STUDY QUESTION:Does the manipulation of gametes or embryos during ARTs increase the risk for monozygotic twinning (MZT)?SUMMARY ANSWER:Frozen embryo transfer (ET) is associated with a lower MZT rate, while blastocyst culture is associated with an increased risk of monozygotic pregnancy.WHAT IS KNOWN ALREADY:Monozygotic twins have a higher risk for perinatal complications. Although an increased incidence of monozygotic pregnancies after ART has been previously reported, data regarding the possible impact of different laboratory procedures are conflicting.STUDY DESIGN, SIZE, DURATION:All clinical pregnancies after single ET carried out in our centre between 2004 and 2013 (n = 6096) were retrospectively analysed for the incidence of MZT. The effect of different laboratory procedures on the incidence of MZT was evaluated.PARTICIPANTS/MATERIALS, SETTING, METHODS:The following ART risk factors were assessed: maternal age, type of ET (fresh versus frozen), zona pellucida (ZP) manipulation (specifically, ICSI, embryo biopsy and assisted hatching), use of donor oocytes, embryo stage at time of ET (cleavage, compaction, early or advanced blastocyst) and culture media.MAIN RESULTS AND THE ROLE OF CHANCE:The overall MZT rate was 2.2% (136/6096). Frozen ET was associated with a significant reduction in MZT incidence (adjusted odds ratio (aOR) 0.48, 95% CI 0.29-0.80), while blastocyst transfer (early or advanced blastocyst) was associated with a significant increase in MZT risk (aOR 2.70, 95% CI 1.36-5.34; aOR 2.05, 95% CI 1.29-3.26, respectively). No significant differences were found between the MZT and singleton (non-MZT) groups regarding maternal age, the use of different ZP manipulation techniques, not type of culture media used.LIMITATION, REASONS FOR CAUTION:This study is limited by its retrospective nature and the fact that monozygosity was not confirmed by genetic testing. Furthermore, since monozygotic pregnancy is a rare event, other ART parameters that may influence its incidence could not be assessed during our analysis.WIDER IMPLICATION OF THE FINDINGS:Our findings warrant future studies designed to investigate the association between specific ART procedures and MZT, namely the potential risk of blastocyst transfer to increase MZT.STUDY FUNDING/COMPETING INTERESTS:No external funding was used for this study. There are no conflicts of interest.

Evaluation of fetal ultrasound (US) accuracy for prediction of sequelae in congenital cytomegalovirus (cCMV) infected fetuses after maternal primary CMV infection. We conducted a prospective observational study between 1996 and 2012. 67 pregnant patients (69 fetuses) were included with serological evidences of maternal primary CMV infection and proven vertical transmission to the fetus (positive CMV viral load on amniotic fluid or positive viral culture of the neonate). Fetal US was performed in all patients. Termination of the pregnancy (TOP) was presented as an option for CMV infected fetuses. Hearing and neurological clinical assessments were performed for all neonates with a CMV positive urine sampling. 67 patients (69 fetuses) with a proven vertical transmission were included in this study, 64 singleton pregnancies and 3 twin pregnancies. 8 fetuses were excluded from the analysis because of insufficient data on the outcomes. Of the remaining 61, TOP was performed for 26 fetuses. In this group, 11 presented fetal US anomalies. Autopsy confirmed histological evidences of fetal CMV infection in all cases. In the 15 fetuses without fetal US anomalies, histological evidence of fetal infection damage was detected in 13 cases. Of the 35 live born infants, 12 had fetal US anomalies suggestive for cCMV infection. Of these 12 infants, 6 had a normal clinical evaluation whereas 6 presented with clinical anomalies from whom 4 cases were considered as severe. In 23 live born children with normal fetal US, 6 infants showed hearing impairments and 2 were diagnosed with mild neurological sequelae. In a group of maternal primary CMV infection acquired in early pregnancy, with proven fetal infection, fetal US anomalies were detected in 37,7% and were confirmed in autopsy or clinical evaluation after birth in 73,9%. In patients with normal fetal US evaluation, autopsy or clinical evaluation after birth could detect CMV-related anomalies in 55% of the patients.

