Serial Amniocenteses Research Articles

Estimated time to emergence of secondary intra-amniotic infection or inflammation since the onset of the preterm premature rupture of membranes

ObjectivePrematurity is the most important prognostic factor for infants born following preterm premature rupture of membranes (PPROM). Therefore, when PPROM occurs between 22 and 33 weeks of gestation, prolonging pregnancy is recommended. Determination of management strategies requires screening for the presence of intra-amniotic infection or inflammation at the time of PPROM diagnosis. If intra-amniotic infection/inflammation is not detected, it is important to monitor the patient to diagnose any new infection/inflammation. We examined the period from PPROM to secondary intra-amniotic infection/inflammation and associated factors. Materials and methodsThis retrospective study was conducted at a single facility. We examined 26 patients who experienced PPROM between 26 and 33 weeks of gestation and were negative for intra-amniotic infection/inflammation at the time of diagnosis and underwent serial amniocentesis. Antibiotic therapy comprising ampicillin, amoxicillin, and clarithromycin for 7 days was started after the first amniocentesis. The period from PPROM to secondary intra-amniotic infection/inflammation was analyzed using a Kaplan–Meier survival curve. The onset of intra-amniotic infection/inflammation was considered as the time at which amniotic fluid bacterial culture results became positive, the time when amniotic fluid Interleukin (IL)-6 increased beyond 2.6 ng/mL, or the day of delivery if histological chorioamnionitis was observed in the delivered placenta. Patients were treated as censored if no intra-amniotic infection/inflammation could be confirmed in the amniotic fluid and delivered placenta. ResultsThe median time from PPROM to secondary intra-amniotic infection/inflammation was 18 days. Six patients developed intra-amniotic infection/inflammation, while 13 patients without intra-amniotic infections/inflammation delivered fewer than 7 days after PPROM. No confounding factors at the time of PPROM diagnosis were associated with the time from PPROM until secondary intra-amniotic infection/inflammation. ConclusionsThe time between PPROM and onset of secondary intra-amniotic infection/inflammation appears prolonged. Treatments other than antimicrobial agents may need to be added to prolong pregnancy.

Transabdominal amniocentesis in expectant management of preterm premature rupture of membranes: A single center prospective study.

The aim of this study was to evaluate the role of IL-6 point-of-care test in amniotic fluid obtained from serial amniocentesis in expectantly managed women with PPROM between 24 and 34 weeks of gestation. We conducted a prospective observational cohort study which included 62 pregnant women with PPROM in gestational weeks between 22+0 and 34+0. Women aged >18 years were eligible if they presented with PPROM and a singleton pregnancy. Only women who delivered at >24.0 weeks were included in the study. In all women, the maternal blood sampling and a transabdominal amniocentesis were performed at the time of admission prior to the administration of corticosteroids, antibiotics, or tocolytics, to rule out signs of chorioamnionitis. Maternal temperature, maternal serum C-reactive protein (CRP) and white blood cell (WBC) counts were assayed every subsequent day until delivery. Amniotic fluid was used for the clinical assessment (IL-6 point-of-care test, identification of microorganisms in the amniotic fluid. After one week of expectant management of PPROM, second amniocentesis with amniotic fluid sampling was performed in patients who did not deliver. For all newborns, medical records regarding neonatal morbidity and mortality were reviewed. In total, 62 women aged 19 to 41 years were recruited in the study. The mean gestational age at the time of PPROM was 31+0, the mean gestational age at labor was 32+1, and the median time from PPROM to childbirth was 112 h. IL-6 point-of-care test values above 1,000 pg/mL (positive Il-6 AMC) were found in 12 women (19.4%) with median interval from PPROM to childbirth 56 h (min-max: 6.4-288). IL-6 point-of-care test values below 1,000 pg/mL (negative Il-6 AMC) were found in 51 women (81.0%). The neonatal mortality rate was 1.9% and was associated with prematurity. The major clinical finding of our study is that serial transabdominal amniocentesis with Il-6 point-of-care test helps to identify a high inflammatory status in amniotic fluid in women with PPROM. Subsequent expectant management of women with PPROM does not lead to worsening of short-term neonatal outcomes.

