The long-term outcome following thoraco-amniotic shunting for congenital lung malformations

AIM OF THE STUDY

Insertion of a thoraco amniotic shunt (TAS) during fetal life is a therapeutic option where there is a high risk of death secondary to large congenital lung malformations (CLM). The aim of this study is to present our center's long-term experience.

METHODS

Retrospective single center review of the period (Jan 2000-Dec 2020). We included all fetuses that underwent TAS insertion for CLM with detailed analysis of those live newborns managed in our center. Data are quoted as median (range).

MAIN RESULTS

Thirty one fetuses underwent 37 TAS insertions at a 25 (20-30) weeks gestational age. This was successful on 1st attempt in 30 (97%) fetuses. In 6 cases a 2nd shunt was required at 6.5 (2-10) weeks following the 1st insertion. Twenty-eight survived to be born. Sixteen (9 male) infants were delivered in our center at 39 (36-41) weeks gestational age and birth weight of 3.1 (2.6-4.2) kg. All infants underwent surgery at 2 (0-535) days (emergency surgery, n = 9; expedited n = 4; elective surgery, n = 3). Final histopathology findings were CPAM Type 1 (n = 14, n.b. associated with mucinous adenocarcinoma, n = 1), CPAM Type 2 (n = 1) and an extralobar sequestration (n = 1). Postoperative stay was 16 (1-70) days with survival in 15/16 (94%). One infant died at 1 day of life secondary to a combination of pulmonary hypoplasia and hypertension. Median follow up period was 10.7 (0.4-20.4) years. Nine (60%) children developed a degree of chest wall deformity though none have required surgical intervention. Clinically, 14/15 (93%) have otherwise normal lung function without limitations of activity, sporting or otherwise. One child has a modest exercise limitation (FVC - 70% predicted).

CONCLUSIONS

TAS insertion is associated with high perinatal survival and should be considered in fetuses at risk of hydrops secondary to large cystic lung malformation. Their long term outcome is excellent although most have a mild degree of chest wall deformity.

GWAS meta-analysis of intrahepatic cholestasis of pregnancy implicates multiple hepatic genes and regulatory elements

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disorder affecting 0.5-2% of pregnancies. The majority of cases present in the third trimester with pruritus, elevated serum bile acids and abnormal serum liver tests. ICP is associated with an increased risk of adverse outcomes, including spontaneous preterm birth and stillbirth. Whilst rare mutations affecting hepatobiliary transporters contribute to the aetiology of ICP, the role of common genetic variation in ICP has not been systematically characterised to date. Here, we perform genome-wide association studies (GWAS) and meta-analyses for ICP across three studies including 1138 cases and 153,642 controls. Eleven loci achieve genome-wide significance and have been further investigated and fine-mapped using functional genomics approaches. Our results pinpoint common sequence variation in liver-enriched genes and liver-specific cis-regulatory elements as contributing mechanisms to ICP susceptibility.

O-174 The association of chromosomal abnormalities with embryo ultrastructure, spindle anomalies and metabolic profiling

Study question

Can metabolic profiling predict embryos at risk of chromosomal abnormalities and how are these reflected in the ultrustructure and cytoskeleton?

Summary answer

Different metabolic profiles are observed between normal and aneuploid/chaotic embryos which are linked to altered mitochondrial and other organelles’ structure/function and spindle and nuclear abnormalities.

What is known already

One of the greatest challenges in IVF is the selection of the best ‘fit’ embryo for implantation in a non-invasive way. Down’s syndrome embryos and Monosomy 21 embryos have previously been shown to have differential expression of metabolites compared to normal embryos, but limited studies, have investigated in detail the metabolic profiling of embryos with other abnormalities in comparison to chromosomally normal embryos or their reflection in the ultrustructure and the cytoskeleton.

Study design, size, duration

Culture media collected on day 3 from 200 embryos which underwent PGT-A, were analysed by hydrophilic interaction liquid chromatography tandem mass spectrometry (HILIC-MS/MS). The chromosomally normal embryos were transferred to the uterus (1–2 embryos/ET) or still remain vitrified for clinical use and 120 of the embryos that were diagnosed with chromosomal abnormalities were either processed for spindle/chromosome configurations analysis (n = 60) by confocal laser scanning microscopy(CLSM) or for ultrastructural analysis (n = 60) by Transmission Electron Microscopy(TEM).

Participants/materials, setting, methods

Metabolic profiling was conducted in a Forensic Toxicology Laboratory by HILIC-MS/MS (100 metabolites). Spindle Chromosome Configuration analysis was conducted in an academic hospital after methanol fixation and immunostaining with α-tubulin, γ-tubulin, acetylated-tubulin antibodies and DAPI or/ PI to visualise DNA. Ultrastructure analysis by TEM was carried out in a Histology/Embryology Laboratory following embryo fixation in 3% glutaraldehyde, 1% osmium tetroxide, washes in  PBS and staining with 1% aqueous uranyl acetate.

Main results and the role of chance

This  study provides screening  for >100 primary metabolites using HILIC-MS/MS in a single run of 40 minutes. Characteristic patient specific metabolic profiles were observed which differed between normal embryos that had resulted in a viable pregnancy and aneuploid and chaotic embryos. Logistic regression analysis revealed a number of metabolites that had a high predictive value including Isoleucine,  lysine and glucose and models were created in combination with embryo score which in the future could serve as non-invasive markers for the detection of chromosomal abnormalities before embryo transfer. TEM analysis revealed differences in the quality of cells and organelle activity which were reflected in the embryo metabolic profiles. Chaotic poor quality embryos showed a lower number of mitochondria, often with no cisternae, increased number of vacuoles, and frequently problems in junctions between cells. Aneuploid but well developed hatching blastocysts had mainly cells with good mitochondrial morphology/ activity, nice Golgi apparatus and well developed rough and smooth endoplasmic reticulum but depending on the aneuploidy involved, inner cell mass cells with limited organelles and occasionally lipofuscin droplets in the trophectoderm were evident. Nuclear and chromosomal abnormalities were interrelated through abnormalities in cytokinesis and spindle formation and reflected in the embryo metabolic profiles.

Limitations, reasons for caution

Although metabolic profiles were compared between normal and chromosomally abnormal embryos identified by PGT-A, all the  normal embryos were transferred to the uterus or remain vitrified for clinical purposes and therefore the ultrastructure analysis and the spindle chromosome configuration analysis are based only on chromosomally abnormal embryos.

Wider implications of the findings

This study identified distinct differences in the metabolic profiles of normal and chromosomally abnormal embryos and provides unique metabolites which in the future could serve as non-invasive biomarkers for the detection of chromosomal abnormalities before embryo transfer.

Trial registration number

not applicable

MO170: Systematic Review of Patients with Chronic Kidney Disease Undergoing Fertility Treatment

BACKGROUND AND AIMS

The prevalence of chronic kidney disease (CKD) in women of reproductive age continues to rise and reduced fertility is recognized even with mild disease. A greater proportion of women with CKD are seeking assisted reproductive technology (ART) treatment; however, our understanding of treatment success and adverse outcomes is limited. Our aim was to perform a systematic review to describe pregnancy and kidney outcomes and complications of pregnancies in women with CKD following ART.

METHOD

The systematic review was performed with reference to the Cochrane Handbook for Systematic Reviews of Interventions and reported with reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following databases were searched from 1946 to May 2021: (1) Cochrane Central Register of Controlled Trials (CENTRAL), (2) Cumulative Index to Nursing and Allied Health Literature (CINAHL), (3) Embase and (4) MEDLINE. Relevant review articles were also searched for additional studies.

