Postnatal Scan Research Articles

Implications of right aortic arch prenatal diagnosis: the multicentric nationwide ARCADE cohort

ObjectivesThis study aims to describe the various presentations of the prenatally diagnosed isolated right aortic arch (RAA), that is, without associated congenital heart defect and to evaluate the impact of...

Evaluating use of IOTA two-step strategy to classify adnexal masses identified in pregnancy: pilot study.

The primary aim was the validation of benign descriptors (BDs), followed by Assessment of Different NEoplasia's of the adneXa (ADNEX) (when BDs cannot be applied), in a two-step strategy to classify adnexal masses in pregnancy. The secondary aim was to describe the natural history of adnexal masses in pregnancy. Retrospective analysis of prospectively collected data of women with an adnexal mass on ultrasonography identified during pregnancy between 2017 and 2022. The study was conducted at Queen Charlotte's and Chelsea Hospital, UK. Relevant clinical and ultrasound data were extracted from the medical records and ultrasound software astraia. Adnexal masses were classified and managed according to expert subjective assessment (SA). Ultrasound features were recorded prospectively at the time of ultrasound examination. Borderline ovarian tumours (BOT) were classified as malignant. Benign Descriptors (BDs) were applied to classify adnexal masses, in cases where BDs were not applicable, the ADNEX model (using a risk of malignancy of >10%) was used, in a two-step strategy. The two-step strategy was applied retrospectively. The reference standard used was histology (where available) or expert SA at the postnatal ultrasound scan. 291 women with a median age of 33 (IQR 29-36) years presented with an adnexal mass in pregnancy, at a median gestation of 12 (IQR 8-17) weeks. 267 (267/291, 91.8%) women were followed up to the postnatal period, as 24 women (24/291, 8.2%) were lost to follow up. Based on the reference standard, 4.1% of adnexal masses (11/267) were classified as malignant (all BOTs) and 95.9% (256/267) as benign (41 on histology and 215 based on expert SA at postnatal ultrasound). BDs could be applied to 68.9% of adnexal masses (184/267); of these only one mass (BOT) was misclassified as benign (1/184, 0.5%). ADNEX was used to classify the residual masses (83/267) and misclassified three BOTs as benign (3/10, 30.0%) and 25 benign masses (based on reference standard) as malignant (25/73, 34.2%), 13 (13/25, 52.0%) of these were classified as decidualised endometriomas on expert SA, with confirmed resolution of decidualisation in the postnatal period. The two-step strategy had a specificity of 90.2%, sensitivity of 63.6%, negative predictive value of 98.3% and positive predictive value of 21.9%. 56 (56/267, 21.0%) women had surgical intervention, four as an emergency during pregnancy (4/267, 1.5%,) and four (4/267, 1.5%) electively during caesarean section. 48 (48/267, 18.0%) women had surgical intervention in the post-natal period, 11 (11/267, 4.1%) in the first 12 weeks postnatal and 37 >12 weeks (37/267, 13.9%) postnatal. 64 (64/267, 24.0%) adnexal masses resolved spontaneously during follow up. Cyst-related complications occurred in four women (4/267, 1.5%) during pregnancy (ovarian torsion n=2, cyst rupture n=2) and six (6/267, 2.2%) in the postnatal period (all ovarian torsion). 196 (196/267, 73.4%) had a persistent adnexal mass, including one of the women who had an ovarian torsion and underwent de-torsion and had a persistent adnexal mass at postnatal ultrasound. Presumed decidualisation occurred in 31.1% (19/61) of endometriomas and had resolved in 89.5% (17/19) by the first postnatal ultrasound scan. We found Benign Descriptors apply to most masses in pregnancy, however the small number of malignant tumours in the cohort (4.1%) restricted the evaluation of the ADNEX model, so expert subjective assessment should be used to classify adnexal masses in pregnancy, when BDs do not apply. A larger multicentre prospective study is required to evaluate the use of the ADNEX model to classify adnexal masses in pregnancy. Our data suggests that most adnexal masses can be managed expectantly during pregnancy given a large proportion of masses spontaneously resolved and the low risk of complications. This article is protected by copyright. All rights reserved.

