Vasa previa in singleton pregnancies: Diagnosis and clinical management based on an international expert consensus

There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. (s): To systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions (FGD) and a Delphi technique. A four-round FGD and a three-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected based on their publication record on vasa previa. First, we convened an FGD panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A three-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa that the experts were asked to rate on a 5-point Likert scale (from strongly disagree = 1 to strongly agree = 5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of 3 or less were deemed to have had no consensus and excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and non-consensus statements were then aggregated. Sixty-eight international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on five continents and have contributed to over 80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, 91% for the first, second, and third rounds, respectively, and 71% completed all three rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including: 1) While there is no agreement on a distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2 cm distance; 2) All pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; 3) When a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at around 32 weeks to rule out vasa previa; 4) Outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; 5)Asymptomatic patients with vasa previa should be delivered by scheduled cesarean between 35- and 37-weeks of gestation; and 6) There was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. Through FGD and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines. [Abstract copyright: Copyright © 2024. Published by Elsevier Inc.

An ethnic predilection for fetal echogenic intracardiac focus identified during targeted midtrimester ultrasound examination: A retrospective review

BACKGROUND: Echogenic intracardiac focus (EIF) has been identified as a common ultrasound finding in association with fetal aneuploidy. Little is known about the association of this soft marker aneuploidy in various ethnic groups. Although it is commonly thought Asians in general have a higher incidence of EIF, it is unknown whether this also applies to Japanese as a subpopulation. The purpose of this study is to determine the antenatal incidence and postnatal significance of EIF observed during sonography in Japanese patients. METHODS: A cohort of Japanese patients who underwent ultrasound screening from 1997 to 1999 in the ultrasound unit at the New York University School of Medicine was identified. Variables included age, gestational age, serum markers, and the presence or absence of aneuploidy. Patients with first degree paternal or maternal Japanese ancestry were included for analysis. Examinations were performed between 14 and 24 weeks gestation. The prevalence of EIF was calculated. The control group was based on previously published data in the U.S (7.3% prevalence). RESULTS: A total of 154 subjects were identified, 148 were available for final analysis. Twenty-two fetuses had an EIF, 19 (86.4%) left-sided, 3 (13.6%) right-sided. Seventeen patients had other sonographic markers associated with aneuploidy. The mean maternal age at diagnosis was 30.7 ± 3.9 years and the mean gestational age was 19.8 ± 1.6 weeks. The prevalence of EIF was 14.8%. Compared to published population prevalence, there was a statistically significant difference (p < 0.005). No abnormal karyotypes were found. CONCLUSION: Asians of Japanese origin may have a higher prevalence of echogenic intracardiac foci, thus affecting the positive predictive value of this sonographic marker for aneuploidy

Sirenomelia sequence: first-trimester diagnosis with both two- and three-dimensional sonography

To describe the sonographic findings of sirenomelia during the first trimester on both two-dimensional sonography with color Doppler imaging and three-dimensional sonography. Two cases of sirenomelia in primiparous patients with histories of infertility are described. The diagnosis was made on the basis of two-dimensional sonography, and three-dimensional sonography was used to further characterize the findings. Both fetuses had size-date discrepancies, increased nuchal translucency, large intra-abdominal vessels, and 2-vessel umbilical cords. Both pregnancies were terminated by dilation and curettage after the patients viewed the three-dimensional pictures of the fetuses. During the first trimester of pregnancy, rare and lethal anomalies can be diagnosed with a high degree of confidence if a thorough, age-dependent anatomic survey of the fetus is performed