RESULTS

The database search identified 3520 records, of which 35 publications were suitable for analysis. A total of 95 fertility treatment cycles were analysed in 74 women with CKD who had ART. The median age of women with CKD at the time of pregnancy was 32.0 years (IQR 29.0, 34.0 years).

The majority of women had in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) (56/74; 75.7%). One woman had an autotransplant of cryopreserved ovarian tissue which led to a spontaneous pregnancy, one woman had a medicated frozen embryo transfer cycle, one woman used donor eggs and five women used gestational surrogates.

Of the 95 cycles, 11 women (15%) did not have a clinical pregnancy; there were 66 clinical pregnancies from 63 women (69%). There were 81 live births in total, with 21 multifetal live births (26%). There was 1 ectopic pregnancy, 13 miscarriages and 2 still births.

Seven cycles in seven women were complicated by ovarian hyperstimulation syndrome (OHSS) (7%) which were all associated with AKI. Full recovery of kidney function occurred in six women; one woman had progression of her CKD. Hypertensive disorders of pregnancy including pre-eclampsia complicated 27 pregnancies (41%). The most common mode of delivery was caesarean section (42/74, 57%). Preterm delivery (<37 weeks’ gestation) occurred in 25 (34%) births. Low birth weight (<2500 g) was present in 46 (79%) of live births and 6 (20%) of birthweights were under the 10th centile. Twelve (15%) neonates required admission to a neonatal intensive care unit (NICU). A total of 7/12 children had normal development at up to 10 years of follow-up. When comparing women with CKD requiring ART to those with natural conception, rates of preterm delivery and caesarean section were similar; however, rates of pre-eclampsia (P = .001) and multifetal deliveries were significantly higher (P < .001) in the ART cohort.

CONCLUSION

To our knowledge, this systematic review represents the most comprehensive assessment of fertility outcomes in patients with CKD who have assisted conception. Limitations include reporting bias due to a high reported live birth rate. Patient selection for fertility treatment and identification of risk factors remains crucial in order to maximize patient safety, screen for adverse events and optimise fertility outcomes.

Prediction of survival in infants with congenital diaphragmatic hernia and the response to inhaled nitric oxide

The use of inhaled nitric oxide (iNO) in treating pulmonary hypertension in infants with congenital diaphragmatic hernia (CDH) is controversial. Our aims were to identify factors associated with survival in CDH infants and whether this was influenced by the response to iNO. Results of CDH infants treated in a tertiary surgical and medical perinatal centre in a ten year period (2011-2021) were reviewed. Factors affecting survival were determined. To assess the response to iNO, blood gases prior to and 30 to 60 min after initiation of iNO were analysed and PaO₂/FiO₂ ratios and oxygenation indices (OI) calculated. One hundred and five infants were admitted with CDH; 46 (43.8%) infants died. The CDH infants who died had a lower median observed to expected lung to head ratio (O/E LHR) (p < 0.001) and a higher median highest OI on day 1 (HOId1) (p < 0.001). HOId1 predicted survival after adjusting for gestational age, Apgar score at 5 min and O/E LHR (odds ratio 0.948 (95% confidence intervals 0.913-0.983)). Seventy-two infants (68.6%) received iNO; 28 survived to discharge. The median PaO₂ (46.7 versus 58.8 mmHg, p < 0.001) and the median PaO₂/FiO₂ ratio (49.4 versus 58.8, p = 0.003) improved post iNO initiation. The percentage change in the PaO₂/FiO₂ ratio post iNO initiation was higher in infants who survived (69.4%) compared to infants who died (10.2%), p = 0.018.

CONCLUSION

The highest OI on day 1 predicted survival. iNO improved oxygenation in certain CDH infants and a positive response was more likely in those who survived.

WHAT IS KNOWN

• The use of iNO is controversial in infants with CDH with respect to whether it improves survival.

WHAT IS NEW

• We have examined predictors of survival in CDH infants including the response to iNO and demonstrated that the highest oxygenation index on day 1 predicted survival (AUCROC =0.908). • Certain infants with CDH responded to iNO and those with a greater response were more likely to survive.

Prenatal cerebellar growth is altered in congenital diaphragmatic hernia on ultrasound

OBJECTIVE

Children with congenital diaphragmatic hernia (CDH) are at risk for neurodevelopmental delay. Herein we report on prenatal changes in biometry and brain perfusion in fetuses with isolated CDH.

STUDY DESIGN

This retrospective study evaluated fetuses with isolated, left-sided CDH in three European referral centers. Abdominal circumference (AC), femur length (FL), head circumference (HC), transcerebellar diameter (TCD), middle cerebral artery (MCA) Doppler, and ventricular width (VW) were assessed during four gestational periods (<24 weeks, 25-28 weeks, 29-32 weeks, >33 weeks). Z-scores were calculated, and growth curves were created based on longitudinal data.

RESULTS

In 367 fetuses, HC, AC and FL were within normal ranges throughout gestation. The TCD diminished with advancing gestational age to fall below the fifth percentile after 32 weeks. A less pronounced but similar trend was seen in VW. The peak systolic velocity of the MCA was consistently approximately 10% lower than normal. Disease severity was correlated to TCD (p = 0.002) and MCA doppler values (p = 0.002). There were no differences between fetuses treated with FETO and those managed expectantly.

CONCLUSION

Fetuses with isolated left-sided CDH have a small cerebellum and reduced MCA peak systolic velocity. Follow up studies are necessary to determine the impact of these changes on neurodevelopment.

Re-evaluating diagnostic thresholds for intrahepatic cholestasis of pregnancy: case-control and cohort study

OBJECTIVE

To determine the optimal total serum bile acid (TSBA) threshold and sampling time for accurate intrahepatic cholestasis of pregnancy (ICP) diagnosis.

DESIGN

Case-control, retrospective cohort studies.

SETTING

Antenatal clinics, clinical research facilities.

POPULATION

Women with ICP or uncomplicated pregnancies.

METHODS

Serial TSBA measurements were performed pre-/postprandially in 42 women with ICP or uncomplicated pregnancy. Third-trimester non-fasting TSBA reference ranges were calculated from 561 women of black, south Asian and white ethnicity. Rates of adverse perinatal outcomes for women with ICP but peak non-fasting TSBA below the upper reference range limit were compared with those in healthy populations.

MAIN OUTCOME MEASURES

Sensitivity and specificity of common TSBA thresholds for ICP diagnosis, using fasting and postprandial TSBA. Calculation of normal reference ranges of non-fasting TSBA.

RESULTS

Concentrations of TSBA increased markedly postprandially in all groups, with overlap between healthy pregnancy and mild ICP (TSBA <40 μmol/l). The specificity of ICP diagnosis was higher when fasting, but corresponded to <30% sensitivity for diagnosis of mild disease. Using TSBA ≥40 μmol/l to define severe ICP, fasting measurements identified 9% (1/11), whereas non-fasting measurements detected over 91% with severe ICP. The highest upper limit of the non-fasting TSBA reference range was 18.3 µmol/l (95% confidence interval: 15.0-35.6 μmol/l). A re-evaluation of published ICP meta-analysis data demonstrated no increase in spontaneous preterm birth or stillbirth in women with TSBA <19 µmol/l.

CONCLUSIONS

Postprandial TSBA levels are required to identify high-risk ICP pregnancies (TSBA ≥40 μmol/l). The postprandial rise in TSBA in normal pregnancy indicates that a non-fasting threshold of ≥19 µmol/l would improve diagnostic accuracy.

TWEETABLE ABSTRACT

Non-fasting bile acids improve the diagnostic accuracy of intrahepatic cholestasis of pregnancy diagnosis.