Effects of hemodynamic alterations and oxygen saturation on cerebral perfusion in congenital heart disease

BackgroundPatients with severe congenital heart disease (CHD) are at risk for neurodevelopmental impairment. An abnormal cerebral blood supply caused by the altered cardiac physiology may limit optimal brain development. The aim of this study was to evaluate the effect of a systemic-to-pulmonary shunt, aortic arch obstruction and arterial oxygen saturation on cerebral perfusion in patients with severe CHD.MethodsPatients with severe CHD requiring cardiac surgery within the first six weeks of life, who underwent pre- and/or postoperative brain magnetic resonance imaging (MRI), and healthy controls with one postnatal scan were included. Cerebral perfusion in deep and cortical gray matter was assessed by pseudocontinuous arterial spin labeling MRI.ResultsWe included 59 CHD and 23 healthy control scans. The presence of a systemic-to-pulmonary shunt was associated with decreased perfusion in cortical (p = 0.003), but not in deep gray matter (p = 0.031). No evidence for an effect of aortic arch obstruction and arterial oxygen saturation on cerebral perfusion was found. After adjusting for hemodynamic and oxygen saturation parameters, deep (p = 0.018) and cortical (p = 0.012) gray matter perfusion was increased in patients with CHD compared to controls.ConclusionWe detected regional differences in compensation to the cerebral steal effect in patients with severe CHD.ImpactPatients with severe congenital heart disease (CHD) have altered postnatal brain hemodynamics.A systemic-to-pulmonary shunt was associated with decreased perfusion in cortical gray matter but preserved perfusion in deep gray matter, pointing towards regional differences in compensation to the cerebral steal effect.No effects of aortic arch obstruction and arterial oxygenation on cerebral perfusion were seen.Cerebral perfusion was increased in patients with CHD compared to healthy controls after adjusting for hemodynamic alterations and oxygen saturation.To improve neuroprotection and neurodevelopmental outcomes, it is important to increase our understanding of the factors influencing cerebral perfusion in neonates with severe CHD.

Brain age predicted using graph convolutional neural network explains neurodevelopmental trajectory in preterm neonates

ObjectivesDramatic brain morphological changes occur throughout the third trimester of gestation. In this study, we investigated whether the predicted brain age (PBA) derived from graph convolutional network (GCN) that accounts for cortical morphometrics in third trimester is associated with postnatal abnormalities and neurodevelopmental outcome.MethodsIn total, 577 T1 MRI scans of preterm neonates from two different datasets were analyzed; the NEOCIVET pipeline generated cortical surfaces and morphological features, which were then fed to the GCN to predict brain age. The brain age index (BAI; PBA minus chronological age) was used to determine the relationships among preterm birth (i.e., birthweight and birth age), perinatal brain injuries, postnatal events/clinical conditions, BAI at postnatal scan, and neurodevelopmental scores at 30 months.ResultsBrain morphology and GCN-based age prediction of preterm neonates without brain lesions (mean absolute error [MAE]: 0.96 weeks) outperformed conventional machine learning methods using no topological information. Structural equation models (SEM) showed that BAI mediated the influence of preterm birth and postnatal clinical factors, but not perinatal brain injuries, on neurodevelopmental outcome at 30 months of age.ConclusionsBrain morphology may be clinically meaningful in measuring brain age, as it relates to postnatal factors, and predicting neurodevelopmental outcome.Clinical relevance statementUnderstanding the neurodevelopmental trajectory of preterm neonates through the prediction of brain age using a graph convolutional neural network may allow for earlier detection of potential developmental abnormalities and improved interventions, consequently enhancing the prognosis and quality of life in this vulnerable population.Key Points•Brain age in preterm neonates predicted using a graph convolutional network with brain morphological changes mediates the pre-scan risk factors and post-scan neurodevelopmental outcomes.•Predicted brain age oriented from conventional deep learning approaches, which indicates the neurodevelopmental status in neonates, shows a lack of sensitivity to perinatal risk factors and predicting neurodevelopmental outcomes.•The new brain age index based on brain morphology and graph convolutional network enhances the accuracy and clinical interpretation of predicted brain age for neonates.

