfusion for thrombocytopenia and acute hypovolemia due to cordocentesis-associated hemorrhage in parvovirus-induced hydrops.

OBJECTIVES: To demonstrate the utility of fetal intracardiac transfusion to correct acute fetal hypovolemia and thrombocytopenia in fetal Parvovirus infection. METHODS: Intracardiac transfusion in a 19-week gestation was indicated due to cordocentesis-associated hemorrhage. RESULTS: Intracardiac transfusion resulted in correction of acute bradycardia, anemia and thrombocytopenia and persistent umbilical cord hemorrhage following attempted intravascular transfusion. CONCLUSIONS: This case illustrates the importance of anticipating both thrombocytopenia and anemia in fetal Parvovirus infection and how an intracardiac approach can be employed in the setting of acute, life-threatening hemorrhage.