Sonographic spectrum and postnatal outcomes of early-onset versus late-onset fetal cerebral ventriculomegaly.

OBJECTIVES: To review the prenatal characteristics and postnatal outcomes of Early-onset and Late-onset cerebral ventriculomegaly (VM). METHODS: Single-center retrospective study 2013-2017; VM cases grouped into Early-onset VM (EVM; Diagnosis at/before 24 weeks) and Late-onset VM (LVM; Beyond 24 weeks). LVM cases had normal ventricle width measurement at mid-trimester scan. Infection serology, cytogenetics, MRI, sonographic follow-up, perinatal and neurodevelopmental outcomes were analyzed. RESULTS: During the 5-year period, 64,662 women underwent an anomaly screening scan and 302 fetuses were identified with ventriculomegaly; 183 (60.6%) classified as early-onset and 119 (39.4%) LVM. The mean ventricular width was significantly higher in LVM cohort (14.1 mm vs 11.6 mm; p < .01). EVM cases were more often associated with structural anomalies (p < .05). Possible etiologies for EVM were aneuploidy and cerebral malformations like Absent Corpus Callosum, spina bifida, Dandy-Walker malformation, etc., whereas LVM followed aqueductal stenosis, hemorrhage, porencephaly, cerebral tumors, etc. Pregnancy outcomes were available for 251 cases. The pregnancy resulted in more live births in LVM group (87.4% vs 65.6%, p = < .01). Multivariate regression analysis demonstrated additional malformations (p < .0001, OR11.5 [95%CI: 4-35.2]), progression of VM (p = .004, OR 10.2 [95% CI: 2.1-52.3]) and severity of VM (OR 5.3 [95%CI: 0.8-37.7]) were significant predictors of Neurodevelopmental Impairment (NDI). Late gestation at diagnosis was more often associated with NDI (p = .063, OR2.4 [95%CI: 0.9-6.2]), although statistically insignificant. CONCLUSIONS: EVM has a significantly different sonographic spectrum and outcomes compared to LVM. EVM is milder and associated with an increased risk of aneuploidy and structural malformations. LVM often occurs secondary to acquired brain lesions.

Perinatal Palliative Care Service: Developing a Comprehensive Care Package for Vulnerable Babies with Life Limiting Fetal Conditions.

Background: Perinatal Palliative Care provides comprehensive and holistic care for expectant and new parents, who receive a diagnosis of life-limiting fetal condition and opt to continue pregnancy and care for their newborn infant. Aim: To develop a service providing individually tailored holistic care during pregnancy, birth, postnatal and bereavement period. Methods: Following a baseline survey of neonatologists and discussions with key stakeholders we launched the Perinatal Palliative service at the KK Women's and Children's hospital, Singapore in January 2017. The multidisciplinary team, led by a Palliative care specialist comprised of Obstetricians, Neonatologists, nurses and medical social workers. The Birth defect clinic referred parents with antenatally diagnosed 'Lethal' fetal conditions. The team checked the understanding and the decision making process of parents and initiated and finalized advance care plans. The service also embraced deserving postnatal referrals upon request. Results: A total of 41 cases were seen from January 2017 to December 2019. Of these, 26/41(63%) were referred antenatally and had completed advance care plans. 18/41 (44%) died during or shortly after birth and 10/41(24%) continue to survive and are supported by the community palliative team. During this time a workflow was formulated and modified based on parent and team feedback. Conclusion: Awareness of the service has increased over the years and a clear workflow has been formulated. Advance care plans are prepared and documented before birth so as to enable service teams on board to provide well timed pertinent care. Feedbacks from parents about this service were positive.

Outcomes following selective fetoscopic laser ablation for twin-to-twin transfusion syndrome: a single-centre experience.