Chronic hypertension in pregnancy stratified by first-trimester blood pressure control and adverse perinatal outcomes: A prospective observational study

INTRODUCTION

The aim of this study was to assess perinatal outcomes in women with chronic hypertension (CH) stratified into four groups according to their blood pressure (BP) control in the first trimester of pregnancy.

MATERIAL AND METHODS

This was a prospective cohort study between January 2011 and June 2017, based in a university hospital in London, UK. The population consisted of four groups: group 1 included women without history of CH, presenting in the first trimester with BP >140/90 mmHg (n = 100). Groups 2-4 had prepregnancy CH; group 2 had BP <140/90 mmHg without antihypertensives (n = 234), group 3 had BP <140/90 mmHg with antihypertensives (n = 272), and group 4 had BP ≥140/90 mmHg despite antihypertensives (n = 194). The main outcome measures were: fetal growth restriction, admission to neonatal (NNU) or neonatal intensive care unit (NICU) for ≥2 days, composite neonatal morbidity, and composite serious adverse neonatal outcome. Outcomes were collected from the hospital databases and for up to 6 weeks postnatally. Differences between groups were assessed using chi-squared test and multivariate logistic regression was used to assess the independent contribution of the four groups to the prediction of pertinent outcomes, after controlling for maternal characteristics.

RESULTS

There was a higher incidence of fetal growth restriction in groups 3 (17.6%) and 4 (18.2%), compared with groups 1 (10.0%) and 2 (11.1%) (P = .04). There were more admissions to the NNU for ≥2 days in groups 3 (23.2%) and 4 (25.0%), compared with groups 1 (17.0%) and 2 (13.2%) (P = .008); and more admissions to NICU for ≥2 days in groups 3 (9.2%) and 4 (9.4%), compared with groups 1 (3.0%) and 2 (3.4%) (P = .01). Composite neonatal morbidity was higher in groups 3 (22.4%) and 4 (21.4%), compared with groups 1 (17.0%) and 2 (11.5%) (P = .009). Composite serious adverse postnatal outcome was higher in groups 3 (3.3%) and 4 (4.2%), compared with groups 1 (1.0%) and 2 (0.9%) but the difference did not reach statistical significance (P = .09). These results were also observed when values were adjusted for maternal characteristics.

CONCLUSIONS

In CH adverse perinatal outcomes are worse in women who are known to have CH and need antihypertensives in the first trimester of pregnancy. Women with newly diagnosed CH in the first trimester have similar outcomes to those with known CH who have antihypertensive treatment discontinued.

Metformin use in obese mothers is associated with improved cardiovascular profile in the offspring

BACKGROUND

Maternal obesity increases the risk for pregnancy complications and adverse neonatal outcome and has been associated with long-lasting adverse effects in the offspring, including increased body fat mass, insulin resistance, and increased risk for premature cardiovascular disease. Lifestyle interventions in pregnancy have produced no or modest effects in the reduction of adverse pregnancy outcomes in obese mothers. The Metformin in Obese Pregnant Women trial was associated with reduced adverse pregnancy outcomes and had no effect on birthweight. However, the long-term implications of metformin on the health of offspring remain unknown.

OBJECTIVE

The purpose of this study was to assess whether prenatal exposure to metformin can improve the cardiovascular profile and body composition in the offspring of obese mothers.

STUDY DESIGN

In 151 children from the Metformin in Obese Pregnant Women trial, body composition, peripheral blood pressure, and arterial pulse wave velocity were measured. Central hemodynamics (central blood pressure and augmentation index) were estimated with the use of an oscillometric device. Left ventricular cardiac function and structure were assessed by echocardiography.

RESULTS

Children were 3.9±1.0 years old, and 77 of them had been exposed to metformin prenatally. There was no significant difference in peripheral blood pressure, arterial stiffness, and body composition apart from gluteal and tricep circumferences, which were lower in the metformin group (P<.05). The metformin group, compared with the placebo group, had lower central hemodynamics (mean adjusted decrease, -0.707 mm Hg for aortic systolic blood pressure, -1.65 mm Hg for aortic pulse pressure, and -2.68% for augmentation index; P<.05 for all) and lower left ventricular diastolic function (adjusted difference in left atrial area, -0.525 cm², in isovolumic relaxation time, -0.324 msec, and in pulmonary venous systolic wave, 2.97 cm/s; P<.05 for all). There were no significant differences in metabolic profile between the groups.

CONCLUSION

Children of obese mothers who were exposed prenatally to metformin, compared with those who were exposed to placebo, had lower central hemodynamic and cardiac diastolic indices. These results suggest that the administration of metformin in obese pregnant women potentially may have a beneficial cardiovascular effect for their offspring.

Metformin in Pregnancy Study (MiPS): protocol for a systematic review with individual patient data meta-analysis

INTRODUCTION

Gestational diabetes mellitus (GDM) is a common disorder of pregnancy and contributes to adverse pregnancy outcomes. Metformin is often used for the prevention and management of GDM; however, its use in pregnancy continues to be debated. The Metformin in Pregnancy Study aims to use individual patient data (IPD) meta-analysis to clarify the efficacy and safety of metformin use in pregnancy and to identify relevant knowledge gaps.

METHODS AND ANALYSIS

MEDLINE, EMBASE and all Evidence-Based Medicine will be systematically searched for randomised controlled trials (RCT) testing the efficacy of metformin compared with placebo, usual care or other interventions in pregnant women. Two independent reviewers will assess eligibility using prespecified criteria and will conduct data extraction and quality appraisal of eligible studies. Authors of included trials will be contacted and asked to contribute IPD. Primary outcomes include maternal glycaemic parameters and GDM, as well as neonatal hypoglycaemia, anthropometry and gestational age at delivery. Other adverse maternal, birth and neonatal outcomes will be assessed as secondary outcomes. IPD from these RCTs will be harmonised and a two-step meta-analytic approach will be used to determine the efficacy and safety of metformin in pregnancy, with a priori adjustment for covariates and subgroups to examine effect moderators of treatment outcomes. Sensitivity analyses will assess heterogeneity, risk of bias and the impact of trials which have not provided IPD.

ETHICS AND DISSEMINATION

All IPD will be deidentified and studies contributing IPD will have ethical approval from their respective local ethics committees. This study will provide robust evidence regarding the efficacy and safety of metformin use in pregnancy, and may identify subgroups of patients who may benefit most from this treatment modality. Findings will be published in peer-reviewed journals and disseminated at scientific meetings, providing much needed evidence to inform clinical and public health actions in this area.

Peri-operative management of percutaneous fetoscopic spina-bifida repair: a descriptive review of five cases from the United Kingdom, with focus on anaesthetic implications

We present a case-based review of the first five percutaneous fetoscopic in-utero spina bifida repair procedures undertaken in the UK. Our focus is on implications of anaesthesia and analgesia for the mother and fetus, provision of uterine relaxation and fetal immobilisation while providing conditions conducive to surgical access. Minimising risks for fetal acidosis, placental and fetal hypoperfusion, maternal and fetal sepsis and maternal fluid overload were the foremost priorities. We discuss optimisation strategies undertaken to ensure fetal and maternal well-being under anaesthesia, shortcomings in the current approach, and possible directions for improvement.

Clinical validation of a novel automated cell-free DNA screening assay for trisomies 21, 13, and 18 in maternal plasma

Objective

To evaluate clinical performance of a new automated cell‐free (cf)DNA assay in maternal plasma screening for trisomies 21, 18, and 13, and to determine fetal sex.

