Absent ductus venosus: different perinatal outcome related to anatomy

Congenital absence of the ductus venosus (ADV) is a rare condition which can present with several anatomic settings and associated to congenital anomalies of other systems. Different clinical patterns in the fetus and the newborn can emerge therefore. We report two cases of ADV with opposite perinatal outcomes. Case #1. A 28 y.o. black woman came at 22 weeks’ gestation (GA) for mid-pregnancy evaluation. She showed polyhydramnion (amniotic fluid index (AFI)= 261mm) associated to normal cardiac anatomy and normal karyotype (46,XX). The enlarged umbilical vein (UV) showed a pulsatile pattern at echoDoppler with direct connection to the RA. A fistula between the UV and the iliac artery was evidenced by colorDoppler as well. Despite normal ventricular contractility (EF) and diastolic function (E/A ratio) at echocardiographic monitoring, fetal cardiac enlargement progressively occurred with mild pericardial effusion. At 28 GA placental detachment occurred and a female infant (BW 915g, <10°p) was born with severe perinatal asphyxia. The infant died at 5 hours of life from severe acidosis refractory to intensive care and resuscitation efforts. Postmortem evaluation confirmed the anatomic pattern and absence of the portal vein (PV) was demonstrated as well. Case #2. A 35 y.o. white woman was admitted to our tertiary care at 33 GA because of monolateral renal agenesis and unique umbilical artery. Despite ADV, mesocardia and mild cardiac enlargement the fetus was stable (normal diastole and contractility). The UV echoDoppler showed a normal flat pattern at the beginning of its abdominal course but it progressively became pulsatile as the UV run cephalad to the heart. The infant was born at 38 GA from a planned cesarean delivery (BW 3080g). The perinatal adaptation, karyotype and phenotype were normal. Echocardiography in the newborn showed normal diastole and contractility (E/A ratio, LVEF, LVDd). The associated congenital anomalies were confirmed. DISCUSSION. ADV is a rare anomaly in which perinatal prognosis is difficult to predict and clinical presentation can vary greatly due to the different patterns, i.e. fetal cardiac failure, associated congenital anomalies, polyhydramnion. We reported 2 cases of ADV with opposite clinical course. As it often occurs, case #2 was detected occasionally, late in pregnancy, with a good hemodynamic status despite some malformative features. The normal perinatal transition shifted the cardiovascular system to a setting which did not need any DV activity in regulating venous return and the neonatal course was asymptomatic. Conversely case #1 showed fetal hemodynamics impaired since the beginning of the 3rd trimester. Maybe this could be the consequence of a huge hemodynamic overload due to the presence of both ADV and veno-arterial fistulas emphasizing the diastolic overload of a direct connection of the UV to the RA. The PV was also absent and this has been decribed as being related to a negative prognosis. It is still difficult to completely understand why some fetuses can tolerate the missing function of the DV in regulating the systemic venous return while others do not. To monitorate fetal cardiac function by echoDoppler can be helpful but it is not a standard yet. So case-by-case detailed evaluation of complete anatomy and analysis of both diastole and contractility remains the better choice. Finally the Obstetrician will be mandatory as any modification in the course of pregnancy can be life-threatening due to the thin hemodynamic balance of these fetuses

Antepartum amnioinfusion: a review

OBJECTIVE: Antepartum amnioinfusion is a relatively recent procedure introduced with fetal medicine techniques. It is usually indicated for severe oligohydramnios in order to avoid the related complications such as pulmonary hypoplasia, the deforming effects of oligohydramnios, variable fetal heart rate decelerations and intraventricular hemorrhage. Antepartum amnioinfusion is also employed to improve ultrasound visualization in cases with oligohydramnios. Our objective was to evaluate the benefits and complications related to this procedure which is still less commonly used compared to intrapartum amnioinfusion, and whose risks are therefore not well established. STUDY DESIGN: Reports of study designs identified from searches of MEDLINE, PUBMED, the Cochrane Collaboration, specialized databases and bibliographies of review articles were identified. Studies in women who underwent amnioinfusion between 1987 and 2002 were included. RESULTS AND CONCLUSIONS: Amnioinfusion seems to offer several benefits, in terms of both prenatal diagnosis and favorable perinatal outcome. Most clinical experiences report that amnioinfusion is safe, both for the mother and for the fetus. However, randomized control-group studies subdivided on the basis of the cause of oligohydramnios (e.g. premature rupture of membranes, fetal growth restriction, obstructive uropathy and renal agenesis) could help to determine the advantages and risks linked to this procedure. Prospective randomized studies should therefore be encouraged, to clarify any possible doubts regarding the procedure, before it can be introduced into routine practice in the management of oligohydramnios

Amniotic fluid index versus largest vertical pocket in the prediction of neonatal outcome in post-term pregnancies during induction of labor

Acta Bio Me

Association beetween fetal Doppler velocimetry abnormalities and confined placental trisomy 22: a case report

The occurrence of trisomy 22 confined to the placenta is rare. We report on a patient who presented with fetal abnormal Doppler velocimetry (elevated umbilical artery pulsatility index), but serial ultrasound examinations revealed a spontaneous recovery throughout pregnancy. A healthy baby was normally delivered at 40 weeks

Diagnostic accuracy of IOTA ultrasound morphology in the hands of less experienced sonographers.

Aim: The purpose of our study was to evaluate the ability of the International Ovarian Tumor Analysis (IOTA) classification and its impact on the identification of benign and malignant adnexal masses by less experienced sonographers. Methods: One hundred and five patients undergoing elective surgical treatment for single adnexal masses at the University of Parma were enrolled. After the final diagnosis, we had the ultrasound recordings reviewed retrospectively by a group of three residents, and the features of each adnexal mass were evaluated according to the morphological score reported by the IOTA Group. Results: Based solely on the qualitative classification of the IOTA Group unilocular cysts were associated with a high, significant probability of a benign lesion (odds ratio (OR) = 12.6 (95% CI, 1.61–99.10), P < 0.001). This probability remained high also with multilocular cysts (OR = 7.9 (95% CI, 1.00–62.38), P < 0.05). By contrast, multilocular-solid cysts were significantly associated with the probability of malignancy (OR = 6.4 (95% CI, 1.81–22.70), P < 0.001), as were solid masses (OR = 5.5 (95% CI, 1.48–20.92), P < 0.05). None of the five ultrasound categories of lesions could be significantly correlated with borderline masses. Conclusions: A simple qualitative classification based solely on the recognition of five different ultrasound categories may be enough to guide the physician to an accurate identification of the nature of the mass. Our findings confirm the diagnostic reliability of the IOTA Group classification by less experienced sonographers. This system is especially helpful because it is capable of discriminating between ovarian masses without further tests and clinical examinations