ABSTRACTObjectivesTo investigate neonatal morbidity in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic endoluminal tracheal occlusion (FETO) and compare it with historical controls with less severe forms of CDH that were managed expectantly.MethodsThis was a prospective, multicenter study on neonatal outcomes and prenatal predictors in 90 FETO survivors (78 left‐sided, 12 right) and 41 controls from the antenatal CDH registry with either severe or moderate hypoplasia who were managed expectantly. We also investigated early neonatal morbidity indicators, including the need for patch repair, duration of mechanical ventilation and supplemental oxygen, age at full enteral feeding and incidence of pulmonary hypertension.ResultsGestational age at delivery was predictive of duration of assisted ventilation (P = 0.046), days on supplemental oxygen (P = 0.019) and age at full enteral feeding (P = 0.020). When delivery took place after 34 weeks' gestation, neonatal morbidity of FETO cases was comparable with that of expectantly managed cases with moderate hypoplasia.ConclusionsFetal intervention for severe CDH is associated with neonatal morbidity that is comparable with that of an expectantly managed group with less severe disease. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

We report on early neonatal morbidity in fetuses with severe congenital diaphragmatic hernia (CDH) undergoing fetal endoluminal tracheal occlusion (FETO) compared to a historical cohort of expectantly managed cases during pregnancy from the antenatal CDH registry (Jan UOG 2009). Prospective multicenter study on fetuses with isolated severe CDH, undergoing FETO and surviving till discharge from neonatal intensive care unit (NICU) (n = 90; 78 left, 12 right). Controls were 100 survivors (95 left, 5 right) expectantly managed categorized by severity of hypoplasia. Postnatal outcome measures were GA@birth, interval between balloon removal and delivery (more or less than 24 hours), age at postnatal surgery (d), use of patch, duration of assisted mechanical ventilation (d), need for oxygen @28 d of life, the occurrence of pulmonary hypertension (PHT) determined by cardiac ultrasound and duration of stay in NICU. Outcome, except for the occurrence of PHT, was significantly different between the three groups (Table 1). Morbidity in survivors following FETO is in-between what is expected in fetuses with severe and moderate hypoplasia, who were managed after birth. FETO patients born < 34 weeks (n = 28), compared to those born after 34 weeks (n = 62), have a higher need for oxygen at 28 days (0.003), are longer on the ventilator (0.0041) and in NICU (0.028) and require more time till full enteral feeding (0.0233). Neonatal morbidity in fetuses with severe CDH undergoing FETO is less than what is expected, more so when born after 34 weeks. It is closer to or comparable with what is expected in fetuses with moderate hypoplasia.

Objectives To predict neonatal survival and pulmonary hypertension by measurement of fetal pulmonary artery reactivity to maternal hyperoxygenation in fetuses with severe congenital diaphragmatic hernia treated by fetoscopic endoluminal tracheal occlusion (FETO).Methods Thirty-eight fetuses underwent FETO at around 28 weeks' gestation and the balloon was removed at 34 weeks in most cases. We performed a hyperoxygenation test and measured the lung-to-head ratio of each fetus before and after each procedure. Outcome measures were neonatal survival, occurrence of pulmonary hypertension and its response to inhaled nitric oxide (iNO).Results Fetuses that survived had a larger increase in lung size and decrease of resistance in the first branch of the main pulmonary artery than did those that died. Both measures were also predictive of pulmonary hypertension unresponsive to iNO. The hyperoxygenation test and lung-to-head ratio were both best predictive for neonatal survival when measured following removal of the balloon (P < 0.002). Discriminant analysis confirmed that these two parameters are independent predictors of outcome.Conclusions In fetuses undergoing FETO, pulmonary vascular reactivity in relation to oxygen and lung size are independent predictors of neonatal survival and pulmonary hypertension. The hyperoxygenation test merits further study in expectantly managed cases. Copyright (C) 2011 ISUOG. Published by John Wiley & Sons, Ltd.

To evaluate the contribution of intrapulmonary artery Doppler in predicting the survival of fetuses with congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO).

To evaluate lung tissue perfusion in fetuses with congenital diaphragmatic hernia (CDH) and to explore the association of lung tissue perfusion with the lung area to head circumference ratio (LHR) and intrapulmonary artery pulsed Doppler.

Middle cerebral artery (MCA) pulsatility index (PI) and umbilical artery (UA) PI, often expressed as cerebroplacental Doppler ratio (CPR), is used for the management of fetal growth restriction. Monochorionic diamniotic (MCDA) twin pregnancies are at increased risk for selective intrauterine growth restriction (sIUGR) occurring in about 14%. We aimed to estimate normative ranges for MCA-PI and UA-PI and compare those to values of MCDA twins affected by sIUGR. To obtain normative values we prospectively examined MCDA pregnancies in a longitudinal study. Patients were recruited between 11 and 14 weeks and fetal MCA and UA Doppler waveforms were assessed biweekly from 15 weeks onwards. Multilevel modeling was used to estimate gestational age-specific reference ranges. Reference curves were compared to longitudinal values of 25 MCDA twins affected by sIUGR. 811 observations of 84 uncomplicated MCDA twins were used to construct normative ranges from 15 to 37 weeks. One hundred and forty one values were obtained from 25 fetuses that developed sIUGR. Their mean CPR over gestation was lower than the one of their co-twins and the normal population. Cerebroplacental ratio seems to be decreased in MCDA twins with sIUGR and might be an additional tool in managing these fetuses.

