Prenatal Surveillance Research Articles

A Matter of Size

Large for gestational age (LGA) is another designation used to assess and monitor growth throughout the pregnancy and after delivery. Large for gestational age is an abnormal growth descriptor that assists in anticipating neonatal needs pre-and postnatally. Careful monitoring for abnormal growth trends in the fetus is imperative prenatally. The relative size of a neonate affects many aspects of prenatal and postnatal surveillance. Nursing care is guided by the maternal history and the delivery room complications that may occur. Anticipating complications in the delivery room is vital to the survival of LGA neonates. Nursing care for LGA neonates requires knowledge based on these potential complications. A thorough physical assessment with appropriate glucose monitoring and parental education is required. Size matters when it comes to the health and welfare of all sizes of neonates. Anticipatory guidance with prenatal monitoring and education can improve outcomes in the neonate at risk for LGA complications at birth.

PART 1

The relative size of a neonate impacts many aspects of prenatal and postnatal surveillance and care. The designations of appropriate for gestational age, small-for-gestational age, intrauterine growth restriction, and large-for-gestational age are systematic categorizations used to assess and monitor growth throughout pregnancy and delivery. Each abnormal growth descriptor aids in anticipating neonatal needs after birth because each has the potential for complications related to feeding, glucose utilization, short- and long-term growth, and development. Maternal risk factors that impact the neonate's size-related can have immediate implications in the delivery room as well as significant effects postnatally. Caring for neonates at risk for size complications requires knowledge based on prenatal and postnatal complications. Neonates must be carefully measured and plotted on growth charts to confirm a visual assessment of size. Each growth complication requires individual attention to detail and careful planning to maximize adequate postnatal growth and nutrition. Size matters when it comes to the health and welfare of neonates. Anticipatory guidance can improve outcomes in the neonate at risk for failure to thrive from size complications at birth. Part 1 of this article provides an overview of the size classifications and a discussion of clinical factors that are associated with or contribute to small-for-gestational age births. Once the neonate's size for gestational age is calculated, a focused physical assessment is described along with nursing care and prognostic implications. Part 2 will focus on the physical assessment, nursing care, prognosis, and complications associated with large-for-gestational-age neonates.

Four years' experience with antepartum cardiotocography using telemedicine

We reviewed the first four years of experience with telemonitoring of patients with high-risk pregnancies. Nine peripheral units (eight in Campania, a region of south Italy, and one in Hungary) recorded cardiotocographic traces and transmitted them via modem to an operations centre at the University 'Federico II' in Naples, where the computerized analysis was performed. The medical report was returned to the peripheral unit via fax or email. Four thousand and twenty one traces were recorded: 2674 (67%) from 764 high-risk patients and 1347 (34%) from 499 patients at apparent low risk. The neonatal outcome was good overall. Questionnaires were sent to the operators working at the peripheral units to evaluate the acquisition of specific skills and their level of satisfaction. Sixty-six questionnaires about cardiotocographic trace interpretation were collected. The number of correct answers increased during the study. A total of 33 questionnaires about job satisfaction were collected. The answers showed that the operators gradually overcame their scepticism during the study. A total of 1098 questionnaires were answered by the patients. Their answers showed a moderate level of satisfaction. Telecardiotocography allowed the decentralization of prenatal surveillance.

Cystic adenomatoid malformation of the lung: Review of genetics, prenatal diagnosis, and in utero treatment

Prenatal identification of lung abnormalities has increased with prenatal surveillance. Treatment usually requires serial ultrasound observation but in rare situations in utero therapy may be required for fetal survival. We review the genetics, prenatal evaluation, and treatment of lung abnormalities with congenital cystic adenomatoid malformation (CCAM). Other lung lesions, bronchopulmonary sequestration (BPS), hybrid lesions involving both malformations, congenital lobar emphysema (CLE), are briefly included as differential diagnosis options. Outcome of fetuses identified to have CCAM lung abnormalities resulting in fetal hydrops and having in utero therapy (thoracoamniotic shunting, fetal thoracotomy, EXIT delivery) are discussed. In the appropriate situation, this maternal fetal surgery approach for CCAM is life-saving for the affected fetus with acceptable maternal morbidity risks in the present and future pregnancies.