French cohort of transient antenatal Bartter syndrome with MAGED2 mutations

Background MAGED2 was recently identified in an X-linked severe and transient form of antenatal Bartter's syndrome associated with polyhydramnios and prematurity but also in idiopathic polyhydramnios in the male offspring. An inappropriate expression of the sodium-chloride transporters NKCC2 and NCC is disclosed. Methods MAGED2 was screened by Sanger Sequencing in a series of 35 cases with transient or antenatal Bartter's syndrome and no pathogenic variant in SLC12A1, KCNJ1, CLCNKB and BSND genes. Results We found 15 cases from 14 families harboring MAGED2 variants including four nonsense, three miss sense, two frame shift and two splice-site variants; two small in frame deletions and one complete deletion of MAGED2 gene. Only one variant was previously reported, p.Arg446Cys. Severe polyhydramnios occurred in all pregnancies, at 18 to 25 weeks of gestation requiring serial amniocentesis (one to ten, when data available). In four cases, polyhydramnios was present in previous or later pregnancies. One pregnancy resulted in medical termination of pregnancy. All the infants (14) were born pre-term with gestational age at delivery between 26 and 36 weeks. All presented a Bartter's syndrome with severe polyuria (median diuresis was 13 mL/kg/h). Surprisingly, two cases were females. The severity of their phenotype and the course of the disease were comparable to those for male. The medical follow-up of 12 patients revealed that the salt and water losses resolved between 2 and 18 months with the end of indomethacin treatment or water and salts supplements. Two cases, with associated neurological disorders died at 1 and 12 months. Conclusion We confirmed with our French series of 15 MAGED2 cases the phenotypic presentation of this transient antenatal Bartter's syndrome. This new syndrome has to be considered in the differential diagnosis of Bartter's syndrome with the screening of MAGED2 as part of the molecular diagnosis.

Acardius-myelacephalus: management of a misdiagnosed case of twin reversed arterial perfusion sequence with tense polyhydramnios

Abstract Background: Twin reversed arterial perfusion (TRAP) sequence is the most severe form of twin to twin transfusion syndrome. Survival of the pump twin is threatened by extreme prematurity from polyhydramnios and cardiac failure, necessitating interventions. Rarely, interventions are indicated as a result of maternal life-threatening complications. The management of an acardiac-myelacephalus variant of TRAP sequence, complicated by severe maternal respiratory distress from tense polyhydramnios is presented in this report. Case presentation: A 29-year-old G3P2, Alive2 was referred to the Perinatal Unit on account of ultrasound diagnosed twin gestation with demise of one twin at an estimated gestational age (EGA) of 29 weeks. She was in severe respiratory distress with central cyanosis, and grossly distended abdomen. Ultrasonography revealed twin gestation with cardiac activity in only one twin and polyhydramnios. The second twin had no recognizable human body structure and retrograde umbilical arterial flow. TRAP sequence with tense polyhydramnios was diagnosed. The respiratory distress was relieved with serial reductive amniocentesis, and she was managed conservatively until an EGA of 34 weeks, when she delivered a live twin that weighed 2.05 kg, and an amorphous twin with a rudimentary limb that weighed 1.82 kg following spontaneous rupture of membranes. Monochorionic placentation was confirmed at delivery. The pump twin was discharged in a satisfactory state after a period of observation. Conclusion: TRAP sequence may be easily misdiagnosed due to its rarity, with adverse consequences. Accurate diagnosis of the condition, and the provision of basic facilities for in utero interventions when indicated are necessary for fetal salvage.

