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Lugthart G, Verweij EJT, Harteveld CL, Tan RNGB, Knapen MFCM, Slaghekke F, Haak MC, Mohseny AB, Smiers FJ. Suppression of Hb Bart's to improve tissue oxygenation and fetal development in homozygous alpha-thalassemia. Am J Hematol 2024. [PMID: 38655712 DOI: 10.1002/ajh.27344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
Intra-uterine reduction of Hb Bart's only reached with exchange transfusions.
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Affiliation(s)
- G Lugthart
- Leiden University Medical Center (LUMC) Willem-Alexander Children's Hospital, Pediatric Hematology and HSCT, Leiden, The Netherlands
| | - E J T Verweij
- Department of Obstetrics and Fetal Therapy, LUMC, Leiden, The Netherlands
| | - C L Harteveld
- Department of Clinical Genetics, LUMC, Leiden, The Netherlands
| | - R N G B Tan
- LUMC Willem-Alexander Children's Hospital, Neonatal Intensive Care Unit, Leiden, The Netherlands
| | - M F C M Knapen
- Department of Obstetrics and Prenatal Medicine, ErasmusMC, Rotterdam, The Netherlands
| | - F Slaghekke
- Department of Obstetrics and Fetal Therapy, LUMC, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics and Fetal Therapy, LUMC, Leiden, The Netherlands
| | - A B Mohseny
- Leiden University Medical Center (LUMC) Willem-Alexander Children's Hospital, Pediatric Hematology and HSCT, Leiden, The Netherlands
| | - F J Smiers
- Leiden University Medical Center (LUMC) Willem-Alexander Children's Hospital, Pediatric Hematology and HSCT, Leiden, The Netherlands
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Noll ATR, Lof FC, Groene SG, Haak MC, Lopriore E, Russo FM, Slaghekke F, Tollenaar LSA, Van der Merwe J, Verweij EJT, Lewi L. Artery-to-vein anastomoses in unequally divided placentas and their association with birthweight discordance. Placenta 2024; 146:58-63. [PMID: 38181521 DOI: 10.1016/j.placenta.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION This study investigated the impact of the shared intertwin circulation in unequally divided monochorionic (MC) placentas on fetal growth. METHODS This retrospective analysis included color-dyed, unequally shared placentas from two tertiary centers. Exclusions included twin-twin transfusion syndrome, twin anemia polycythemia sequence, and lethal anomalies. Measurement of the external diameters and areas of the artery-to-artery (AA), artery-to-vein (AV), and vein-to-vein (VV) anastomoses was performed. The ratio of the shared circulation (AV ratio) was determined by comparing the areas of the summed venous components of shared AV anastomoses to those in the individual AV anastomoses of the smaller placental part. The birth weight ratio/placental ratio (BWR/PR), total AV size areas and net AV transfusion were calculated. Univariable and multivariable linear regressions were performed to assess the relationship between BWR/PR, the AV ratio, the areas of the different anastomoses and cord insertion discordance. RESULTS Among 352 placentas, 97 % (340) had intertwin AV anastomoses, and 50 % (176) were from pregnancies with selective growth restriction. The AV ratio, AA, VV, total AV areas, and cord insertion discordance negatively correlated with BWR/PR. Multivariable linear regression confirmed the independent negative association between BWR/PR and the AV ratio, suggesting that a larger shared circulation benefits the twin with the smaller placental part. Type III sFGR placentas exhibited the highest AV ratio, resulting in the lowest BWR/PR. DISCUSSION A larger shared circulation mitigates the impact of an unequally divided placenta on fetal growth. This effect surpasses the influence of AA and VV diameters and is most prominent in Type III sFGR placentas.
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Affiliation(s)
- A T R Noll
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands; Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F C Lof
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - S G Groene
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - M C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - F M Russo
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - L S A Tollenaar
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, the Netherlands
| | - J Van der Merwe
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - E J T Verweij
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, the Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.
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Athalye C, van Nisselrooij A, Rizvi S, Haak MC, Moon-Grady AJ, Arnaout R. Deep-learning model for prenatal congenital heart disease screening generalizes to community setting and outperforms clinical detection. Ultrasound Obstet Gynecol 2024; 63:44-52. [PMID: 37774040 PMCID: PMC10841849 DOI: 10.1002/uog.27503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVES Despite nearly universal prenatal ultrasound screening programs, congenital heart defects (CHD) are still missed, which may result in severe morbidity or even death. Deep machine learning (DL) can automate image recognition from ultrasound. The main aim of this study was to assess the performance of a previously developed DL model, trained on images from a tertiary center, using fetal ultrasound images obtained during the second-trimester standard anomaly scan in a low-risk population. A secondary aim was to compare initial screening diagnosis, which made use of live imaging at the point-of-care, with diagnosis by clinicians evaluating only stored images. METHODS All pregnancies with isolated severe CHD in the Northwestern region of The Netherlands between 2015 and 2016 with available stored images were evaluated, as well as a sample of normal fetuses' examinations from the same region and time period. We compared the accuracy of the initial clinical diagnosis (made in real time with access to live imaging) with that of the model (which had only stored imaging available) and with the performance of three blinded human experts who had access only to the stored images (like the model). We analyzed performance according to ultrasound study characteristics, such as duration and quality (scored independently by investigators), number of stored images and availability of screening views. RESULTS A total of 42 normal fetuses and 66 cases of isolated CHD at birth were analyzed. Of the abnormal cases, 31 were missed and 35 were detected at the time of the clinical anatomy scan (sensitivity, 53%). Model sensitivity and specificity were 91% and 78%, respectively. Blinded human experts (n = 3) achieved mean ± SD sensitivity and specificity of 55 ± 10% (range, 47-67%) and 71 ± 13% (range, 57-83%), respectively. There was a statistically significant difference in model correctness according to expert-graded image quality (P = 0.03). The abnormal cases included 19 lesions that the model had not encountered during its training; the model's performance in these cases (16/19 correct) was not statistically significantly different from that for previously encountered lesions (P = 0.41). CONCLUSIONS A previously trained DL algorithm had higher sensitivity than initial clinical assessment in detecting CHD in a cohort in which over 50% of CHD cases were initially missed clinically. Notably, the DL algorithm performed well on community-acquired images in a low-risk population, including lesions to which it had not been exposed previously. Furthermore, when both the model and blinded human experts had access to only stored images and not the full range of images available to a clinician during a live scan, the model outperformed the human experts. Together, these findings support the proposition that use of DL models can improve prenatal detection of CHD. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C Athalye
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - A van Nisselrooij
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - S Rizvi
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - M C Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - A J Moon-Grady
- Department of Pediatrics, Division of Cardiology, University of California, San Francisco, San Francisco, CA, USA
| | - R Arnaout
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Pediatrics, Division of Cardiology, University of California, San Francisco, San Francisco, CA, USA
- Bakar Computational Health Sciences Institute; Department of Radiology; UCSF Berkeley Joint Program in Computational Precision Health; Center for Intelligent Imaging; Biological and Medical Informatics, University of California, San Francisco, San Francisco, CA, USA
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van Hoek MJC, van Klink JMM, Verweij EJT, Middeldorp JM, Haak MC, Lopriore E, Slaghekke F. Perinatal outcome after selective fetal reduction in monochorionic twin pregnancies: A comparison of techniques over a 20-year period. Prenat Diagn 2023. [PMID: 37170409 DOI: 10.1002/pd.6385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/22/2023] [Accepted: 05/07/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To assess perinatal outcome after fetal reduction in complicated monochorionic (MC) twin pregnancies comparing different techniques. METHODS A retrospective cohort study at a national referral center, comparing data between four techniques: interstitial laser coagulation (ILC), radiofrequency ablation (RFA), fetoscopic laser coagulation (FLC) and bipolar cord coagulation (BCC). The primary outcome was mortality of the co-twin. Secondary outcomes were preterm pre-labor rupture of membranes (PPROM), gestational age at delivery and neonatal morbidity. RESULTS 259 MC twin pregnancies underwent selective fetal reduction: 29 IL, 64 RFA, 85 FLC and 81 BCC. Perinatal mortality rate was 29% and fetal demise of the co-twin occurred in 19%. The lowest mortality rate was seen after BCC (17%, P=0.012). PPROM occurred in 18% without significant differences between techniques. Mean gestational age at delivery in liveborn children was 35 weeks and did not differ between techniques. Severe cerebral injury and neonatal morbidity were reported in 4% and 14% respectively, without significant differences between techniques. CONCLUSIONS Selective fetal reductions in MC twins are precarious procedures with an increased risk of perinatal mortality of the co-twin. Our results show the lowest mortality rates after BCC. However, high PPROM rates were seen irrespective of the technique. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- M J C van Hoek
- Department of Obstetrics, Leiden University Medical Center, Fetal Therapy, Leiden, the Netherlands
| | - J M M van Klink
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - E J T Verweij
- Department of Obstetrics, Leiden University Medical Center, Fetal Therapy, Leiden, the Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Fetal Therapy, Leiden, the Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Fetal Therapy, Leiden, the Netherlands
| | - E Lopriore
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - F Slaghekke
- Department of Obstetrics, Leiden University Medical Center, Fetal Therapy, Leiden, the Netherlands
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Noben L, Lempersz C, van den Heuvel ER, Zhan Z, Vandenbussche FPHA, Coumans ABC, Haak MC, Vullings R, Oei SG, Clur SAB, van Laar JOEH. The electrical heart axis in fetuses with congenital heart disease, measured with non-invasive fetal electrocardiography. PLoS One 2022; 17:e0275802. [PMID: 36264863 PMCID: PMC9584524 DOI: 10.1371/journal.pone.0275802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 09/23/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To determine if the electrical heart axis in different types of congenital heart defects (CHD) differs from that of a healthy cohort at mid-gestation. METHODS Non-invasive fetal electrocardiography (NI-fECG) was performed in singleton pregnancies with suspected CHD between 16 and 30 weeks of gestation. The mean electrical heart axis (MEHA) was determined from the fetal vectorcardiogram after correction for fetal orientation. Descriptive statistics were used to determine the MEHA with corresponding 95% confidence intervals (CI) in the frontal plane of all fetuses with CHD and the following subgroups: conotruncal anomalies (CTA), atrioventricular septal defects (AVSD) and hypoplastic right heart syndrome (HRHS). The MEHA of the CHD fetuses as well as the subgroups was compared to the healthy control group using a spherically projected multivariate linear regression analysis. Discriminant analysis was applied to calculate the sensitivity and specificity of the electrical heart axis for CHD detection. RESULTS The MEHA was determined in 127 fetuses. The MEHA was 83.0° (95% CI: 6.7°; 159.3°) in the total CHD group, and not significantly different from the control group (122.7° (95% CI: 101.7°; 143.6°). The MEHA was 105.6° (95% CI: 46.8°; 164.4°) in the CTA group (n = 54), -27.4° (95% CI: -118.6°; 63.9°) in the AVSD group (n = 9) and 26.0° (95% CI: -34.1°; 86.1°) in the HRHS group (n = 5). The MEHA of the AVSD and the HRHS subgroups were significantly different from the control group (resp. p = 0.04 and p = 0.02). The sensitivity and specificity of the MEHA for the diagnosis of CHD was 50.6% (95% CI 47.5% - 53.7%) and 60.1% (95% CI 57.1% - 63.1%) respectively. CONCLUSION The MEHA alone does not discriminate between healthy fetuses and fetuses with CHD. However, the left-oriented electrical heart axis in fetuses with AVSD and HRHS was significantly different from the control group suggesting altered cardiac conduction along with the structural defect. TRIAL REGISTRATION Clinical trial registration number: NL48535.015.14.