P-757 The classification and management of adnexal masses identified during pregnancy

Abstract Study question How do we classify adnexal masses (ovarian cysts) identified during pregnancy and how should we manage them? Summary answer Adnexal masses (ovarian cysts) should be managed expectantly in pregnancy, given the low rate of complications and low prevalence of malignancy. What is known already Conservative management of adnexal masses (ovarian cysts) is preferable during pregnancy, due to the maternal and fetal risks associated with surgery. Accurate diagnosis is key to safe expectant management. Various ultrasound-based models exist to classify adnexal masses; however, none have been validated for use in pregnancy. Adnexal mass morphology can change during pregnancy due to decidualisation, which is often difficult to distinguish from underlying neoplastic processes. We aim to evaluate:(1) the performance of current methods of adnexal mass classification in pregnancy, (2) understand the natural course of adnexal masses in pregnancy, particularly the presence of decidualisation and incidence of complications. Study design, size, duration Retrospective analysis of prospectively collected data between January 2017- November 2022. To classify adnexal masses (ovarian cysts), we evaluated: Expert subjective assessment (SA), IOTA Simple Rules (SR) and the IOTA Assessment of Different Neoplasias of the Adnexa (ADNEX) model. The end point was either the histological examination of tissue removed at surgery or the subjective classification of adnexal masses at the postnatal scan in women managed conservatively. Participants/materials, setting, methods Women with an adnexal mass identified on gynaecological ultrasound in pregnancy at a tertiary London University Hospital were included. Relevant clinical data was extracted, including age, gestation and cyst-related complications. Adnexal masses were classified at the first antenatal and postnatal ultrasound examination according to SA, SR and the ADNEX model (10% risk of malignancy cut off) and correlated to histology for adnexal masses managed surgically. IOTA simple descriptors were used to classify benign adnexal masses. Main results and the role of chance 254 women (median age 33-years old, range:18-49) with an adnexal mass/cyst were included at a median gestation of 12 weeks, (range:4-36). 13 (5.1%) conceived through assisted reproductive techniques. Spontaneous resolution occurred in 24.5% of cases, and 21 were lost to follow up (8.3%). According to Simple Descriptors, 38.6% were simple, 22.0% were endometriomas and 19.7% were dermoid cysts. Antenatally, SA outperformed ADNEX, based on specificity (94.6 vs.92.2%) and sensitivity (60 vs.55.6%) respectively. SA and ADNEX had a negative predictive value(NPV) of 96.1% and 98.3% respectively. Postnatally, SA had a higher sensitivity than ADNEX (75 vs.50%), but a lower specificity (94.1 vs.96.9%). SA and ADNEX had a NPV of 94.1% and 97.5% respectively. Three (1.3%) underwent acute surgery during pregnancy: one ovarian torsion (9/40), and two cyst ruptures (11/40, 30/40). Presumed decidualisation occurred in 29.5% of endometriomas. Three (1.3%) underwent cyst removal during caesarean section, two for suspicion of BOTs (one had suspected decidualisation) and one for patient preference. On histology, the suspected decidualised mass was a serous BOT, and the suspected BOT was a struma ovarii. In the postnatal period (12 weeks), four underwent surgery for suspicion of BOTs, two were confirmed BOTs and two were benign cystadenomas on histology. Limitations, reasons for caution The dataset as expected contains a relatively small number of malignancies (prevalence 3.9%) and so any analysis of test performance to discriminate between benign and malignant disease must be interpreted with caution. A larger prospective multicentre study is needed to do this. Wider implications of the findings Our data suggest that a number of cysts in pregnancy will resolve, a few will be associated with acute complications and the risk of malignancy is very low. Accordingly, the study supports an expectant management approach for adnexal masses (ovarian cysts) detected in pregnancy. Trial registration number Not applicable

Onset of Chiari type 1 malformation: insights from a small series of intrauterine MR imaging cases.