Neonatal toxicity and transient neurodevelopmental deficits following prenatal exposure to lithium: Another clinical report and a review of the literature

I report the case of an infant girl who was exposed to lithium during gestation and her follow-up at the age of 1 year. She presented with transient neurodevelopmental deficits including lethargy, hypotonia, and poor oral feeding ability in the neonatal period. She required supportive treatment and made gradual improvement in neurologic functioning. On examination at the age of 1 year, physical findings and psychomotor development were normal. The English literature from 1978 to 2004 is reviewed. A total of 30 patients who were exposed to lithium during gestation with adequate clinical description were identified. A significant number of these babies presented with neurodevelopmental deficits and depressed neurological status including hypotonia, respiratory distress syndrome, cyanosis, lethargy, and weak suck and Moro reflexes in the neonatal period. The majority of these abnormalities resolved and most babies made full recovery. Other abnormalities were structural as well as functional involvement of the cardiovascular system, macrosomia, prematurity, jaundice, diabetes insipidus, and involvement of the thyroid gland. While the use of lithium during pregnancy does not appear to significantly increase the risk of congenital anomalies, it is frequently associated with perinatal complications and reversible neonatal toxicity. Suggested guidelines for appropriate monitoring of infants and breast-feeding of exposed babies are presented. In addition, prenatal surveillance of women with bipolar disorders who are being treated with lithium is briefly discussed.

Changes in the birth prevalence of selected birth defects after grain fortification wiht folic acid in the United States: Findings from a multi-state population-based study

Observational studies and clinical trials have suggested that periconceptional use of folic acid can reduce the risk of birth defects other than neural tube defects (NTDs). Using data reported by states to the National Birth Defects Prevention Network, we examined whether folic acid fortification might have decreased the prevalence of other specific birth defects. For each of 16 birth defect categories selected for study, birth prevalence for two time periods was calculated with data submitted from a number of states in 1995-1996 ("pre-fortification") and 1999-2000 ("post-fortification"). Changes in birth prevalence between the two time periods were assessed by calculating prevalence ratios and 95% confidence intervals for each defect, and compared by maternal race/ethnicity and availability of prenatally diagnosed cases. We confirmed previously reported reductions in the birth prevalence of NTDs. In addition, we found modest, yet statistically significant, decreases in the birth prevalence for transposition of the great arteries(12%), cleft palate only (12%), pyloric stenosis (5%), upper limb reduction defects (11%), and omphalocele (21%). More substantial subgroup decreases were observed for renal agenesis among programs that conduct prenatal surveillance (28%), for common truncus among Hispanics (45%), and for upper limb reduction defects among Hispanics (44%). There were modest yet significant increases in the prevalence of obstructive genitourinary defects (12%) and Down syndrome (7%), but not among programs conducting prenatal surveillance for these defects. These results suggest some modest benefit from the folic acid fortification on the prevalence of a number of non-NTD birth defects.

Neural tube defects and associated anomalies in South Carolina.

Neural tube defects (NTDs) occur as isolated malformations and in the company of other birth defects. This study was conducted to determine the frequency of coexisting anomalies and the relationship between them. Since 1992, NTDs have been identified through prenatal and postnatal surveillance activities in South Carolina. The type of NTD and presence of associated anomalies were determined by prenatal ultrasound, postnatal and/or postmortem examination. During the ten-year period from 1992 to 2002, 564 NTDs were identified by the surveillance system. Seventeen percent of NTDs (98/564) had associated malformations. In approximately half (n = 51) of these cases, the NTDs and associated anomalies were components of a recognizable syndrome. In the remaining cases (n = 47), no syndrome was identified or suspected, but the associated anomalies were believed in most instances to be secondary to space limitation or neural crest abnormalities imposed by the NTD. Seventeen percent of NTDs in South Carolina have associated malformations. In most cases, the associated anomalies are considered either components of a multiple malformation syndrome or secondary to the NTD.

