The aims were to report the maternal, fetal and short-term neonatal outcomes of percutaneous fetoscopic fetal spina bifida (SB) repair and to assess the learning curve in a single centre. The first eight consecutive cases of percutaneous fetoscopic SB repair using a biocellulose patch were divided into two equal groups by chronological order. Maternal, fetal and short-term neonatal outcomes were analysed. The setting was a tertiary university-affiliated medical centre (January 2017–May 2020). There were no significant differences in defect location, size and gestational age at surgery between two groups. Hindbarin herniation were documented in all cases. Fetoscopic repair was completed in all cases. No maternal death or admission to the ICU were reported. Two patients had planned unremarkable Caesarean delivery and six women had normal vaginal delivery. The procedure duration was significantly shortened in the second group. There was no case of IUFD. Gestational age at delivery and birthweight were significantly higher and duration of hospitalisation at NICU was significantly shorter in the second group (table 1). In the first group there was a single case of premature infant died due to sepsis. Our preliminary results suggest that procedure duration and short-term neonatal outcome significantly improve according to surgical team experience. Relatively small number of operated cases required to achieve improvement in this specific surgical technique. VP21.13: Table 1. Preoperative assessment, surgery and postnatal data First 4 cases (12.2018–09.2019) Last 4 cases (11.2019– 05.2020)

The aim of this study is to assess the added benefit of prenatal MRI to imaging by ultrasound in predicting neonatal sequelae in fetal primary CMV infection. We included only cases with proven primary CMV infection. Prenatal evaluation included both monthly detailed US scans and 3rd trimester fetal MRI scan at 30-34 weeks of gestation. Long term outcome was assessed using database search and a telephone interview. Outcome variables included termination of pregnancy (TOP), hearing abnormalities (SNHL), neurological disabilities (NDI) or composite outcome (all three). The study included 243 patients with both fetal sonographic and fetal brain MRI evaluation. The rate of fetuses with serial normal sonography was 85/123 (69%), 75/97 (77%) and 22/23 (95%) after 1st, 2nd and 3rd trimester infection respectively. After excluding patients with US finding, the rate of MRI findings was as followed:1st trimester: 12 had abnormal finding on MRI (14%) including five with anatomical abnormalities (2-TOP, 1-partial NSHL, 2-healthy) and seven with H/I signals (2-mild motor delay and 5-healthy); 2nd trimester: 10 had abnormal finding on MRI (13%) three with anatomical abnormalities (1-TOP, 2-healthy) and seven with H/I signals (1-TOP, 6-healthy); 3rd trimester: 5 had abnormal finding on MRI (22%) including one with anatomical abnormalities and four with H/I signals (all healthy). When sonographic abnormalities were excluded, MRI findings were not associated with NDI (9.1% vs. 5.1%, p = 0.48), SNHL (8.4% vs. 7.3%, p = 0.91) or composite outcome (13.6% vs. 11.1%, p = 0.86). No association was found in a sub-analysis of first trimester infection only. Our data show that after exclusion of sonographic abnormalities, anatomical findings on MRI are not significantly associated with NDI, SNHL or composite outcome.

The aim of this study is to assess the implications of CMV infection in second trimester compared to first trimester on neonatal development. We included cases with proven primary CMV infection at first and second trimester. Prenatal evaluation included both monthly detailed US scans and third trimester fetal brain MRI. Long term outcome was assessed using database search and a telephone interview. Outcome variables included termination of pregnancy (TOP), hearing abnormalities (SNHL), neurological disabilities (NDI) or composite outcome (all three). The study included 220 patients with both fetal sonographic and fetal brain MRI evaluation and long term outcome. Altogether there were 123 and 97 cases with first and second trimester infection, respectively. The rate of fetuses with both normal US and MRI was 73/123 (59%) and 65/97 (67%) after first and second trimester, respectively. There were 20 cases of TOP (14 and 6 for first and second trimester respectively). The rate of SNHL was 20/109 (18.3%) for first trimester and 2/91 (2.1%) for second trimester infection. The rate of NDI was 12/109 (11%) for first trimester and 3/91 (3.2%) for second trimester infection. The rate of composite outcome was 26/109 (23.9%) for first trimester and only 4/91 (4.4%) for second trimester. Thus SNHL, NDI and composite outcome were more likely after first trimester infection compared to second trimester (p < 0.05). It should be noted that the hearing impairment was more severe in first trimester infection with 4 cases of complete deafness (3 of them with normal US and normal MRI) requiring implants while in second trimester infection there was only partial or unilateral SNHL. Our data shows that SNHL and NDI can occur after second trimester infection, however it is significantly less common and all cases of SNHL after second trimester infection were partial or unilateral.