Method

Maternal plasma samples from 1200 singleton pregnancies were analyzed with a new non–sequencing cfDNA method, which is based on imaging and counting specific chromosome targets. Reference outcomes were determined by either cytogenetic testing, of amniotic fluid or chorionic villi, or clinical examination of neonates.

Results

The samples examined included 158 fetal aneuploidies. Sensitivity was 100% (112/112) for trisomy 21, 89% (32/36) for trisomy 18, and 100% (10/10) for trisomy 13. The respective specificities were 100%, 99.5%, and 99.9%. There were five first pass failures (0.4%), all in unaffected pregnancies. Sex classification was performed on 979 of the samples and 99.6% (975/979) provided a concordant result.

Conclusion

The new automated cfDNA assay has high sensitivity and specificity for trisomies 21, 18, and 13 and accurate classification of fetal sex, while maintaining a low failure rate. The study demonstrated that cfDNA testing can be simplified and automated to reduce cost and thereby enabling wider population‐based screening.

What is already known about this topic?

Maternal plasma cell‐free (cf)DNA analysis with next-generation sequencing has a high sensitivity and specificity for fetal trisomy 21 and other common autosomal trisomies.

A new amplification-free, nonsequencing, and targeted cfDNA assay has been developed.

Proof‐of‐principle analysis found the new assay has promising results in screening for trisomy 21.

What does this study add?

The new assay has high sensitivity and specificity for trisomies 21, 18, and 13 in singleton pregnancies.

It can accurately determine fetal sex.

It is suitable for use in biochemical screening laboratories since it is highly automated and does not require specialized personnel.

PlGF isoform 3 in maternal serum and placental tissue

OBJECTIVES

Four isoforms originating from alternative splicing of PGF gene have been reported for placental growth factor (PlGF). Main PlGF isoforms 1 and 2 have been associated with screening and diagnosis of pre-eclampsia (PE). Despite of the vast amount of research around PlGF in PE, protein levels of isoforms PlGF-3 and -4 have not been reported in human serum samples.

STUDY DESIGN

In this study a PlGF-3 specific DELFIA research immunoassay based on a custom recombinant Fab binder was developed and characterized. Serum levels of a third PlGF isoform during pregnancy were determined and screening performance of PlGF-3 for PE and small for gestational age (SGA) was investigated.

MAIN OUTCOME MEASURES

Levels of serum and placental tissue PlGF 3 and predictive power of PlGF-3 for Pre-eclampsia and SGA.

RESULTS

PlGF-3 was below the detection limit of 1.6 pg/mL in most of the serum samples collected during pregnancy. Detected protein levels of PlGF-3 were not associated to be predictive for PE or SGA. However, measurable, and relatively higher amounts of PlGF-3 was extracted from placental tissue samples.

CONCLUSION

Data obtained indicates that very low amounts of PlGF-3 is present in blood but significantly higher amounts of protein is present in placental tissue where it is prominently associated with cellular membranes.

Does first-trimester serum pregnancy-associated plasma protein A differ in pregnant women with sickle cell disease?

OBJECTIVE

To assess whether levels of first-trimester pregnancy-associated plasma protein A (PAPP-A) differ between women with and without sickle cell disease (SCD).

METHODS

Retrospective study of 101 singleton pregnancies in women with SCD (including 55 with genotype HbSS, 37 with genotype HbSC, and nine with other genotypes). Measured levels of PAPP-A were converted to multiple of the median (MoM) values corrected for gestational age and maternal characteristics. Median PAPP-A MoM in the SCD group was compared with that of 1010 controls.

RESULTS

In the SCD group median, PAPP-A MoM was lower than in the non-SCD group (0.72, interquartile range [IQR] = 0.54-1.14 versus 1.09, IQR = 0.74-1.49; P < .001). Within the SCD group median PAPP-A MoM was lower for those with genotype HbSS than HbSC (0.62, IQR = 0.44-1.14 versus 0.94, IQR = 0.72-1.25; .006). In 7.3% (4/55) of the HbSS group, there was stillbirth, and in these cases, PAPP-A was less than or equal to 0.5 MoM; in the control group, the incidence of stillbirth was lower (1%; P < .001). In HbSS disease, the incidence of small for gestational age (SGA) neonates was increased.

CONCLUSION

Pregnancies with HbSS have lower PAPP-A MoM values and higher incidence of stillbirth and birth of SGA neonates than in non-SCD controls.

A Multimodality Navigation System for Endoscopic Fetal Surgery: A Phantom Case Study for Congenital Diaphragmatic Hernia

This article presents a multi-modality tracking and navigation system achieved by merging optical tracking and ultrasound imaging into a novel navigation software to help in surgical pre-planning and real-time target setting and guidance. Fetal surgeries require extensive experience in coordination of hand-eye-ultrasound-surgical equipment, knowledge, and precise assessment of relative anatomy. While there are navigation systems available for similar constrained working spaces in arthroscopic and cardiovascular procedures, fetal minimally invasive surgery does not yet have a dedicated navigation platform capable of supporting robotic instruments that can be adapted to the set of unique procedures. This article discusses the testing of the novel multi-modality navigation system in a phantom environment developed for this purpose. The outcomes suggest that the subjects demonstrated an increase in average reaching accuracy by about 60% and an overall reduction in time taken by 33.6%. They also showed higher levels of confidence in reaching the targets, which was visualised from the pattern of trajectory of movements during the procedure. To evaluate the navigation system, a phantom surgical environment was found necessary. Therefore, the article also discusses the details of the development of a fetal phantom environment for congenital diaphragmatic hernia for surgical testing, evaluation, and training. A surgical procedure was conducted on the phantom using the proposed tracking navigation system and using only ultrasound.

A retrospective multicenter study of the natural history of fetal ovarian cysts

AIM

We investigated the natural history of fetal ovarian cysts to estimate the risk of torsion according to size.

METHODS

Cases were identified from 1/1/2000 until 1/1/2015. Data were collected pre- and postnatally on cyst size and sonographic features until an outcome of surgery, torsion, or resolution. Fisher's exact test for categorical data and logistic regression for continuous data were used to test the significance of size on torsion; P value <0.05 was considered significant.

RESULTS

37 patients with unilateral ovarian cysts were included. 12 (32%) resolved spontaneously prenatally, 14 (38%) resolved spontaneously postnatally, 5 (14%) underwent surgery postnatally and 6 (16%) cases underwent torsion. Rate of torsion increased with size from 0% (n=0) in cysts ≤20mm to 33% (n=2) in cysts >50mm; however, the overall trend failed to reach statistical significance (P=0.1). Cysts of 0-40mm had a significantly higher rate of spontaneous resolution (90% vs. 44% in >40mm, P=0.003), but the rate of torsion was not significantly different (10% in 0-40mm vs. 25% in >40mm, P=0.26). The median time to postnatal resolution was 10 (5-27) weeks in those treated conservatively.

CONCLUSION

Cysts >40mm are significantly less likely to resolve spontaneously; however torsion showed no significant correlation with cyst size. No complications were observed in cysts <20mm.

LEVEL OF EVIDENCE

IV, case series with no comparison group.

Factors Associated with Placental Vascularization Measured by 3D Power Doppler Ultrasonographic Sphere Biopsy between 11 and 14 Weeks of Gestation

OBJECTIVE

Preeclampsia is associated with placental vascularization disorders. Ultrasonographic sphere biopsy (USSB) of the placenta can estimate the vascularization of the placenta and potentially the risk of preeclampsia. We aimed to explore the factors related to placental vascularization measured with USSB in the first trimester.

