Sick Fetus Research Articles

Outcome of Monochorionic Pregnancies after Selective Feticide with Bipolar Cord Coagulation: A German Single Center Experience.

Objectives: To review the outcome of complicated monochorionic pregnancies after fetoscopic selective feticide with bipolar cord coagulation in an experienced German center. Methods: All cases that underwent selective feticide using fetoscopic bipolar umbilical cord occlusion (and simultaneous dissection in monoamniotics) at the University of Bonn in the past 10 years were retrospectively analyzed for antenatal and neonatal course and outcome. An adverse outcome was defined as either intrauterine death (IUD), neonatal death (NND), preterm prelabour rupture of membranes (PPROM), or preterm delivery (PTD) before 32.0 weeks of gestation. Results: We diagnosed 56 monochorionic pregnancies, including 43 diamniotic and 8 monoamniotic twins, as well as 5 triplets, complicated by discordant fetal anomalies (n = 10), selective intrauterine growth restriction (n = 29), twin-to-twin transfusion syndrome (n = 13), twin reversed arterial perfusion sequence (n = 3), or severe early twin anemia polycythemia sequence (n = 1), that underwent fetoscopic selective feticide in the 10 years study period. Selective feticide was performed by bipolar cord coagulation at a median gestational age of 21.2 weeks. PPROM occurred in 11 cases, 7 (12.5%) before 32.0 weeks and 4 (7.1%) between 34.0 and 36.0 weeks, respectively. There were five (8.9%) co-twins IUDs at a median of 2 weeks after the intervention. We observed 12 (21.4%) PTDs before 32.0 weeks of gestation and 2 (3.6%) NNDs. Mean gestational age at delivery was 37.1 weeks, with an overall survival of the co-twin of 87.5%. Conclusion: In experienced hands, fetoscopic selective feticide is an effective treatment in complicated monochorionic pregnancies. By sacrificing a sick fetus that jeopardizes the entire pregnancy, a higher survival rate of the co-twin can be achieved.

Investigating myocardial performance in normal and sick fetuses by abdominal Doppler signal derived indices.

IntroductionFetal myocardial performance indices are applied to assess aspects of systolic and diastolic function in developing fetal heart. The aim of this study was to determine normal values of Tei Index (TI) and modified TI (KI) for systolic and diastolic performance in early (<30 weeks), Mid (30–35 weeks) and late (36–41 weeks) relating to both normal fetuses as well as fetuses carrying a variety of fetal abnormalities, which do not call for precise anatomic imaging.Material and methodsFetal Electrocardiogram Signals (FES) and Doppler Ultrasound Signal (DUS) were simultaneously documented from 55 normal and 25 abnormal fetuses with a variety of abnormalities including Congenital Heart Diseases (CHDs) and a variety of non-CHDs. The isovolumic contraction time (ICT), isovolumic relaxation time (IRT), ventricular ejection time (VET) and ventricular filling time (VFT) were estimated from continuous DUS signals by a hybrid of Hidden Markov and Support Vector Machine based automated model. The TI and the KI were calculated by using the formula (ICT ​+ ​IRT)/VET and (ICT ​+ ​IRT)/VFT respectively.ResultsThe TI was not found to show any significant change from early to late fetuses, nor between normal and abnormal cases. On the other hand, KI was shown to significantly decline in values from early to late normal cases and from normal to abnormal groups. Significant correlation (r = −0.36; p < 0.01) of gestational ages with only KI (not TI) was found in this study.ConclusionModified TI (KI) may be a useful index to monitor the normal development of fetal myocardial function and identify fetuses with a variety of CHD and non-CHD cases.

