An update of diagnostic efficacy of ultrasound and magnetic resonance imaging in the diagnosis of clinically significant placenta accreta spectrum disorders

Systematic screening and diagnosis of placenta accreta spectrum disorder (PAS) either by ultrasound or magnetic resonance imaging (MRI) would allow referral of high-risk women to specialized multidisciplinary teams. We aimed to report recent findings regarding the diagnostic accuracy of ultrasound and magnetic resonance imaging in the diagnosis of PAS

Small-for-gestational-age fetus diagnosed in the second trimester: Possible etiologies and short-term neonatal outcomes

Introduction: The aim of our study was to investigate the causes of fetal growth <10th centile diagnosed <26 weeks' gestation in singleton pregnancies and compare pregnancy outcomes in relation to the identified etiology. Material and methods: Historical cohort study conducted in two Italian hospitals which included all small-for-gestational-age fetuses diagnosed between 18+0 and 26+0 weeks over a 10-year period. Fetuses were divided into three groups depending on the prenatally suspected etiology: chromosomal abnormalities (Group 1), malformations (Group 2) and isolated (Group 3). These groups were compared regarding pregnancy outcomes. Fetuses in Group 3 were divided into small-for-gestational-age and fetal growth restriction following the Delphi Consensus criteria and the outcomes were further compared. Fisher's Exact or Mann-Whitney test were used for comparison of groups. Results: In all, 435 fetuses were included. Of these, 20 cases (4.6%) were associated with chromosomal abnormalities (Group 1), 98 (22.5%) with fetal malformations (Group 2) and 317 (72.9%) were isolated (Group 3). A higher percentage of live births was reported for Group 3 (P < 0.001). Termination of pregnancy was more common in Group 1 (P < 0.001). No differences in gestational age at delivery, birthweight, intrauterine death or neonatal death were detected within groups. Growth-restricted fetuses had lower gestational age at delivery, birthweight and number of live births (P < 0.001), higher rates of termination of pregnancy, intrauterine death (P < 0.001) and neonatal death <10 days (P = 0.002) compared to small-for-gestational-age. In 17 cases a chromosomal abnormality, genetic syndrome or adverse neurological outcome was diagnosed after birth: six from Group 2 (11.3% of live births in this group) and 11 from Group 3 (4.3%). Conclusions: We report that fetal growth <10th percentile diagnosed before 26 weeks is not isolated before birth in 27% of cases. Malformations and chromosomal abnormalities are common etiologies; therefore, detailed anomaly scans and invasive testing should be offered. In addition, there is a residual risk of neonatal death and postnatal diagnosis of a genetic syndrome or neurodevelopmental impairment despite normal prenatal tests. These results expand the small amount of information on the outcome of cases with very early diagnosis of impaired fetal growth currently available and highlight the importance of detailed counseling with couples

Treatment of Early Cesarean Scar Pregnancy with Double Balloon Catheter: A Systematic Review of the Literature

Background: Cesarean scar pregnancy (CSP) is a pregnancy in the scar area or “niche” from a prior hysterotomy, usually from a cesarean section. Currently, there is no consensus on the best management of CSP. A recent proposed treatment consists in placing a cervical ripening double-balloon catheter in the uterus under ultrasound guidance. Methods: In this systematic review on cervical ripening double-balloon catheter (CRDBC) treatment for CSP, we performed a literature search in electronic databases (Scopus, PubMed, MEDLINE, and Cochrane Library), from their inception until April 2023. The review was written following PRISMA guidelines for systematic reviews. Results: We identified 30 studies, and we finally analyzed 5 studies that met the inclusion criteria (one case report, two retrospective case series studies, a retrospective cohort study, and a retrospective multicentric case series). The total of pregnancies treated with CRDBC is 71, of which 8 (11%) were cervical pregnancies. The gestational age at treatment ranges from 5 + 0 to 10 + 1 gestational weeks, with variable human chorionic gonadotropin (hCG) levels (433–64.700 IU/mL). Most of the patients (73%) received adjuvant systemic methotrexate (MTX) and the catheter dwell time ranges from 1 to 5 days. Treatment was successful in all the patients. Maternal complications, defined as the need for transfusion, vaginal bleeding resulting in readmission, or requiring further treatment occurred in a small number of patients (4.2%). Conclusions: CRDBC was successful in the treatment of early CSPs. The effectiveness and safety of this minimally invasive method is testified to a small rate of maternal complications. Further prospective studies are warranted to explore this treatment modality