P05.10: Perinatal outcome of small for gestational age babies born after 34 weeks of gestation: role of prenatal surveillance

P05.10: Perinatal outcome of small for gestational age babies born after 34 weeks of gestation: role of prenatal surveillance

Sacrococcygeal teratoma: prenatal assessment, fetal intervention, and outcome

Purpose To understand the natural history and define indications for fetal intervention in sacrococcygeal teratoma (SCT), the authors reviewed all cases of fetal SCT presenting for evaluation. Methods Prenatal diagnostic studies including ultrasound scan, magnetic resonance imaging (MRI), echocardiography and pre- and postnatal outcomes were reviewed in 30 cases of SCT that presented between September 1995 and January 2003. Results The mean gestational age (GA) at presentation was 23.9 weeks (range, 19 to 38.5) with 3 sets of twins (10%). Overall outcomes included 4 terminations, 5 fetal demises, 7 neonatal deaths, and 14 survivors. Significant obstetric complications occurred in 81% of the 26 continuing pregnancies: polyhydramnios (n = 7), oligohydramnios (n = 4), preterm labor (n = 13), preeclampsia (n = 4), gestational diabetes (n = 1), HELLP syndrome (n = 1), and hyperemesis (n = 1). Fetal intervention included cyst aspiration (n = 6), amnioreduction (n = 3), amnioinfusion (n = 1), and open fetal surgical resection (n = 4). Indications for cyst aspiration and amnioreduction were maternal discomfort, preterm labor, and prevention of tumor rupture at delivery. Although 15 SCTs were solid causing risk for cardiac failure, only 4 fetuses met criteria for fetal debulking based on ultrasonographic and echocardiographic evidence of impending high output failure and favorable anatomy at 21, 23.6, 25, and 26 weeks’ gestation. Intraoperative events included maternal blood transfusion (n = 1), fetal blood transfusion (n = 2), chorioamniotic membrane separation (n = 2), and fetal arrest requiring successful cardiopulmonary resuscitation (CPR) (n = 1). In the fetal resection group, 3 of 4 survived with mean GA at delivery of 29 weeks (range, 27.6 to 31.7 weeks), mean birth weight of 1.3 kg, hospital stay ranging from 16 to 34 weeks, and follow-up ranging from 20 months to 6 years. Postnatal complications in the fetal surgery group included neonatal death (n = 1, secondary to premature closure of ductus arteriosus with cardiac failure), embolic event (n = 1, resulting in unilateral renal agenesis, jejunal atresia), chronic lung disease (n = 1), and tumor recurrence (n = 1). Conclusions For fetal SCT, the rapidity at which cardiac compromise can develop and the high incidence of obstetric complications warrant close prenatal surveillance. Amnioreduction, cyst aspiration, and surgical debulking are potentially life-saving interventions.

Right congenital diaphragmatic hernia: prenatal assessment and outcome

Purpose To understand the natural history of right congenital diaphragmatic hernia (CDH), the authors retrospectively reviewed 27 cases of right CDH that presented for prenatal evaluation or postnatal treatment. Methods Between 1995 and September 2002, a total of 194 cases of fetal CDH were evaluated and included 22 right-sided defects. The authors reviewed prenatal diagnostic studies (ultrasound scan, magnetic resonance imaging [MRI] echocardiography) and pre- and postnatal outcomes in these 22 cases of right CDH. Five additional cases of right CDH without a prenatal diagnosis were reviewed. Results The mean gestational age at evaluation was 26.1 weeks. The lung area to head circumference ratio (LHR) ranged from 0.32 to 2.5. In all cases, the fetal liver was herniated into the right chest. Associated anomalies were common. There were no karyotype abnormalities (17 of 22 tested). There were 4 terminations. Nine of the 18 (50%) continuing pregnancies had polyhydramnios, premature rupture of membranes, or preterm labor. The mean gestational age at birth was 36.8 weeks. One patient underwent tracheal occlusion at 27 weeks, and 2 patients died before postnatal repair. Overall survival rate (22 prenatal plus 5 postnatal diagnoses) was 19 of 27 (70%). Postnatal survival rate was 19 of 23 (83%). A Gore-tex (W. L. Gore and Associates, Flagstaff, AZ) patch was utilized in 14 of 21 neonates undergoing surgery. Twelve of 23 (52%) required extracorporeal membrane oxygenation (ECMO) with a 75% survival rate. Significant morbidity occurred in 10 of 19 survivors and included neurologic sequelae in 6 of 19 (32%). Conclusions MRI was helpful in the determination of liver position and confirmation of diagnosis. The high incidence of preterm complications, frequent need for ECMO, and high prevalence of comorbidities are indicative of the severity of this CDH population and warrant close prenatal surveillance and delivery at a tertiary care center with ECMO capability.