APPLICABILITY OF FETAL DOPPLER ULTRASOUND TO IDENTIFY ALTERATIONS SUGGESTIVE OF EXTRA-CARDIAC ANOMALIES (FIRST PART)

Introduction: Fetal Doppler ultrasound is the method of choice to identify alterations that put the fetus at risk;this tool has revolutionized the traditional conception of Perinatology as it gives the opportunity to understand that the pathophysiological process of the sick fetus presents a hemodynamic deterioration. Objective: To describe the applicability of fetal Doppler ultrasound in the main extra cardiac anomalies. Methods: Bibliographic review of scientific articles published in Spanish and English and their corresponding validation under CASPe and PRISMA tools. Results: A bibliographic analysis of 92 citations was carried out under the aforementioned systematic search in which the main fetal anomalies were separated under the supradiaphragmatic, infradiaphragmatic and cerebral concept. Conclusion: There are a limited literature regarding Doppler ultrasound evaluation in relation to extra-cardiac anomalies,and among them there are discrepancies in the findings found between various authors.

Highly Sensitive and Specific Detection of SRY Gene for Non–invasive Prenatal Diagnosis

Abstract Through detecting SRY gene of cell–free fetal DNA (cffDNA) in maternal peripheral blood, the sex of fetuses can be determined, risks of sex–linked genetic disorders can be assessed and birth rate of sick fetuses can be decreased. In this study, a method of real–time polymerase chain reaction (PCR) coupled with invader assay, which was highly sensitive, highly specific and non–contaminated with closed tube detection, was established to detect SRY gene. The optimal reaction conditions were determined to be 250 nM of detection probes, 7.5 U of FEN1 enzyme, 0.5 U of Taq polymerase and 67 °C of annealing temperature in pre–amplification. Finally, it was demonstrated that the simulated samples as low as 4‰ (4 copies μL −1 ) could be detected and two clinical samples with the gestation age of 9 and 10 weeks respectively were also successfully detected. The experimental results indicated that this method could be used to detect SRY gene of cffDNA in maternal peripheral blood, providing an effective technique for clinical non–invasive prenatal diagnosis based on SRY gene.

Microcystic congenital pulmonary airway malformation of the lung causing non immune hydrops fetalis and Mirror syndrome: a case report

Congenital Pulmonary Airway Malformation (CPAM) is a rare lung anomaly with a highly variable prognosis depending on the presence of fetal hydrops and the size of the cyst. CPAM associated with fetal hydrops carries a grave fetal prognosis and development of “mirror syndrome” calls for immediate delivery of fetus as this condition is potentially life threatening for the mother, if no intervention is done. We report on the pathological findings of a non-immune hydropic fetus with cardiac shift to right side, moderate hydromnios and a rare maternal condition which “mirrors” the sick fetus known as “mirror syndrome” by developing edema and high blood pressure due to microcystic CPAM at 26 weeks of gestation.

Fetal demise on MRI

Sir, I read with interest the paper by Victoria et al. [1] titled “MR evaluation of fetal demise.” Whilst I am pleased to see such work published and the effort the authors have taken with the work, I feel it is worth pointing out to the authors and other readers a few points that need to be considered when interpreting fetal death on MRI. Several of the image features pointed out by the authors depend on the scanner type and sequence used and care should be taken to avoid overinterpretation. White blood in the chambers of the heart is frequently seen on balanced gradient echo sequences and must not be mistaken as fetal death. Skin odema can be seen in fetuses with hydrops and, again, is not diagnostic of fetal demise. In addition, if the fetus died several weeks prior to scanning, there is often no skin odema but a small featureless fetus—the fetal papyrus. Small pleural effusions are common in cases of fetal demise but again are seen in other pathologies. The lack of fluid in the stomach and bladder depends on the time between fetal demise and MR imaging and may also be a feature of other pathologies. The changes in the eyes are not seen after a recent demise and I am unsure as to what time after demise the changes start to occur. In my experience, the most reliable and consistent feature of fetal demise is the traditional Spalding sign seen on MR images as overlapping of the sutures of the skull and total lack of extra-axial CSF space. Beware of the lack of CSF space in cases with meningoceles; these do not have overlapping sutures. Loss of grey-white matter differentiation can be due to pathology other than demise, although this often is indicative of a sick fetus where demise is imminent. When seen in association with loss of the extra-axial CSF space, this is probably the best sign of fetal demise of any duration seen on fetal MR images. As mentioned by the authors, the use of a cine sequence for fetal cardiac motion is useful but ultimately real-time ultrasound is required prior to any change in management.