The aim of this study was to identify predictors of twin‐to‐twin transfusion syndrome (TTTS) and selective intrauterine growth restriction (sIUGR) in monochorionic diamniotic (MCDA) twin pregnancies with moderate amniotic fluid discordance (mAFD).

Objectives Left ventricular cardiac output is decreased in fetuses with congenital diaphragmatic hernia (CDH). Our aim was to assess whether this alters cerebral perfusion or growth in utero.Methods Fetal head circumference, biparietal diameter, lung-to-head ratio and middle cerebral artery (MCA) Doppler flow patterns were assessed by ultrasonography in 103 fetuses with prenatally diagnosed CDR Total fetal lung volume and cerebral volume were measured using magnetic resonance imaging. Values were transformed to gestational age-independent scores (multiples of the median (MoM)) and compared with controls. Subanalyses were made according to whether the CDH was left-(n = 86) or right-sided (n = 17) and to whether it was isolated (n = 86) or associated with other anomalies (n = 17).Results MCA flow velocity was significantly lower in fetuses with CDH than in healthy fetuses (0.79 0.19 MoM; P < 0.0001) but MCA pulsatility index was unchanged (0.99 +/- 0.25 MoM; P = 0.79). Cranial biometry and cerebral volume in CDH fetuses fell in the normal range. Gestational age-adjusted lung area was correlated with MCA peak systolic velocity, which was in turn correlated with brain volume.Conclusions Fetal cerebral blood flow velocities are decreased in CDH yet cranial and cerebral growth are conserved. Further work will be needed to address whether part of the neurologic impairment observed in long-term survivors of CDH finds its origin in the prenatal period. Copyright (C) 2010 ISUOG. Published by John Wiley & Sons, Ltd.

Minimal invasive intrauterine interventions have gained their place in fetal medicine. Interventions on the placenta, umbilical cord, fetal membranes or on the fetus require special endoscopes with their respective sheaths, cannulas and additional instruments. Instruments for fetal therapy are purpose designed for the procedure of interest and most gynaecologists are therefore not familiar with them. We review the currently available instrumentation used during operations for complicated monochorionic multiple pregnancies, congenital diaphragmatic hernia, amniotic band syndrome, urinary tract obstruction and hydrothorax.

The fetus is a source of nonembryonic stem cells (SC), with potential applications in perinatal medicine. Cells derived from the placenta, membranes, amniotic fluid or fetal tissues are higher in number, expansion potential and differentiation abilities compared with SC from adult tissues. Although some obstacles keep SC biology at distance from clinical application, the feasibility of using (homologous) SC for tissue engineering for the fetus with a congenital birth defect has been demonstrated. Also, other pathologies may benefit from SC technology.

Retrospective study of 310 consecutive lasers at 2 centres using different access diameters. Databases were searched for following characteristics: maternal, TTTS disease (cervical length; stage; deepest vertical pool; gestation at laser), procedural (placenta location; access diameter; number ports and anastomoses; volume drained; anesthetic technique; perioperative intra-amniotic bleeding) and pregnancy outcome (ARX; gestation at delivery; IUFD). Univariate and multivariate logistic regression analysis was performed. Repeat invasive procedures (n = 31), TOP or double IUFD (n = 21) after laser were excluded. Used diameters were 2.3, 3.3, 3.5 and 3.8 mm. There were no differences in maternal, procedure characteristics, except for earlier gestational age at laser for the 2.3 mm diameter group. There were no differences in rate of ARX or PTB < 32 weeks. Quintero stage (p = 0.014; r2 0.03) was the only variable associated with ARX (univariate analysis). ARX (p < 0.0001; r2 0.05), gestational age at laser (p < 0.001; r2 0.03), parity (p = 0.049; r2 0.01) and perioperative intra-amniotic bleeding (p = 0.0343; r2 0.01) were associated with PTB < 32 weeks. ARX (p < 0.001), gestation at laser (p = 0.003) and parity (p = 0.040) were significantly associated with PTB < 32 weeks in multivariate analysis (r2 0.09). The access diameter used does not affect the amniorrhexis rate. PTB is more frequent with increasing parity and gestation at laser.

