ABSTRACT Objective To summarize reported outcomes associated with thoracoamniotic shunting (TAS) in fetuses with pleural effusion or congenital lung lesions. Methods We conducted a search across MEDLINE, CINAHL, Cochrane CENTRAL, Web of Science, Scopus, and EMBASE databases, from inception to 6 November 2025, for studies reporting the incidence of perinatal outcomes after TAS in pregnancies complicated by fetal pleural effusion or congenital lung lesions. Quality and risk‐of‐bias assessments were performed utilizing the Downs and Black scale. Single‐arm random‐effects meta‐analyses with generalized linear mixed‐effects models were performed to generate pooled proportions with 95% CI. Heterogeneity was assessed using Cochran's Q and quantified by the I 2 statistic. Subgroup analyses were conducted according to the primary diagnosis (pleural effusion or congenital lung lesions). Results Overall, 45 studies, including 1976 fetuses that underwent TAS, were included in the systematic review. Among fetuses with pleural effusion, the pooled proportion of fetal death was 8.3% (95% CI, 5.8–11.6%) ( I 2 = 18.1%) and that of perinatal death was 29.5% (95% CI, 26.4–32.7%) ( I 2 = 27.7%). In cases of congenital lung lesion, the corresponding pooled proportions were 6.6% (95% CI, 3.5–12.1%) ( I 2 = 0%) and 22.6% (95% CI, 13.2–35.9%) ( I 2 = 0%), respectively. Shunt‐related complications included shunt displacement (13.2% (95% CI, 8.8–19.4%) in cases of pleural effusion and 10.2% (95% CI, 4.3–22.3%) in cases of congenital lung lesion) and shunt obstruction or malfunction (14.1% (95% CI, 9.1–21.1%) and 8.6% (95% CI, 2.8–23.4%), respectively). Preterm prelabor rupture of membranes after TAS was reported in 19.3% (95% CI, 13.8–26.4%) of cases of pleural effusion and 15.4% (95% CI, 5.9–34.5%) of cases of congenital lung lesion, and birth < 37 weeks occurred in 64.3% (95% CI, 58.1–70.2%) and 41.6% (95% CI, 29.4–54.8%) of cases, respectively. In hydropic fetuses, resolution of hydrops was achieved in 63.3% (95% CI, 52.9–72.6%) of cases of pleural effusion and 95.1% (95% CI, 82.5–98.8%) of cases of congenital lung lesion. Conclusions TAS in fetuses with pleural effusion or congenital lung lesions is associated with prenatal thoracic decompression and may contribute to resolution of pleural effusion and hydrops in selected cases, with indirect comparisons with historical data suggesting a possible reduction in mortality. Standardized selection criteria and prospective and/or multicenter studies are needed to better define the benefits and risks of TAS. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.
ABSTRACT Objectives To systematically validate and compare ultrasonography, using the ultrasound‐based International Ovarian Tumor Analysis – Assessment of Different NEoplasias in the adneXa (IOTA‐ADNEX) model, with magnetic resonance imaging (MRI), using the MRI‐based ADNEX MR scoring system, as second‐line imaging modalities for estimating the risk of adnexal malignancy in patients identified as being at risk of malignancy on first‐line ultrasound examination. Methods This was a prospective, single‐center diagnostic accuracy study designed as a head‐to‐head comparison. All patients referred to a tertiary referral center at Aarhus University Hospital, Aarhus, Denmark, for suspected adnexal malignancy on first‐line imaging between May 2021 and December 2022 were offered second‐line diagnostic testing. This comprised both a systematic expert ultrasound examination, including IOTA‐ADNEX risk estimation, and a systematic MRI scan with ADNEX MR scores assigned by expert radiologists. The imaging assessments were performed prospectively, with ultrasound examiners and radiologists blinded to the results of other imaging modalities and to the reference standard (tumor outcome). The reference standard was a histopathological diagnosis of the primary adnexal mass or, in a small number of cases, clinical follow‐up. Borderline tumors, invasive adnexal malignancy and metastases to the adnexa were grouped as malignancies. Diagnostic performance of the IOTA‐ADNEX model, ADNEX MR scoring system and CA 125 for predicting malignancy was evaluated using the area under the receiver‐operating‐characteristics curve (AUC), and AUCs were compared using DeLong's test. Diagnostic metrics were estimated at clinically relevant cut‐offs and scores. Agreement between modalities was assessed for the identification of morphological features and overall risk estimation using Cohen's kappa statistics, intraclass correlation coefficients (ICC) and Bland–Altman plots. For the IOTA‐ADNEX model, calibration and the ability to discriminate between tumor subtypes were evaluated. Results The included cohort comprised 342 patients (342 lesions analyzed). In the final cohort, 78.1% of patients were postmenopausal and the overall prevalence of malignancy was 58.8%. The AUC for distinguishing patients with benign tumors from those with malignant tumors was 0.96 (95% CI, 0.94–0.98) for the IOTA‐ADNEX model (with or without CA 125) compared with an AUC of 0.93 (95% CI, 0.91–0.96) for ADNEX MR. Agreement between ultrasound and MRI ranged from moderate to substantial for key morphological features (κ = 0.46–0.75) and from good to excellent for lesion‐size measurements (ICC = 0.78–0.92). The IOTA‐ADNEX model performed similarly to the ADNEX MR scoring system regardless of lesion morphology or size. The IOTA‐ADNEX model had good calibration. Furthermore, its multinomial discriminative ability between tumor subtypes was generally high, although performance was reduced when distinguishing borderline tumors from Stage‐I invasive malignancy (AUC, 0.71 (95% CI, 0.56–0.82)). Conclusions The IOTA‐ADNEX model and ADNEX MR scoring system demonstrated comparable diagnostic accuracy for differentiating benign from malignant adnexal masses in this study. Results appeared to be consistent when stratified by lesion morphology. Both modalities may be used for second‐line assessment of masses deemed at risk of malignancy in the first‐line ultrasound examination, depending on resources in specific centers. © 2026 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