Surveillance and outcome of fetuses with gastroschisis.

Infants with gastroschisis have a high survival rate. However, the rate (10-15%) of intrauterine fetal death (IUFD) is considerable, and the association with fetal distress is well known. The aim of this study was to describe the outcome of fetuses with a prenatal diagnosis of gastroschisis. The impact of correct prenatal diagnosis, surveillance and signs of complicating risk factors were evaluated. All fetuses with prenatally diagnosed gastroschisis at the National Center for Fetal Medicine from January 1988 to August 2002 were registered and prospectively evaluated with regular ultrasound examinations. From 34-36 completed gestational weeks the fetuses were monitored daily to every second day with cardiotocography (CTG). Gastroschisis was diagnosed in 64 fetuses at a mean gestational age of 19 + 2 weeks. All had normal karyotype. Associated anomalies were found in four cases (6.3%). Three pregnancies (4.7%) were terminated, all for reasons other than gastroschisis. One fetus (1.6%) died in utero. Thirteen fetuses (22%) had abnormal CTG leading to subsequent Cesarean sections. Mean gestational age at delivery was 36 + 1 weeks. Mean birth weight was 2586 g. Thirteen infants (22%) were small for gestational age (SGA). In 15 cases (25%) meconium-stained amniotic fluid was found; 14 of these had abnormal CTG and/or were SGA. Small bowel atresia was found in four infants (6.7%). Four infants died postnatally at the age of 0-9 months. CTG surveillance of fetuses with gastroschisis may improve the outcome through detection of fetal distress thereby reducing the risk of IUFD. Other clinical situations of importance that are associated with gastroschisis are described and discussed.

P102: Abnormal umbilical, portal and hepatic venos system-its correlation to associated malformation, congestive heart failure, liver dysfunction and fetal outcome

To present our experience in the prenatal diagnosis and surveillance of abnormalities of the fetal central veins. An observational study of 12 fetuses with an abnormal umbilical, potal and umbilical venous system being diagnosed at two centers in Bonn and Trondheim. the abnormality was related to associated malformations, development of congestive heart failure or fetal hydrops, abnormal echogenity of the liver parenchyma and outcome of pregnancy. In group 1, five fetuses had an umbilical vein which went directly into the right atrium, by-passing the liver. No ductus venosus, no portal veins and abnormal hepatic veins were detected. Echogenic foci in the liver were present in absence of portal veins. One fetus with Turner Syndrome dies in utero. The other fetuses had no associated malformations, but congestive heart failure secondary to volume overload and fetal hydrops in two cases. The outcome was uneventful after a short period of disturbed adaption. In group 2 of five fetuses, the umbilical vein went below the liver into the inferior Vena cava or via the iliac vein into the distal IVC. A ductus venosus was present in all but one fetus. Portal veins were absent in all and hepatic veins were abnormal developed in four fetuses. Associated malformations were seen in two cases. The other had a transient cardiomegaly and a favourable outcome. In group 3 two siblings had a normal umbilical vein, but an abnormal located ductus venosus. There was hepatomegaly and polyhydramnios in one and hepatomegaly and increasing ascites in the other. Autopsy showed a congenital cholangiopathy after neonatal death and abruption of pregnancy. Malformation of the umbilical, portal and hepatic venous system are rare, but can be associated with malformations or disturbed cardiac or hepatic function requiring intra-uterine or post partal therapy.