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Affiliation(s)
- L. Noben
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
- Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
- * E-mail:
| | - C. Lempersz
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
- Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
| | - E. R. van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Z. Zhan
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - F. P. H. A. Vandenbussche
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A. B. C. Coumans
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M. C. Haak
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - R. Vullings
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - S. G. Oei
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
- Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - S. A. B. Clur
- Department of Pediatric Cardiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - J. O. E. H. van Laar
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
- Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
- Department of Pediatric Cardiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Groene SG, de Vries LS, Slaghekke F, Haak MC, Heijmans BT, de Bruin C, Roest AAW, Lopriore E, van Klink JMM, Steggerda SJ. Changes in structural brain development after selective fetal growth restriction in monochorionic twins. Ultrasound Obstet Gynecol 2022; 59:747-755. [PMID: 34931729 PMCID: PMC9415097 DOI: 10.1002/uog.24832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/19/2021] [Accepted: 12/05/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Fetal growth restriction (FGR) may alter brain development permanently, resulting in lifelong structural and functional changes. However, in studies addressing this research question, FGR singletons have been compared primarily to matched appropriately grown singletons, a design which is inherently biased by differences in genetic and maternal factors. To overcome these limitations, we conducted a within-pair comparison of neonatal structural cerebral ultrasound measurements in monochorionic twin pairs with selective FGR (sFGR). METHODS Structural cerebral measurements on neonatal cerebral ultrasound were compared between the smaller and larger twins of monochorionic twin pairs with sFGR, defined as a birth-weight discordance (BWD) ≥ 20%, born in our center between 2010 and 2020. Measurements from each twin pair were also compared with those of an appropriately grown singleton, matched according to sex and gestational age at birth. RESULTS Included were 58 twin pairs with sFGR, with a median gestational age at birth of 31.7 (interquartile range, 29.9-33.8) weeks and a median birth weight of 1155 g for the smaller twin and 1725 g for the larger twin (median BWD, 32%). Compared with both the larger twin and the singleton, the smaller twin had significantly smaller cerebral structures (corpus callosum, vermis, cerebellum), less white/deep gray matter and smaller intracranial surface area and volume. Intracranial-volume discordance and BWD correlated significantly (R2 = 0.228, P < 0.0001). The median intracranial-volume discordance was smaller than the median BWD (19% vs 32%, P < 0.0001). After correction for intracranial volume, only one of the observed differences (biparietal diameter) remained significant for the smaller twin vs both the larger twin and the singleton. CONCLUSIONS In monochorionic twins with sFGR, neonatal cerebral ultrasound reveals an overall, proportional restriction in brain growth, with smaller cerebral structures, less white/deep gray matter and smaller overall brain-size parameters in the smaller twin. There was a positive linear relationship between BWD and intracranial-volume discordance, with intracranial-volume discordance being smaller than BWD. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S. G. Groene
- Neonatology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
- Molecular Epidemiology, Department of Biomedical Data SciencesLeiden University Medical CenterLeidenThe Netherlands
| | - L. S. de Vries
- Neonatology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. Slaghekke
- Fetal Therapy, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - M. C. Haak
- Fetal Therapy, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - B. T. Heijmans
- Molecular Epidemiology, Department of Biomedical Data SciencesLeiden University Medical CenterLeidenThe Netherlands
| | - C. de Bruin
- Pediatric Endocrinology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - A. A. W. Roest
- Pediatric Cardiology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - E. Lopriore
- Neonatology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - J. M. M. van Klink
- Neonatology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - S. J. Steggerda
- Neonatology, Willem‐Alexander Children's Hospital, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
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Tedjawirja VN, van Klink JM, Haak MC, Klumper FJ, Middeldorp JM, Miller JL, Rosner M, Baschat AA, Lopriore E, Oepkes D. Questionable benefit of intrauterine transfusion following single fetal death in monochorionic twin pregnancy. Ultrasound Obstet Gynecol 2022; 59:824-825. [PMID: 35137996 DOI: 10.1002/uog.24876] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Affiliation(s)
- V N Tedjawirja
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M van Klink
- Department of Medical Psychology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - M Rosner
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - A A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - E Lopriore
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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van Nisselrooij AEL, Moon-Grady AJ, Wacker-Gussmann A, Tomek V, Malčić I, Grzyb A, Pavlova A, Kazamia K, Thakur V, Sinkovskaya E, Harkel ADJT, Haak MC. The aorto-left ventricular tunnel from a fetal perspective: original case series and literature review. Prenat Diagn 2022; 42:267-277. [PMID: 35018638 PMCID: PMC9303731 DOI: 10.1002/pd.6090] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/16/2021] [Accepted: 12/29/2021] [Indexed: 11/24/2022]
Abstract
Introduction Aorto‐left ventricular tunnel (ALVT) accounts for <0.1% of congenital heart defects. Evidence on the prognosis from a fetal perspective is limited. With this retrospective international case series, we provide information on the outcome of fetuses with ALVT. Methods All members of the Association for European Pediatric and Congenital Cardiology's (AEPC) fetal working group and fetal medicine units worldwide were invited for participation. We observed antenatal parameters, neonatal outcome and postnatal follow‐up. Additionally, a systematic search of the literature was performed. Results Twenty fetuses with ALVT were identified in 10 participating centers (2001–2019). Fetal echocardiographic characteristics of ALVT included an increased cardiac–thorax ratio (95%), left ventricular end‐diastolic diameter (90%) and a dysplastic aortic valve (90%). Extracardiac malformations were rare (5%). Eight fetuses died at a median gestational age (GA) of 21 + 6 weeks (range, 19–24): all showed signs of hydrops prior to 24 weeks or at autopsy. All others (60%, 12/2) were live–born (median GA 38 + 4, range 37–40), underwent surgery and were alive at last follow up (median 3.2 years, range 0.1–17). The literature reported 22 ALVT fetuses with similar outcome. Conclusions In the absence of fetal hydrops, ALVT carries a good prognosis. Fetuses who survive to 24 weeks without hydrops are likely to have a good outcome. What's already known about this topic?Aorto‐left ventricular tunnel (ALVT) is an extremely rare diagnosis that may cause congenital heart failure and fetal hydrops, leading to fetal or neonatal death. A few case reports show that after corrective surgery in the neonatal period, cases with ALVT tend to have a good prognosis.
What does this study add?This is the first study that evaluates prenatal characteristics, prognostic parameters and outcome following a prenatal diagnosis of ALVT in a cohort of cases worldwide, including a systematic review of the literature as well. In the absence of fetal hydrops, ALVT carries a good prognosis. Fetuses who survive to 24 weeks without hydrops are likely to have a good outcome.
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Affiliation(s)
- A E L van Nisselrooij
- Department of Fetal Medicine and Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - A J Moon-Grady
- Division of Pediatric Cardiology, Department of Pediatrics, University of California, San Francisco, California
| | - A Wacker-Gussmann
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Munich, Germany
| | - V Tomek
- Children's Heart Centre Prague, University Hospital Motol, Prague, Czech Republic
| | - I Malčić
- Department of Child's Cardiology, Zagreb University Hospital, Zagreb, Croatia
| | - A Grzyb
- Department of Perinatal Cardiology and Congenital Anomalies, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - A Pavlova
- Department of Cardiology, Ukrainian Children's Cardiac Centre, Kyiv, Ukraine
| | - K Kazamia
- Children's Heart Centre Stockholm-Uppsala, Karolinska University Hospital, Stockholm, Sweden
| | - V Thakur
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - E Sinkovskaya
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - A D J Ten Harkel
- Department of Fetal Medicine and Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - M C Haak
- Department of Fetal Medicine and Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
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Zwanenburg F, Van Munsteren JC, Wisse LJ, De Ruiter MC, Haak MC, Jongbloed MRM. Aortic stenosis: correlation of prenatal echocardiography to postmortem histology. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Foetal aortic stenosis (AS) is a challenging congenital heart disease considering its potential to progress during the course of pregnancy. Especially at midgestation, it remains extremely difficult to distinguish the cases that end up biventricular from the cases that will develop into an hypoplastic left heart syndrome.
Purpose
To test the hypothesis that the degree of myocardial maturation is a possible predictor of biventricular outcome, we present 4 cases of foetal AS with a varying degree of severity and uniquely correlate differences in myocardial function based on prenatal echocardiography to their post-mortem histopathologic maturation.