Objectives To examine operative and perinatal aspects of fetal endoscopic tracheal occlusion (FETO) in congenital diaphragmatic hernia (CDH).Methods This was a multicenter study of singleton pregnancies with CDH treated by FETO. The entry criteria for FETO were severe CDH on the basis of sonograpbic evidence of intrathoracic herniation of the liver and low lung area to bead circumference ratio (LHR) defined as the observed to the expected normal mean for gestation (o/e LHR) equivalent to an LHR of I or less.Results FETO was carried out in 2.10 cases, including 175 cases with left-sided, 34 right-sided and one with bilateral CDH. In 188 cases the CDH was isolated and in 22 there was an associated defect. FETO was performed at a median gestational age of 27.1 (range, 23.0-33.3) weeks. The first eight cases were done under general anesthesia, but subsequently either regional or local anesthesia was used. The median duration of FETO was 10 (range, 3-93) min. Successful placement of the balloon at the first procedure was achieved in 203 (96.7%) cases. Spontaneous preterm prelabor rupture of membranes (PPROM) occurred in 99 (47.1%) cases at 3-83 (median, 30) days after FETO and within 3 weeks of the procedure in 35 (16.7%) cases. Removal of the balloon was prenatal either by fetoscopy or ultrasound-guided puncture, intrapartum by ex-utero intrapartum treatment, or postnatal either by tracheoscopy or percutaneous puncture. Delivery was at 25.7-41.0 (median, 353) weeks and before 34 weeks in 65 (30.9%) cases. In 204 (97.1%) cases the babies were live born and 98 (48.0%) were discharged from the hospital alive. There were 10 deaths directly related to difficulties with removal of the balloon. Significant prediction of survival was provided by the o/e LHR and gestational age at delivery. On the basis of the relationship between survival and o/e LHR in expectantly managed fetuses with CDH, as reported in the antenatal CDH registry, we estimated that in fetuses with left CDH treated with FETO the survival rate increased from 24.1% to 49.1%, and in right CDH survival increased from 0% to 35.3% (P < 0.001).Conclusions FETO in severe CDH is associated with a high incidence of PPROM and preterm delivery but a substantial improvement in survival. Copyright (C) 2009 ISUOG. Published by John Wiley & Sons, Ltd.

OBJECTIVES:The pre-existing compression of the left ventricle in congenital diaphragmatic hernia (CDH) could be aggravated by the amplified lung growth after fetoscopic endoluminal tracheal occlusion (FETO). Our aim was to document left ventricular (LV) size and function in fetuses with isolated left-sided CDH and to document the effect of FETO on the fetal heart. METHODS:We determined cardiac axis, LV diameters, ejection fraction, shortening fraction, mitral E/A index and myocardial performance index (MPI) in 27 fetuses with isolated left-sided CDH, and compared these with values in a reference population (n = 117). In fetuses with severe CDH that subsequently underwent FETO and/or reversal of occlusion, additional measurements were obtained 24 h before and after each fetal intervention. We recorded fetal electrocardiograms non-invasively in six CDH fetuses and compared the duration of the QRS complex with data obtained from 12 controls. RESULTS:LV end-diastolic diameter was 32% smaller in CDH fetuses than in controls (P < 0.0001) but LV function was comparable. QRS duration was no different between CDH and control fetuses. FETO did not affect cardiac size but reduced the MPI (P = 0.004). Reversal of FETO had no significant effect on cardiac size and function. CONCLUSIONS:CDH fetuses have a smaller left ventricle than do healthy fetuses. There is no overall adverse impact of CDH and FETO on LV cardiac function.

We used pregnant does to study fetal lung development to validate MRI as a tool for accurate in utero identification and lung volumetry and to find a MRI marker for lung maturation. 4 pregnant does were scanned using a 3 Tesla MRI (Magnetom Trio, Siemens, Erlangen, Germany) at different stages of lung development (day 25–30; term=32). Rabbits were sedated and scanned in the supine position using an 8 channel knee coil. T2-weighted imaging was performed for anatomical referencing and intra-uterine fetal localization. Diffusion weighted MR images (DWI-MRI) served as a surrogate marker for lung development and signal intensities were recorded. After euthanasia fetuses were harvested identifying them by location. Post-mortem fetal T2-weighted imaging was performed to determine body and lung volumes. Body weights (accuracy 0.01g) and lung volumes (fluid displacement method) were determined after imaging. Linear regression was used for statistics. The number of fetuses/doe ranged between 6–11 (total n=31). MRI allowed for correct intra-uterine localization, i.e. matching in-vivo versus ex-vivo. In-utero DWI-MRI was highly reproducible (relative SD:4.8%) and a strong correlation was found between MRI volumetry and autopsy: fetal body volume versus weight (R2 0.99, p 0.0001) and fetal lung volume by MRI versus displacement method (R2 0.92, p 0.0001). Lung signal intensity decreased during gestation (p 0.001). Intra-uterine fetal MRI in a rabbit model allows for correct fetal identification and accurate volumetry and enables to detect significant changes in lung signal intensities as pregnancy progresses. 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.