Multifetal pregnancy in older women and perinatal outcomes

Objective: To examine multifetal pregnancy in older women and perinatal outcomes. Design: A cross-sectional study. Setting: A nationwide vital registry. Patient(s): A national population-based database that links the live birth, fetal, and infant death certificates reported of multiple gestations in the United States from 1995 to 1997. It includes 155,777 twin and 5,630 triplet pregnancies. Intervention(s): None. Main Outcome Measure(s): Very preterm birth (<33 weeks), very low birthweight (<1,500 g), and perinatal and infant deaths. Result(s): Compared with those with singleton pregnancies, women with multifetal gestation tended to be older, non-Hispanic white, better educated, married, and nulliparous and to have earlier and more frequent prenatal care. Pregnancies conceived by assisted reproductive technology accounted for an increasing number of multiple gestations in older women. In women with lower socioeconomic status, older age was associated with higher risks of poor perinatal outcomes in twin pregnancy (relative risks ranging from 1.0 to 1.9 with a dose-response pattern). However, in women with higher socioeconomic status, older women did not have a higher risk of poor perinatal outcomes than younger women. Conclusion(s): The effect of older maternal age on perinatal outcomes in multifetal pregnancies may have been altered by assisted reproductive technology, frequent prenatal surveillance, and advanced neonatal care.

Socioeconomic and environmental risk factors of bacterial vaginosis in early pregnancy.

The main aim of this prospective study was to determine the socioeconomic, demographic and environmental factors that may be associated with the occurrence of bacterial vaginosis at early pregnancy in an indigent population from Central Poland. A group of 196 pregnant women was selected randomly from the patients of 10 district maternity units in the Lodz region, Central Poland. Only singleton pregnancies between 8 and 16 week of gestation were qualified for inclusion in the survey. A standard questionnaire covering medical, socioeconomic, demographic, constitutional and environmental items was administered to every subject and was verified with medical records. Cervico-vaginal swabs were collected from the women under study and tested for bacterial vaginosis (BV) according to Spiegel's criteria. Based on the results of Gram stain, BV was diagnosed in 51 women (28.5%), grade I microflora among 66 (36.9%) and grade II among 62 women (34.6%). In the univariate analysis, only single marital status proved to be an important risk factor associated with BV during pregnancy, this was confirmed in the multivariate analysis. Pregnant women who present risk factors for abnormal cervico-vaginal microflora should be covered by comprehensive prenatal surveillance, which enables early detection and treatment of this pathology. Research that identifies the causal pathways and mechanisms through which social disadvantage leads to a higher risk of preterm birth may help to reduce current socioeconomic and demographic disparities and improve pregnancy outcome.

Screening with a uterine Doppler in low risk pregnant women followed by low dose aspirin in women with abnormal results: a multicenter randomised controlled trial

Objectives To assess whether systematic screening with an uterine artery Doppler in low risk pregnant women followed by the prescription of low dose aspirin in cases with abnormal results reduced the incidence of intrauterine growth restriction and pre-eclampsia. Design A multicentre randomised trial. Population 3317 low risk pregnant women. In the Doppler group, the uterine artery Doppler was performed between 20 and 24 weeks. Women with abnormal results received 100 mg of aspirin daily until the 35th week. Main outcome measures Intrauterine growth restriction was defined as birthweight below the tenth and the third centile according to gestational age. Pre-eclampsia was defined as hypertension associated with proteinuria > 0.5g/L. Results Intrauterine growth restriction, whether defined by the third or tenth centile, did not differ significantly between the two groups (RR = 1.22 [0.73 - 2.04] and 1.18 [0.93 - 1.51] respectively). Screening with uterine artery Doppler did not affect birthweight or any of the criteria of perinatal morbidity. There was no effect on the incidence of pre-eclampsia (RR = 1.99 [0.97 - 4.09]) or hypertensive disorders. These results were the same for nulliparae and multiparae. Conclusions There is no justification for screening with uterine artery Doppler in a low risk population, even if abnormal results are followed by aspirin treatment and increased prenatal surveillance. Future studies must assess predictive tests that can be performed early in pregnancy and can identify populations at very high risk of pre-eclampsia and intrauterine growth restriction. Only when all of these conditions are fulfilled, aspirin or other treatments may prove its efficacy.

