Objective The objective of the study was to examine the effect of selective fetoscopic laser photocoagulation (SFLP) vs serial amnioreduction (AR) on perinatal mortality in severe twin-twin ...transfusion syndrome (TTTS). Study Design This was a 5 year multicenter, prospective, randomized controlled trial. The primary outcome variable was 30 day postnatal survival of donors and recipients. Results There was no statistically significant difference in 30-day postnatal survival between SFLP or AR treatment for donors at 55% (11 of 20) vs 55% (11 of 20) ( P = 1.0, odds ratio OR 1, 95% confidence interval CI 0.242 to 4.14) or recipients at 30% (6 of 20) vs 45% (9 of 20) ( P = .51, OR 1.88, 95% CI 0.44 to 8.64). There was no difference in 30 day survival of 1 or both twins on a per-pregnancy basis between AR at 75% (15 of 20) and SFLP at 65% (13 of 20) ( P = .73, OR 1.62, 95% CI 0.34 to 8.09). Overall survival (newborns divided by the number of fetuses treated) was not statistically significant for AR at 60% (24 of 40) vs SFLP 45% (18 of 40) ( P = .18, OR 2.01, 95% CI 0.76 to 5.44). There was a statistically significant increase in fetal recipient mortality in the SFLP arm at 70% (14 of 20) vs the AR arm at 35% (7 of 20) ( P = .25, OR 5.31, 95% CI 1.19 to 27.6). This was offset by increased recipient neonatal mortality of 30% (6 of 20) in the AR arm. Echocardiographic abnormality in recipient twin Cardiovascular Profile Score is the most significant predictor of recipient mortality ( P = .055, OR 3.025/point) by logistic regression analysis. Conclusion The outcome of the trial did not conclusively determine whether AR or SFLP is a superior treatment modality. TTTS cardiomyopathy appears to be an important factor in recipient survival in TTTS.
Objective We report our experience in the treatment of patients with twin-reversed arterial perfusion (TRAP) sequence using radiofrequency ablation to stop perfusion to the acardiac twin and protect ...the pump twin. Study Design An IRB approved retrospective review of all patients (n = 29) who underwent percutaneous radiofrequency ablation of an acardiac twin, using ultrasound guidance and either a 14 or 17 gauge radiofrequency needle for twin-reversed arterial perfusion sequence, from 1998 to 2005, was performed by review of hospital and outpatient medical records. Results The outcomes of all 29 of the patients treated with radiofrequency ablation are known. Twenty-six of the patients had monochorionic-diamniotic pregnancies, whereas 2 had monochorionic-monoamniotic pregnancies. One patient had a triplet pregnancy with a monochorionic-diamniotic pair with TRAP sequence. Overall, 25 of 29 pump twins survived (86%), delivering at a mean gestational age of 34.6 weeks. Survival was 24 of 26 (92%) in monochorionic-diamniotic pregnancies with a mean gestational age of 35.6 weeks. Two women in our early experience sustained thermal injuries from the site of grounding pads. Conclusion Radiofrequency ablation of the acardiac twin effectively protects the pump twin from high-output cardiac failure and death. Greater than 90% survival can be achieved in monochorionic-diamniotic pregnancies complicated by TRAP sequence with a mean gestation age at time of delivery close to term. Our limited experience in cases of monochorionic-monoamniotic TRAP sequence does not allow the determination of efficacy in this group.
Objective We sought to identify differences in echocardiographic profiles of monochorionic (MC)/diamniotic (DA) pregnancies with early or mild twin-twin transfusion syndrome (TTTS), compared to MC/DA ...twins affected only by discordant growth or discordant fluid. Study Design This was a retrospective evaluation of sonograms and echocardiograms of twin pregnancies referred for suspected TTTS. Results A total of 112 MC/DA pairs were studied. In all, 41 did not have/develop TTTS, and 61 had stage I/II TTTS. Ten developed TTTS after initially not meeting criteria. TTTS recipients had a higher rate of venous Doppler or tricuspid inflow abnormalities than purported recipients in non-TTTS pregnancies (86% vs 37%, P < .001). TTTS recipients had shorter tricuspid inflow duration/R-R intervals than non-TTTS fetuses (32 ± 6% vs 37 ± 4%, P < .001). Logistic regression and recursive partitioning identified shorter tricuspid inflow duration, longer isovolumic relaxation, and ductus venosus abnormality associated with TTTS. Conclusion Diastolic pathology, specifically shorter tricuspid inflow duration, may be considered a hallmark of TTTS distinguishing these pregnancies from other MC/DA twin complications.
