Objective The purpose of this study was to test the hypothesis that a standardized multidisciplinary treatment approach in patients with morbidly adherent placenta, which includes accreta, increta, ...and percreta, is associated with less maternal morbidity than when such an approach is not used (nonmultidisciplinary approach). Study Design A retrospective cohort study was conducted with patients from 3 tertiary care hospitals from July 2000 to September 2013. Patients with histologically confirmed placenta accreta, increta, and percreta were included in this study. A formal program that used a standardized multidisciplinary management approach was introduced in 2011. Before 2011, patients were treated on a case-by-case basis by individual physicians without a specific protocol (nonmultidisciplinary group). Estimated blood loss, transfusion of packed red blood cells, intraoperative complications (eg, vascular, bladder, ureteral, and bowel injury), neonatal outcome, and maternal postoperative length of hospital stay were compared between the 2 groups. Results Of 90 patients with placenta accreta, 57 women (63%) were in the multidisciplinary group, and 33 women (37%) were in the nonmultidisciplinary group. The multidisciplinary group had more cases with percreta ( P = .008) but experienced less estimated blood loss ( P = .025), with a trend to fewer blood transfusions ( P = .06), and were less likely to be delivered emergently ( P = .001) compared with the nonmultidisciplinary group. Despite an approach of indicated preterm delivery at 34-35 weeks of gestation, neonatal outcomes were similar between the 2 groups. Conclusion The institution of a standardized approach for patients with morbidly adherent placentation by a specific multidisciplinary team was associated with improved maternal outcomes, particularly in cases with more aggressive placental invasion (increta or percreta), compared with a historic nonmultidisciplinary approach. Our standardized approach was associated with fewer emergency deliveries.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
2.
Education in the time of COVID-19 Bloom, David Adam; Reid, Janet R.; Cassady, Christopher I.
Pediatric radiology,
07/2020, Volume:
50, Issue:
8
Journal Article
The purpose of this study is to establish normal total fetal lung volume reference ranges from 18 to 38 weeks' gestation at 1-week intervals.
A retrospective analysis of 665 patients who underwent ...fetal MRI at two tertiary fetal centers from 2001 to 2013 was performed. Total fetal lung volume was measured in at least two planes, either manually or using a 3D workstation. The mean, median, SD, minimum, maximum, and lower and upper quartiles for total fetal lung volume were determined per gestational week. A t test was used to compare our values to previously reported values. A new formula to calculate total fetal lung volume derived from our data was created using a regression model. Comparisons between total fetal lung volume obtained by different imaging planes and manual versus semiautomatic calculation were also performed.
The mean normal total fetal lung volume showed a weekly increase from 18 through 35 weeks' gestation. Means were compared with the expected total fetal lung volume generated by the Rypens formula, showing statistically significant lower mean total fetal lung volume from week 19 to week 22 (p < 0.05). Comparison between our data-derived total fetal lung volume formula and the Rypens formula showed very similar values at every gestational age. No difference in total fetal lung volume was seen when comparing imaging planes or manual versus semiautomatic methods.
Measured mean total fetal lung volume values at 19-22 weeks are significantly lower than those predicted by the Rypens formula. Therefore, we propose preferential use of our values for prenatal counseling and delivery planning.
OBJECTIVE:To describe development of a two-port fetoscopic technique for spina bifida repair in the exteriorized, carbon dioxide-filled uterus and report early results of two cohorts of patientsthe ...first 15 treated with an iterative technique and the latter 13 with a standardized technique.
METHODS:This was a retrospective cohort study (2014–2016). All patients met Management of Myelomeningocele Study selection criteria. The intraoperative approach was iterative in the first 15 patients and was then standardized. Obstetric, maternal, fetal, and early neonatal outcomes were compared. Standard parametric and nonparametric tests were used as appropriate.
RESULTS:Data for 28 patients (22 endoscopic only, four hybrid, two abandoned) are reported, but only those with a complete fetoscopic repair were analyzed (iterative technique n=10 compared with standardized technique n=12). Maternal demographics and gestational age (median range) at fetal surgery (25.4 22.9–25.9 compared with 24.8 24–25.6 weeks) were similar, but delivery occurred at 35.9 (26–39) weeks of gestation with the iterative technique compared with 39 (35.9–40) weeks of gestation with the standardized technique (P<.01). Duration of surgery (267 107–434 compared with 246 206–333 minutes), complication rates, preterm prelabor rupture of membranes rates (4/12 33% compared with 1/10 10%), and vaginal delivery rates (5/12 42% compared with 6/10 60%) were not statistically different in the iterative and standardized techniques, respectively. In 6 of 12 (50%) compared with 1 of 10 (10%), respectively (P=.07), there was leakage of cerebrospinal fluid from the repair site at birth. Management of Myelomeningocele Study criteria for hydrocephalus–death at discharge were met in 9 of 12 (75%) and 3 of 10 (30%), respectively, and 7 of 12 (58%) compared with 2 of 10 (20%) have been treated for hydrocephalus to date. These latter differences were not statistically significant.