WS12‐02Systematic screening with a uterine Doppler in low‐risk pregnant women followed by low‐dose aspirin in cases with abnormal results: results of the two French multicenter randomised controlled trial

ObjectivesTwo large multicenter randomised trials were performed in France to assess whether systematic screening with an artery uteroplacental Doppler (AUD) in low‐risk pregnant women followed by the prescription of low‐dose aspirin in cases with abnormal results reduced the incidence of intrauterine growth restriction (IUGR) and of preeclampsia.Study design and populationThe first trial ‘Seine Saint‐Denis’ (SSD) trial included 3317 low‐risk pregnant women (multi and primigravidae) in 17 French maternity Hospitals and the second ‘Erasme’ trial included 1869 primigravidae in 12 centres. In the Doppler group, the AUD was performed between 20 and 24 weeks, and women with abnormal results received 100 mg of aspirin daily until the 35th week.ResultsIn the Doppler group, 232 patients (15.7%) had an abnormal result in the SSD trial and 20% in the ERASME trial. The predictive value of the AUD was comparable to that reported in the studies of low‐risk populations, but with a low sensitivity. Finally, IUGR, whether defined by the third or tenth percentile, and preeclampsia did not differ significantly between the treatment groups in both trials.ConclusionsThere is no proof justifying the recommendation of a systematic AUD in a low‐risk population, even if abnormal results are followed by aspirin treatment and increase in prenatal surveillance. Future studies must assess predictive tests that can be performed early in pregnancy and can identify populations at very high risk of preeclampsia and IUGR. Only when all of these conditions are fulfilled can aspirin prove its efficacy.

Predictive Value of Uterine Artery Velocimetry at Midgestation in Low- and High-Risk Populations: A New Perspective

Objective: The aim of this study was to assess the value of uterine artery Doppler velocimetry performed at 18–20 and 22–24 weeks of gestation in predicting preeclampsia and adverse pregnancy outcome in low- and high-risk patients. Methods: 865 pregnant women were evaluated: 335 and 530 pregnant women represented the high- and low-risk groups, respectively. Doppler ultrasound examination of the uterine arteries was performed at 18–20 weeks of gestation in 385 patients and at 22–24 weeks of gestation in 659 patients. Pregnancy outcome was evaluated in terms of: onset of preeclampsia; birth weight <2,500 g; birth weight <1,750 g; delivery before 36 weeks, and delivery before 32 weeks. Results: At 18–20 weeks of gestation the sensitivity for the prediction of preeclampsia was 100 and 94% in low- and high-risk groups, respectively. Excellent negative predictive values towards birth weight <1,750 g (97% in low-risk and 93% in high-risk groups) and delivery prior to 32 weeks of gestation (99% in low-risk and 95% in high-risk groups) were obtained. At 22–24 weeks of gestation the sensitivity for the prediction of preeclampsia was 100 and 97% in low- and high-risk groups, respectively. Negative predictive values towards birth weight <1,750 g were 97% in low-risk and 94% in high-risk groups, whereas towards delivery prior to 32 weeks of gestation they were 98% in low-risk and 94% in high-risk groups. Conclusion: Doppler evaluation of the uterine artery at 18–20 and 22–24 weeks of gestation represents a useful predictive test in high-risk pregnancy and can also be used in prenatal surveillance of a low-risk population.