INTRODUCTION: Fetoscopic laser photocoagulation (FLP), a treatment option for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies, is currently the treatment of choice at our centre. We previously reported on our experience of FLP from June 2011 to March 2014. This paper audits our fetal surgery performance since then. METHODS: 15 consecutive patients who underwent FLP for Stage II-III TTTS before 26 weeks of gestation from June 2011 to January 2017 were retrospectively reviewed, consisting of five cases from our initial experience and ten subsequent cases. Perioperative, perinatal and neonatal outcomes were analysed. RESULTS: Of 15 pregnancies, 10 (66.7%) and 5 (33.3%) were for Stage II and III TTTS respectively, with FLP performed at an earlier Quintero stage in the later cohort. Overall mean gestational ages at presentation, laser and delivery were comparable between the cohorts at 19.7 (15.4-24.3) weeks, 20.3 (16.3-25.0) weeks and 31.2 (27.6-37.0) weeks, respectively. 2 (13.3%) cases had intra-amniotic bleeding and 1 (6.7%) had iatrogenic septostomy. 1 (6.7%) case had persistent TTTS requiring repeat FLP, and another (6.7%) had preterm premature rupture of membranes at seven weeks post procedure. The overall perinatal survival rate was 21 (75.0%) out of 28 infants. One mother underwent termination of pregnancy for social reasons at 1.4 weeks post procedure. Double survival occurred in 8 (57.1%) out of 14 pregnancies, while 13 (92.9%) had at least one survivor. CONCLUSION: FLP requires a highly specialised team and tertiary neonatal facility. Continual training improves maternal and perinatal outcomes, ensuring comparable standards with international centres.

Gender-Specific Reference Charts of Fetal Head Circumference in a Singaporean Population.

INTRODUCTION: With the global outbreak of Zika virus and its association with microcephaly, an up-to-date fetal head circumference (HC) nomogram is crucial to offer a reference standard in order to make an accurate diagnosis. This study was conducted to revise the local fetal HC nomogram. MATERIALS AND METHODS: In this retrospective study, ultrasound data was used for construction of the fetal HC nomogram from a total of 6155 pregnancies in the ethnic Chinese population with low risk profile at KK Women's and Children's Hospital over a 10-year period. Regression model was fitted to calculate the mean and standard deviation of HC at each gestational age (GA). Comparison of HC between ethnic groups (no significant differences) and genders were made. The revised chart was compared with another commonly used reference chart (Hadlock). In an independent test population, different reference charts were used to estimate number of cases with microcephaly. RESULTS: A statistically significant difference of HC between the genders was observed across all gestational ages. Gender-specific reference charts and equation were computed. Our revised fetal HC chart showed a different distribution from the Hadlock chart. Compared with the gender-specific charts, the Hadlock HC chart would significantly under-report microcephaly cases in male fetuses, and tend to over-report in female fetuses. CONCLUSION: This study provides a new set of gender-specific fetal HC charts in the Singaporean population for antenatal ultrasound surveillance of microcephaly.

Fetoscopic laser photocoagulation in twin-to-twin transfusion syndrome: experience from a single institution.

INTRODUCTION: Twin-to-twin transfusion syndrome (TTTS) is the most common serious complication of monochorionic (MC) twin pregnancies, with perinatal mortality rates of up to 90% if untreated. This study aimed to review the perinatal and perioperative outcomes of MC twin pregnancies treated for TTTS by fetoscopic laser photocoagulation (FLP) since its introduction at KK Women's and Children's Hospital (KKH), Singapore, in 2011. METHODS: This was a retrospective review of five consecutive patients who underwent FLP of placental anastomoses for TTTS at KKH from June 2011 to March 2014. FLP was offered to patients who were diagnosed with TTTS of at least Quintero Stage II before 26 weeks of gestation. The main outcome measures were perioperative complications and perinatal survival rates. RESULTS: Five sets of MC twin pregnancies underwent FLP during the study period - three pregnancies were diagnosed with Stage III TTTS and two pregnancies with Stage II TTTS. Median gestational ages at initial presentation, laser photocoagulation and delivery were 19 (range 17-20) weeks, 20 (range 19-23) weeks and 29 (range 28-34) weeks, respectively. One patient had bleeding into the amniotic cavity intraprocedurally. Overall, the perinatal survival rate, double-infant survival rate and survival rate for at least one twin were 60% (6/10 fetuses), 40% (2/5 twins) and 80% (4/5 twins), respectively. CONCLUSION: FLP is a feasible treatment for TTTS, with minimal maternal complications. Perinatal survival rates of this patient group that was managed at our centre were comparable to those of international centres.