CONCLUSION:Fetoscopic open neural tube defect repair does not appear to increase maternal–fetal complications as compared with repair by hysterotomy, allows for vaginal delivery, and may reduce long-term maternal risks.
CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, https://clinicaltrials.gov, NCT02230072.
Background
Pulmonary hypoplasia is the primary cause of perinatal death in lethal skeletal dysplasias. The antenatal ultrasound correlates for lethality are indirect, measuring the thorax (thoracic ...circumference, TC) or femur compared to the abdomen (TC/AC, FL/AC). A single study has correlated lethality with the observed-to-expected total lung volume (O/E-TFLV) on fetal MRI in 23 patients.
Objective
Our aim was to define a cutoff value to predict lethality more specifically using MRI-derived O/E-TFLV.
Materials and methods
Two large fetal center databases were searched for fetuses with skeletal dysplasia and MRI; O/E-TFLV was calculated. Ultrasound measures were included when available. Each was evaluated as a continuous variable against lethality (stillbirth or death in the first month of life). Logistic regression and receiver operating characteristic (ROC) curve analyses evaluated the prediction ability. AUC, sensitivity, and specificity were calculated.
P
< 0.05 was considered statistically significant.
Results
A total of 80 fetuses met inclusion criteria. O/E-TFLV < 0.49 was a significant risk factor in predicting lethality, with sensitivity and specificity of 0.63 and 0.93, respectively, and an AUC of 0.81 (
P
< 0.001). FL/AC < 0.129 was also a strong variable with sensitivity, specificity, and AUC of 0.73, 0.88, and 0.78, respectively (
P
< 0.001). TC/AC and TC percentile were not significant risk factors for lethality. An O/E-TFLV of < 0.38 defines a specificity for lethality at 1.00.
Conclusion
MRI-derived O/E-TFLV and US-derived FL/AC are significant predictors of lethality in fetuses with skeletal dysplasia. When prognosis is uncertain after ultrasound, calculation of MRI-derived O/E-TFLV may provide additional useful information for prognosis and delivery planning.
Graphical abstract
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
OBJECTIVE:To evaluate feasibility and initial outcomes of fetoscopic tracheal occlusion for severe diaphragmatic hernia compared with a historical cohort who had not received fetal tracheal ...occlusion.
METHODS:Outcomes in a prospective observational cohort who underwent fetoscopic tracheal occlusion for severe fetal left diaphragmatic hernia without associated anomalies were compared with our historical nontreated cohort of matched fetuses of similar severity. Fetuses were classified using the same ultrasonography and magnetic resonance imaging methodology—prospectively in the fetoscopic tracheal occlusion group and retrospectively in the historical nontreated cohort. Obstetric and postnatal outcomes were evaluated and compared.
RESULTS:Between January 2004 and June 2015, 218 fetuses with diaphragmatic hernia were evaluated. Twenty (9%) fetuses had severe left diaphragmatic hernia (lung–head ratio 1.0 or less and liver herniation), of which 9 of 20 were managed without tracheal occlusion. Eleven were offered the procedure and in 10, it was successful. Mean (±standard deviation) gestational age was 27.9±1.1 weeks at attempted balloon placement, 34.1±1.1 weeks at removal, and 35.3±2.2 weeks at delivery. One patient required an ex utero intrapartum treatment procedure at delivery to remove the balloon. There were no maternal complications or fetal deaths. All neonates underwent postnatal repair with a patch. The 6-month, 1-year, and 2-year survival rates were significantly higher in our treated cohort than in our nontreated historical cohort (80% compared with 11%, risk difference 69%, 95% confidence interval CI 38–100%, P=.01; 70% compared with 11%, risk difference 59%, 95% CI 24–94%, P=.02; and 67% compared with 11%, risk difference 56%, 95% CI 19–93%, P=.04, respectively) with reduced need for extracorporeal membrane oxygenation (30% compared with 70%, risk difference 40%, 95% CI 10–79%, P=.05).