Objective The purpose of this study was to investigate the relationship between lung-to-head ratio (LHR) and gestational age (GA) in fetuses with isolated left congenital diaphragmatic hernia and to ...determine the applicability and reliability of LHR to predict postnatal outcome beyond 24-26 weeks of gestation. Study Design The institutional review board approved this retrospective review of the University of California, San Francisco, Fetal Treatment Center database for cases with left congenital diaphragmatic hernia who were referred between March 1995 and June 2004. LHR was determined at the initial evaluation. One hundred seven live-born fetuses at 20-34 weeks of gestation (excluding cases that were lost to follow-up, with factors that potentially could influence the LHR measurement or postnatal outcome, or that were terminated electively). Results The median GA at LHR measurement was 25.6 weeks; the median LHR was 1.01; the median GA at birth was 37.7 weeks; and the overall survival rate was 59% (64/107). The median LHR of nonsurvivors was significantly lower than that of survivors, but neither GA at LHR measurement nor at delivery was significantly different between the groups. Multiple logistic regression analysis confirmed LHR to be an independent predictor of postnatal survival, and receiver-operator characteristic curve analysis demonstrated that an LHR of ≥0.97 has the highest performance in predicting postnatal survival. When fetuses were grouped by GA at initial LHR measurement to determine reliability of LHR, specifically with respect to GA, in the 26-34 and 24-26 weeks of gestation groups, median LHR of survivors was significantly higher than that of nonsurvivors, and receiver-operator characteristic curve analysis confirmed LHR to be a reliable predictor of postnatal survival. However, for fetuses at 20-24 weeks of gestation, there was a trend toward a higher LHR in survivors, although this did not reach statistical significance. Conclusion A significant positive linear relationship exists between LHR and GA at the time of measurement, such that LHR reliably predicts postnatal survival in fetuses with left congenital diaphragmatic hernia at 24-34 weeks of gestation and less reliable at 20-24 weeks. However, given the limitations of a retrospective, cross-sectional study, further prospective longitudinal studies that will investigate the change of LHR with GA and its association with fetal outcome are necessary.
Obstetric ultrasound (US) is an integral part of fetal surgery for open and minimally invasive techniques. With advances in US imaging, the ability to refine diagnosis, predict prognosis, and ...contribute to fetal treatment continues to grow. Current research in fetal diagnosis and treatment includes identifying the most reliable sonographic features for determining prognosis before and after surgery.
To determine the diagnostic performance of specific ultrasonographic (US) features in discriminating endometriomas from other adnexal masses.
Two sonologists independently reviewed the sonograms of ...252 adnexal masses in 226 women and recorded US features by using a standardized checklist. The diagnostic performance of specific US features and overall reviewer impression in discriminating endometriomas from other adnexal masses were evaluated.
There were 40 endometriomas. Diffuse low-level internal echoes were present in 38 (95%) endometriomas and 40 (19%) nonendometriomas (positive likelihood ratio, 5). The positive likelihood ratio for the diagnosis of endometrioma increased to 8 if masses with neoplastic features at gray-scale US were excluded, allowing identification of 30 endometriomas (75%). The presence of multilocularity or hyperechoic wall foci further increased the positive likelihood ratio to 48, allowing the identification of 18 endometriomas (45%).
An adnexal mass with diffuse low-level internal echoes and absence of particular neoplastic features is highly likely to be an endometrioma if multilocularity or hyperechoic wall foci are present. A patient with a mass with diffuse low-level internal echoes and other US features may benefit from additional imaging.
The purpose of this study was to quantify the likelihood ratio (LR) of specific sonographic features and experienced sonologist assessment in diagnosing a hemorrhagic ovarian cyst and to better ...understand the diagnostic power of sonography in making this diagnosis.
Two sonologists, blinded to the patient's clinical history, independently reviewed the sonograms of 252 adnexal masses. For each mass, each sonologist recorded features using a standardized checklist, which included observations regarding the presence of fibrin strands, a retracting clot, septations, and wall irregularity. Each reviewer independently chose 1 specific conclusion from a list of possibilities that included the diagnosis of a hemorrhagic ovarian cyst. Sonographic observations and sonologist predictions were compared with pathologic findings (n = 214) or follow-up sonography (n = 38).