Methods
We selected 4 cases with midgestational AS from our tertiary foetal cardiology service between 2018–2020. Speckle tracking recordings of the cardiac four-chamber view were performed during routine foetal echocardiography to quantify myocardial wall motion as a marker for myocardial function. Three cases decided to terminate the pregnancy and donated the cardiac specimen. Immunohistochemical labelling (ICH) against key markers for myocardial maturation (troponin-I, N-cadherin, connexin-43, MLC2A, MLC2V and α-SMA) and fibrosis (Sirius Red) were compared with 2 normal foetal cardiac specimens.
Results
Two cases with critical AS presented extremely decreased global and segmental longitudinal strain (GLS and SLS) values (GLS −2% and −0.9%) in the left ventricle (LV), indicating an impaired myocardial wall deformation. Post-mortem ICH showed overt endocardial fibro-elastosis (EFE) and pathological fibrosis patterns in the subendocardial layer which was remarkably spatially correlated to the EFE. The cardiomyocytes were disorganised with reduced expression of troponin-I and disturbed expression of connexin-43. The remaining 2 cases had normal LV appearance on foetal echocardiography, showing a mild reduction in left ventricular GLS and SLS (GLS −11.8% and −14.2%). Post-mortem ICH of 1 of these cases showed mild EFE with a milder fibrosis pattern. Cardiomyocytes were less disorganised but also showed a disturbed expression of connexin-43. The 4th case continued the pregnancy and had a biventricular outcome.
Conclusions
This is a unique case series showing that myocardial function correlates with high extent to histology. The degree of the reduction in myocardial function corresponded with the amount of pathological fibrosis patterns and disorganisation of the cardiomyocyte network. Myocardial wall motion on foetal echocardiography seems to hold promise as a possible marker for cardiac maturation.
Funding Acknowledgement
Type of funding sources: None. Speckle tracking and fibrosis patterns
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Affiliation(s)
- F Zwanenburg
- Leiden University Medical Center, Leiden, Netherlands (The)
| | | | - L J Wisse
- Leiden University Medical Center, Leiden, Netherlands (The)
| | - M C De Ruiter
- Leiden University Medical Center, Leiden, Netherlands (The)
| | - M C Haak
- Leiden University Medical Center, Leiden, Netherlands (The)
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Tollenaar LSA, Lopriore E, Middeldorp JM, Klumper FJCM, Haak MC, Oepkes D, Slaghekke F. Prevalence of placental dichotomy, fetal cardiomegaly and starry-sky liver in twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol 2020; 56:395-399. [PMID: 31856326 PMCID: PMC7496878 DOI: 10.1002/uog.21948] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 11/12/2019] [Accepted: 12/04/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the prevalence of three additional ultrasound markers, placental dichotomy, cardiomegaly and 'starry-sky' liver, in monochorionic twin pregnancy with twin anemia-polycythemia sequence (TAPS). METHODS All monochorionic twin pregnancies, diagnosed antenatally with TAPS at our center between 2006 and 2019, were reviewed retrospectively for the presence of placental dichotomy, cardiomegaly in the donor twin and a starry-sky liver in the recipient twin. TAPS was diagnosed based on delta middle cerebral artery (MCA) peak systolic velocity (PSV) > 0.5 multiples of the median. The primary outcome was the prevalence of placental dichotomy, cardiomegaly, starry-sky liver and at least one of these markers in both spontaneous and post-laser TAPS. The secondary outcome was the prevalence of these ultrasound markers according to the antenatal stage of TAPS. RESULTS A total of 91 monochorionic twin pregnancies with TAPS were eligible for analysis. Placental dichotomy was observed in 44% (40/91) of TAPS cases. A total of 70% (64/91) of the TAPS donors developed cardiomegaly and a starry-sky liver was identified in 66% (53/80) of the TAPS recipients. The prevalence of cardiomegaly and starry-sky liver was roughly comparable between spontaneous and post-laser TAPS (69% (33/48) vs 72% (31/43) and 64% (25/39) vs 68% (28/41), respectively). Pregnancies with spontaneous TAPS showed a higher prevalence of placental dichotomy compared with post-laser TAPS (63% (30/48) vs 23% (10/43)). At least one of the three ultrasound markers was detected in 86% (78/91) of TAPS cases, meaning that 14% (13/91) of cases presented solely with discordant MCA-PSV values. There was a trend towards increased prevalence of all three ultrasound markers with increasing antenatal TAPS stage. CONCLUSIONS Placental dichotomy, fetal cardiomegaly and a starry-sky liver are commonly found in TAPS pregnancy. Investigating the presence of these ultrasound markers can be of additional help in improving antenatal detection of TAPS in monochorionic twin pregnancy. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L. S. A. Tollenaar
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - E. Lopriore
- Division of Neonatology, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - J. M. Middeldorp
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. J. C. M. Klumper
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - M. C. Haak
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - D. Oepkes
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. Slaghekke
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
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van Nisselrooij AEL, Teunissen AKK, Clur SA, Rozendaal L, Pajkrt E, Linskens IH, Rammeloo L, van Lith JMM, Blom NA, Haak MC. Why are congenital heart defects being missed? Ultrasound Obstet Gynecol 2020; 55:747-757. [PMID: 31131945 PMCID: PMC7317409 DOI: 10.1002/uog.20358] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Congenital heart defects (CHD) are still missed frequently in prenatal screening programs, which can result in severe morbidity or even death. The aim of this study was to evaluate the quality of fetal heart images, obtained during the second-trimester standard anomaly scan (SAS) in cases of CHD, to explore factors associated with a missed prenatal diagnosis. METHODS In this case-control study, all cases of a fetus born with isolated severe CHD in the Northwestern region of The Netherlands, between 2015 and 2016, were extracted from the PRECOR registry. Severe CHD was defined as need for surgical repair in the first year postpartum. Each cardiac view (four-chamber view (4CV), three-vessel (3V) view and left and right ventricular outflow tract (LVOT, RVOT) views) obtained during the SAS was scored for technical correctness on a scale of 0 to 5 by two fetal echocardiography experts, blinded to the diagnosis of CHD and whether it was detected prenatally. Quality parameters of the cardiac examination were compared between cases in which CHD was detected and those in which it was missed on the SAS. Regression analysis was used to assess the association of sonographer experience and of screening-center experience with the cardiac examination quality score. RESULTS A total of 114 cases of isolated severe CHD at birth were analyzed, of which 58 (50.9%) were missed and 56 (49.1%) were detected on the SAS. The defects comprised transposition of the great arteries (17%), aortic coarctation (16%), tetralogy of Fallot (10%), atrioventricular septal defect (6%), aortic valve stenosis (5%), ventricular septal defect (18%) and other defects (28%). No differences were found in fetal position, obstetric history, maternal age or body mass index (BMI) or gestational age at examination between missed and detected cases. Ninety-two cases had available cardiac images from the SAS. Compared with the detected group, the missed group had significantly lower cardiac examination quality scores (adequate score (≥ 12) in 32% vs 64%; P = 0.002), rate of proper use of magnification (58% vs 84%; P = 0.01) and quality scores for each individual cardiac plane (4CV (2.7 vs 3.9; P < 0.001), 3V view (3.0 vs 3.8; P = 0.02), LVOT view (1.9 vs 3.3; P < 0.001) and RVOT view (1.9 vs 3.3; P < 0.001)). In 49% of missed cases, the lack of detection was due to poor adaptational skills resulting in inadequate images in which the CHD was not clearly visible; in 31%, the images showed an abnormality (mainly septal defects and aortic arch anomalies) which had not been recognized at the time of the scan; and, in 20%, the cardiac planes had been obtained properly but showed normal anatomy. Multivariate regression analysis showed that the volume of SAS performed per year by each sonographer was associated significantly with quality score of the cardiac examination. CONCLUSIONS A lack of adaptational skills when performing the SAS, as opposed to circumstantial factors such as BMI or fetal position, appears to play an important role in failure to detect CHD prenatally. The quality of the cardiac views was inadequate significantly more often in undetected compared with detected cases. Despite adequate quality of the images, CHD was not recognized in 31% of cases. A high volume of SAS performed by each sonographer in a large ultrasound center contributes significantly to prenatal detection. In 20% of undetected cases, CHD was not visible even though the quality of the images was good. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A. E. L. van Nisselrooij
- Department of Obstetrics and Fetal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - A. K. K. Teunissen
- Department of Obstetrics and Fetal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - S. A. Clur
- Department of Paediatric CardiologyEmma Children's Hospital, Amsterdam University Medical CentersAmsterdamThe Netherlands
| | - L. Rozendaal
- Department of Paediatric CardiologyLeiden University Medical CenterLeidenThe Netherlands
| | - E. Pajkrt
- Department of ObstetricsAmsterdam University Medical CentersAmsterdamThe Netherlands
| | - I. H. Linskens
- Department of ObstetricsAmsterdam University Medical CentersAmsterdamThe Netherlands
| | - L. Rammeloo
- Department of Paediatric CardiologyEmma Children's Hospital, Amsterdam University Medical CentersAmsterdamThe Netherlands
| | - J. M. M. van Lith
- Department of Obstetrics and Fetal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - N. A. Blom
- Department of Paediatric CardiologyLeiden University Medical CenterLeidenThe Netherlands
| | - M. C. Haak
- Department of Obstetrics and Fetal MedicineLeiden University Medical CenterLeidenThe Netherlands
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12
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de Ruigh AA, Simons NE, van 't Hooft J, van Teeffelen AS, Duijnhoven RG, van Wassenaer-Leemhuis AG, Aarnoudse-Moens C, van de Beek C, Oepkes D, Haak MC, Woiski M, Porath MM, Derks JB, van Kempen L, Roseboom TJ, Mol BW, Pajkrt E. Child outcomes after amnioinfusion compared with no intervention in women with second-trimester rupture of membranes: a long-term follow-up study of the PROMEXIL-III trial. BJOG 2020; 128:292-301. [PMID: 31984652 PMCID: PMC7818451 DOI: 10.1111/1471-0528.16115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess the effect of transabdominal amnioinfusion or no intervention on long-term outcomes in children born after second-trimester prelabour rupture of the membranes (PROM between 16+0/7 -24+0/7 weeks) and oligohydramnios. POPULATION Follow up of infants of women who participated in the randomised controlled trial: PPROMEXIL-III (NTR3492). METHODS Surviving infants were invited for neurodevelopmental assessment up to 5 years of corrected age using a Bayley Scales of Infant and Toddler Development or a Wechsler Preschool and Primary Scale of Intelligence. Parents were asked to complete several questionnaires. MAIN OUTCOME MEASURES Neurodevelopmental outcomes were measured. Mild delay was defined as -1 standard deviation (SD), severe delay as -2 SD. Healthy long-term survival was defined as survival without neurodevelopmental delay or respiratory problems. RESULTS In the amnioinfusion group, 18/28 children (64%) died versus 21/28 (75%) in the no intervention group (relative risk 0.86; 95% confidence interval [CI] 0.60-1.22). Follow-up data were obtained from 14/17 (82%) children (10 amnioinfusion, 4 no intervention). In both groups, 2/28 (7.1%) had a mild neurodevelopmental delay. No severe delay was seen. Healthy long-term survival occurred in 5/28 children (17.9%) after amnioinfusion versus 2/28 (7.1%) after no intervention (odds ratio 2.50; 95% CI 0.53-11.83). When analysing data for all assessed survivors, 10/14 (71.4%) survived without mild neurodevelopmental delay and 7/14 (50%) were classified healthy long-term survivor. CONCLUSIONS In this small sample of women suffering second-trimester PROM and oligohydramnios, amnioinfusion did not improve long-term outcomes. Overall, 71% of survivors had no neurodevelopmental delay. TWEETABLE ABSTRACT Healthy long-term survival was comparable for children born after second-trimester PROM and treatment with amnioinfusion or no intervention.