Twin pregnancy discordant for trisomy 14 mosaicism: prenatal sonographic findings

The survival of infants with trisomy 14 mosaicism has been scarcely reported in the literature, with only 15 cases being documented up to 1992. We present a case of a dichorionic twin pregnancy in which prenatal sonography at 24 weeks' gestation showed that one of the twins had several anomalies including intrauterine growth restriction, alobar holoprosencephaly, a cleft lip and palate, a recessive chin, a small stomach, overlapping fingers, a ventricular septal defect, and polyhydramnios. Twin 2 was structurally normal. In view of the lethal condition and associated polyhydramnios affecting one of the twins, prenatal surveillance for signs of tense polyhydramnios and premature labour was undertaken. The pregnancy proceeded uneventfully until 37 weeks, at which time a Caesarean section was performed. At birth, neonatal blood from the abnormal twin confirmed trisomy 14 mosaicism in 12 per cent of lymphocytes. The infant died on day 36 of life.

Twin pregnancy discordant for trisomy 14 mosaicism: prenatal sonographic findings

The survival of infants with trisomy 14 mosaicism has been scarcely reported in the literature, with only 15 cases being documented up to 1992. We present a case of a dichorionic twin pregnancy in which prenatal sonography at 24 weeks' gestation showed that one of the twins had several anomalies including intrauterine growth restriction, alobar holoprosencephaly, a cleft lip and palate, a recessive chin, a small stomach, overlapping fingers, a ventricular septal defect, and polyhydramnios. Twin 2 was structurally normal. In view of the lethal condition and associated polyhydramnios affecting one of the twins, prenatal surveillance for signs of tense polyhydramnios and premature labour was undertaken. The pregnancy proceeded uneventfully until 37 weeks, at which time a Caesarean section was performed. At birth, neonatal blood from the abnormal twin confirmed trisomy 14 mosaicism in 12 per cent of lymphocytes. The infant died on day 36 of life. © 1998 John Wiley & Sons, Ltd.

Fetal ovarian cyst decompression to prevent torsion

Background/Purpose: Neonates who have ovarian torsion caused by an ovarian cyst often lose their ovary because the torsion and infarction occurred antenatally. Because ultrasound scan has been so effective in diagnosing ovarian cysts in utero, we have a better understanding of their natural history and can select appropriate cases for cyst decompression in utero to prevent torsion. The authors reviewed experience with seven fetuses who had fetal ovarian cyst. Methods: During a 26-month period, seven patients were referred for the evaluation of fetal ovarian cyst. The mean gestational age at presentation was 31.9 ± 3.6 weeks (±SD; range, 27 to 37 weeks). There was no history of maternal risk factors such as diabetes mellitus or fetal risk factors such as hyperthyroidism or placentomegally. All seven cases involved isolated unilateral cysts without associated anomalies or chromosomal abnormalities. Mean initial cyst diameter was 3.4 ± 1.7 cm (±SD; range, 1 to 6.1). Indications used for ovarian cyst decompression included anechoic cysts with a diameter ≥4 cm, a cyst “wandering” about the abdomen on serial sonograms, or demonstrating rapid enlargement (>1 cm/wk). Results: All but one cyst progressed in size during observation. One fetal ovarian cyst (diameter, 2 cm) subsequently regressed spontaneously and another (diameter, 2.1 cm) stabilized during prenatal ultrasound surveillance. One “cyst” observed with a diameter of 3.5 cm proved to be a persistent cloaca. Four fetal ovarian cysts met criteria for decompression. Because of fetal position, decompression could not be performed in one. One cyst (seen before defining criteria for decompression) with a diameter of 5 cm was observed only and underwent torsion. Two cysts (diameters, 6.1 cm and 4 cm) were decompressed in utero under local anesthesia with ultrasound guidance, of 95 mL and 35 mL, respectively. High cyst fluid progesterone (12,041 and 1,990 ng/dL, respectively) and testosterone (1,298 and 2,900 ng/dL, respectively) confirmed the etiology of the cyst as ovarian. Neither cyst recurred, and postnatal ultrasound scan confirmed resolution. There was no maternal or fetal morbidity or mortality and only the patient observed before development of criteria for decompression lost her ovary because of torsion. Conclusions: Fetal ovarian cysts tend to present as isolated unilateral lesions in normal fetuses in the third trimester. Spontaneous regression of fetal ovarian cysts may occur. Fetal ovarian cyst decompression, in select cases, may preserve ovaries at risk for torsion.