STUDY DESIGN

A prospective cohort was conducted in women recruited at 11 to 14 weeks. Three-dimensional acquisition of the placenta with power Doppler was undertaken along with crown-rump length (CRL). Using USSB of the full placental thickness at its center, vascularization index, flow index, and vascular flow index were measured. Pearson's correlation coefficients and multivariate linear regression were used to correlate the vascularization indices with CRL and maternal characteristics.

RESULTS

A total of 5,612 women were recruited at a mean gestational age of 12.8 ± 0.6 weeks. We observed that vascularization indices increase with CRL. After adjustment, we observed that maternal age, ethnicity other than Caucasian, and body mass index were associated with lower vascularization indices, while diabetes, smoking, and assisted reproduction technology were not. We observed that parous women without history of preeclampsia had greater vascularization indices compared with nulliparous women.

CONCLUSION

Placental vascularization indices assessed by USSB fluctuate with gestational age, ethnicity, maternal age, body mass index, and previous pregnancy history.

Fetoscopic endoluminal tracheal occlusion and reestablishment of fetal airways for congenital diaphragmatic hernia

Background

Congenital diaphragmatic hernia (CDH) is a congenital anomaly with high mortality and morbidity mainly due to pulmonary hypoplasia and hypertension. Temporary fetal tracheal occlusion to promote prenatal lung growth may improve survival. Entrapment of lung fluid stretches the airways, leading to lung growth.

Methods

Fetal endoluminal tracheal occlusion (FETO) is performed by percutaneous sono-endoscopic insertion of a balloon developed for interventional radiology. Reversal of the occlusion to induce lung maturation can be performed by fetoscopy, transabdominal puncture, tracheoscopy, or by postnatal removal if all else fails.

Results

FETO and balloon removal have been shown safe in experienced hands. This paper deals with the technical aspects of balloon insertion and removal. While FETO is invasive, it has minimal maternal risks yet can cause preterm birth potentially offsetting its beneficial effects.

Conclusion

For left-sided severe and moderate CDH, the procedure is considered investigational and is currently being evaluated in a global randomized clinical trial (https://www.totaltrial.eu/). The procedure can be clinically offered to fetuses with severe right-sided CDH.

Subarachnoid space diameter in chromosomally abnormal fetuses at 11-13 weeks' gestation

OBJECTIVES

To examine the subarachnoid space diameters in chromosomally abnormal fetuses at 11-13 weeks' gestation.

METHODS

Stored three-dimensional (3D) ultrasound volumes of the fetal head at 11-13 weeks' gestation from 407 euploid and 88 chromosomally abnormal fetuses (trisomy 21, n = 40; trisomy 18, n = 19; trisomy 13, n = 7; triploidy, n = 14; Turner syndrome, n = 8) were analyzed. The subarachnoid space diameters, measured in the sagittal and transverse planes of the fetal head, in relation to biparietal diameter (BPD) in each group of aneuploidies was compared to that in euploid fetuses. A total of 20 head volumes were randomly selected and all the measurements were recorded by two different observers to examine the interobserver variability in measurements.

RESULTS

In euploid fetuses, the anteroposterior, transverse and sagittal diameters of the subarachnoid space increased with BPD. The median of the observed to expected diameters for BPD were significantly increased in triploidy and trisomy 13 but were not significantly altered in trisomies 21 and 18 or Turner syndrome. In triploidy, the subarachnoid space diameters for BPD were above the 95th centile of euploid fetuses in 92.9% (13 of 14) cases. The intraclass reliability or agreement was excellent for all three subarachnoid space diameters.

CONCLUSION

Most fetuses with triploidy at 11-13 weeks' gestation demonstrate increased subarachnoid space diameters.

Peripheral blood cell microRNA quantification during the first trimester predicts preeclampsia: Proof of concept

Objective

We investigated the capacity of microRNAs isolated from peripheral blood buffy coat collected late during the first trimester to predict preeclampsia.

Study design

The cohort study comprised 48 pregnant women with the following pregnancy outcomes: 8 preeclampsia and 40 with normal delivery outcomes. Quantitative rtPCR was performed on a panel of 30 microRNAs from buffy coat samples drawn at a mean of 12.7±0.5 weeks gestation. MicroRNA Risk Scores were calculated and AUC-ROC calculations derived.

Results

The AUC-ROC for preeclampsia risk was 0.91 (p<0.0001). When women with normal delivery and high-risk background (those with SLE/APS, chronic hypertension and/or Type 2 Diabetes) were compared to women who developed preeclampsia but with a normal risk background (without these mentioned risk factors), preeclampsia was still predicted with an AUC-ROC of 0.92 (p<0.0001).

Conclusion

MicroRNA quantification of peripheral immune cell microRNA provides sensitive and specific prediction of preeclampsia in the first trimester of pregnant women. With this study, we extend the range during which disorders of the placental bed may be predicted from early to the end of the first trimester. This study confirms that buffy coat may be used as a sample preparation.

FETAL GOITRE IN MATERNAL GRAVES' DISEASE

Fetal goitre is found in about 1 in 5,000 births, usually in association with maternal Graves' disease, due to transplacental passage of high levels of thyroid stimulating antibodies or of anti-thyroid drugs. A goitre can cause complications attributable to its size and to the associated thyroid dysfunction. Fetal ultrasound examination allows easy recognition of the goitre but is not reliable in distinguishing between fetal hypo- and hyperthyroidism. Assessment of the maternal condition and, in some cases, cordocentesis provide adequate diagnosis of the fetal thyroid function. First-line treatment consists of adjusting the dose of maternal anti-thyroid drugs. Delivery is aimed at term. In cases with large goitres, caesarean-section is indicated.

Evaluation of Abdominal Fetal Electrocardiography in Early Intrauterine Growth Restriction

Objectives: This descriptive study was performed to evaluate the capability of a non-invasive transabdominal electrocardiographic system to extract clear fetal electrocardiographic (FECG) measurements from intrauterine growth restricted (IUGR) fetuses and to assess whether abdominal FECG parameters can be developed as markers for evaluating the fetal cardiac status in IUGR.

Methods: Transabdominal FECG was attempted in 20 controls and 15 IUGR singleton pregnancies at 20+0−33+6 weeks gestation. Standard ECG parameters were compared between the study groups and evaluated for their correlation. Accuracy for the prediction of IUGR by cut off values of the different FECG parameters was also determined.

Results: Clear P-QRST complexes were recognized in all cases. In the IUGR fetuses, the QT and QTc intervals were significantly prolonged (p = 0.017 and p = 0.002, respectively). There was no correlation between ECG parameters and Doppler or other indices to predict IUGR. The generation of cut off values for detecting IUGR showed increasing sensitivities but decreasing specificities with the prolongation of ECG parameters.

Conclusion: The study of fetal electrocardiophysiology is now feasible through a non-invasive transabdominal route. This study confirms the potential of FECG as a clinical screening tool to aid diagnosis and management of fetuses after key limitations are addressed. In the case of IUGR, both QT and QTc intervals were significantly prolonged and thus validate earlier study findings where both these parameters were found to be markers of diastolic dysfunction. This research is a useful prelude to a test of accuracy and Receiver Operating Characteristics (ROC) study.

Maternal autoimmune disorders and fetal defects

Maternal autoantibodies can cross the placenta and cause fetal damage. This article summarizes the development and management of fetal thyroid goiter in response to maternal Graves' disease and/or its treatment with antithyroid medication, fetal heart block due to maternal anti-Ro and anti-La antibodies, fetal athrogryposis multiplex congenita in association with maternal myasthenia gravis and fetal brain hemorrhage due to maternal autoimmune thrombocytopenia.