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Affiliation(s)
- A A de Ruigh
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - N E Simons
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - J van 't Hooft
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - A S van Teeffelen
- Department of Obstetrics and Gynaecology, Grow, School for Oncology and Developmental Biology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - R G Duijnhoven
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - A G van Wassenaer-Leemhuis
- Department of Neonatology, Emma Children's Hospital Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - C Aarnoudse-Moens
- Department of Neonatology, Emma Children's Hospital Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - C van de Beek
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - D Oepkes
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - M Woiski
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - M M Porath
- Department of Obstetrics and Gynaecology, Maxima Medical Centre (MMC), Veldhoven, The Netherlands
| | - J B Derks
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht (UMCU), Utrecht, The Netherlands
| | - Lem van Kempen
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - T J Roseboom
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - B W Mol
- Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - E Pajkrt
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), Amsterdam, The Netherlands
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van Nisselrooij AEL, Jansen FAR, van Geloven N, Linskens IH, Pajkrt E, Clur S, Rammeloo LA, Rozendaal L, van Lith JMM, Blom NA, Haak MC. Impact of extracardiac pathology on head growth in fetuses with congenital heart defect. Ultrasound Obstet Gynecol 2020; 55:217-225. [PMID: 30868678 PMCID: PMC7027464 DOI: 10.1002/uog.20260] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 02/22/2019] [Accepted: 03/08/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Neurodevelopmental delay is frequently encountered in children with a congenital heart defect (CHD). Fetuses with major CHD have a smaller head circumference (HC), irrespective of altered cerebral flow or brain oxygenation. This cohort study compared head growth in cases with isolated vs those with non-isolated CHD to evaluate the effect of additional pathology on head size in these fetuses. METHOD All CHD cases diagnosed prenatally in the period January 2002-July 2014 were selected from our regional registry, PRECOR. Cases of multiple pregnancy, and those affected by maternal diabetes, severe fetal structural brain anomalies or functional CHD were excluded. Subjects were divided into groups according to whether the CHD was isolated, and the non-isolated group was subdivided into three groups: cases with genetic anomaly, extracardiac malformation or placental pathology. In both isolated and non-isolated CHD groups, CHDs were also grouped according to their potential effect on aortic flow and oxygen saturation. Mean HC Z-scores at 20 weeks and increase or decrease (Δ) of HC Z-scores over the course of pregnancy were compared between isolated and non-isolated groups, using mixed linear regression models. RESULTS Included were 916 cases of CHD diagnosed prenatally, of which 378 (41.3%) were non-isolated (37 with placental pathology, 217 with genetic anomaly and 124 with extracardiac malformation). At 20 weeks, non-isolated cases had significantly lower HC Z-scores than did isolated cases (Z-score = -0.70 vs -0.03; P < 0.001) and head growth over the course of pregnancy showed a larger decrease in this group (Δ HC Z-score = -0.03 vs -0.01 per week; P = 0.01). Cases with placental pathology had the lowest HC Z-score at 20 weeks (Z-score = -1.29) and the largest decrease in head growth (Δ HC Z-score = -0.06 per week). In CHD subjects with a genetic diagnosis (Z-score = -0.73; Δ HC Z-score = -0.04 per week) and in those with an extracardiac malformation (Z-score = -0.49; Δ HC Z-score = -0.02 per week), HC Z-scores were also lower compared with those in subjects with isolated CHD. CHDs that result in low oxygenation or flow to the brain were present more frequently in isolated than in non-isolated cases. CONCLUSIONS Smaller HC in fetuses with CHD appears to be associated strongly with additional pathology. Placental pathology and genetic anomaly in particular seem to be important contributors to restricted head growth. This effect appears to be irrespective of altered hemodynamics caused by the CHD. Previously reported smaller HC in CHD should, in our opinion, be attributed to additional pathology. Neurodevelopment studies in infants with CHD should, therefore, always differentiate between isolated and non-isolated cases. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A. E. L. van Nisselrooij
- Department of Obstetrics and Fetal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - F. A. R. Jansen
- Department of Obstetrics and Fetal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - N. van Geloven
- Medical StatisticsDepartment of Biomedical Data Sciences, Leiden University Medical CenterLeidenThe Netherlands
| | - I. H. Linskens
- Amsterdam UMC, University of Amsterdam, Obstetrics, Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
| | - E. Pajkrt
- Amsterdam UMC, University of Amsterdam, Obstetrics, Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
| | - S.‐A. Clur
- Department of Paediatric CardiologyEmma Children's Hospital, University Medical Center AmsterdamAmsterdamThe Netherlands
| | - L. A. Rammeloo
- Department of Paediatric CardiologyEmma Children's Hospital, University Medical Center AmsterdamAmsterdamThe Netherlands
| | - L. Rozendaal
- Department of Paediatric CardiologyLeiden University Medical CenterLeidenThe Netherlands
| | - J. M. M. van Lith
- Department of Obstetrics and Fetal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - N. A. Blom
- Department of Paediatric CardiologyLeiden University Medical CenterLeidenThe Netherlands
| | - M. C. Haak
- Department of Obstetrics and Fetal MedicineLeiden University Medical CenterLeidenThe Netherlands
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14
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Tollenaar LSA, Lopriore E, Slaghekke F, Oepkes D, Middeldorp JM, Haak MC, Klumper FJCM, Tan RNGB, Rijken M, Van Klink JMM. High risk of long-term neurodevelopmental impairment in donor twins with spontaneous twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol 2020; 55:39-46. [PMID: 31432580 DOI: 10.1002/uog.20846] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/03/2019] [Accepted: 08/09/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the long-term neurodevelopmental and behavioral outcomes in surviving infants of pregnancies with spontaneous twin anemia-polycythemia sequence (TAPS), to compare outcome between donors and recipients, and to investigate potential risk factors for neurodevelopmental impairment (NDI). METHODS This was a retrospective study of a consecutive cohort of spontaneous-TAPS survivors delivered between 2005 and 2017 at the Leiden University Medical Center, The Netherlands. Neurological, motor, cognitive and behavioral development were assessed at a median age of 4 years. The primary outcome was NDI, which was a composite outcome of cerebral palsy, deafness, blindness and motor and/or cognitive delay. NDI was subdivided into two grades of severity: mild-to-moderate and severe NDI. Outcome was compared between surviving donor and recipient twins. Logistic regression analysis was used to assess risk factors for NDI. RESULTS Forty-nine twin pregnancies complicated by spontaneous TAPS were eligible for inclusion. The perinatal survival rate was 83% (81/98) of twins. Neurodevelopmental assessment was performed in 91% (74/81) of surviving twins. NDI occurred in 30% (22/74) of TAPS survivors, and was found more often in donors (44%; 15/34) than in recipients (18%; 7/40) (odds ratio (OR), 4.1; 95% CI, 1.8-9.1; P = 0.001). Severe NDI was detected in 9% (7/74) of survivors and was higher in donors compared with recipients (18% (6/34) vs 3% (1/40)), although the difference did not reach statistical significance; P = 0.056). Donors demonstrated lower cognitive scores compared with recipients (P = 0.011). Bilateral deafness was identified in 15% (5/34) of donors compared with 0% (0/40) of recipients (P = 0.056). Parental concern regarding development was reported more often for donor than for recipient twins (P = 0.001). On multivariate analysis, independent risk factors for NDI were gestational age at delivery (OR, 0.7; 95% CI, 0.5-0.9; P = 0.003) and severe anemia (OR, 6.4; 95% CI, 2.4-17.0; P < 0.001). CONCLUSION Surviving donor twins of pregnancies complicated by spontaneous TAPS have four-fold higher odds of NDI compared with recipient cotwins, are at increased risk of cognitive delay and have a high rate of deafness. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L S A Tollenaar
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J C M Klumper
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - R N G B Tan
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M Rijken
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M M Van Klink
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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15
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Tollenaar LSA, Lopriore E, Middeldorp JM, Haak MC, Klumper FJ, Oepkes D, Slaghekke F. Improved prediction of twin anemia-polycythemia sequence by delta middle cerebral artery peak systolic velocity: new antenatal classification system. Ultrasound Obstet Gynecol 2019; 53:788-793. [PMID: 30125414 PMCID: PMC6593803 DOI: 10.1002/uog.20096] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/27/2018] [Accepted: 08/08/2018] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To investigate the diagnostic accuracy of delta middle cerebral artery peak systolic velocity (MCA-PSV) > 0.5 multiples of the median (MoM) and compare its predictive value with that of the current MCA-PSV cut-off values of > 1.5 MoM in the donor and < 1.0 MoM in the recipient, for the diagnosis of twin anemia-polycythemia sequence (TAPS) in monochorionic twin pregnancy. METHODS This was a retrospective consecutive cohort study comprising all uncomplicated monochorionic twin pregnancies and twin pregnancies with a postnatal diagnosis of TAPS managed between 2003 and 2017 in the Dutch national referral center for fetal therapy. Cases with incomplete MCA-PSV Doppler measurements 1 week prior to delivery or with incomplete hemoglobin measurements within 1 day after birth were excluded. The postnatal diagnosis of TAPS was based on an intertwin hemoglobin difference > 8 g/dL and at least one of the following: reticulocyte count ratio > 1.7 or presence of minuscule anastomoses on the placental surface. We compared the predictive accuracy of the current diagnostic method using MCA-PSV cut-off values of > 1.5 MoM in the donor and < 1.0 MoM in the recipient with that of a new method based on intertwin difference in MCA-PSV > 0.5 MoM for prediction of TAPS. RESULTS In total, 45 uncomplicated and 35 TAPS monochorionic twin pregnancies were analyzed. The sensitivity and specificity of the cut-off MCA-PSV values (donor > 1.5 MoM, recipient < 1.0 MoM) to predict TAPS was 46% (95% CI, 30-62%) and 100% (95% CI, 92-100%), respectively; positive predictive value was 100% (95% CI, 81-100%) and negative predictive value 70% (95% CI, 58-80%). Delta MCA-PSV showed a sensitivity of 83% (95% CI, 67-92%) and a specificity of 100% (95% CI, 92-100%); the positive and negative predictive values were 100% (95% CI, 88-100%) and 88% (95% CI, 77-94%), respectively. Of the 35 cases with TAPS diagnosed postnatally, 13 twin pairs showed a delta MCA-PSV > 0.5 MoM but did not fulfill the cut-off MCA-PSV criteria. Of these 13 TAPS twins, nine donors and four recipients had normal MCA-PSV values. There was a high correlation between delta MCA-PSV and intertwin difference in hemoglobin level (R = 0.725, P < 0.01). CONCLUSION Delta MCA-PSV > 0.5 MoM has a greater diagnostic accuracy for predicting TAPS compared to the current MCA-PSV cut-off criteria. We therefore propose a new antenatal classification system for TAPS. In monochorionic twin pregnancies with delta MCA-PSV > 0.5 MoM on Doppler ultrasound, but normal MCA-PSV values in the donor or recipient, obstetricians should be aware of the therapeutic implications and neonatal morbidities associated with TAPS. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L. S. A. Tollenaar