The 18‐week fetal examination and detection of anomalies

From its beginning in the fifties the use of ultrasound in gynaecology and obstetrics has expanded extensively. Ultrasound technology has taken us from a time when the mother was our prime focus to the present where it is the unborn baby. Ultrasound assessments may have significant consequences for pregnancy care by optimizing the time, the mode and the location of the delivery as well as preparing the postnatal staff for a prenatally defined fetal problem. A major factor in the development was the groundbreaking work of an obstetrician, Ian Donald, and an engineer, Tom Brown, at Queen Mother's Hospital in Glasgow, who produced an ultrasound instrument called the Diasonograph. The first screening program offering a systematic ultrasound examination to a large pregnant population began in Malmoe, in 1973 and aimed to detect twins. Since then the examination has evolved over the years to include a systematic evaluation of the intrauterine contents. A number of randomized controlled trials have been reported and several large studies have reported the efficiency of routine fetal examinations for the detection of anomalies. Detection rates for the various subsets are presented. The learning curve regarding the ability to detect anomalies and the importance of proper training has also been shown. The procedure 'routine fetal examination' has been significant in supporting the continuous development of fetal medicine. The consequences of the improved dating of every pregnancy and the in utero transport of a sick fetus rather than an emergency transportation of a sick neonate, have an established evidence base. Ultrasound technology has had a remarkable ability to trigger great technical minds to move the technology forward year after year. Through a continuous cooperation between technicians and clinicians, this impressive technology of ultrasound will continue to support our work for the unborn child.

Parents’ informational needs at the birth of a baby with a surgically correctable anomaly

Previous studies have assessed informational needs of parents of sick fetuses, neonates and children to identify favourable patterns of physician-parent interaction. The aim of this paper was to assess parents' informational needs before and after the operation when the one affected by a surgically correctable anomaly is a newborn. In the period ranging from 1997 to 2000 all couples with newborns undergoing major surgical procedures at birth, at the Newborn Surgery Unit of the Hospital Bambino Gesù, were surveyed by means of a questionnaire. Thirty couples form the object of the study. The two genders did not show significant difference in any of the considered items. All 30/30 mothers (M; 100%) and 29/30 fathers (F; 97%) had never heard about the anomaly before the diagnosis was established in their baby. All parents (100%) stated that it would be better if the surgeon informed them with written educational material. Principal informational needs before operation regard: the description of the anomaly (M = 10; F = 11) and the prognosis in terms of survival chances of the baby (M = 17; F = 15); after surgery the cause of the anomaly (M = 5; F = 3); the steps of the recovery process (M = 10; F = 12) as well as the quality of their baby's life (M = 9; F = 9). In the immediate perioperative period the surgeon should well address parents' informational needs, which may significantly differ from his communication plan.

The Tei index for evaluation of fetal myocardial performance in sick fetuses

Objective The Tei index is a useful, new, noninvasive Doppler index of combined systolic and diastolic function calculated by isovolumic relaxation time plus isovolumic contraction time divided by ejection time. Sick fetuses were evaluated with the Tei index. Methods The study group underwent two-dimensional/Doppler echocardiographic measurement of their Tei index and included 10 monochorionic diamniotic (MD) twin pairs with non-twin to twin transfusion syndrome (TTTS), 4 twin pairs with TTTS, 12 fetuses with intrauterine growth retardation (IUGR), 14 fetuses of diabetic mothers, 3 hydrops fetalis fetuses, 8 fetuses of mothers treated with a tocolytic agent, and 40 normal fetuses (control group). Results The Tei indices in the following groups were significantly higher than the control: recipient fetuses in TTTS, large for gestational age (LGA) fetuses of diabetic mothers, and fetuses with hydrops fetalis. Conclusion The Tei index may be a useful tool for the assessment of fetal cardiac status in a variety of sick fetuses. Recipient fetuses in TTTS, LGA fetuses of diabetic mothers, and hydrops fetalis fetuses may have abnormal myocardial performance. The Tei index readily provides early detection of diminished myocardial function, particularly ventricular dysfunction.