Gestational disruptions in metabolic rhythmicity of the liver, muscle, and placenta affect fetal size

Maternal metabolic adaptations are essential for successful pregnancy outcomes. We investigated how metabolic gestational processes are coordinated, whether there is a functional link with internal clocks, and whether disruptions are related to metabolic abnormalities in pregnancy, by studying day/night metabolic pathways in murine models and samples from pregnant women with normally grown and large-for-gestational age infants. In early mouse pregnancy, expression of hepatic lipogenic genes was up-regulated and uncoupled from the hepatic clock. In late mouse pregnancy, rhythmicity of energy metabolism-related genes in the muscle followed the patterns of internal clock genes in this tissue, and coincided with enhanced lipid transporter expression in the fetoplacental unit. Diurnal triglyceride patterns were disrupted in human placentas from pregnancies with large-for-gestational age infants and this overlapped with an increase in BMAL1 expression. Metabolic adaptations in early pregnancy are uncoupled from the circadian clock, whereas in late pregnancy, energy availability is mediated by coordinated muscle-placenta metabolic adjustments linked to internal clocks. Placental triglyceride oscillations in the third trimester of human pregnancy are lost in large-for-gestational age infants and may be regulated by BMAL1. In summary, disruptions in metabolic and circadian rhythmicity are associated with increased fetal size, with implications for the pathogenesis of macrosomia.-Papacleovoulou, G., Nikolova, V., Oduwole, O., Chambers, J., Vazquez-Lopez, M., Jansen, E., Nicolaides, K., Parker, M., Williamson, C. Gestational disruptions in metabolic rhythmicity of the liver, muscle, and placenta affect fetal size.

Clinical performance of non-invasive prenatal testing (NIPT) using targeted cell-free DNA analysis in maternal plasma with microarrays or next generation sequencing (NGS) is consistent across multiple controlled clinical studies

Objective

To evaluate the clinical performance of non‐invasive prenatal testing for trisomy 21, 18, and 13 using targeted cell‐free DNA (cfDNA) analysis.

Methods

Targeted cfDNA analysis using DANSR™ and FORTE™ with microarray quantitation was used to evaluate the risk of trisomy 21, 18, and 13 in blinded samples from 799 singleton, twin, natural, and IVF pregnancies. Subjects either had fetal chromosome evaluation by karyotype, FISH, QF‐PCR, or karyotype for newborns with suspected aneuploidy at birth. The results of targeted cfDNA analysis were compared to clinical genetic testing outcomes to assess clinical performance.

Results

Targeted cfDNA analysis with microarray quantification identified 107/108 trisomy 21 cases (99.1%), 29/30 trisomy 18 cases (96.7%), and 12/12 trisomy 13 cases (100%). The specificity was 100% for all three trisomies. Combining this data with all published clinical performance studies using DANSR/FORTE methodology for greater than 23 000 pregnancies, the sensitivity of targeted cfDNA analysis was calculated to be greater than 99% for trisomy 21, 97% for trisomy 18, and 94% for trisomy 13. Specificity for each trisomy was greater than 99.9%.

Conclusion

Targeted cfDNA analysis demonstrates consistently high sensitivity and extremely low false positive rates for common autosomal trisomies in pregnancy across quantitation platforms. © 2015 Ariosa Diagnostics Inc. Prenatal Diagnosis published by John Wiley & Sons, Ltd.

What's already known about this topic?

NIPT using targeted cfDNA analysis with NGS has high sensitivity and specificity for fetal trisomy 21 and other autosomal trisomies.

What does this study add?

This study establishes the high sensitivity and specificity of NIPT using targeted cfDNA analysis with a microarray quantitation platform, and demonstrates that clinical performance is based on the targeted cfDNA analysis method rather than the quantitation method, as the performance using microarray is comparable with performance from previous NGS studies.

Is variation in copy number of the human beta defensin gene cluster associated with preterm birth?

BACKGROUND

Increased expression of antimicrobial peptides including human beta defensins (HBD) has been reported in the amniotic fluid and vaginal secretions of women who deliver preterm. We have previously shown that these women have increased first trimester serum HBD2. The gene encoding HBD2, DEFB4A, is part of a defensin beta (DEFB) cluster on chromosome 8 that is variable in copy number. Increased serum HBD2 is associated with increased DEFB copy number. We aimed to test the hypothesis that variation in DEFB copy number is associated with preterm birth.

METHODS

In a retrospective, case-control study, genomic DNA and serum were extracted from blood collected from white European women at 11-13 weeks' gestation attending King's College Hospital between March 1, 2006, and Sept 30, 2010. DEFB copy number was determined by paralogue ratio test. Serum HBD2 concentration was measured by ELISA. Data were analysed with Pearson correlation (Excel, version 2010) and binary logistic regression (SPSS, version 20).

FINDINGS

Cases were 102 women who either delivered preterm in the index pregnancy or had a history of preterm delivery. Controls were 152 women who had had at least one previous term delivery and delivered at term in the index pregnancy; they had no history of preterm birth. Modal copy number was 4 (range 2-7). Serum was available from 140 women (30 cases, 54 controls, 56 not included in the genetic association study). Median HBD2 concentration was 761·5 pg/mL (IQR 449·6-1232·0). There was no association between DEFB copy number and preterm birth, nor was there a correlation between copy number and serum HBD2 concentration.

INTERPRETATION

Although variation in HBD2 protein expression in the first trimester might be useful to predict risk of preterm birth, we found no association between DEFB copy number and preterm birth. Nor did we find a correlation between DEFB copy number and serum HBD2 expression in the first trimester of pregnancy; this might be due to variation in regulatory sequences-some of which are progesterone and oestrogen sensitive-between individual copies.

FUNDING

Wellcome Trust, Wellbeing of Women.

Respiratory muscle strength in healthy infants and those with surgically correctable anomalies

Assessment of respiratory muscle strength provides important diagnostic and prognostic information. Normative data in healthy, term infants is, however, limited. Surgically correctable birth defects, congenital diaphragmatic hernia (CDH) and abdominal wall defects (AWD), commonly have impaired diaphragm function. The study aims were to obtain normative data for respiratory muscle strength in healthy, term born infants at birth and at 6 weeks postnatal age (PNA) and to investigate the influence of growth and maturation on inspiratory muscle strength in CDH/AWD infants. Maximal inspiratory (cPimax) and expiratory (cPemax) pressures during crying were measured at birth in 67 healthy, term born infants (mean (SD) gestational age (GA) 39.4 (1.7) weeks) and reassessed in 27 at 6 weeks PNA. cPimax and functional residual capacity (FRC) (22.3 (4.2) ml/kg) were also measured in 23 infants with AWD/CDH (mean (SD) GA 36.9 (2.1) weeks) and reassessed in 16 at median (range) 6.5 (1.5-15) months PNA. In healthy infants, mean (SD) cPimax was 88.8 (19.33) cmH2 O and cPemax 61.8 (13.5) cmH2 O at birth, increasing significantly at followup to 100.9 (15.2) cmH2 O (P < 0.05) and 82.6 (19.4) cmH2 O (P < 0.001) respectively. Mean (SD) cPimax was significantly lower (47.5 (22.4) cmH2 O, P < 0.0001) in AWD/CDH infants compared to healthy infants at birth but had increased significantly to 88.1 (27.6) cmH2 O (P < 0.0001) at followup which correlated significantly with increases in FRC (r(2)  = 0.33, P = 0.0263). Infants with AWD and CDH have significantly reduced inspiratory muscle strength compared to healthy term born infants but strength increases markedly in early life.

Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial

Congenital diaphragmatic hernia (CDH) may be isolated or associated with other structural anomalies, the latter with poor prognosis. The defect allows viscera to herniate through the defect into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. When isolated, survival chances can be predicted by antenatal measurement of lung size and liver herniation. Chromosomal microarrays and exome sequencing contribute to understanding genetic factors underlying isolated CDH. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion (FETO) under local anesthesia. The Tracheal Occlusion To Accelerate Lung growth trial (www.totaltrial.eu) is an international randomized trial investigating the role of fetal therapy for severe and moderate pulmonary hypoplasia. Despite an apparent increase in survival following FETO, the search for lesser invasive and more potent prenatal interventions must continue.

A case-control study of maternal periconceptual and pregnancy recreational drug use and fetal malformation using hair analysis

Objective

Maternal recreational drug use may be associated with the development of fetal malformations such as gastroschisis, brain and limb defects, the aetiology due to vascular disruption during organogenesis. Using forensic hair analysis we reported evidence of recreational drug use in 18% of women with a fetal gastroschisis. Here we investigate this association in a variety of fetal malformations using the same method.

Methods

In a multi-centre study, women with normal pregnancies (controls) and those with fetal abnormalities (cases) gave informed consent for hair analysis for recreational drug metabolites using mass spectrometry. Hair samples cut at the root were tested in sections corresponding to 3 month time periods (pre and periconceptual period).

Results

Women whose fetus had gastroschisis, compared to women with a normal control fetus, were younger (mean age 23.78±SD4.79 years, 18–37 vs 29.79±SD6 years, 18–42, p = 0.00001), were more likely to have evidence of recreational drug use (15, 25.4% vs 21, 13%, OR2.27, 95^thCI 1.08–4.78, p = 0.028), and were less likely to report periconceptual folic acid use (31, 53.4% vs 124, 77.5%, OR0.33, 95^thCI 0.18–0.63, p = 0.001). Age-matched normal control women were no less likely to test positive for recreational drugs than women whose fetus had gastroschisis. After accounting for all significant factors, only young maternal age remained significantly associated with gastroschisis. Women with a fetus affected by a non-neural tube central nervous system (CNS) anomaly were more likely to test positive for recreational drugs when compared to women whose fetus was normal (7, 35% vs 21, 13%, OR3.59, 95^th CI1.20–10.02, p = 0.01).

Conclusions

We demonstrate a significant association between non neural tube CNS anomalies and recreational drug use in the periconceptual period, first or second trimesters, but we cannot confirm this association with gastroschisis. We confirm the association of gastroschisis with young maternal age.

In vivo assessment of the biomechanical properties of the uterine cervix in pregnancy

Measuring the stiffness of the cervix might be useful in the prediction of preterm delivery or successful induction of labor. For that purpose, a variety of methods for quantitative determination of physical properties of the pregnant cervix have been developed. Herein, we review studies on the clinical application of these new techniques. They are based on the quantification of mechanical, optical, or electrical properties associated with increased hydration and loss of organization in collagen structure. Quasi-static elastography determines relative values of stiffness; hence, it can identify differences in deformability. Quasi-static elastography unfortunately cannot quantify in absolute terms the stiffness of the cervix. Also, the current clinical studies did not demonstrate the ability to predict the time point of delivery. In contrast, measurement of maximum deformability of the cervix (e.g. quantified with the cervical consistency index) provided meaningful results, showing an increase in compliance with gestational age. These findings are consistent with aspiration measurements on the pregnant ectocervix, indicating a progressive decrease of stiffness along gestation. Cervical consistency index and aspiration measurements therefore represent promising techniques for quantitative assessment of the biomechanical properties of the cervix.

Is early delivery beneficial in gastroschisis?

PURPOSE

Gastroschisis neonates have delayed time to full enteral feeds (ENT), possibly due to bowel exposure to amniotic fluid. We investigated whether delivery at <37weeks improves neonatal outcomes of gastroschisis and impact of intra/extra-abdominal bowel dilatation (IABD/EABD).

METHODS

A retrospective review of gastroschisis (1992-2012) linked fetal/neonatal data at 2 tertiary referral centers was performed. Primary outcomes were ENT and length of hospital stay (LOS). Data (median [range]) were analyzed using parametric/non-parametric tests, positive/negative predictive values, and regression analysis.

RESULTS

Two hundred forty-six patients were included. Thirty-two were complex (atresia/necrosis/perforation/stenosis). ENT (p<0.0001) and LOS (p<0.0001) were reduced with increasing gestational age. IABD persisted to last scan in 92 patients, 68 (74%) simple (intact/uncompromised bowel), 24 (26%) complex. IABD or EABD diameter in complex patients was not significantly greater than simple gastroschisis. Combined IABD/EABD was present in 22 patients (14 simple, 8 complex). When present at <30weeks, the positive predictive value for complex gastroschisis was 75%. Two patients with necrosis and one atresia had IABD and collapsed extra-abdominal bowel from <30weeks.

CONCLUSION

Early delivery is associated with prolonged ENT/LOS, suggesting elective delivery at <37weeks is not beneficial. Combined IABD/EABD or IABD/collapsed extra-abdominal bowel is suggestive of complex gastroschisis.

Tracheomegaly in infants with severe congenital diaphragmatic hernia treated with fetal endoluminal tracheal occlusion

OBJECTIVE

To measure and evaluate the effects of tracheal dimensions on survival and ventilation in a large series of infants with congenital diaphragmatic hernia (CDH) treated antenatally with fetal endoluminal tracheal occlusion (FETO).

STUDY DESIGN

Tracheal dimensions on chest radiograph (CR) were measured by 2 blinded radiologists. Survival, day 1 best oxygenation index and duration of ventilation, continuous positive airway pressure, and hospital stay were recorded. Survivors with a minimum 12-month follow-up were longitudinally compared for incidence of gastroesophageal reflux, chest infections, chest deformities, and hernia recurrence.

RESULTS

Seventy infants with CDH (41 who underwent FETO) were treated between 2004 and 2010. Hernia repair was performed in 26 infants without FETO (8 with patch repair) and 35 infants with FETO (26 with patch repair; P = .0015). Infants with FETO had a wider trachea than those without FETO at T1 (P < .0001) and between T1 and the carina (P < .0001). Tracheal diameter was similar in survivors and nonsurvivors in the FETO group. Tracheal size was not correlated with day 1 best oxygenation index in the FETO group (R2 = 0.17) or the non-FETO group (R2 = 0.07). There were no between-group differences in duration of mechanical ventilation (P = .30), continuous positive airway pressure (P = .20), or hospital stay (P = .30). In the longitudinal study, tracheal widths were larger on the last CR than on preoperative CR in patients without FETO (T1, P = .02; widest point, P = .001; carina, P = .0001), and for patients with FETO at the widest point (P < .0001) and at the carina (P < .0001), but not at T1 (P = .12). There were no differences in clinical variables between the FETO and non-FETO groups.

CONCLUSION

FETO has a significant impact on tracheal size of infants with CDH; however, tracheal size does not affect survival or the requirement for early respiratory support.

Metabolic profiles of adult Wistar rats in relation to prenatal and postnatal nutritional manipulation: the role of birthweight

OBJECTIVE

This experimental study aimed to prospectively investigate the impact of combinations of prenatal and postnatal food manipulations on the metabolic profile of adult offspring.