A new antibiotic regimen treats and prevents intra-amniotic inflammation/infection in patients with preterm PROM

Objectives: To determine whether a new antibiotic regimen could reduce the frequency of intra-amniotic inflammation/infection in patients with preterm PROM. Study design: This retrospective cohort study was conducted to evaluate the effect of antibiotics on the frequency of intra-amniotic inflammation/infection based on the results of follow-up transabdominal amniocenteses from 89 patients diagnosed with preterm PROM who underwent serial amniocenteses. From 1993–2003, ampicillin and/or cephalosporins or a combination was used (“regimen 1”). A new regimen (ceftriaxone, clarithromycin and metronidazole) was used from 2003–2012 (“regimen 2”). Amniotic fluid was cultured and matrix metalloproteinase-8 (MMP-8) concentrations were measured. Results: (1) The rates of intra-amniotic inflammation and intra-amniotic inflammation/infection in patients who received regimen 2 decreased during treatment from 68.8% to 52.1% and from 75% to 54.2%, respectively. In contrast, in patients who received regimen 1, the frequency of intra-amniotic inflammation and infection/inflammation increased during treatment (31.7% to 55% and 34.1% to 58.5%, respectively); and (2) intra-amniotic inflammation/infection was eradicated in 33.3% of patients who received regimen 2, but in none who received regimen 1. Conclusion: The administration of ceftriaxone, clarithromycin and metronidazole was associated with a more successful eradication of intra-amniotic inflammation/infection and prevented secondary intra-amniotic inflammation/infection more frequently than an antibiotic regimen which included ampicillin and/or cephalosporins in patients with preterm PROM.

EMBARAZO GEMELAR CON FETO ACARDÍACO: MANEJO CONSERVADOR. A PROPÓSITO DE UN CASO

Se presenta la experiencia en el manejo de una gestación gemelar con feto acardíaco, entidad rara, con una incidencia de 1 en 35000 gestaciones y con una mortalidad que alcanza el 100% para el feto acardíaco y 50% para el feto sano. La existencia del feto acardíaco supone una sobrecarga para el feto normal, pues existen anastomosis arterio-arteriales y veno-venosas que los comunican, manteniendo el corazón del feto normal las circulaciones periféricas de ambos; esta situación origina múltiples anomalías en el feto receptor, mientras que la sobrecarga hemodinámica en el feto perfusor puede condicionar el desarrollo de una insuficiencia cardíaca, hidropesía, polihidramnios y parto pretérmino. En el manejo del presente caso clínico, se optó por una actitud conservadora, combinando tratamiento médico (digitálicos) con amniocentesis descompresivas seriadas.

Therapeutic modalities of twin to twin transfusion syndrome

Twin to twin transfusion syndrome (TTTTS) accounts for approximately 10% of monochorionic twin pregnancies and, if left untreated, is associated with high morbidity and mortality rate. A net transfusion of blood flow from one fetus (donor twin) to the other (recipient twin) via placental vascular anastomoses has been supposed as the major etiology of TTTTS. The donor twin becomes hypovolemic and oliguria, oligohydramnios, and a variable degree of growth restriction develop, whereas the recipient twin manifests polyuria, polyhydramnios, and hydrops in response to hypervolemia. TTTTS can be treated by either serial amniocentesis or selective fetoscopic laser coagulation of the communicating vessels. The rationale for removal of large volumes of amniotic fluid is to prevent preterm delivery secondary to polyhydramnios and to improve fetal circulation by reducing pressure on the chorionic plate. On the other hand, the goal of laser therapy is to occlude vascular anastomoses, thereby interrupting intertwin blood exchange. Although laser treatment is associated with increased survival rate and reduced neurologic complications, compared with amnioreduction, it requires highly specialized centers, whereas serial amniocentesis has the advantage of being performed worldwide. Therefore, the optimal treatment for pregnancies complicated with TTTTS is still controversial.