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - E. Lopriore
- Division of Neonatology, Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands
| | - J. M. Middeldorp
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - M. C. Haak
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. J. Klumper
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - D. Oepkes
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
| | - F. Slaghekke
- Division of Fetal Medicine, Department of ObstetricsLeiden University Medical CenterLeidenThe Netherlands
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Jansen FAR, van Zwet EW, Everwijn SMP, Teunissen AKK, Rozendaal L, van Lith JMM, Blom NA, Haak MC. Fetuses with Isolated Congenital Heart Defects Show Normal Cerebral and Extracerebral Fluid Volume Growth: A 3D Sonographic Study in the Second and Third Trimester. Fetal Diagn Ther 2019; 45:212-220. [PMID: 30654359 DOI: 10.1159/000488674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 03/07/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The aim of our study is to explore whether the cerebral growth is delayed in fetuses with congenital heart defects (CHD) in the second and early third trimester. METHODS A prospective cohort study was conducted in 77 CHD cases, with 75 healthy controls. 3D cerebral volume acquisition was performed sequentially. The volumes of the fetal hemicerebrum and extracerebral fluid were compared by linear regression analysis, and the Sylvian fissure was measured. RESULTS Between 19 and 32 weeks of gestation, 158 measurements in cases and 183 measurements in controls were performed (mean 2.2/subject). The volume growth of the hemicerebrum (R2 = 0.95 vs. 0.95; p = 0.9) and the extracerebral fluid (R2 = 0.84 vs. 0.82, p = 0.9) were similar. Fetuses with abnormal oxygen delivery to the brain have a slightly smaller brain at 20 weeks of gestation (p = 0.02), but this difference disappeared with advancing gestation. CHD cases demonstrated a slightly shallower Sylvian fissure (mean ratio 0.146 vs. 0.153; p = 0.004). CONCLUSIONS Our study shows no differences in cerebral growth, studied in an unselected cohort, with successive cases of isolated CHD. Even in the severest CHD cases, cerebral size is similar in the early third trimester. The cause and meaning of a shallower Sylvian fissure is unclear; possibly, it is a marker for delayed cerebral maturation or it might be an expression of decreasing amount of extracerebral fluid.
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Affiliation(s)
- F A R Jansen
- Leiden University Medical Centre, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands,
| | - E W van Zwet
- Leiden University Medical Centre, Department of Medical Statistics, Leiden, The Netherlands
| | - S M P Everwijn
- Leiden University Medical Centre, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
| | - A K K Teunissen
- Leiden University Medical Centre, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
| | - L Rozendaal
- Leiden University Medical Centre, Department of Paediatric Cardiology, Leiden, The Netherlands
| | - J M M van Lith
- Leiden University Medical Centre, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
| | - N A Blom
- Leiden University Medical Centre, Department of Paediatric Cardiology, Leiden, The Netherlands
| | - M C Haak
- Leiden University Medical Centre, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
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17
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van Nisselrooij AEL, Rozendaal L, Linskens IH, Clur SA, Hruda J, Pajkrt E, van Velzen CL, Blom NA, Haak MC. Postnatal outcome of fetal isolated ventricular size disproportion in the absence of aortic coarctation. Ultrasound Obstet Gynecol 2018; 52:593-598. [PMID: 28598570 DOI: 10.1002/uog.17543] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 05/02/2017] [Accepted: 05/25/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Cardiac ventricular size disproportion is a marker for aortic coarctation (CoA) in fetal life, but approximately 50% of fetuses do not have CoA after birth. The aim of this study was to evaluate the postnatal outcome of cases with fetal ventricular size disproportion in the absence of CoA after birth. METHODS All cases with fetal isolated ventricular size disproportion diagnosed between 2002 and 2015 were extracted from a prenatal congenital heart defects regional registry. Cases were stratified according to presence or absence (non-CoA) of aortic arch anomalies after birth. Postnatal outcome of non-CoA cases was evaluated by assessing the presence of cardiac and other congenital malformations, genetic syndromes and other morbidity after birth. Non-CoA cases were further classified according to whether they had cardiovascular pathology requiring medication or intervention. RESULTS Seventy-seven cases with fetal ventricular size disproportion were identified, of which 46 (60%) did not have CoA after birth. Of these, 35 did not require cardiovascular intervention or medication, whereas 11 did. Of the 46 non-CoA cases, six presented with clinical pulmonary hypertension requiring treatment after birth, cardiac defects were present in 24 cases and syndromic features were seen in four. Overall, 43% of all non-CoA children were still under surveillance at the end of the study period. CONCLUSIONS The postnatal course of cases with fetal ventricular size disproportion is complicated by prenatally undetected congenital defects (46%) and pulmonary or transition problems (35%) in a significant number of cases that do not develop CoA. Proper monitoring of these cases is therefore warranted and it is advisable to incorporate the risks for additional morbidity and neonatal complications in prenatal counseling. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A E L van Nisselrooij
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - L Rozendaal
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - I H Linskens
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - S A Clur
- Department of Pediatric Cardiology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - J Hruda
- Department of Pediatric Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - E Pajkrt
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - C L van Velzen
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - N A Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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18
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van Baaren GJ, Vis JY, Wilms FF, Oudijk MA, Kwee A, Porath MM, Scheepers HCJ, Spaanderman MEA, Bloemenkamp KWM, Haak MC, Bax CJ, Cornette JMJ, Duvekot JJ, Nij Bijvanck BWA, van Eyck J, Franssen MTM, Sollie KM, Vandenbussche FPHA, Woiski M, Bolte AC, van der Post JAM, Bossuyt PMM, Opmeer BC, Mol BWJ. Cost-effectiveness of diagnostic testing strategies including cervical-length measurement and fibronectin testing in women with symptoms of preterm labor. Ultrasound Obstet Gynecol 2018; 51:596-603. [PMID: 28370518 DOI: 10.1002/uog.17481] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/29/2017] [Accepted: 03/22/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of combining cervical-length (CL) measurement and fetal fibronectin (fFN) testing in women with symptoms of preterm labor between 24 and 34 weeks' gestation. METHODS This was a model-based cost-effectiveness analysis evaluating seven test-treatment strategies based on CL measurement and/or fFN testing in women with symptoms of preterm labor from a societal perspective, in which neonatal outcomes and costs were weighted. Estimates of disease prevalence, test accuracy and costs were based on two recently performed nationwide cohort studies in The Netherlands. RESULTS Strategies using fFN testing and CL measurement separately to predict preterm delivery are associated with higher costs and incidence of adverse neonatal outcomes compared with strategies that combine both tests. Additional fFN testing when CL is 15-30 mm was considered cost effective, leading to a cost saving of €3919 per woman when compared with a treat-all strategy, with a small deterioration in neonatal health outcomes, namely one additional perinatal death and 21 adverse outcomes per 10 000 women with signs of preterm labor (incremental cost-effectiveness ratios €39 million and €1.9 million, respectively). Implementing this strategy in The Netherlands, a country with about 180 000 deliveries annually, could lead to an annual cost saving of between €2.4 million and €7.6 million, with only a small deterioration in neonatal health outcomes. CONCLUSION In women with symptoms of preterm labor at 24-34 weeks' gestation, performing additional fFN testing when CL is between 15 and 30 mm is a viable and cost-saving strategy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G-J van Baaren
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - J Y Vis
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F F Wilms
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - M A Oudijk
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - A Kwee
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M M Porath
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - H C J Scheepers
- Department of Obstetrics and Gynecology, University Hospital Maastricht, Maastricht, The Netherlands
| | - M E A Spaanderman
- Department of Obstetrics and Gynecology, University Hospital Maastricht, Maastricht, The Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - C J Bax
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - J M J Cornette
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J J Duvekot
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - B W A Nij Bijvanck
- Department of Obstetrics and Gynecology, Isala Clinics, Zwolle, The Netherlands
| | - J van Eyck
- Department of Obstetrics and Gynecology, Isala Clinics, Zwolle, The Netherlands
| | - M T M Franssen
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - K M Sollie
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - F P H A Vandenbussche
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - M Woiski
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - A C Bolte
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - J A M van der Post