CONCLUSION:Fetoscopic tracheal occlusion is feasible and is associated with improved postnatal outcomes in severe left diaphragmatic hernia.
CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, https://clinicaltrials.gov, NCT00881660.
Congenital lung malformations (CLMs) have a variable natural history: some patients require urgent perinatal surgical intervention (UPSI) and others remain asymptomatic. These lesions have potential ...growth until 26-28 wk gestation. CLM volume ratio (CVR) has been shown to predict the risk of hydrops in CLMs. However, no criteria exist to delineate lesions requiring urgent surgical intervention in the perinatal period. Our goal was to determine prenatal diagnostic features that predict the need for UPSI in patients diagnosed with CLM.
Records and imaging features of all fetuses evaluated by our fetal center between May 2015 and December 2018 were retrospectively reviewed. Data included demographics, fetal ultrasound and magnetic resonance imaging, CVR, surgical treatment, and outcome. Features were analyzed for their ability to predict the need for UPSI.
Sixty-four patients were referred for CLM, with 48 patients serially followed. Nine (18.8%) patients were followed nonoperatively, 35 (72.9%) underwent resection, and four (8.3%) were lost to follow-up. Of the patients who underwent resection, 24 (68.5%) were electively resected and 11 were urgently resected. Five (14.3%) patients underwent ex utero intrapartum treatment resection, and six (17.1%) were urgently resected for symptomatic CLM. There were no cases of UPSI with final CVR <1.1. Of the patients with final CVR 1.1-1.7, 43% required urgent resection. CVR ≥1.1 has 100% sensitivity and 87.8% specificity to predict patients requiring UPSI (area under the curve of 0.98).
A final CVR ≥1.1 is highly predictive for UPSI. Patients with a final CVR ≥1.1 should be referred for delivery at centers with pediatric surgeons equipped for potential UPSI for CLM.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
Motion remains a major limitation of fetal magnetic resonance imaging (MRI). Some centers have required mothers to fast before MRI in an effort to reduce motion; however, there is no ...current literature that describes the effect of maternal diet on fetal activity.
Objective
The objective is to define associations between specific foods and beverages consumed before and the severity of fetal motion during fetal MRI.
Materials and methods
Patients were asked to recall the specific foods or drinks consumed before their scan. An experienced technologist rated the level of fetal activity on a 3-point scale, from much less motion than normal (1) to much more (3). Two hundred twenty-eight patients were included. A non-inferiority test was used to establish statistical equivalence between the MR scores of those having a particular food item and those not. For items not shown to be equivalent, an additional superiority analysis evaluated for the presence of any significant difference. Additional data on time from meal to MRI and amniotic fluid index were also analyzed.
Results
Eleven of 15 comparisons were statistically significant for equivalence (
P
<0.05). In the remaining four categories, a superiority analysis revealed no significant differences. Analysis of meal-to-scan times showed no significant association with mean MR score (
P
=0.57). Amniotic fluid index correlated positively with scores, but the association was not statistically significant (
P
=0.39).
Conclusion
Neither fasting nor a specific consumption was associated with a significant difference in fetal motion on MR. It is therefore likely unnecessary for mothers to alter their diets on the day of an MRI study.
Abstract Purpose The purpose of this study was to compare the predication accuracy of a newly described postnatally-based clinical prediction model to fetal imaging-based predictors of mortality for ...infants with CDH. Methods We performed a retrospective review of all CDH patients treated at a comprehensive fetal care center from January 2004 to January 2014. Prenatal data reviewed included lung-to-head ratio (LHR), observed/expected-total fetal lung volume (O/E-TFLV), and percent liver herniation (%LH). Based on the postnatal prediction model, neonates were categorized as low, intermediate, and high risk of death. The primary outcome was 6-month mortality. Results Of 176 CDH patients, 58 had a major cardiac anomaly, and 28 had a genetic anomaly. Patients with O/E-TFLV < 35% and %LH > 20% were at increased risk for mortality (44% and 36%, respectively). There was a significant difference in mortality between low, intermediate, and high-risk groups (4% vs. 22% vs. 51%; p < 0.001). On multivariate regression, the O/E-TFLV and postnatal-based mortality risk score were the two independent predictors of 6-month mortality. Conclusion The CDH Study Group postnatal predictive model provides good discrimination among three risk groups in our patient cohort. The prenatal MRI-based O/E-TFLV is the strongest prenatal predictor of 6-month mortality in infants with CDH and will help guide prenatal counseling and discussions regarding fetal intervention and perinatal management.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
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