Morphometric studies on idiopathic Chiari malformation type 1 (CM1) pathogenesis have been mainly based on post-natal neuroimaging. Prenatal clues related to CM1 development are lacking. We present pre- and post-natal imaging time course in idiopathic CM1 and assess fetal skull and brain biometry to establish if clues about CM1 development are present at fetal age. Multicenter databases were screened to retrieve intrauterine magnetic resonance (iuMR) of children presenting CM1 features at post-natal scan. Syndromes interfering with skull-brain growth were excluded. Twenty-two morphometric parameters were measured at fetal (average 24.4weeks; range 21 to 32) and post-natal (average 15.4months; range 1 to 45) age; matched controls were included. Among 7000 iuMR cases, post-natal scans were available for 925, with postnatal CM1 features reported in seven. None of the fetuses presented CM1 features. Tonsillar descent was clear at a later post-natal scan in all seven cases. Six fetal parameters resulted to be statistically different between CM1 and controls: basal angle (p = 0.006), clivo-supraoccipital angle (p = 0.044), clivus' length (p = 0.043), posterior cranial fossa (PCF) width (p = 0.009), PCF height (p = 0.045), and PCFw/BPDb (p = 0.013). Postnatally, only the clivus' length was significant between CM1 cases and controls. Pre- and post-natal CM1 cases did not share striking common features, making qualitative prenatal assessment not predictive; however, our preliminary results support the view that some of the pathogenetic basis of CM1 may be embedded to some extent already in intrauterine life.

Fetal brain imaging provides valuable information in cCMV infected infants

Background Congenital CMV infection (cCMV) is the most common congenital infection with 10–15% of cases developing symptomatic disease. Early antiviral treatment is of essence when symptomatic disease is suspected. Recently, the use of neonatal imaging has been implicated as a prognostic tool for long term sequalae among asymptomatic newborns at high risk. Even though neonatal MRI is commonly used in neonatal symptomatic cCMV disease, it is less often used in asymptomatic newborns, mainly due to cost, access and difficulty to perform. We have therefore developed an interest in assessing the use of fetal imaging as an alternative. Our primary aim was to compare the fetal and neonatal MRIs in a small cohort 10 asymptomatic neonates with congenital CMV infection. Methods We performed a single-center retrospective cohort study (case-series) on a convenience sample of children born from January 2014 to March 2021 with confirmed congenital CMV infection who had undergone both fetal and neonatal MRIs. We created a checklist of relevant cerebral abnormalities and asked 4 blinded radiologists to assess the MRIs (2 for each, namely fetal and neonatal) and then compared the findings between the fetal and neonatal imaging as well as the concordance in reporting of abnormalities within each category. Findings Overall concordance between prenatal and postnatal scans was high (70%). When comparing the two blinded reports for each MRI, we found high levels of concordance: 90% concordance for fetal MRIs and 100% for neonatal MRIs. The most common abnormalities identified in both fetal and neonatal scans were “abnormal white matter hyperintensity” and “subependymal cysts.” Interpretation Even though this is a small descriptive study, it indicates that fetal MRI could potentially provide us with similar information as neonatal imaging. This study could form the basis for subsequent larger future studies.

Prenatal diagnosis of Joubert’s syndrome overlapping with Dandy–Walker malformation on fetal MRI

Magnetic resonance imaging (MRI) of the fetal brain plays an important role in the confirmation of congenital malformations diagnosed on ultrasound. It also helps in additionally detecting various associated central nervous system and other systemic abnormalities. We report a rare case of Joubert’s syndrome overlapping with Dandy– Walker malformation (DWM), antenatally detected by fetal MRI whose findings were confirmed on post-natal MRI scan. Prenatal diagnosis of such an association is important in predicting the neurodevelopmental outcome of the child, and for genetic counseling of the parents, as Joubert’s syndrome has a poorer prognosis, and a higher rate of recurrence than DWM.

COllaborative Neonatal Network for the first European CPAM Trial (CONNECT): a study protocol for a randomised controlled trial

IntroductionConsensus is lacking on the optimal management of asymptomatic congenital pulmonary airway malformation (CPAM). For future studies, the CONNECT consortium (the COllaborative Neonatal Network for the first European CPAM Trial)—an...

First-time fathers show longitudinal gray matter cortical volume reductions: evidence from two international samples.