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - P M M Bossuyt
- Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - B C Opmeer
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - B W J Mol
- Department of Obstetrics and Gynecology, The Robinson Institute, School of Pediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia
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19
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Eschbach SJ, Boons LSTM, Van Zwet E, Middeldorp JM, Klumper FJCM, Lopriore E, Teunissen AKK, Rijlaarsdam ME, Oepkes D, Ten Harkel ADJ, Haak MC. Right ventricular outflow tract obstruction in complicated monochorionic twin pregnancy. Ultrasound Obstet Gynecol 2017; 49:737-743. [PMID: 27363529 DOI: 10.1002/uog.16008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/16/2016] [Accepted: 06/17/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Severe right ventricular outflow tract obstruction (RVOTO) is a potential complication in recipient twins of twin-to-twin transfusion syndrome (TTTS) that requires postnatal follow-up or treatment. We aimed to evaluate pregnancy characteristics of neonates with RVOTO from complicated monochorionic twin pregnancies, determine the incidence of RVOTO in TTTS cases and construct a prediction model for its development. METHODS This was an observational cohort study of all complicated monochorionic twin pregnancies with a postnatal diagnosis of RVOTO examined at our center. Cases were referred for evaluation of the need for fetal therapy or intervention because of TTTS, selective intrauterine growth restriction (sIUGR) or multiple congenital malformations in one of the twins. Ultrasound data were retrieved from our monochorionic twin database. Among liveborn TTTS recipients treated prenatally with laser therapy, those with RVOTO were compared with those without RVOTO (controls). We describe four additional cases with RVOTO that were not TTTS recipients. RESULTS A total of 485 twin pregnancies received laser therapy for TTTS during the study period. RVOTO was diagnosed in 3% (11/368) of liveborn TTTS recipients, of whom two showed mild Ebstein's anomaly. Before laser therapy, pericardial effusion was seen in 45% (5/11) of RVOTO cases (P < 0.01) and abnormal A-wave in the ductus venosus (DV) in 73% (8/11) (P = 0.03), significantly higher proportions than in controls. Mean gestational age at laser therapy was 17 + 3 weeks in RVOTO cases compared with 20 + 3 weeks in controls (P = 0.03). A prediction model for RVOTO was constructed incorporating these three significant variables. One TTTS donor had RVOTO after the development of transient hydrops following laser therapy. Three larger twins in pregnancies complicated by sIUGR developed RVOTO, the onset of which was detectable early in the second trimester. CONCLUSIONS RVOTO occurs in TTTS recipient twins but can also develop in TTTS donors and larger twins of pregnancies complicated by sIUGR. Abnormal flow in the DV, pericardial effusion and early gestational age at onset of TTTS are predictors of RVOTO in TTTS recipients, which suggests increased vulnerability to hemodynamic imbalances in the fetal heart in early pregnancy. These findings could guide diagnostic follow-up protocols after TTTS treatment. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S J Eschbach
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L S T M Boons
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J C M Klumper
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A K K Teunissen
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M E Rijlaarsdam
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A D J Ten Harkel
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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20
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van Os MA, Kleinrouweler CE, Schuit E, van der Ven AJ, Pajkrt E, de Groot CJM, Mol BWJ, Haak MC. Influence of cut-off value on prevalence of short cervical length. Ultrasound Obstet Gynecol 2017; 49:330-336. [PMID: 27194622 DOI: 10.1002/uog.15967] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/24/2016] [Accepted: 04/29/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To assess the distribution of cervical length (CL) in a large cohort of asymptomatic low-risk women with singleton pregnancy and no previous preterm birth and to explain the low prevalence of short CL ≤ 30 mm in this cohort. METHODS This was a secondary analysis of a multicenter cohort study with an embedded randomized controlled trial (Triple P trial; NTR-2078) on the prevention of preterm birth with progesterone. In the cohort study, CL was measured in asymptomatic low-risk women with singleton pregnancy to investigate its predictive capacity to identify those at increased risk for preterm birth. A short CL was defined by a cut-off value of ≤ 30 mm, based on existing literature. Women with a short CL were subsequently included in a randomized controlled trial evaluating the effect of progesterone, compared with placebo, on preterm birth. In total, 57 centers and 20 234 women participated in the study. Normal distributions for CL were simulated based on the mean and SD of the original data. The distribution of CL was assessed for each individual center and measurements were compared between levels of care: primary (29 ultrasound centers), secondary (21 general hospitals) and tertiary (seven university medical centers) care institutions. Comparison was also performed between centers with low, intermediate and high volume of CL measurements. CL distributions before (n = 12 284 women) and after (n = 7950 women) a national symposium, at which the prevalence of short CL measurements was addressed publicly, were analyzed. RESULTS Between November 2009 and August 2013, 20 234 women had CL measurements, of whom 367 (1.8%) had a short CL. Mean ± SD CL was 44.2 ± 7.8 mm. A 'dip' in the distribution of CL measurements between 20 and 30 mm was observed, defined by a ratio of < 50% when comparing the number of measurements in observed and simulated normal distributions. The dip was present in 89% of participating centers. All centers showed a dip in the distribution of measurements ≤ 30 mm when analyzed according to the level of care and volume of measurements. A significant difference was found when comparing the distribution before and after publicly addressing the low prevalence of short CL (1.7% vs 2.0% of measurements were ≤ 30 mm, respectively; P < 0.001). CONCLUSIONS A cut-off value of 30 mm for CL was used to include women in a randomized clinical trial that was embedded in a cohort study. We suggest that the use of a predefined cut-off value for a short cervix influences the distribution of the CL measurements. Since the measurement is not blinded, preference of assessors for the control or intervention arms may have introduced selection bias. This might have resulted in fewer measurements around the cut-off value. Other trials using similar designs could benefit from this observation and take precautions to avoid selection bias. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M A van Os
- Department of Obstetrics and Gynaecology, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - C E Kleinrouweler
- Department of Obstetrics and Gynaecology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - E Schuit
- Department of Obstetrics and Gynaecology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Stanford Prevention Research Center, Stanford University, Stanford, CA, USA
| | - A J van der Ven
- Department of Obstetrics and Gynaecology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - E Pajkrt
- Department of Obstetrics and Gynaecology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynaecology, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - B W J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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21
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Gijtenbeek M, Haak MC. [The standard mid-pregnancy anomaly scan in the Netherlands: what is its effect?]. Ned Tijdschr Geneeskd 2017; 161:D1293. [PMID: 28659205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
- The mid-pregnancy anomaly scan was introduced into the Netherlands in 2007. The scan is performed at 18- 21 weeks of pregnancy.- The detection rate of open spina bifida is 94%.- In the Netherlands, 60% of all congenital heart defects are diagnosed prenatally compared with 35-40% in other countries. There is a strong relationship between the severity of the heart defect and the detection rate, as more than 95% of all univentricular heart defects are detected.- The detection rate of isolated cleft lip and cleft palate has increased from 32% to 87%.- The absolute number of abortions has not increased since the implementation of the anomaly scan. However, perinatal morbidity and mortality have decreased.- To further increase the quality of the screening programme, prenatal and postnatal congenital defect registries should be linked and studies into the effect of intensive training of sonographists with modern teaching methods should be performed.
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Affiliation(s)
- M Gijtenbeek
- Leids Universitair Medisch Centrum, afd. Verloskunde, Leiden
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22
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Gijtenbeek M, Haak MC, Ten Harkel DJ, Te Pas AB, Middeldorp JM, Klumper FJCM, van Geloven N, Oepkes D, Lopriore E. Persistent Pulmonary Hypertension of the Newborn in Twin-Twin Transfusion Syndrome: A Case-Control Study. Neonatology 2017; 112:402-408. [PMID: 28926832 DOI: 10.1159/000478844] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 06/20/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Persistent pulmonary hypertension of the newborn (PPHN) is associated with severe morbidity and mortality. Twin-twin transfusion syndrome (TTTS) is suggested to increase the risk of PPHN. OBJECTIVES To describe the incidence of PPHN in TTTS twins and to identify risk factors in TTTS twins for the development of severe PPHN. METHODS Cases with severe PPHN were extracted from our monochorionic twin database (2002-2016). Severe PPHN was defined as severe hypoxaemia requiring mechanical ventilation and inhaled nitric oxide (iNO) treatment, confirmed by strict echocardiographic criteria. A case-control comparison within TTTS survivors was conducted to identify risk factors for PPHN. RESULTS The incidence of PPHN in TTTS twins was 4% (24/598, 95% confidence interval [CI] 2.7-5.9%) and 0.4% (2/493, 95% CI 0.1-1.5%) in uncomplicated monochorionic twins (odds ratio [OR] 10.3, 95% CI 2.4-43.9; p = 0.002). Two risk factors were independently associated with PPHN: severe prematurity (OR 3.3, 95% CI 1.0-11.4) and recipient status (OR 3.9, 95% CI 1.4-11.0). In TTTS recipients, another risk factor for PPHN is anaemia at birth (OR 7.2, 95% CI 1.8-29.6). CONCLUSION Clinicians caring for neonates with TTTS should be aware of the 10-fold increased risk of PPHN compared to uncomplicated monochorionic twins. PPHN occurs more often in case of premature delivery and in recipient twins, particularly in the presence of anaemia at birth. As the development of severe PPHN is difficult to predict, we advise that all TTTS twins should be delivered in a tertiary care centre with iNO treatment options.
