Abstract Objective With the recognition of the role of fetoscopic laser ablation for twin to twin transfusion syndrome (TTTS), there is a requirement for auditable standards for this technically ...challenging and specialized treatment. The purpose of this study is to report on the perinatal and medium-term neurodevelopmental outcomes following an 8-year national single center experience in the management of TTTS using the selective fetoscopic laser ablation technique. Study design An audit of all cases of TTTS treated with selective laser ablation by a single national fetal medicine team was performed. Overall perinatal survival and medium-term neurodevelopmental outcomes were reported and correlated with gestational age at diagnosis, placental location, volume of amnio-reduction, Quintero staging and percentage inter-twin growth discordance. Procedure-related complications were recorded. Results The overall fetal survival for the first 105 consecutive cases of TTTS was 61% (128/210 fetuses). Dual survival occurred in 47% (49/105) of cases, and with a single survival rate of 28% (30/105), perinatal survival of least one infant was achieved in 75% (79/105) of cases. No correlation was found between any clinical or sonographic marker and perinatal outcome, although dual survival was noted to be significantly decreased with increasing Quintero stage ( p = 0.041). Currently, 86% of survivors have been reported to have a normal medium-term neurological outcome. Conclusion Fetoscopic laser ablation is the established optimal treatment for severe twin to twin transfusion syndrome (TTTS). We report comparable short and medium-term outcomes following the selective fetoscopic technique comparing results from our national program with internationally published single-center outcomes, supporting the efficacy and safety of this treatment at our center.
Abstract Objective Pre-eclampsia (PET) and intrauterine growth restriction (IUGR), often associated with impaired placental function, are among the most common conditions contributing to increased ...perinatal mortality and morbidity. This study investigates if three dimensional power Doppler (3DPD) of the placenta and computerised analysis of placental calcification is different between PET/IUGR and normal pregnancies. Study design This was a prospective cohort study involving 50 women with pre-eclampsia and/or IUGR, or with IUGR only from 24 to 40 weeks’ gestation. 3DPD ultrasound was used to calculate placental volume, vascularisation index (VI), flow index (FI) and vascularisation-flow index (VFI). Following each scan the percentage of placental calcification was also calculated, by computer analysis. Results were compared with normal (control) values, and findings correlated with maternal and fetal Doppler parameters and placental histology. Results Volume, VI, and VFI are not influenced by gestational age in PET/IUGR pregnancies. FI was found to increase with gestational age ( p = 0.009) and was lower than normal in the total study group from 24 to 30 weeks ( p = 0.006). In the pregnancies affected by PET, whether or not IUGR was present, all three indices were lower than normal values between 24 and 30 weeks (VI: p = 0.038, FI: p = 0.004, VFI: p = 0.015). Vascularisation and flow indices were less than the normal 50th centile in the majority of cases of utero-placental insufficiency ( p = 0.047), and vascularisation and vascularisation flow indices were lower in cases of accelerated placental maturation ( p = 0.016 and 0.041 respectively). Placental volume greater than the 50th centile between 24 and 30 weeks was associated with the presence of infarction on histology ( p = 0.021). Flow index ( p = 0.002) and vascularisation flow index ( p = 0.036) were lower in the presence of bilateral uterine artery notches. Calcification, similar to the control group, was related to an increasing UAPI ( p = 0.041) and MCA PI <5th centile ( p = 0.010). Conclusions The study findings suggest that there may be a role for 3DPD placental assessment of volume, vascularisation and blood flow and computer analysis of placental calcification in the identification and management of PET/IUGR pregnancy.
•A trend toward increasing morbidity was observed with increasing Genesis risk score.•A trend toward increasing rate of operative vaginal delivery was also observed.•The Genesis nomogram has the ...potential to estimate maternal and neonatal morbidity.
In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery.
The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks’ gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated.
A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p < 0.001), PPH (p < 0.008), NICU admission (p < 0.001), low Apgar score at one-minute (p < 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p < 0.001), PPH (p = 0.022), birth injury (p < 0.001), shoulder dystocia (p = 0.002) and Apgar score of<7 at one-minute (p < 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of>50%.
In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.
Contemporary approaches to monitoring quality of care in obstetrics often focus on comparing Cesarean Delivery rates. Varied rates can complicate interpretation of quality of care. We previously ...developed a risk prediction tool for nulliparous women who may require intrapartum Cesarean delivery which identified five key predictors. Our objective with this study was to ascertain if patient heterogeneity can account for much of the observed variation in Cesarean delivery rates, thereby enabling Cesarean delivery rates to be a better marker of quality of care.
This is a secondary analysis of the Genesis study. This was a large prospective study of 2336 nulliparous singleton pregnancies recruited at seven hospitals. A heterogeneity score was calculated for each hospital. An adjusted Cesarean delivery rate was also calculated incorporating the heterogeneous risk score.
A cut-off at the 90th percentile was determined for each predictive factor. Above the 90th percentile was considered to represent ‘high risk’ (with the exception of maternal height which identified those below the 10th percentile). The patient heterogeneous risk score was defined as the number of risk factors > 90th percentile (<10th percentile for height). An unequal distribution of high-risk patients between centers was observed (p < 0.001). The correlation between the Cesarean delivery rate and the patient heterogeneous risk score was high (0.76, p < 0.05). When adjusted for patient heterogeneity, Cesarean delivery rates became closer aligned.
Inter-institutional diversity is common. We suggest that crude comparison of Cesarean delivery rates between different hospitals as a marker of care quality is inappropriate. Allowing for marked differences in patient characteristics is essential for correct interpretation of such comparisons.
PDF