Emerging evidence points to the transition to parenthood as a critical window for adult neural plasticity. Studying fathers offers a unique opportunity to explore how parenting experience can shape the human brain when pregnancy is not directly experienced. Yet very few studies have examined the neuroanatomic adaptations of men transitioning into fatherhood. The present study reports on an international collaboration between two laboratories, one in Spain and the other in California (United States), that have prospectively collected structural neuroimaging data in 20 expectant fathers before and after the birth of their first child. The Spanish sample also included a control group of 17 childless men. We tested whether the transition into fatherhood entailed anatomical changes in brain cortical volume, thickness, and area, and subcortical volumes. We found overlapping trends of cortical volume reductions within the default mode network and visual networks and preservation of subcortical structures across both samples of first-time fathers, which persisted after controlling for fathers' and children's age at the postnatal scan. This study provides convergent evidence for cortical structural changes in fathers, supporting the possibility that the transition to fatherhood may represent a meaningful window of experience-induced structural neuroplasticity in males.

Diagnosis of isolated right aortic arch: Accuracy of prenatal diagnosis, associated genomic disorders and interest of systematic postnatal imaging. The ARCADE multicentre retrospective observational study

Prenatal diagnosis of isolated right aortic arch (RAA) have increased during the past decades. However, diagnosis accuracy, genetic testing, and post-natal follow-up are still not consensual. We aimed to analyse French pediatric cardiologists practice regarding prenatal diagnosis of isolated RAA. We collected all livebirth with isolated RAA prenatally diagnosed in 14 French congenital heart disease centres from 2015 to 2020. We compare, using kappa coefficient of concordance, the anatomical position of aortic arch, ductus arteriosus and aberrant left subclavian artery described by prenatal echo, postnatal echo, and CT scan when available. We also assessed available genetic results and functional postnatal status. We included 309 neonates with prenatal diagnosis of isolated RAA. Regarding patients with an isolated RAA, left ductus arteriosus have been described in 76% of cases. Diagnosis of aberrant left subclavian artery was missing in 73% of cases. Four patients with prenatal isolated RAA had a postnatal diagnosis of double aortic arch (DAA). Correlation between pre- and post-natal echo was excellent regarding aortic arch position (kappa = 0.97). 108 neonates (35%) underwent postnatal CT scan due to onset of respiratory symptoms (53%) or systematic centre protocol (47%). CT-scan revealed five more unknown DAA. Correlation between prenatal echo and CT-scan was good (kappa = 0.79). Furthermore, systematic CT-scan showed 13 major tracheal compression resulting in six arterial ring surgeries during the study period. Lastly, 165 patients (53%) underwent a genetic testing. Nine patients (5.4%) presented a 22q11 deletion. Performance of prenatal diagnosis of isolated RAA is excellent, with a good correlation between pre- and post-natal echocardiography or gold standard-CT scan. Prenatal diagnosis of aberrant left subclavian artery and DAA is still challenging. CT scan improve anatomical description and functional impact of aortic arch anomalies and may be proposed to complete postnatal follow-up. Lastly, amniocentesis should be considered to detect genetic disorders.

673 The Role of the First Postnatal Ultrasound Scan to Predict Outcome in Children with Antenatally Diagnosed Hydronephrosis

Abstract Aim We aimed to determine if the renal pelvic diameter on the first postnatal scan can predict the need for surgical intervention in children with antenatally diagnosed hydronephrosis. Method Data of all babies with antenatal hydronephrosis born in our centre from 2009–2015 were obtained from the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS). The medical records were analysed retrospectively for diagnosis, investigations, and interventions. Mean follow-up was 7 (4–10) years. The results were expressed as mean and percentage. Statistical data analysis was performed on GraphPad. Results 224 babies were included in the study. 162 (72%) were males, and 92 (39%) had bilateral hydronephrosis. 163 (73%) had spontaneous resolution of hydronephrosis. The resolution rates were similar for unilateral and bilateral cases. The mean renal pelvic diameter was 6.2mm in the resolved group and 16.2mm in the persistent group (p<0.01). The highest renal pelvic diameter undergoing spontaneous resolution was 24mm. Of the 61 (27%) children with persistent hydronephrosis, 38 (17%) children required surgery. Pyeloplasty for pelviureteric junction obstruction was the most common procedure. 23 (10%) patients continued to have persistent dilatation but needed no intervention. Renal duplex was the most common diagnosis in this group, followed by vesicoureteric reflux. All babies with a pelvic diameter of 25mm or above on their first postnatal ultrasound required surgical intervention. Conclusion The majority of antenatal hydronephrosis resolves spontaneously. However, interventions are necessary if the pelvic diameter is above 25mm.