Legal Briefs: Anemia From Rh Hemolytic Disease of the Fetus and Newborn

A 3,480-g male infant was born at 36 weeks' gestation to a 32-year-old gravida 1 para 1 woman whose pregnancy was complicated by a group B Streptococcus –positive cervical culture result and hemolytic disease of the fetus and newborn (HDFN) due to Rh incompatibility. The prior pregnancy resulted in an infant who was healthy but whose records were unavailable during litigation. On an early prenatal visit for the current pregnancy, the mother's antibody screen result was positive with a titer of 1:8, at which point the obstetrician gave her an injection of anti-Rh antibodies (Rho[D] immune globulin, sold under the brand name RhoGAM). The pregnancy was not monitored for HDFN; the antibody titers were not drawn again until the day of delivery. The plaintiff obstetrician was critical of the treating obstetrician for administering RhoGAM because the patient was already sensitized, for not following the antibody titers, and for not performing aggressive fetal surveillance required in an Rh sensitized pregnancy. He pointed out that the antibody titers of 1:32 or less require serial antibody titers every 2 to 4 weeks. When and if the titers become 64 or greater, then titers and serial amniocentesis become necessary. Because the mother experienced decreased fetal movement for 1 day, her obstetrician admitted her for an evaluation. The plaintiff experts pointed out that decreased fetal movement underscored the anemia, indicating the fetus' attempt to conserve energy. The biophysical profile was found to be 2/10, the only normal score being normal amniotic fluid volume. Of note was an increase in liver size and mild ascites on the fetal ultrasonogram. Pericardial and pleural effusions were not present. The plaintiff experts pointed out that abdominal fluid collections precede pleural and pericardial effusions in hydrops from HDFN. The antibody titer was 1:2,048. The plaintiff obstetrician pointed out that this …

Intra-amniotic Fluconazole Therapy for Candida albicans Intra-amniotic Infection

The consequences of intra-amniotic Candida infection can be devastating. Currently, standard management includes delivery. We identified only one previous case reporting intrauterine antifungal therapy, which used transcervical amphotericin B. We present two cases of intra-amniotic Candida infection treated with intra-amniotic fluconazole instilled before membrane rupture. Two patients presented with intra-amniotic Candida albicans infection that was diagnosed during previability. Both underwent cerclage placement before culture results were available. Aggressive antifungal therapy was instituted using oral, vaginal, and intra-amniotic fluconazole instilled through serial amniocenteses. Both fetuses survived without sequelae. Intra-amniotic Candida infection is associated with preterm rupture of membranes, preterm labor, severe neonatal infection, and fetal death. Early diagnosis and treatment is essential.

Antenatal Bartter syndrome: a rare cause of unexplained severe polyhydramnios

A woman presented with polyhydramnios at 22 weeks of gestation with a structurally normal fetus and placenta. Biochemical analysis of amniotic fluid detected a very high level of chloride (582 mmol/L), which led to the diagnosis of Bartter syndrome. With serial amniocentesis and indomethacin therapy, the pregnancy continued to 36 weeks. Neonatal and subsequent investigations further supported the diagnosis of Bartter syndrome. The infant was well at birth and now, at 5 months of age, is gaining weight normally on indomethacin.

P24.03: Fetal anemia with normal Doppler velocimetry in the middle cerebral artery

Ultrasound evaluation of middle cerebral artery peak systolic velocity (MCA-PSV) is the standard investigation for the diagnosis of fetal anemia. It has replaced serial amniocentesis for surveillance in red cell alloimmunization but has also proved effective in the detection of fetal anemia due to other disease states. MCA-PSV greater than 1.5 multiples of the median (MoM) for gestational age is an indication for diagnostic cordocentesis. Critically, the seminal work on this screening tool reported a sensitivity of 100% for the detection of moderate-to -severe fetal anemia. We present a case of significant fetal anemia associated with normal indices on repeated interrogation of the middle cerebral artery. A 25-year-old woman presented for a routine structural sonogram at 20 weeks’ gestation. Fetal hydrops was identified with severe ascites, scalp edema and a pericardial effusion. Maternal serology confirmed recent parvovirus seroconversion with positive IgG and IgM. MCA-PSV was 31 cm/s, corresponding to between 1.0 MoM and 1.29 MoM for this gestation. Despite the normal MCA-PSV, a diagnostic cordocentesis was performed which confirmed significant fetal anemia with haematocrit of 23%. Intrauterine transfusion (IUT) of 35cc packed red cells was performed. Repeat sonographic evaluation 4 days later showed persistent hydrops and MCA-PSV 23 cm/s (normal). Two weeks following IUT, fetal hydrops had resolved. MCA-PSV remained within normal limits. The remainder of the pregnancy was uncomplicated. This case illustrates the possibility of false negative MCA-PSV in the setting of fetal anemia. In the absence of another cause for fetal hydrops definitive diagnostic testing with fetal cordocentesis should be performed.