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Affiliation(s)
- Manon Gijtenbeek
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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23
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Jansen FAR, Blom NA, Haak MC. Re: Prevalence of prenatal brain abnormalities in fetuses with congenital heart disease: a systematic review. Ultrasound Obstet Gynecol 2016; 48:538-539. [PMID: 27704668 DOI: 10.1002/uog.16022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/08/2016] [Indexed: 06/06/2023]
Affiliation(s)
- F A R Jansen
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands.
| | - N A Blom
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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24
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Jansen FAR, van Zwet EW, Rijlaarsdam MEB, Pajkrt E, van Velzen CL, Zuurveen HR, Kragt A, Bax CL, Clur SAB, van Lith JMM, Blom NA, Haak MC. Head growth in fetuses with isolated congenital heart defects: lack of influence of aortic arch flow and ascending aorta oxygen saturation. Ultrasound Obstet Gynecol 2016; 48:357-364. [PMID: 27256792 DOI: 10.1002/uog.15980] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 05/02/2016] [Accepted: 05/27/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Congenital heart defects (CHDs) are reported to be associated with a smaller fetal head circumference (HC) and neurodevelopmental delay. Recent studies suggest that altered intrauterine brain hemodynamics may explain these findings. Our objectives were to evaluate the pattern of head growth in a large cohort of fetuses with various types of CHD, analyze these patterns according to the type of CHD and estimate the effect of cerebral hemodynamics with advancing gestation in the second and third trimesters. METHODS Singleton fetuses with an isolated CHD were selected from three fetal medicine units (n = 436). Cases with placental insufficiency or genetic syndromes were excluded. CHD types were clustered according to the flow and oxygen saturation in the aorta. Z-scores of biometric data were constructed using growth charts of a normal population. HC at different gestational ages was evaluated and univariate and multivariate mixed regression analyses were performed to examine the patterns of prenatal HC growth. RESULTS Fetuses with severe and less severe types of CHD demonstrated statistically significant HC growth restriction with increasing gestational age (slope of -0.017/day); however, there was no statistically significant effect of fetal hemodynamics on HC growth. Fetuses with CHD but normal brain oxygenation and normal aortic flow showed a significant decrease in HC growth (slope of -0.024/day). Only fetuses with isolated tetralogy of Fallot demonstrated a smaller HC z-score at 20 weeks of gestation (-0.67 (95% CI, -1.16 to -0.18)). CONCLUSIONS Despite the decline in head growth in fetuses with a prenatally detected isolated CHD, HC values were within the normal range, raising the question of its clinical significance. Furthermore, in contrast to other studies, this large cohort did not establish a significant correlation between aortic flow or oxygen saturation and HC growth. Factors other than altered fetal cerebral hemodynamics may contribute to HC growth restriction with increasing gestational age, such as (epi)genetic or placental factors. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F A R Jansen
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - E W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - M E B Rijlaarsdam
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Pajkrt
- Department of Obstetrics, AMC University Hospital, Amsterdam, The Netherlands
| | - C L van Velzen
- Department of Obstetrics, VU Medical Center, Amsterdam, The Netherlands
| | - H R Zuurveen
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - A Kragt
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - C L Bax
- Department of Obstetrics, VU Medical Center, Amsterdam, The Netherlands
| | - S-A B Clur
- Department of Pediatric Cardiology, AMC University Hospital, Amsterdam, The Netherlands
| | - J M M van Lith
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - N A Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatric Cardiology, AMC University Hospital, Amsterdam, The Netherlands
| | - M C Haak
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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25
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van Velzen CL, Clur SA, Rijlaarsdam MEB, Pajkrt E, Bax CJ, Hruda J, de Groot CJM, Blom NA, Haak MC. Prenatal diagnosis of congenital heart defects: accuracy and discrepancies in a multicenter cohort. Ultrasound Obstet Gynecol 2016; 47:616-622. [PMID: 26350159 DOI: 10.1002/uog.15742] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 08/05/2015] [Accepted: 09/03/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To examine the accuracy of fetal echocardiography in diagnosing congenital heart disease (CHD) at the fetal medicine units of three tertiary care centers. METHODS This was a multicenter cohort study of tertiary echocardiography referrals between 2002 and 2012. Prenatal and postnatal diagnoses were compared and the degree of agreement was classified as 'correct' (anatomy correct and the postnatal diagnosis led to a similar outcome as expected), 'discrepant' (anatomical discrepancies present but the severity and prognosis of the defect were diagnosed correctly) or 'no similarity' (the pre- and postnatal diagnoses differed completely). RESULTS We included 708 cases with CHD for which both prenatal and postnatal data were available. The prenatal diagnosis was correct in 82.1% of cases and discrepancies present were present in 9.9%; however, these did not result in a different outcome. In 8.1% there was no similarity between prenatal and postnatal diagnoses. Disagreement between pre- and postnatal diagnoses occurred significantly more frequently in cases that presented with a normal four-chamber view than in those with an abnormal four-chamber view (5.5% vs 1.9%). Incorrect identification of the outflow tracts and incorrect differentiation between unbalanced atrioventricular septal defect and hypoplastic left heart syndrome were relatively commonly encountered. In many cases with disagreement, trisomy 21, extracardiac anomaly or a high maternal body mass index was present. CONCLUSIONS The prenatal diagnosis and estimated prognosis of fetal echocardiography in our tertiary referral centers were appropriate in 92% of cases. Some types of CHD remain difficult to diagnose or rule-out prenatally, therefore awareness and education are of considerable importance. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C L van Velzen
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - S A Clur
- Department of Pediatric Cardiology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - M E B Rijlaarsdam
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Pajkrt
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - C J Bax
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - J Hruda
- Department of Pediatric Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - N A Blom
- Department of Pediatric Cardiology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
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26
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Eschbach SJ, Boons LSTM, Wolterbeek R, Middeldorp JM, Klumper FJCM, Lopriore E, Oepkes D, Haak MC. Prediction of single fetal demise after laser therapy for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2016; 47:356-362. [PMID: 26395988 DOI: 10.1002/uog.15753] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/16/2015] [Accepted: 09/02/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Single fetal demise (SFD) occurs in up to 20% of monochorionic pregnancies treated with laser coagulation for twin-twin transfusion syndrome (TTTS). We aimed to determine the independent factors associated with SFD to improve outcome in the care of TTTS pregnancies in the future. METHODS This was a case-control study on twin pregnancies treated for TTTS between 2007 and 2013. Data on ultrasound, laser surgery and outcome were retrieved from our monochorionic twin database. We analyzed separately cases of SFD in donor and recipient twins, and compared them with treated pregnancies that resulted in two live births. RESULTS Of the 273 TTTS pregnancies treated with laser coagulation, SFD occurred in 30 donors (11.0%) and 27 recipients (9.9%). In 67% of pregnancies with SFD, the death occurred within 1 week after laser treatment. For SFD in donors, absent/reversed end-diastolic flow in the umbilical artery was the strongest predictor (odds ratio (OR), 3.0 (95% CI, 1.1-8.0); P = 0.01), followed by the presence of an arterioarterial anastomosis (OR, 4.2 (95% CI, 1.4-13.1); P = 0.03) and discordance in estimated fetal weight (OR, 1.0 (95% CI, 1.0-1.1); P = 0.04). For SFD in recipients, independent predictors were absent/reversed A-wave in the ductus venosus (OR, 3.6 (95% CI, 1.2-10.5); P = 0.02) and the absence of recipient-to-donor arteriovenous anastomoses (OR, 10.6 (95% CI, 1.8-62.0); P < 0.01). CONCLUSIONS Our findings confirm earlier reports that suggest that abnormal blood flow is associated with SFD after laser treatment for TTTS. The association of SFD with the type of anastomoses is a new finding. We speculate that the type of anastomoses present determines the degree of hemodynamic change during laser therapy. Future strategies should aim at stabilizing fetal circulation before laser therapy to decrease the vulnerability to acute preload and afterload changes. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S J Eschbach
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L S T M Boons
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - R Wolterbeek
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J C M Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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27
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van der Ven AJ, van Os MA, Kleinrouweler CE, Verhoeven CJM, de Miranda E, Bossuyt PM, de Groot CJM, Haak MC, Pajkrt E, Mol BWJ, Kazemier BM. Midpregnancy Cervical Length in Nulliparous Women and its Association with Postterm Delivery and Intrapartum Cesarean Delivery. Am J Perinatol 2016; 33:40-6. [PMID: 26115020 DOI: 10.1055/s-0035-1556067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the association between midpregnancy cervical length and postterm delivery and cesarean delivery during labor. STUDY DESIGN In a multicenter cohort study, cervical length was measured in low-risk singleton pregnancies between 16 and 22 weeks of gestation. From this cohort, we identified nulliparous women who delivered beyond 34 weeks and calculated cervical length quartiles. We performed logistic regression to compare the risk of postterm delivery and intrapartum cesarean delivery to cervical length quartiles, using the lowest quartile as a reference. We adjusted for induction of labor, maternal age, ethnicity, cephalic position, preexisting hypertension, and gestational age at delivery. RESULTS We studied 5,321 nulliparous women. Women with cervical length in the 3rd and 4th quartile were more likely to deliver at 42(+0) to 42(+6) weeks (adjusted odds ratio [aOR] 2.02, 95% confidence interval [CI] 1.07-3.79 and aOR 1.97, 95% CI 1.06-3.67, respectively). The frequency of intrapartum cesarean delivery increased with cervical length quartile from 9.4% in the 1st to 14.9% in the 4th quartile (p = 0.01). This increase was only present in intrapartum cesarean delivery because of failure to progress and not because of fetal distress. CONCLUSION The longer the cervix at midtrimester the higher the risk of both postterm delivery and intrapartum cesarean delivery.