The obstructive index in antenatal unilateral pelviureteric junction obstruction: A novel predictor of the failure of conservative management.

To find the impact of the obstructive index (OI) as a predictor of management in antenatal pelviureteric junction obstruction. Records of 135 cases of antenatally detected unilateral pelviureteric junction obstruction, selected for initial observation were retrospectively analyzed. All patients who underwent pyeloplasty on follow up were assigned to Group A. Those patients who were still on conservative management were assigned to Group B. The pelvic anteroposterior diameters of the affected (PAPD[A]) and normal kidney (PAPD[N]) of the same patient, along with the cortical thickness of the affected kidneys (CT[A]) and normal kidneys (CT[N]) on postnatal ultrasound scan, the T1/2 of the affected (T1/2 [A]) and normal kidneys (T1/2 [N]), the differential renal function (DRF), and the shape of the curve on a diuretic renogram were noted for each patient at 6 weeks. The OI was defined as (PAPD[A] × T1/2 [A]) / (PAPD[N] × T1/2 [N]). The median duration of follow up was 55 months (36-110). Median age at surgery was 12 months (4-80). Group A had 30 patients with 105 in Group B. On multivariate analysis, OI and shape of curve predicted need for surgery with statistical significance. Median OI in Group A was 18.9 compared to 4.82 in Group B (P < 0.001, Mann-Whitney). Using receiver operating characteristic analysis, the area under curve for the OI was 0.95. A level of 12.2 could predict failure of conservative management with a sensitivity of 93.3% and a specificity of 92.4%. The OI can reliably predict the need for surgery at a very early stage, thus avoiding repeated tests and saving time.

Short- and Long-Term Outcomes of Prenatally Diagnosed Dandy-Walker Malformation, Vermian Hypoplasia, and Blake Pouch Cyst.

Dandy-Walker continuum, which includes Dandy-Walker malformation, vermian hypoplasia, and Blake pouch cyst, is among the most commonly diagnosed posterior fossa malformation by fetal magnetic resonance imaging (MRI). The objective of our retrospective study was to evaluate fetal and postnatal MRI scan and clinical outcomes. Seventy-two patients were identified; 40 patients had postnatal imaging and follow-up (7 Dandy-Walker malformation, 26 vermian hypoplasia, and 7 Blake pouch cyst). Although all patients with Dandy-Walker malformation required ventriculoperitoneal shunts and 66% were intubated at birth, none required tracheostomy tube and 2 of 5 surviving children had no neurologic deficits. Vermian hypoplasia was strongly associated with genetic conditions and cardiac malformations; odds of not ambulating normally were 12 times greater if a syndrome or injury was present. Echocardiogram and genetic screening are recommended with vermian hypoplasia. There is a risk for epilepsy in both Dandy-Walker malformation and vermian hypoplasia. Blake pouch cyst can be complicated by hydrocephalus, but outcome is favorable.

FREQUENCY OF CONGENITAL ANOMALIES OF THE KIDNEY AND URINARY TRACT BY MEANS OF ULTRASONOGRAPHY IN NEONATES AT A TERTIARY-CARE HOSPITAL

Objective: To determine the frequency of congenital anomalies of the kidney and urinary tract by means of ultrasound in neonates.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Radiology and Diagnostic Imaging, Rehman Medical Institute, Peshawar, from May 2015 to Jan 2016.&#x0D; Methodology: A total of 150 neonates reporting for routine abdominal ultrasonography were included. Honda Convex Scanner model HS-2000 with probe of frequency of 5-7 MHz was used for the ultrasonography.&#x0D; Results: Mean age of the neonates was 13.8 ± 7.5 days. Seventy-six (50.7%) were male and 74 (49.3%) were female. Congenital anomalies of the kidney and urinary tract were observed in 10 (6.7%) neonates. Most neonates had more than one anomaly. The left side was involved in 6 (4%) neonates while right side was involved in 4 (2.7%). Hydronephrosis was the most common abnormality found in 8 (5.3%) cases. The location of kidneys was abnormal (ectopic) in 2 (1.3%) neonates. Abnormal dimension was seen in seven cases and abnormal corticomedullary differentiation was found in 5 (3.3%) cases. Non-symmetrical cases were 5 (3.3%). Hydroureter was observed in 3 (2%) neonates and urinary bladder was abnormal in 2 (1.3%) neonates.&#x0D; Conclusion: The frequency of congenital anomalies of the kidney and urinary tract in neonates by means of postnatal ultrasonographic scan in our study population was 6.7%. Hydronephrosis was the most common anomaly.