ANTENATAL BARTTER SYNDROME: Analysis of Two Cases with Placental Findings

The prenatal diagnosis of Bartter syndrome can be based on the high chloride level in the amniotic fluid. Microscopic examination of the placenta in untreated cases showed extensive mineralization in the chorionic villi in previous studies. Two cases were presented at 26–29 weeks of gestation with severe polyhydramnios. The mothers were treated with Indomethacin, KCl, and serial amniocentesis in order to reduce the amniotic fluid volume and prevent fetal hypokalemia. The microscopic examination of the placenta revealed focal calcification and acute atherosis in placental vessels. The treatment with Indomethacin in the antenatal period can prevent severe nephrocalcinosis.

EL DOPPLER DE LA ARTERIA CEREBRAL MEDIA REEMPLAZA A LA ESPECTROFOTOMETRÍA DEL LÍQUIDO AMNIÓTICO COMO EL ESTÁNDAR EN EL MANEJO DE LA ISOINMUNIZACIÓN FETAL

SUMMARY Fetal anemia could be a devastating condition to the fetus. The main cause of fetal anemia is red-cell alloimmunization. The standard of care for this condition has been the serial amniocentesis to measure bilirubin levels by spectrophotometry of the amniotic fluid. Amniotic fluid bilirubin measurements are of limited value in the second trimester and in other causes of fetal anemia, besides amniocentesis is an invasive method with fetal risk. During the last 10 to 12 years a non invasive method to predict fetal anemia become available: measurement of the peak systolic velocity of the middle cerebral artery. Increased velocity may reflect fetal anemia. Here we present the evidence to support the use of this non invasive method to replace amniocentesis as the standard care in the management of red-cell alloimmunization and other causes of fetal anemia.

Minimizing neonatal adverse events associated with the management of red cell alloimunization: A decision analysis

OF RED CELL ALLOIMUNIZATION: A DECISION ANALYSIS ANGELA SILBER, SERDAR URAL, University of Pennsylvania, Obstetrics and Gynecology, Philadelphia, Pennsylvania OBJECTIVE: Compare strategies for managing patients with red cell alloimunization and identify the path that maximizes perinatal survival and outcome. STUDY DESIGN: Using decision analysis, we compared 3 screening strategies: Doppler ultrasound measurements of middle cerebral artery (MCA) peak velocity followed by cordocentesis, serial amniocentesis with determination of amniotic fluid delta-OD450 and no testing. Outcomes included perinatal death and prematurity sequelae, including grade III-IV intraventricular hemorrhage (IVH). Baseline assumptions included procedure-specific and gestational agespecific estimates of perinatal morbidity and mortality. The high pay calculation path was chosen, for survival intact pay off defined as 1, survival with sequelae given pay off 0.5 and for death, 0. RESULTS: The optimal strategy with the highest pay off is MCA Doppler screening. The pay off for MCA Doppler screening reached 0.91; with the amniocentesis protocol the pay off reached 0.71 and for no testing, 0.22. CONCLUSION: The MCA Doppler strategy is the one with the highest pay off, suggesting higher overall and intact neonatal survival when compared to the amniocentesis and no testing strategies. In the absence of randomized controlled trials, this analysis suggests that MCA Doppler strategy is the optimal scheme for managing red cell alloimmunization.