Prenatal diagnosis of congenital cytomegalovirus (CMV) infection is based on amniocentesis performed after 21 weeks of gestation and 7 weeks after maternal infection. However, recently, congenital CMV infection after a negative amniocentesis result has been reported. Our aim was to determine the incidence and neurological outcome of congenital CMV infection following a negative amniocentesis result. A retrospective cohort study of infants with congenital CMV infection followed in a single tertiary care center between the years 2009-2018. Short and long term neurological outcomes of 16 infants with congenital CMV infection born after a negative amniocentesis (study group) were compared to 45 CMV infected infants born after a positive amniocentesis (control group). Symptoms at birth were defined as occurrence of one of the following: small for gestational age, microcephaly and abnormal BERA test. Of 344 pregnancies in which amniocentesis was performed at our center following maternal CMV infection and determined negative, 16 neonates (4.6%) were eventually tested positive for CMV after birth. The rate of first trimester primary maternal CMV infection was significantly higher in the study group compared to the control group (75% vs 33%, p<0.01). However, despite the higher rate of first trimester infection in the study group, the short and long term neurological outcome of infants from this group appeared to be improved compared to controls: There was a trend towards decreased rate of symptoms at birth (6.2% vs 22.2% respectively, p=0.15) as well as decreased rate of hearing impairment at the age of 1 among infants following a negative amniocentesis as compared to controls (6.2% vs 19.5%, p=0.2). Congenital CMV may occur following primary maternal infection and a negative amniocentesis. However, the outcome of these infants is favorable, supporting the hypothesis that fetal infection in these cases occurred late in gestation following secondary maternal infection.

To evaluate the accuracy of prenatal and post-natal parameters to predict neonatal outcome in isolated congenital diaphragmatic hernia (CDH) by a single centre with recurrent prenatal evaluations. Retrospective study of all cases of CDH evaluated prenatally and treated postnatally in a single tertiary centre between 2008 and 2017. In all cases, evaluation included either LHR measurement, O/E LHR. MRI was additionally used in the last 5 years for prenatal evaluation. 77 fetuses evaluated prenatally, 17 (22%) decided to have TOP after counseling and one fetal demise occurred. Fifty-nine neonates with prenatal evaluation were delivered. Study group included 50/59 who had isolated CDH. Median number prenatal evaluations and lung measurements/fetus was 4 (range 2-9). Perinatal survival was 76%. O/E LHR was significantly lower in cases with perinatal death compared to survivors (p=0.01). Prenatal evaluation was significantly related to survival (Mild-87%, Moderate-62%, Severe-14%, p<0.001). Prenatal evaluation by O/E LHR was not significantly associated to treatment by ECMO. In cases with multiple evaluations, the minimal O/E LHR was most accurate to predict survival (vs. maximal, first or last evaluation, figure 1). MRI was used as an additive tool for evaluation in 86% of cases (altered severity of disease in 6/35 cases) and its main benefit was corrected diagnosis of "liver up" cases compared to prenatal US. Low postnatal 1st pH and high ventilation pressure were also significantly related to perinatal mortality. O/E LHR is correctly associated to perinatal survival. In cases with multiple evaluations, the minimal O/E LHR is the most accurate. Prenatal MRI has an advantage in correctly identifying patients with intra-thoracic liver with left CDH. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