An unusual presentation of recurrent uterine rupture during pregnancy.

We describe a case of recurrent uterine rupture at the site of a previous rupture. Our patient had a history of right interstitial pregnancy with spontaneous uterine fundal rupture at 18 weeks of pregnancy. During her subsequent pregnancy, she was monitored closely by a senior consultant obstetrician. The patient presented at 34 weeks with right hypochondriac pain. She was clinically stable and fetal monitoring showed no signs of fetal distress. Ultrasonography revealed protrusion of the intact amniotic membranes in the abdominal cavity at the uterine fundus. Uterine rupture is a rare but hazardous obstetric complication. High levels of caution should be exercised in patients with a history of prior uterine rupture, as they may present with atypical symptoms. Ultrasonography could provide valuable information in such cases where there is an elevated risk of uterine rupture at the previous rupture site.

Ruptured interstitial ectopic pregnancy at 18 weeks gestation diagnosed by MRI: a case report.

Ectopic pregnancy in the interstitial part of the fallopian tube is a rare event, associated with a high rate of complications due to delayed diagnosis. Rupture of such pregnancy often results in catastrophic hemorrhage. Several reports highlighted the role of magnetic resonance imaging in establishing the diagnosis of interstitial pregnancy, but magnetic resonance imaging findings of a ruptured advanced interstitial ectopic pregnancy have not been published before. The authors therefore present characteristic findings on magnetic resonance imaging of a ruptured interstitial ectopic pregnancy which had reached 18 weeks, in a 25-year-old woman who presented with acute abdominal pain.

Incidence and outcome of prenatally diagnosed, chromosomally normal congenital heart defects in Singapore.

INTRODUCTION: Congenital heart defect (CHD) is a significant cause of neonatal and infant mortality. We aimed to evaluate the incidence and pregnancy outcome of foetuses diagnosed with chromosomally normal CHD in KK Women's and Children's Hospital (KKH), Singapore, in 2008-2009. METHODS: We reviewed the medical records of pregnant women who underwent first trimester screening and were diagnosed with foetal CHD at KKH. Additional information was obtained from the Birth Defect Registry for the period 2008-2009. Foetuses with abnormal karyotype or minor lesions not expected to be detected by ultrasonography were excluded. RESULTS: 38 out of 9,834 euploid foetuses were diagnosed with CHD. Major defects were found in 26 (68%) foetuses, while 12 (32%) had minor CHDs. Tetralogy of Fallot, atrioventricular septal defect, hypoplastic left heart syndrome, transposition of the great arteries and ventricular septal defect constituted the five most common major CHDs observed. In 14 (54%) foetuses with prenatally diagnosed major CHD, the outcome was termination of pregnancy, while 12 (46%) pregnancies continued to birth. Among the live-born babies with major CHD, eight (67%) underwent surgery. CONCLUSION: The incidence of non-chromosomal major CHD in Singapore was about 2.6 per 1,000 foetuses. A detection rate of 88.5% was achieved for major CHD during the study period. Advances in CHD management have thrown up new challenges for clinicians in the area of diagnosis, treatment and ethics. Therefore, it may be beneficial to constitute a regulatory entity as a fundamental guide to improve the future management of foetuses diagnosed with CHD.

Lessons learnt from two women with morbidly adherent placentas and a review of literature.

INTRODUCTION: Pathologically adherent placentas occur when there is a defect of the decidua basalis, typically arising from previous caesarean section, resulting in abnormally invasive implantation of the placenta. The depth of placental invasion varies from the superficial (accreta), to transmural and possibly beyond (percreta). CLINICAL PICTURE: We report on 2 cases, one treated "conservatively", the other with a caesarean hysterectomy, both of which led to a safe outcome for both mother and baby. CONCLUSIONS: Management relies on accurate early diagnosis with appropriate perioperative multidisciplinary planning to anticipate and avoid massive obstetric haemorrhage at delivery.