Doppler Ultrasonography versus Amniocentesis to Predict Fetal Anemia

When red blood cell alloimmunization takes place during pregnancy, the fetus is at risk of hemolytic anemia, which may lead to hydrops and death as early as 17 weeks gestation. Timely diagnosis and blood transfusions may, however, result in survival rates higher than 90%. Until now, these pregnancies have been monitored by serial amniocentesis to estimate bilirubin levels expressed as the change in optical density at a wavelength of 450 nm (ΔOD 450 ). A noninvasive alternative is to use Doppler ultrasonography to measure the peak velocity of systolic blood flow in the middle cerebral artery. The present prospective international study enrolled women with RhD-, Rhc-, RhE-, or Fy a -alloimmunized pregnancies who had an indirect antiglobulin titer of 1:64 or higher and an antigen-positive fetus. The final study group included 164 pregnancies with 165 fetuses, 74 of whom were severely anemic as defined by a hemoglobin deficit 5 or more standard deviations (SD) below the mean for gestational age. Another 25 fetuses had mild anemia with a deficit 2 to 5 SDs below the mean. Doppler ultrasonography was 88% sensitive in detecting severe fetal anemia (95% confidence interval [CI], 78-93%). Its specificity was 82% (95% CI, 73-89%) and its accuracy was 85% (95% CI, 79-90%). Amniotic fluid ΔOD 450 was 76% sensitive (95% CI, 65-84%), 77% specific (95% CI, 67-84%), and 76% accurate (95% CI, 69-82%). The Doppler study was 12% more sensitive and 9% more accurate than were measurements of amniotic fluid ΔOD 450 . The findings in this large-scale prospective study indicate that invasive testing by amniocentesis can safely be replaced by Doppler measurements of peak systolic blood flow in the middle cerebral artery for detecting severe hemolytic anemia in Rh-alloimmunized pregnancies.

P05.16: Monoamniotic twins discordant for anencephaly managed expectantly with amnioreduction: case report

Monoamniotic twin pregnancy discordant for anencephaly (MATDA) is a rare occurrence with only nine prior reported cases. Selective termination has been advocated in managing this kind of twins. We report the case, including expectant management with serial amniocentesis and a good outcome. The case was a 22-year-old primigravida woman diagnosed with MATDA at 24 weeks. Ultrasound findings included anencephaly, cervical rachischisis, a single placenta, absent membrane, severe polyhydramnios. Cordo- and placentocentesis showed a normal karyotype for the twins. Serial amnioreductions were performed. Amniotic fluid samples were submitted to the shake (Clements) test for fetal lung maturity assessment. The woman was managed expectantly until 35 weeks when a preterm labor began and Cesarean section was performed. The surviving male infant weighed 2100 g. and had a deformed right auricle and atresia of the auditory canal. He was discharged home in good condition one month later.

Prevention and management of RhD alloimmunisation in pregnancy

Rhesus D alloimmunisation remains a major problem despite the use of anti-D prophylaxis. Immunisation during pregnancy commonly occurs in the absence of any overt sensitizing event. Appropriate and timely intervention can significantly reduce the rate of immunisation (17% - 1%). In this respect, a simple algorhythm for the management of RhD negative women in pregnancy is presented. Traditionally, identifying and monitoring fetuses at risk of anaemia in RhD alloimmunised pregnancies required invasive testing such as serial amniocentesis. This procedure is associated with significant complications. Recent evidence favours a non-invasive approach by measuring the peak systolic velocity in the fetal middle cerebral artery. This Doppler method has the same accuracy in predicting fetuses at risk of anaemia when compared with amniocentesis, but without its complications. We therefore present new guidelines for the monitoring of RhD alloimmunised pregnancies. Obstetrics & Gynaecology Forum Vol. 15 (3) 2005: 27-30

Management of twin–twin transfusion syndrome in pregnancies with iatrogenic detachment of membranes following therapeutic amniocentesis and the role of interim amniopatch