"Blind" vaginal fetal fibronectin as a predictor of spontaneous preterm delivery

To assess the accuracy of vaginal fetal fibronectin sampling without use of a sterile speculum examination as a screening test for predicting spontaneous preterm birth. A historical cohort of patients who were followed up with serial fetal fibronectin testing between 1998 and 2001 was identified. All patients were considered to be at high risk for preterm delivery and were screened with fetal fibronectin testing without using a speculum at 2- to 3-week intervals from 22 weeks to 32 weeks of gestation. Charts were reviewed for fetal fibronectin results and pregnancy outcome data. Groups were compared using chi(2) analysis or Fisher exact test with significance defined as P < .05. A total of 1,396 fetal fibronectin tests from 416 pregnancies were performed via the "blind" sampling technique. Overall, 24.9% of pregnancies delivered spontaneously before 37 weeks; 9.1% delivered spontaneously before 34 weeks. For delivery before 34 weeks of gestation, the test had a sensitivity of 44.7%, a specificity of 88.4%, a positive predictive value of 27.9%, and a negative predictive value of 94.1%. For delivery within 14 and 21 days of a single fetal fibronectin assessment, the test had a sensitivity of 52% and 45.5%, a specificity of 94.5% and 94.9%, a positive predictive value of 14.6% and 22.5%, and a negative predictive value of 99.1% and 98.2%, respectively. "Blind" vaginal fetal fibronectin sampling has high negative predictive values and specificities in predicting spontaneous preterm birth. II-2

The Efficacy of Sonographically Indicated Cerclage in Multiple Gestations

Objective The purpose of this study was to determine the efficacy of sonographically indicated cerclage in multiple gestations with sonographic evidence of short cervical length (CL). Methods Between 1996 and 2002, all multiple gestations undergoing serial CL determinations in the second trimester were identified in 2 separate institutions. Cervical lengths were measured sonographically with transvaginal probes (4–8 MHz). Short CL was defined as a closed CL of 2.5 cm or less. When a short CL was identified before 24 weeks, the study group underwent sonographically indicated cerclage via the modified Shirodkar technique; control patients were placed on bed rest without surgical intervention. The primary outcome was incidence of spontaneous preterm birth before 32 weeks. The groups were compared with the Mann‐Whitney U test and the Fisher exact test, with a 2‐sided P < .05 used to define statistical significance. Odds ratios were calculated, and 95% confidence intervals were reported. Results A total of 414 sets of twin gestations and 92 sets of triplet gestations were identified. The median gestational age at delivery for twin gestations was 34.0 weeks for patients who received cervical cerclage and 34.4 weeks for patients with short cervix and no cerclage (P = .77). The median gestational age at delivery for triplet gestations was 34.1 weeks for patients who received cervical cerclage and 33.0 weeks for patients with short cervix and no cerclage (P = .21). There was no difference in the rate of spontaneous preterm delivery at fewer than 28, 30, 32, and 34 weeks or in the rate of preterm premature ruptured membranes. Conclusions In our study of multiple gestations with short CL, sonographically indicated cerclage was not associated with a lower incidence of spontaneous preterm delivery compared with conservative management

Association of copy number variants with specific ultrasonographically detected fetal anomalies

OBJECTIVE: To evaluate the association of other-than-common benign copy number variants with specific fetal abnormalities detected by ultrasonogram. METHODS: Fetuses with structural anomalies were compared to fetuses without detected abnormalities for the frequency of other-than-common benign copy number variants. This is a secondary analysis from the previously published National Institute of Child Health and Human Development microarray trial. Ultrasound reports were reviewed and details of structural anomalies were entered into a nonhierarchical web-based database. The frequency of other-than-common benign copy number variants (ie, either pathogenic or variants of uncertain significance) not detected by karyotype was calculated for each anomaly in isolation and in the presence of other anomalies and compared to the frequency in fetuses without detected abnormalities. RESULTS: Of 1,082 fetuses with anomalies detected on ultrasound, 752 had a normal karyotype. Other-than-common benign copy number variants were present in 61 (8.1%) of these euploid fetuses. Fetuses with anomalies in more than one system had a 13.0% frequency of other-than-common benign copy number variants, which was significantly higher (p<0.001) than the frequency (3.6%) in fetuses without anomalies (n = 1966). Specific organ systems in which isolated anomalies were nominally significantly associated with other-than-common benign copy number variants were the renal (p= 0.036) and cardiac systems (p=0.012) but did not meet the adjustment for multiple comparisons. CONCLUSIONS: When a fetal anomaly is detected on ultrasonogram, chromosomal microarray offers additional information over karyotype, the degree of which depends on the organ system involved