Pre and postnatal diagnosis of congenital portosystemic shunt: Impact of interventional therapy

Prenatal sonographic characteristics and postnatal outcomes of congenital portosystemic shunt diagnosed during the fetal period: a systematic review

BACKGROUND

Congenital portosystemic shunt (CPSS) is a rare vascular malformation which results in anomalous communication between the portal venous system and the systemic vein. The objective of this review is to describe the prenatal ultrasonic characteristics and postnatal outcomes of CPSS diagnosed prenatally, along with providing some suggestions for perinatal monitoring.

MATERIALS AND METHODS

A systematic literature search was conducted in PubMed and Ovid electronic databases in a period from January 2012 to May 2024, using the terms: "congenital portosystemic shunt", "ductus venosus", "Abernethy malformation" and "umbilical-portal-systemic venous shunt". All original studies reporting CPSS patients diagnosed prenatally were included. Studies published in languages other than English or studies that did not report the clinical information of patients were excluded. Two reviewers independently screened articles for inclusion and extracted data.

RESULTS

A total of 39 studies which included 525 cases were enrolled in the systematic review. Among the included patients, 49 (9%) had umbilical-systemic shunt (USS), 264 (50%) had ductus venosus-systemic shunt (DVSS), 159 (30%) had intrahepatic portal-systemic shunt (IHPSS), 32 (6%) had extrahepatic portal-systemic shunt (EHPSS) and 9 (2%) had mixed shunts which meant that they had more than one type of shunts. There were also 12(3%) patients were excluded because the specific type was not described in the study. CPSS patients could have severe comorbidities such as chromosomal aberrations and cardiovascular malformations. Compared with other groups, fetuses with IHPSS had the lowest incidence of severe comorbidities. Most patients received conservative treatment while interventional and surgical treatments were used for some patients.

CONCLUSION

We suggest that fetuses diagnosed with CPSS should be treated differently according to their types and clinical manifestations. IHPSS patients are more likely to have good outcomes so they may benefit from the "wait-and-see" approach while the other groups deserve closer monitoring. Personalized treatment is essential as CPSS patients can be asymptomatic or have severe complications.

Classical Hereditary galactosemia: findings in patients and animal models

Classic galactosemia is a rare inborn error of metabolism that affects the metabolism of galactose, a sugar derived from milk and derivates. Classic galactosemia is caused by variants of the GALT gene, which lead to absent or misfolded forms of the ubiquitously present galactose-1-phosphate uridylyltransferase enzyme (GALT) driving galactose metabolites to accumulate, damaging cells from neurons to hepatocytes. The disease has different prevalence around the world due to different allele frequencies among populations and its symptoms range from cognitive and psychomotor impairment to hepatic, ophthalmological, and bone structural damage. The practice of newborn screening still varies among countries, dairy restriction treatment is a consensus despite advances in preclinical treatment strategies. Recent clinical studies in Duarte variant suggest dairy restriction could be reconsidered in these cases. Despite noteworthy advances in the classic galactosemia understanding, preclinical trials are still crucial to fully understand the pathophysiology of the disease and help propose new treatments. This review aims to report a comprehensive analysis of past studies and state of art research on galactosemia screening, its clinical and preclinical trials, and treatments with the goal of shedding light on this complex and multisystemic innate error of the metabolism.

Congenital intra-hepatic porto-systemic shunts diagnosed during intrauterine life: Systematic review

OBJECTIVE

To describe the ultrasonographic characteristics of congenital porto-systemic venous shunts (CPSS) diagnosed during pregnancy, their outcomes, and their evolution.

METHODS

Two independent researchers selected 493 review articles and case reports through the analysis of titles, abstracts, and full text. The PubMed and LILACS databases were searched. Through the application of filters according to the PRISMA protocol, only six articles were used in the research. The following information was collected, when available: gestational age at diagnosis, gender, birth weight, type of shunt, associated anomalies/complications and treatment/progression.

RESULTS

The data were obtained from 27 cases, with 22 (82%) fetuses diagnosed with intra-hepatic CPSS and 5 (18%) with extra-hepatic CPSS. The median time of intrauterine diagnosis was 33 weeks. In 12 (57.1%) of the 21 pregnancies evaluated, delivery was preterm. The estimated fetal weight ranged from 1150 to 3760 g, with 4 (25%) cases at <3rd, 3 (18.75%) cases at <10th, 8 (50%) cases at <50th, and 1 (6.25%) case at >97th percentile for gestational age. The most frequent obstetric complication was fetal growth restriction, which occurred in nine (60%) cases. As for postnatal treatment, 19 (70.4%) cases were conservatively treated, and 8 (29.6%) cases required surgical intervention.

CONCLUSION

The diagnosis of CPSS still represents a challenge during prenatal care. Its early identification aims to provide guidance to pregnant women and their families, as well as follow-up and anticipation of possible complications, in addition to the evaluation of the mode of delivery and postnatal follow-up, directing the short- and long-term prognosis.

Prenatal diagnosis of abnormality of the umbilical portal DV complex: difficulty in universal classification due to various alternative routes in hepatic circulation for placental drainage

OBJECTIVE

To review our experience with fetal abnormality of the umbilical-portal-DV complex and to discuss the new classification system for umbilical portal systemic venous shunts (UPSVS) according to our cases.

METHODS

This study was a retrospective analysis of fetuses with a prenatal diagnosis of abnormality of the umbilical-portal-DV complex. The integrity of the fetal umbilical-portal ductus venosus complex and the hepatic venous system were evaluated using two-dimensional color Doppler sonography. The origin of the shunt, the location of the drainage, and the presence or absence of intrahepatic portal venous system and DV were noted.

RESULTS

35 cases of abnormality of the umbilical-portal-DV complex were identified. Agenesis of ductus venous was detected in 33 of them. Based on the abnormality of the umbilical-portal-DV complex, we divided the cases into five groups. Group 1, ductus venosus agenesis with normal hepatic venous anatomy (n = 11); Group 2 downward displacement of the umbilical-portal-DV complex (n = 13); Group 3, umbilical-systemic shunt (n = 5); Group 4, intrahepatic portosystemic shunt (n = 4), Group 5, hepatic arteriovenous malformation (n = 2). Three different intrahepatic portosystemic shunt and one different downward displacement of the umbilical-portal-DV complex cases were detected.

CONCLUSIONS

Disruption of the normal anatomy of the umbilical-portal-DV complex causes various alternative pathway of the placental drainage. This illustrates highlights the challenge of creating a universal classification.