Repair of the myometrial scar defect at repeat caesarean section: a modified surgical technique

BackgroundTo investigate whether the existing surgical technique for uterine closure at repeat lower segment Caesarean section (LSCS) can be modified to achieve adequate residual myometrial thickness (RMT) to ensure scar integrity and reduce complications in future pregnancy.MethodsWomen with a significant scar defect at repeat LSCS had the anterior uterine wall closed by a single experienced obstetrician with a technique focused on recognition, mobilisation and apposition of the retracted myometrial edges at the boundary of the defect. This was aimed at anatomical restoration of the lower segment. The RMT at the scar area was assessed by postnatal pelvic ultrasound scan at three months.ResultsThirty women with a history of at least one previous CS, incidentally found to have a large defect at operation underwent the technique with prior consent. A postnatal scan showed a mean residual myometrial thickness of 8.4 mm (SD ±1.3 mm; range 5.6–11.0 mm). The average operating time was 91 mins and the average blood loss 728 ml. Two women who underwent the repair have gone on to have a further uneventful CS.ConclusionThis modified technique resulted in scan evidence of an RMT indicative of uterine wall stability postnatally and offers the potential for reducing the risk of rupture and placenta accreta spectrum (PAS) in future pregnancy.

Epidemiology, Genetics and Epigenetics of Congenital Heart Diseases in Twins.

Congenital heart defects (CHDs) refer to abnormalities in the heart function that arise at the fetal stages. It is the most common birth defect that affects 0.8% of all liveborn infants. There is an increase in the incidence of congenital heart disease in monochorionic twin gestation. A six-fold increase in CHDs exists among monochorionic twins especially in association with twin-twin transfusion syndrome (TTTS) compared to dichorionic twin pregnancy. In this review article, we discussed the epidemiology, the role of genetics like protein-coding genes, epigenetics, placenta, hemodynamics and environmental factors in the etiology of CHD in twins.We conducted a literature search in PubMed indexed journals using the medical terms "twin pregnancy" and "congenital heart defect" to provide an overview of the uptrend in CHD in twin pregnancies, primarily due to assisted reproductive technologies (ARTs) and multiple other factors. Both the heart and placenta are vascular and share a common development window; therefore, CHD can develop secondary to placental pathologies. Among environmental factors, the strongest association of maternal smoking with CHD has been seen. We studied the causative factors to suggest improvement in echocardiographic skills in case of abnormal findings in twin gestations to decrease the CHD-associated morbidity and mortality, as early diagnosis allows doctors to precisely determine the risk of CHD. Systemic ultrasound scanning with five transverse views is very effective in diagnosing fetal CHD in twin pregnancy. In the case of genetics, prenatal counseling allows the expectant to understand the full ramifications of possible events after the pregnancy. The pathological basis of malformations specific to conjoined twinning and twin reversed arterial perfusion sequence is addressed. Also, there is evidence that folate supplementation may be protective against CHD but more research is needed to clarify the mechanisms.We concluded from the literature that monochorionic twins are at high risk of CHD. Chorionicity seems to play a more vital role than zygosity. Even the type of heart defect in monochorial twin pregnancies was unique from single, dizygotic, or dichorionic twin pregnancies. We also emphasize improving echocardiographic skills of technicians in referring ART dichorionic twin fetuses with suspicious findings to fetal cardiologists and performing postnatal scans in the case of TTTS. To understand the role of the placenta, making use of newer technologies and examining the placenta both during pregnancy and beyond delivery will play a vital role in understanding the etiology. Even identifying early signals impacting the heart and placental vasculature and correcting them using advanced technology could downtrend the incidence in coming years. Increased maternal age as well as multiple pregnancies increasing the risk of CHD has also been implicated. For more clarity on the role of genetics, the cost of DNA sequencing needs to decrease. This will enable whole-genome sequencing in the future thus helping to discover the gene responsible for CHD ultimately proving beneficial for future generations. For environmental factors, we have to rely on observational studies to assess the risk to the unborn child. There is difficulty in studying natural factors due to the unreliability of exposure to contaminants like pesticides and air pollution.