DESIGN

On day 12 of gestation, 67 timed pregnant rats were randomized into three nutritional groups, control: standard laboratory food; starved: 50% food restricted, FR; fat-fed: fat-rich diet, FF. Seven hundred and seventy-four (774) pups were born on day 21 and culled to 8 (4 males, 4 females) per litter to normalize rearing. Rats born to starved mothers were later subdivided, based on birthweight (BiW), into fetal growth restricted (FGR) and non-FGR. The pups were then weaned to the diet of their fostered mother until one year old. Thus, 12 groups were studied: 1.

CONTROL/CONTROL

14 rats, 2.

CONTROL/FR

12 rats, 3.

CONTROL/FF

15 rats, 4.

FGR/CONTROL

16 rats, 5.

FGR/FR

10 rats, 6.

FGR/FF

15 rats, 7. non-

FGR/CONTROL

10 rats, 8. non-

FGR/FR

17 rats, 9. non-

FGR/FF

10 rats, 10.

FF/CONTROL

15 rats, 11.

FF/FR

14 rats, and 12.

FF/FF

13 rats. During sacrifice, body weight (BW) and liver weight (LW) were measured (expressed in grams) and concentrations of serum glucose, triglycerides, HDL and NEFA were determined.

RESULTS

Postnatal food restriction, compared to control diet significantly reduced BW (p=0.004, p=0.036, p<0.001, p=0.008) and LW (p<0.001) in all study groups. Postnatal control diet significantly increased BW in non-FGR compared to FGR rats (p=0.027). No significant differences were detected in biochemical parameters (excluding NEFA) between FGR and non-FGR, regardless of the postnatal diet.

CONCLUSIONS

Interaction between prenatal and postnatal nutrition produces distinct metabolic profiles. Apart from BiW, prenatal diet had an important impact on the metabolic profile of the adult offspring, implying that intrauterine events should be considered in the estimation of the metabolic risk of an individual, independently of BiW.

Clinical Perspective of Cell-Free DNA Testing for Fetal Aneuploidies

Cell-free DNA testing in maternal blood provides the most effective method of screening for trisomy 21, with a reported detection rate of 99% and a false positive rate of less than 0.1%. After many years of research, this method is now commercially available and is carried out in an increasing number of patients, and there is an expanding number of conditions that can be screened for. However, the application of these methods in clinical practice requires a careful analysis. Current first-trimester screening strategies are based on a complex combination of tests, aiming at detecting fetal defects and predicting the risk of main pregnancy complications. It is therefore necessary to define the optimal way of combining cell-free DNA testing with current first-trimester screening methods. In this concise review we describe the basis of cell-free DNA testing and discuss the potential approaches for its implementation in combination with current tests in the first trimester.

A comprehensive analysis of common genetic variation around six candidate loci for intrahepatic cholestasis of pregnancy

OBJECTIVES

Intrahepatic cholestasis of pregnancy (ICP) has a complex etiology with a significant genetic component. Heterozygous mutations of canalicular transporters occur in a subset of ICP cases and a population susceptibility allele (p.444A) has been identified in ABCB11. We sought to expand our knowledge of the detailed genetic contribution to ICP by investigation of common variation around candidate loci with biological plausibility for a role in ICP (ABCB4, ABCB11, ABCC2, ATP8B1, NR1H4, and FGF19).

METHODS

ICP patients (n=563) of white western European origin and controls (n=642) were analyzed in a case-control design. Single-nucleotide polymorphism (SNP) markers (n=83) were selected from the HapMap data set (Tagger, Haploview 4.1 (build 22)). Genotyping was performed by allelic discrimination assay on a robotic platform. Following quality control, SNP data were analyzed by Armitage's trend test.

RESULTS

Cochran-Armitage trend testing identified six SNPs in ABCB11 together with six SNPs in ABCB4 that showed significant evidence of association. The minimum Bonferroni corrected P value for trend testing ABCB11 was 5.81×10(-4) (rs3815676) and for ABCB4 it was 4.6×10(-7)(rs2109505). Conditional analysis of the two clusters of association signals suggested a single signal in ABCB4 but evidence for two independent signals in ABCB11. To confirm these findings, a second study was performed in a further 227 cases, which confirmed and strengthened the original findings.

CONCLUSIONS

Our analysis of a large cohort of ICP cases has identified a key role for common variation around the ABCB4 and ABCB11 loci, identified the core associations, and expanded our knowledge of ICP susceptibility.

Design of a flexible fetoscopy manipulation system for congenital diaphragmatic hernia

Recent advancements in fetal surgery have proven that tracheal occlusion in fetuses with congenital diaphragmatic hernia is an effective way to prevent the occurrence of pulmonary hypoplasia. A novel flexible fetoscope with a parallel mechanism structure of a thumbstick to carry on the fetal tracheal balloon occlusion by the targeting and manipulation of the fetal endoscope at a high standard of quick response and dexterity is proposed in this paper. This design is compared with a commercial rigid fetoscope in terms of operation timing and reduced stress to the fetus at neck level. Experiments using a phantom have demonstrated that the flexible fetoscope has a better dexterity and is able to perform stable tracheoscopy and balloon inflation at different levels of the trachea, with the help of a fiberoptic camera.

Outcome of CDH infants following fetoscopic tracheal occlusion - influence of premature delivery

PURPOSE

To evaluate the mortality and morbidity of infants with congenital diaphragmatic hernia who had undergone fetal endoscopic tracheal occlusion (FETO) and whether this was influenced by premature birth.

METHODS

The gestational age at delivery, lung-head ratio (LHR) pre and post FETO, neonatal outcomes, and respiratory, gastro-intestinal, neurological, surgical, and musculoskeletal problems at follow up of consecutive infants who had undergone FETO were determined. Elective reversal of FETO was planned at 34 weeks of gestation.

RESULTS

The survival rate of the 61 FETO infants was 48%, with 84% delivered prematurely. Thirty-one delivered <35 weeks of gestation. Their survival rate was 18%. Twenty-three of 24 infants who had emergency balloon removal were born <35 weeks of gestation. Survival was related to gestational age at delivery (OR 0.55, 95% CI 0.420, 0.77, p<0.001) and the duration of FETO (OR 0.73, 95% CI 0.59, 0.91, p<0.005). Infants born prior to 35 weeks of gestation compared to those born at ≥ 35 weeks required a longer duration of ventilation (median 45 days versus 12 days, p<0.001), and a greater proportion had surgery for gastro-oesophageal reflux (50% versus 9%, p=0.011).

CONCLUSION

These results emphasize the need to reduce premature delivery following FETO.

Metabolomic analysis for first-trimester trisomy 18 detection

OBJECTIVE

The purpose of this study was to determine whether nuclear magnetic resonance-based metabolomic markers in first-trimester maternal serum can detect fetuses with trisomy 18.

STUDY DESIGN

This was a study of pregnancies between 11 weeks and 13 weeks 6 days' gestation. We analyzed 30 cases of trisomy 18 and a total of 114 euploid cases. Nuclear magnetic resonance-based metabolomic analysis was performed. A further analysis was performed that compared 30 cases with trisomy 18 and 30 trisomy 21 (T21) cases.

RESULTS

Metabolomic markers were sensitive for trisomy 18 detection. A combination of 2-hydroxybutyrate, glycerol and maternal age had a 73.3% sensitivity and 96.6% specificity for trisomy 18 detection, with an area under the receiver operating curve: 0.92 (P < .001). Other metabolite markers, which include trimethylamine, were sensitive for distinguishing trisomy 18 from T21 cases.

CONCLUSION

This is the first report of prenatal trisomy 18 detection that has been based on metabolomic analysis. Preliminary results suggest that such markers are sensitive not only for the detection of fetal trisomy 18 but also for distinguishing this aneuploidy from T21.