The aim of this study is to assess the additional benefit of fetal MRI in cases with proven fetal primary CMV infection. Fetal CMV infection was confirmed in all patients. Prenatal evaluation included monthly detailed US scans and third trimester fetal MRI scan at 30-34 weeks of gestation. Pregnancy outcome and long-term outcome were assessed using the Vineland II adaptive behaviour scales (VBAS). 206 patients were included in the study. Of these, 73 patients had either abnormal MRI or US findings. 18 patients had termination of pregnancy (12 after abnormal US confirmed by MRI and six after new findings on MR). Of the 183 cases for which we had postnatal follow-up, 27.8% had abnormal postnatal brain US, 14.4% had hearing loss and 11.1% had other neurological impairment. Abnormal postnatal US was associated with first trimester infection (OR 2.4, p=0.044), abnormal fetal US (OR=6.8, p=0.009), fetal sonographic cerebral findings (OR=17, p<0.001) and abnormal fetal MRI (OR=15, p<0.001). On multiple regression analysis only fetal sonographic cerebral findings were associated with postnatal cerebral findings (p=0.025). Hearing loss was associated only with first trimester infection (OR=1.9, p=0.039) while other neurological impairment was associated with first trimester infection (OR=3.9, p=0.04) and abnormal MRI (OR=4.28, p=0.005). On multiple regression analysis only first trimester infection was associated with postnatal neurological impairment (p=0.049). VBAS score was significantly associated to first trimester infections (p=0.05) but not to fetal sonographic or MR findings. MRI is a useful diagnostic tool in the evaluation of women with proven fetal CMV infection. Abnormal fetal MRI is significantly associated with abnormal postnatal US findings and neurological impairment. However, we did not find it to be associated with hearing loss. In the data analysed in this study, only first trimester infection showed such an association.

To determine whether preoperative fetal weight discordancy affect perinatal outcomes following laser therapy for Twin–twin transfusion syndrome (TTTS). A retrospective cohort study of all monochorionic-diamniotic twin pregnancies complicated by TTTS and treated by fetoscopic laser coagulation at a single tertiary centre between 2013 and 2017. Pregnancies were allocated into two groups according to preoperative fetal weight discordancy: (i) < 25% (ii) ≥25%. Sixty-seven women were included. Both groups were similar with respect to preoperative baseline characteristics other than fetal weight discordancy including gestational age procedure, cervical length and staging distribution. Patients with severe preoperative discordancy≥25% had decreased perinatal survival rate of at least one twin (71.43 versus 92.31%, p=0.04) and increased rate of no survivors (28.57% versus 7.69%, p=0.04). Moreover, patients in this group delivered at a significantly lower gestational age (28.75 versus 32.03, p= 0.005) and were more likely to deliver before 28 weeks (38.46% versus 13.16%, p=0.019) and 32 weeks (65.38% versus 36.84%, p=0.025) of gestation. In TTTS pregnancies treated with laser surgery, preoperative fetal weight discordancy ≥25% was associated with decreased perinatal survival and higher rates of preterm delivery. Therefore, the presence of preoperative selective intra-uterine growth restriction confers a significant risk for adverse perinatal outcome.

To examine the perinatal outcome of monochorionic diamniotic (MCDA) twins complicated by selective intrauterine growth restriction (sIUGR) according to the umbilical artery (UA) Doppler flow of the smaller twin. A prospective cohort study of 88 MCDA twin pregnancies with sIUGR. All patients were diagnosed before 26 weeks of gestation and managed in a single fetal therapy centre. UA end-diastolic flow was recorded at first examination and was monitored on a weekly basis throughout gestation. Cases were classified as sIUGR type I, II or III based on UA Doppler pattern. Patients with sIUGR type II or III were hospitalised at 26-28 weeks of gestation for close fetal surveillance. Perinatal outcomes were determined according to UA Doppler waveform pattern at final examination. Of 88 MCDA twin pregnancies included, 28 underwent cord occlusion using radiofrequency ablation resulting in perinatal survival of 88.8% and median gestational age at delivery of 37.3 weeks (range 28-41). Conservative management was employed in 60 cases. In 26 (43%) cases, the classification according to UA flow pattern has changed during gestation. The perinatal survival of MC twins with sIUGR type I, II and III was 100%, 83.3% and 75% respectively. The type III group included 3 cases of double IUFD at 21, 22 and 27 weeks of gestation, which occurred 1-3 weeks after the Doppler pattern changed from type I or II to type III. The median gestational age at delivery was 34.9 (range 30.6-36.9) weeks in type I, 30.2 weeks (range 27.7-33.7) in type II and 32 weeks (range 31-33.4) in type III (p=0.03). Severe brain lesions were not observed in any of the large twins and in 2 (3.7%) of the IUGR twins. The classification system of MC twins complicated by sIUGR based on UA Doppler pattern is correlated with perinatal outcome. However, the UA Doppler pattern can change over time and have impact on the risk of fetal death. Nevertheless, under strict fetal surveillance, the perinatal outcome of these pregnancies is favourable. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