A very-short-term intermittency of fetal heart rates and developmental milestone.

We noticed that fetal heart rates (FHR) of immature fetuses intermittently showed unstable sudden and brief falls below baseline FHR that occur over a few or several heartbeats. The frightening falls do not occur in mature fetuses. In nonlinear dynamics, the degree of such abrupt falls in time series is quantified as intermittency. We aimed to investigate the nature and maturational changes of intermittency of the FHR in normal fetuses and to present the intermittency values of normal fetuses according to gestational weeks. FHR data of 450 normal fetuses between 23 and 40 wk of gestation were studied. We performed multifractal analysis and highlighted a very-short-term intermittency (C1alpha, 4 </= scale < 16 heartbeats). The C1alpha values exhibited a strong negative linear correlation (r = -0.732, p = 0.0001) with the gestational weeks. At 27-28, 29-30, 33-34, and 37-38 gestational weeks, the C1alpha values were significantly lower than those of the previous 2 or 4 gestational weeks. The maturation of normal fetuses is related to decreasing the severity of the unstable sudden and brief falls in FHR that is measured by C1alpha, the very-short-term intermittency. The C1alpha values according to the gestational weeks that we presented can be used as credible normal milestone values when estimating the degree of maturity of certain FHR. Because the C1alpha captures the degree of the unstable fall in FHR, the C1alpha may also be used in identifying sick fetuses that are associated with hemodynamic instability and sudden bradycardia.

Longitudinal measurements of fetal heart rate (FHR) monitoring in second trimester

We investigated the possibility of clinical diagnosis of preterm fetal well-being in the second trimester using the duration of LTVs of less than 4.5 beats/min and characteristic FHR acceleration. Fetuses between 24 and 32 weeks gestation, unlike near-term fetuses are seldom quiet and therefore the prolonged absence of fetal movement may be the best indicator of a sick fetus at these gestational ages. The amplitude and duration of the acceleration of the FHR were also clinically useful diagnostic tools for fetus well-being during the second trimester.

An assessment of the first decade's experience with antepartum fetal heart rate testing.

The utility of antepartum fetal heart rate (APFHR) monitoring (nonstress test and the contraction stress test) was evaluated for a 10-year interval from 1974 through 1983. The number of high-risk patients evaluated increased from 2.9 to 25.1% of all deliveries. The decade's perinatal mortality rate differed from 22.4 per 1000 in the nontested population to 11.8 per 1000 in the tested population; the stillbirth rate differed from 11.1 per 1000 to 5.4 per 1000 uncorrected, 2.2 per 1000 corrected, and perinatal morbidity also differed from 26.1 per 1000 to 24.9 per 1000 (NS). Improvement statistics appear to plateau by the fourth year. An abnormal APFHR test was associated with a lethal congenital anomaly in 2.54% of patients (versus 0.5 to 1.5% in the general population). Evaluation for the presence of congenital anomalies appears to be indicated in the fetus with an abnormal APFHR test. A lower stillbirth rate occurred within 4 days of a normal APFHR test (0.027%) compared with a test interval of 5 to 7 days (0.11%). Thus, APFHR testing performed twice weekly may offer a better outcome for the fetus at risk than once weekly testing. This report confirms that the chief value of APFHR testing is its ability to identify the normal healthy fetus. These tests are somewhat less accurate at identification of the sick fetus. The nonstress test and contraction stress test were found to be of similar clinical predictive value.