Of the 252 masses, there were 30 hemorrhagic cysts. One sonologist correctly identified 25 hemorrhagic cysts, with 1 false-positive, 2 false-negative, and 3 indeterminate calls (LR 185). The other sonologist correctly identified 24 hemorrhagic cysts, with 1 false-positive, 0 false-negative, and 6 indeterminate calls (LR 178). The 2 cases incorrectly diagnosed as hemorrhagic cysts were endometriomas at pathologic diagnosis. Specific sonographic observations and combinations of observations performed as follows: retracting clot (LR >67); fibrin strands (LR 40); fibrin strands and no septations (LR 100); and fibrin strands, no septations, and smooth wall (LR 200).
Fibrin strands and a retracting clot are paramount observations in allowing high confidence in the diagnosis of hemorrhagic ovarian cysts. Approximately 90% of hemorrhagic ovarian cysts will exhibit at least 1 of these 2 features.
This study was undertaken to determine if the diagnosis of cystic teratomas of the ovary can be made by experienced sonologists using only specific associated sonographic features.
Two sonologists ...independently reviewed the sonograms of 252 adnexal masses. For each mass, each sonologist recorded sonographic features using a standardized checklist, which included four descriptions associated with cystic teratomas. From a list of diagnostic possibilities, each reviewer chose one specific conclusion, with emphasis on achieving the highest combination of sensitivity and positive predictive value for any particular diagnosis. The sensitivity, positive predictive value, and positive likelihood ratio for the diagnosis of cystic teratoma were evaluated for each sonographic finding and for each sonologist's interpretation.
Of the 252 masses, 74 cystic teratomas were found, 55 of which showed two or more associated sonographic features. Each reviewer had a 98% positive predictive value with 85% sensitivity for the diagnosis and identification of cystic teratomas (positive likelihood ratio = 152). The positive predictive value was 100% when an adnexal mass had two or more sonographic features associated with dermoid masses. The positive predictive value for individual sonographic features associated with dermoid masses was 80% for a shadowing echodensity, 75% for regionally bright echoes, 50% for hyperechoic lines and dots, and 20% for a fluid-fluid level.
An adnexal mass showing two or more of the sonographic features associated with cystic teratomas can be confidently diagnosed as a cystic teratoma.
To evaluate the accuracy of Doppler ultrasonography (US) in determination of patency and detection of stenosis in transjugular intrahepatic portosystemic shunts (TIPS).
Retrospective review was ...performed of 251 Doppler sonograms obtained in 79 patients who underwent TIPS placement. Sonograms were evaluated for (a) the presence of a spectral waveform or color flow signal within the shunt, (b) the maximum peak flow velocity (Vmax) measured at the midportion of the TIPS, and (c) the direction of intraparenchymal portal venous flow. Independent review was performed of 116 transjugular portal venograms obtained after TIPS placement.
Doppler US showed TIPS occlusion in 25 of 26 (96%) cases and confirmed patency in 192 of 193 (99%) cases. Low Vmax within the TIPS (< 50 cm/sec) correlated to a diameter stenosis of 50% or greater at angiography in 25 of 32 (78%) stenotic cases and was not present in 71 of 72 (99%) cases in which no hemodynamically significant stenosis was seen. An interval change in direction of intraparenchymal portal venous flow from hepatofugal to hepatopetal was seen in association with TIPS stenoses in all stenotic cases and was not found in 24 of 26 (92%) cases in which stenosis was not seen.
Doppler US allows accurate determination of TIPS patency. A Vmax of 50 cm/sec or less within the shunt and interval change from hepatofugal to hepatopetal intraparenchymal portal venous flow are reliable indicators of stenosis.
To determine whether sonograms of the liver and spleen, obtained with 5-MHz linear-array transducers, aid in detection of hepatosplenic microabscesses in patients with acquired immunodeficiency ...syndrome (AIDS).
Abdominal sonographic examinations (n = 111) were performed in 102 consecutive patients with AIDS. A 3.5-MHz sector transducer was used in each study, with additional images of the hepatic and splenic parenchyma obtained with a 5-MHz linear-array transducer. Each study was reviewed without benefit of the 5-MHz images, and categories of the hepatic and splenic parenchyma were as follows: 1, lesions definitely present; 2, lesions possibly present; and 3, lesions absent. The 5-MHz images were subsequently reviewed, and studies were recategorized. Findings were correlated with results of pathologic examination.
The 5-MHz scans enabled identification of focal hepatic or splenic lesions in 14 of 96 studies placed in category 2 or 3 on the basis of the 3.5-MHz sector scans.
In patients with AIDS, 5-MHz sonograms of the liver and spleen enable detection of microabscesses not confidently identified on 3.5-MHz scans.
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