ABSTRACT Objective To determine the influence of preoperative uterine artery (UtA) Doppler abnormalities on disease severity, intertwin fetal‐size discordance and perinatal outcomes in cases of twin–twin transfusion syndrome (TTTS) treated with fetoscopic laser surgery. Methods This was a retrospective cohort study of TTTS pregnancies that underwent fetoscopic laser surgery using data that had been collected between August 2014 and July 2025. Inclusion required prelaser UtA Doppler examination and available neonatal outcomes. Preoperative ultrasound biometry, maternal and fetal Doppler data and Quintero staging were reviewed. UtA pulsatility index (PI) Z ‐scores were calculated; abnormal UtA Doppler was defined as mean UtA‐PI ≥ 95 th percentile and/or UtA notching. The primary outcome was the distribution of UtA Doppler abnormalities across TTTS stages. Secondary outcomes included the relationship between UtA Doppler findings and survival, gestational age at intervention, intertwin fetal‐size discordance and intertwin birth‐weight discordance. Analyses included non‐parametric tests and regression models to identify predictors of intertwin size discordance. Results Of 509 treated cases, 378 pregnancies were included. Abnormal UtA Doppler occurred in 23.5% of pregnancies and was most frequent in those with Stage‐III TTTS (32.4%; P = 0.004). Abnormal UtA Doppler findings were associated with lower maternal age, Stage‐III TTTS and greater intertwin size discordance. Patients with UtA Doppler abnormalities had earlier laser surgery (median, 18.4 vs 19.4 weeks; P = 0.008) and exhibited greater prelaser intertwin fetal‐size discordance (median, 23.9% vs 18.9%; P = 0.012), with higher proportions of intertwin discordance ≥ 25% before laser surgery (49.4% vs 33.2%; P = 0.006) and at birth (28.4% vs 13.9%; P = 0.004) compared to those without abnormal UtA Doppler. However, immediate post‐laser survival and overall perinatal survival did not differ by UtA Doppler status. Multivariable linear regression analysis identified umbilical artery Doppler parameters as the primary determinant of intertwin size discordance, while abnormal UtA Doppler remained independently associated with intertwin size discordance both at the time of laser surgery and at birth. However, receiver‐operating‐characteristics‐curve analysis showed that abnormal mean UtA‐PI Z ‐score alone did not predict intertwin birth‐weight discordance of ≥ 25%. Conclusions Abnormal preoperative UtA Doppler was not a principal determinant of TTTS severity, but was most frequent in Stage‐III TTTS. Abnormal UtA Doppler was associated with intertwin fetal‐size discordance before laser treatment, with discordance persisting at birth despite successful surgery. Although abnormal UtA Doppler was independently associated with intertwin fetal‐size discordance, elevated mean UtA‐PI was not a clinically useful independent predictor of intertwin size discordance at birth. UtA Doppler and umbilical artery Doppler may be complementary in predicting fetal growth effects of placental dysfunction, independent of the acute cardiovascular effects of TTTS. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.
ABSTRACT Objectives Fetal ventriculomegaly (VM) is a common prenatal finding with heterogeneous etiology and unpredictable outcome, yet its management remains among the least standardized in fetal medicine. This study aimed to establish expert consensus on key decision points in the prenatal management of fetal VM, and to systematically map the domains of persistent uncertainty as a structured framework for future research priorities. Methods A two‐round modified Delphi study was conducted with an international panel of experts in fetal medicine, selected through a systematic review of publications that included more than 50 cases of VM over the preceding decade. Round 1 comprised 39 multiple‐choice questions, with consensus achieved when ≥ 75% of panelists selected a single answer option; items that did not reach consensus were reformulated into Likert‐scale statements for Round 2, which comprised 60 statements rated on a 9‐point Likert scale. In Round 2, consensus was defined by two simultaneous criteria: ≥ 75% of valid respondents scoring in the agreement (score, 7–9) or disagreement (score, 1–3) zone, with an interquartile range of ≤ 2. Non‐consensus domains were classified using a post ‐ hoc taxonomic framework into three categories: absent evidence (Type 1), divergent clinical frameworks (Type 2) and undefined construct (Type 3), which could occur independently or in combination. Results Of 56 experts who completed Round 1, 45 (80%) also completed Round 2. In Round 1, consensus was reached on 20/39 (51%) questions. In Round 2, 6/60 (10%) statements reached positive consensus and four (7%) reached negative consensus; 50 (83%) did not reach consensus. Over the two rounds, consensus was achieved on standardized measurement technique, three‐tier grading, comprehensive neurosonographic and investigative work‐up, individualization of the timing of fetal magnetic resonance imaging, stepwise neurosurgical referral and delivery management of fetal VM. Classification of non‐consensus domains identified 15/50 (30%) items as Type 1, 16/50 (32%) as Type 2, 4/50 (8%) as Type 3 and 15/50 (30%) as Type 1+3. Ventricular asymmetry, the largest non‐consensus cluster with 12 items, was classified as Type 1+3 in 11/12 (92%) statements, reflecting the simultaneous absence of prospective outcome data and of a universally accepted operational definition. Conclusions This Delphi study provides structured expert‐derived guidance, primarily applicable to specialist and referral settings, on the prenatal management of fetal VM across key clinical domains. Beyond consensus recommendations, we propose that the original contribution of this study is a hypothesis‐generating taxonomic map of persistent uncertainty, classifying unresolved domains by the nature of the underlying evidence gap and identifying the specific prerequisites (definitional, methodological or empirical) required before consensus can be achieved. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.