To determine the perinatal outcome of monochorionic twin pregnancies complicated by twin anemia polycythemia sequence (TAPS) and treated by intrauterine blood transfusion. All monochorionic twins diagnosed with TAPS between 2012 and 2016 at a single fetal therapy centre and that underwent intrauterine transfusion (IUT) were included. Neonatal mortality and morbidity were evaluated. Severe central nervous system (CNS) injury was defined as IVH grade 3-4, ischemic foci or periventricular leukomalacia. During the study period, 225 monochorionic twins were followed at our centre, of whom 70 underwent laser ablation due to Twin–twin transfusion syndrome. TAPS was diagnosed in 15 cases; 10 of them were spontaneous and 5 occurred following laser surgery. Out of 12 patients diagnosed prenatally with TAPS, 7 cases were treated with intrauterine blood transfusion for the anemic twin. The median gestational age at diagnosis was 25.3 weeks of gestation (range 24-27) and the first IUT was performed at 27.4 weeks of gestation (range 25.1-29.3). Four patients required a second IUT 4-21 days after the first one. The median gestational age at delivery was 30 weeks of gestation (range 26.7-32.6) with an interval of 17 days (range 3-44) between the first IUT and delivery resulting in survival of 13 (93%) of the neonates. All of the polycythemic twins survived, two of them were complicated by severe CNS injury. Among the anemic twins, there was one neonatal death following delivery at 26.7 weeks of gestation, but none of the six anemic survivors suffered from severe brain injury. Monochorionic twin pregnancies complicated by TAPS diagnosed at late second trimester can be managed by IUT of the anemic twin allowing deferral of delivery and resulting in favourable neonatal outcome. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Purpose: The purpose of this study was to describe fetal brain anomalies identified during nuchal translucency (NT) examination and their clinical management.Materials and methods: In this retrospective study, we evaluated charts of pregnant women performed the first trimester scan (FTS) between 1.1.2011 and 31.12.14 in a tertiary referral center. Study population consisted of 952 patients scheduled for routine NT scan for aneuploidy screening between 11.0 and 13.6 gestational weeks, and 32 referred patients due to suspicious CNS finding during previous NT scan. Targeted brain assessment was performed according to clinical judgment during routine scans and in all referred cases. Patients with suspicious CNS findings were referred to pregnancy termination or further evaluation including genetic consultation and second trimester anatomical scan.Results: Thirty-one fetuses were diagnosed with variable brain anomalies. Acrania/anencephaly was the most common defect (nine cases) while the rarest findings were inter-hemispheric cyst, microcephaly, and Walker-Warburg Syndrome (one case each). Genetic testing revealed variable results. Twenty-six (83.9%) couples decided to terminate their pregnancies.Conclusions: The current report highlights the evolving ability to detect CNS malformation during NT scan. FTS novel findings expand our embryological understanding of early fetal development. While severe anomalies can be managed by early termination, other defects necessitate comprehensive evaluation and repetitive imaging.