Perinatal and 2-year neurodevelopmental outcome in late preterm fetal compromise: the TRUFFLE 2 randomised trial protocol

Introduction: Following the detection of fetal growth restriction, there is no consensus about the criteria that should trigger delivery in the late preterm period. The consequences of inappropriate early or late delivery are potentially important yet practice varies widely around the world, with abnormal findings from fetal heart rate monitoring invariably leading to delivery. Indices derived from fetal cerebral Doppler examination may guide such decisions although there are few studies in this area. We propose a randomised, controlled trial to establish the optimum method of timing delivery between 32 weeks and 36 weeks 6 days of gestation. We hypothesise that delivery on evidence of cerebral blood flow redistribution reduces a composite of perinatal poor outcome, death and short-term hypoxia-related morbidity, with no worsening of neurodevelopmental outcome at 2 years. Methods and analysis: Women with non-anomalous singleton pregnancies 32+0 to 36+6 weeks of gestation in whom the estimated fetal weight or abdominal circumference is &lt;10th percentile or has decreased by 50 percentiles since 18-32 weeks will be included for observational data collection. Participants will be randomised if cerebral blood flow redistribution is identified, based on umbilical to middle cerebral artery pulsatility index ratio values. Computerised cardiotocography (cCTG) must show normal fetal heart rate short term variation (≥4.5 msec) and absence of decelerations at randomisation. Randomisation will be 1:1 to immediate delivery or delayed delivery (based on cCTG abnormalities or other worsening fetal condition). The primary outcome is poor condition at birth and/or fetal or neonatal death and/or major neonatal morbidity, the secondary non-inferiority outcome is 2-year infant general health and neurodevelopmental outcome based on the Parent Report of Children's Abilities-Revised questionnaire. Ethics and dissemination: The Study Coordination Centre has obtained approval from London-Riverside Research Ethics Committee (REC) and Health Regulatory Authority (HRA). Publication will be in line with NIHR Open Access policy. Trial registration number: Main sponsor: Imperial College London, Reference: 19QC5491. Funders: NIHR HTA, Reference: 127 976. Study coordination centre: Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS with Centre for Trials Research, College of Biomedical &amp; Life Sciences, Cardiff University. IRAS Project ID: 266 400. REC reference: 20/LO/0031. ISRCTN registry: 76 016 200

Fetal anemia: Diagnosis and management

Fetal anemia has been known for many years as a dangerous complication of pregnancy. Its most common causes are maternal alloimmunization and parvovirus B19 infection, although it can be associated with many different pathological conditions including fetal aneuploidies, vascular tumors, and arteriovenous malformations of the fetus or placenta and inherited conditions such as alpha-thalassemia or genetic metabolic disorders. Doppler ultrasonographic assessment of the peak velocity of systolic blood flow in the middle cerebral artery for the diagnosis of fetal anemia and intravascular intrauterine transfusion for its treatment are the current practice standards. Live birth rates as high as 95% have been reported in recent years. The additional role of intravenous immunoglobulin therapy and the long-term consequences of the condition are the subjects of active ongoing research. © 201

Timing of intra‐fetal laser therapy for twin reversed arterial perfusion ( TRAP ) sequence: Retrospective series and systematic review and meta‐analysis

Objective To estimate the neonatal survival rate after intra-fetal laser (IFL) treatment for twin reversed arterial perfusion (TRAP) sequence, and to investigate the effect of gestational age at the time of procedure. Methods Retrospective cohort study of TRAP sequences followed at our institution from 2013-2020. Systematic review and meta-analysis of the neonatal survival rate after IFL was conducted. Both diamniotic and monoamniotic monochorionic pregnancies were included. A subgroup analysis to compare outcomes according to gestational age at procedure (= 16(+0) weeks) was planned. Results Thirteen pregnancies were followed at our center and seven were treated with IFL: the survival rate was 57%. Ten studies published between 2008 and 2020 for a total of 156 cases were included in the meta-analysis. The overall neonatal survival after IFL was 79% (95% CI 0.72-0.86, I-2 22%). A random-effects model comparing neonatal survival for IFL performed = 16(+0) weeks showed no significant difference between the two groups (OR = 0.93; 95% CI 0.37-2.33). Conclusion IFL is a safe and minimally invasive technique for the treatment of TRAP sequence, with a survival rate of 79%. Gestational age at treatment (before or after 16 weeks) does not seem to affect neonatal survival rate