Double ureteric obstruction mimicking bowel obstruction managed by minimal invasive surgery

This case highlights bowel obstruction like symptoms post-laparoscopic pyeloplasty for pelvi-ureteric junction obstruction (PUJO), caused by concomitant vesico-ureteric-junction obstruction (VUJO). The endoscopic management is presented along with a review of the literature. A 16-month-old-girl was diagnosed antenatally with a left hydronephrosis. The post-natal scan confirmed severe left pelvi-calyceal dilatation with cortical thinning, no ureteric dilatation, and a 32 mm anterior-posterior (AP) renal pelvis. The mercaptoacetyltriglycine (MAG-3) renogram demonstrated thinned cortex with steady accumulation of contrast and poor drainage along with split renal function of 26% on left side. The patient underwent a laparoscopic pyeloplasty for PUJO, with some difficulty in passing the JJ stent distally. Postoperatively, the patient developed symptoms of ileus, that were progressively unsettled with bilious vomiting and abdominal distension. An ultrasound examination revealed the distal end of stent still positioned in the distal ureter with stable upper tract dilatation. Serial radiographs showed progressive distended bowel loops with the stent coiled in ureter. On the fourth day; as symptoms did not improve, emergency laparoscopy was performed that confirmed no mechanical cause of obstruction and no bowel injury. Cystourethroscopy in the same session revealed ipsilateral VUJO. The left ureteral orifice was cannulated with difficulty using a 0.0014 inch guide wire, following which the vesico-ureteric junction was dilated with 4Fr ureteric catheter and a 3.7Fr JJ stent was placed. The newly inserted JJ stent displaced the existing stent into the renal pelvis. Post-operative course showed dramatic improvement in obstructive symptoms. Both JJ stents were subsequently removed after 3 months using a cystoscope and rigid uretero-renoscope. Pre-operative diagnosis of coexistent VUJO and to PUJO is clinically challenging and requires high level of suspicion especially when postoperative recovery is not smooth. With the availability of endo-ureterotomy procedures PUJO and VUJO could be managed together without the risk of endangering ureteric vascularity.

Morphology of vascular ring arch anomalies influences prognosis and management

ObjectiveThis study aimed to explore the anatomical features of aortic arch anomalies associated with vascular rings, hoping to identify those which may increase the risk of symptomatic presentation and surgical...

Prenatal ultrasound diagnosis of duplication gallbladder: a multicenter study.

Gallbladder duplication is a rare anatomic anomaly characterized by the presence of an accessory gallbladder. To appraise the prevalence and significance of prenatal diagnosis of duplication of gallbladder in a multicenter study. This was a multicenter case series with literature review. Clinical records of all consecutive pregnant women with a prenatal diagnosis of duplication of gallbladder, who were referred to our Centers were included in this study. The diagnosis of duplication of gallbladder was based on the evidence of double gallbladder in the standard abdominal circumference plane using grey scale. Postnatal magnetic resonance cholangiopancreatography (MRCP) 3D and postnatal neonatal abdominal ultrasound scan were offered soon after birth to confirm the diagnosis of double gallbladder. The systematic review was conducted using electronic databases from inception of each database through December 2019. Five studies, including a total of seven cases, were identified as relevant and included in the systematic review. Gestational age at diagnosis ranged from 20 to 32weeks of gestation. Associated findings were reported in only one case, where the fetus presented with a left-sided gallbladder, and bilateral renal agenesis with Potter sequence. None of the included cases reported abnormal karyotype. Our cases series included nine cases (0.03%) of double gallbladder with postnatal confirmation, with an overall incidence of this anomaly of 0.03%.Associated findings were reported in only two cases, one with IUGR and omphalocele, that opted for I-TOP, and one with single umbilical artery. Except for the I-TOP, neonatal outcome was favorable in all cases. Duplication of the gallbladder is a very rare malformation with only seven cases reported in the literature diagnosed prenatally. This anomaly is not associated with abnormal karyotype, and the neonatal outcome is favorable if there are no other associated abnormalities.