ABSTRACTObjectiveTo define the contribution of maternal variables which influence the measured level of maternal serum placental growth factor (PlGF) in screening for pregnancy complications.MethodsMaternal characteristics and medical history were recorded and serum levels of PlGF were measured in women with a singleton pregnancy attending for three routine hospital visits at 11 + 0 to 13 + 6, 19 + 0 to 24 + 6 and 30 + 0 to 34 + 6 or 35 + 0 to 37 + 6 weeks' gestation. For women delivering phenotypically normal live births or stillbirths ≥ 24 weeks' gestation, variables from maternal demographic characteristics and medical history important in the prediction of PlGF were determined from a linear mixed‐effects multiple regression.ResultsSerum levels of PlGF were measured in 38 002 cases in the first trimester, 10 281 in the second trimester and 12 392 in the third trimester. Significant independent contributions to serum PlGF were provided by gestational age, maternal age, weight and racial origin, cigarette smoking, diabetes mellitus, and gestational age at delivery and birth‐weight Z‐score of the neonate in the previous pregnancy. The machine used to measure serum PlGF was also found to have a significant effect. Allowing for other factors, the effect of maternal age on PlGF changed over the three trimesters, whereas other variables had constant effects over the three trimesters. Random‐effects multiple regression analysis was used to define the contribution of maternal variables that influence the measured serum PlGF and express the values as multiples of the median (MoMs). The model was shown to provide an adequate fit of MoM values for all covariates, both in pregnancies that developed pre‐eclampsia and in those without this complication.ConclusionsA model was fitted to express the measured level of maternal serum PlGF across the three trimesters of pregnancy as MoMs, after adjusting for variables of maternal characteristics and medical history that affect this measurement. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

To define the contribution of maternal variables which influence the measured level of maternal serum soluble fms‐like tyrosine kinase‐1 (sFlt‐1) in screening for pregnancy complications.

ABSTRACTObjectiveThis study aimed to compare measurement of the lateral cerebral ventricular diameter using either the traditional axial view or the coronal plane.Materials and methodsWe performed a prospective study on 144 fetuses, 77 evaluated as part of a routine fetal scan and 67 referred for a neurosonogram. Distal lateral ventricles were measured both in axial and coronal plane.ResultsGood visualization of the ventricles was achieved in 91% of the cases using the coronal plane (both ventricles) and in 95% of the cases using the axial plane (only the distal ventricle) (p > 0.001). The mean width of the distal lateral ventricle in the axial plane was 7.9 ± 1.9 mm versus 8.2 ± 1.9 mm on the coronal plane (p < 0.001). This larger diameter by 0.3 mm was not dependent on the indication for the scan or the gestational age. Slight asymmetry was present on coronal images in the routine group (0.2 mm), and that was even larger in the referral group (1.6 mm) (p < 0.001).ConclusionCoronal measurement of both ventricles is feasible and has the advantage over measurement in the axial view in which only the distal ventricle is clearly visible and measurable. © 2013 John Wiley & Sons, Ltd.

The aim of this study was to compare the diameter of the lateral ventricles measured by traditional axial view with novel measurement at the coronal plane. Prospective study of 144 fetuses in which sonographic measurements of the lateral ventricles using axial and coronal planes were performed at 19 to 38 weeks of gestational. 77 were evaluated as part of a routine fetal scan and 67 were referred for targeted scan. For each fetus, only the distal lateral ventricle's diameter was measured by the “classical” transventricular axial plane, whereas both ventricles were measured at the posterior coronal plane at the level of the atria using transfontanellar approach. The mean gestational age was 27.7 ± 4.6 weeks. A good visualization of both ventricles was achieved in 91% of the cases using the coronal plane. In the entire study group, the mean width of the distal lateral ventricle on the axial plane was 7.9 ± 1.9 mm versus 8.2 ± 1.9 mm on the coronal plane [p-value < 0.001]. The mean axial width was 6.6 ± 1.1 mm in patients who came for a routine scan, versus 9.3 ± 1.6 mm in patients who were referred for a neurosonogram [p-value < 0.001]. Our study showed that Coronal measurement of both proximal and distal ventricles are feasible, which is advantage over the axial view in which only the distal ventricle is clearly visible and measurable. Supporting information can be found in the online version of this abstract. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

A spontaneous intra-amniotic hemorrhage is a very rare condition, which has been previously described in symptomatic patients. We report a case of an asymptomatic spontaneous intra-amniotic hemorrhage at 38 weeks of gestation, resulting in a favorable maternal and neonatal outcome following sonographic antenatal detection of an intra-amniotic blood clot. This pathology should be acknowledged, since a good clinical outcome depends on early diagnosis.