Detachment of membranes may occur after therapeutic amniocentesis for twin-twin transfusion syndrome (TTTS). Subsequent amniocenteses or endoscopic fetal therapy may be hindered or made altogether impossible by this complication. The purpose of this study was to describe our experience in the assessment and management of TTTS patients with iatrogenic detached membranes (IDM). Patients with IDM referred for fetal surgery for TTTS were considered ineligible for standard surgery and were offered different alternatives, including expectant management, serial amniocentesis, or an attempt at surgery with or without prior amniopatch. Pregnancy outcomes were compared between surgical and non-surgical patients. Nine hundred and forty-four patients with a diagnosis of TTTS were referred between July 1997 and December 2004, of whom 322 (34.1%) had a prior therapeutic amniocentesis. Twenty-six of the 322 patients (8%) had IDM. Ten patients opted to be managed with subsequent amniocenteses, two of which had an amniopatch. One patient had voluntary interruption of pregnancy. Fifteen patients underwent surgery, 10 of whom underwent an amniopatch. Overall, resealing of membranes occurred in 8/12 (66%) patients treated with an amniopatch. Survival of at least one fetus was greater in patients treated surgically with or without an amniopatch (12/15, 80% vs. 4/11, 36%, P = 0.04). Membrane detachment is an important complication of therapeutic amniocentesis in the treatment of TTTS. Although successful treatment of IDM can be achieved with an interim amniopatch, this alternative is not without risks. Therapeutic amniocenteses should be discouraged in patients considering endoscopic fetal surgery for TTTS.

A randomized trial of amnioreduction versus septostomy in the treatment of twin-twin transfusion syndrome

Left untreated, severe twin-to-twin transfusion syndrome (TTTS) presenting in the early second trimester of pregnancy is often associated with significant maternal morbidity and almost universal perinatal loss. Removal of excessive amounts of amniotic fluid through serial amniocenteses (amnioreduction) has been the mainstay of therapy. We sought to compare amnioreduction to intentional perforation of the intervening twin membrane (septostomy). Pregnant women with TTTS before 24 weeks' gestation were randomly assigned to serial amnioreduction or septostomy. A single puncture technique under ultrasound guidance was used for the septostomy. The primary outcome measure was survival to neonatal discharge, and was assessed based on the number of pregnancies or the number of fetuses as appropriate. The study was terminated at the planned interim analysis stage after 73 women were enrolled. This was because the rate of survival of at least 1 infant was similar in the amnioreduction group compared to the septostomy group (78% vs 80% of pregnancies, respectively; RR=0.94, 95%CI 0.55-1.61; P=.82). Patient undergoing septostomy were more likely to require a single procedure for treatment (64% vs 46%; P=.04). Although overall perinatal survival is not enhanced, septostomy offers the advantage of often requiring a single procedure compared to serial amnioreduction in the treatment of severe twin-to-twin transfusion syndrome.

Differenzialdiagnose des Polyhydramnions beim Hyperprostaglandin-E-Syndrom: Case-Report

A polyhydramnion is diagnosed in 0.4 to 3.3 % of all pregnancies. The most common causes of increased amniotic fluid include maternal diabetes mellitus, fetal malformations and chromosomal aberrations, twin-to-twin transfusion syndrome, rhesus incompatibility syndrome, and congenital infections. After exclusion of other etiologies for polyhydramnion, the very rare, autosomal-recessive transferred hyperprostaglandin E syndrome (HPS) has to be considered. We report on a 31-year-old women who visited our obstetrical outpatient clinics at 22 + 4 weeks of gestation for prenatal ultrasound scanning and amniocentesis. This, the patient's third pregnancy had been without complications so far. She had delivered two children before, one of them bearing the HPS. The women herself suffered from epilepsy. At 26 + 0 weeks of gestation the pregnancy was complicated by a polyhydramnion requiring serial amniocentesis for reducing amniotic fluid load. Among others, her amniotic fluid was analyzed for chloride concentration and for genetic aberrations regarding HPS. Serological investigations and an oral glucose tolerance test (oGTT) were performed. Amniocentesis revealed a normal chromosomal pattern. The oGTT demonstrated values in the normal range. Serological investigations regarding TORCH infections were without pathological findings. The chloride concentration was highly increased in the amniotic fluid, which is suspicious for HPS. Finally, molecular analysis proved an NKCC2-mutation responsible for HPS. A cesarean section was performed at 33 + 3 weeks of gestation. If HPS is suspected to be the cause of polyhydramnions, the chloride concentrations in the amniotic fluid and molecular analysis for HPS should be performed. Interdisciplinary care, diagnostics and therapy in an experienced perinatal center are essential for an optimal outcome of the pregnancy and the newborn infant.