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Affiliation(s)
- A J van der Ven
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
| | - M A van Os
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
| | - C E Kleinrouweler
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
| | - C J M Verhoeven
- Department of Obstetrics and Gynaecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - E de Miranda
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
| | - P M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics (KEBB), Academic Medical Center, Amsterdam, The Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
| | - M C Haak
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Pajkrt
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
| | - B W J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Australia
| | - B M Kazemier
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
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28
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Bruijn MMC, Vis JY, Wilms FF, Oudijk MA, Kwee A, Porath MM, Oei G, Scheepers HCJ, Spaanderman MEA, Bloemenkamp KWM, Haak MC, Bolte AC, Vandenbussche FPHA, Woiski MD, Bax CJ, Cornette JMJ, Duvekot JJ, Nij Bijvanck BWA, van Eyck J, Franssen MTM, Sollie KM, van der Post JAM, Bossuyt PMM, Opmeer BC, Kok M, Mol BWJ, van Baaren GJ. Quantitative fetal fibronectin testing in combination with cervical length measurement in the prediction of spontaneous preterm delivery in symptomatic women. BJOG 2015; 123:1965-1971. [DOI: 10.1111/1471-0528.13752] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2015] [Indexed: 11/29/2022]
Affiliation(s)
- MMC Bruijn
- Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| | - JY Vis
- Clinical Chemistry and Haematology; University Medical Centre Utrecht; Utrecht the Netherlands
| | - FF Wilms
- Obstetrics and Gynaecology; Catharina Hospital; Eindhoven the Netherlands
| | - MA Oudijk
- Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| | - A Kwee
- Obstetrics and Gynaecology; University Medical Centre Utrecht; Utrecht the Netherlands
| | - MM Porath
- Obstetrics and Gynaecology; Máxima Medical Centre; Veldhoven the Netherlands
| | - G Oei
- Obstetrics and Gynaecology; Máxima Medical Centre; Veldhoven the Netherlands
| | - HCJ Scheepers
- Obstetrics and Gynaecology; University Hospital Maastricht; Maastricht the Netherlands
| | - MEA Spaanderman
- Obstetrics and Gynaecology; University Hospital Maastricht; Maastricht the Netherlands
| | - KWM Bloemenkamp
- Obstetrics; Leiden University Medical Centre; Leiden the Netherlands
| | - MC Haak
- Obstetrics; Leiden University Medical Centre; Leiden the Netherlands
| | - AC Bolte
- Obstetrics and Gynaecology; Radboud University Medical Centre; Nijmegen the Netherlands
| | - FPHA Vandenbussche
- Obstetrics and Gynaecology; Radboud University Medical Centre; Nijmegen the Netherlands
| | - MD Woiski
- Obstetrics and Gynaecology; Radboud University Medical Centre; Nijmegen the Netherlands
| | - CJ Bax
- Obstetrics and Gynaecology; VU University Medical Centre; Amsterdam the Netherlands
| | - JMJ Cornette
- Obstetrics and Gynaecology; Erasmus Medical Centre; Rotterdam the Netherlands
| | - JJ Duvekot
- Obstetrics and Gynaecology; Erasmus Medical Centre; Rotterdam the Netherlands
| | - BWA Nij Bijvanck
- Obstetrics and Gynaecology; Isala Clinics; Zwolle the Netherlands
| | - J van Eyck
- Obstetrics and Gynaecology; Isala Clinics; Zwolle the Netherlands
| | - MTM Franssen
- Obstetrics and Gynaecology; University Medical Centre Groningen; Groningen the Netherlands
| | - KM Sollie
- Obstetrics and Gynaecology; University Medical Centre Groningen; Groningen the Netherlands
| | - JAM van der Post
- Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| | - PMM Bossuyt
- Clinical Epidemiology, Biostatistics and Bioinformatics; Academic Medical Centre; Amsterdam the Netherlands
| | - BC Opmeer
- Clinical Research Unit; Academic Medical Centre; Amsterdam the Netherlands
| | - M Kok
- Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| | - BWJ Mol
- The Robinson Institute; School of Paediatrics and Reproductive Health; University of Adelaide; Adelaide SA Australia
| | - G-J van Baaren
- Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
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29
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Grande M, Jansen FAR, Blumenfeld YJ, Fisher A, Odibo AO, Haak MC, Borrell A. Genomic microarray in fetuses with increased nuchal translucency and normal karyotype: a systematic review and meta-analysis. Ultrasound Obstet Gynecol 2015; 46:650-658. [PMID: 25900824 DOI: 10.1002/uog.14880] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 04/09/2015] [Accepted: 04/10/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To estimate the incremental yield of detecting copy number variants (CNVs) by genomic microarray over karyotyping in fetuses with increased nuchal translucency (NT) diagnosed by first-trimester ultrasound. METHODS This was a systematic review conducted in accordance with PRISMA criteria. We searched PubMed, Ovid MEDLINE and Web of Science for studies published between January 2009 and January 2015 that described CNVs in fetuses with increased NT, usually defined as ≥ 3.5 mm, and normal karyotype. Search terms included: fetal or prenatal, nuchal translucency or cystic hygroma or ultrasound anomaly, array comparative genomic hybridization or copy number variants, with related search terms. Risk differences were pooled to estimate the overall and stratified microarray incremental yield using RevMan. Quality assessment of included studies was performed using the Quality Assessment tool for Diagnostic Accuracy Studies (QUADAS-2) checklist. RESULTS Seventeen studies met the inclusion criteria for analysis. Meta-analysis indicated an incremental yield of 5.0% (95% CI, 2.0-8.0%) for the detection of CNVs using microarray when pooling results. Stratified analysis of microarray results demonstrated a 4.0% (95% CI, 2.0-7.0%) incremental yield in cases of isolated NT and 7.0% (95% CI, 2.0-12.0%) when other malformations were present. The most common pathogenic CNVs reported were 22q11.2 deletion, 22q11.2 duplication, 10q26.12q26.3 deletion and 12q21q22 deletion. The pooled prevalence for variants of uncertain significance was 1%. CONCLUSION The use of genomic microarray provides a 5.0% incremental yield of detecting CNVs in fetuses with increased NT and normal karyotype.
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Affiliation(s)
- M Grande
- Department of Maternal-Fetal Medicine, Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Catalonia, Spain
| | - F A R Jansen
- Leiden University Medical Center, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
| | - Y J Blumenfeld
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - A Fisher
- Elliot Health System, Manchester, NH, USA
| | - A O Odibo
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of South Florida, Tampa, FL, USA
| | - M C Haak
- Leiden University Medical Center, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
| | - A Borrell
- Department of Maternal-Fetal Medicine, Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Catalonia, Spain
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30
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van Steenis A, Zhao DP, Steggerda SJ, Kist WJ, Haak MC, Oepkes D, Lopriore E. Double fatal outcome after ruptured vasa previa in monochorionic twins: case report and review of the literature. J Matern Fetal Neonatal Med 2015; 29:2523-6. [PMID: 26366672 DOI: 10.3109/14767058.2015.1092957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Vasa previa is a condition in which one or more fetal blood vessels run through the amniotic membranes and cross or run near the external orifice of the uterus. Rupture of membranes can lead to tearing of these vessels and cause acute fetal exsanguination. In monochorionic twin (MC) pregnancies, acute exsanguination in one twin can lead to severe complications in the co-twin due to the presence of inter-twin placental vascular connections. We report a MC pair with severe perinatal asphyxia due to acute exsanguination after prenatally undetected ruptured vasa previa. This resulted in severe hemorrhagic shock in both twins with double fatal outcome. Antenatal detection of vasa previa is of paramount importance to prevent severe morbidity and mortality, especially in MCs. A review of the literature is presented.
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Affiliation(s)
- A van Steenis
- a Division of Neonatology , Department of Pediatrics, Leiden University Medical Center , Leiden , the Netherlands and
| | - D P Zhao
- a Division of Neonatology , Department of Pediatrics, Leiden University Medical Center , Leiden , the Netherlands and
| | - S J Steggerda
- a Division of Neonatology , Department of Pediatrics, Leiden University Medical Center , Leiden , the Netherlands and
| | - W J Kist
- b Division of Fetal Medicine , Department of Obstetrics, Leiden University Medical Center , Leiden , the Netherlands
| | - M C Haak
- b Division of Fetal Medicine , Department of Obstetrics, Leiden University Medical Center , Leiden , the Netherlands
| | - D Oepkes
- b Division of Fetal Medicine , Department of Obstetrics, Leiden University Medical Center , Leiden , the Netherlands
| | - Enrico Lopriore
- a Division of Neonatology , Department of Pediatrics, Leiden University Medical Center , Leiden , the Netherlands and
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31
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van Os MA, van der Ven AJ, Bloemendaal PM, Pajkrt E, de Groot CJM, Mol BWJ, Haak MC. Effect of e-learning on quality of cervical-length measurements. Ultrasound Obstet Gynecol 2015; 46:327-331. [PMID: 25504977 DOI: 10.1002/uog.14764] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 12/03/2014] [Accepted: 12/03/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To assess the effect of implementation of a newly developed e-learning module on the quality of cervical-length measurements. METHODS With the introduction of cervical-length (CL) measurement in a research setting, a CL measurement e-learning module (CLEM) was developed with the purpose to enhance the knowledge and skills of experienced ultrasonographers. CLEM was designed specifically for ultrasonographers who perform ultrasound in a general obstetrical practice but who do not regularly perform CL measurements. CLEM consists of five theoretical questions and three caliper-placement tests to learn the CL measurement technique. The quality of the CL measurements of CLEM participants was compared with images of non-participants using a CL measurement image score (CIS), defined as the sum of six items which assess the quality of the image. Each CLEM participant submitted five CL images and the images of non-CLEM participants were selected randomly from an ultrasound database. RESULTS The CIS of the CLEM participants (n = 61) were significantly higher than those of non-CLEM participants (n = 23) (164.9 vs 155.6, respectively; P = 0.03). Visualization of the internal os and positioning of the calipers on the internal and external ora were found to have significantly higher CIS among the CLEM participants than among the non-CLEM participants (P = 0.001 and P < 0.001, respectively). CONCLUSIONS Introducing CLEM may improve the quality of CL measurements obtained by trained and untrained sonographers.
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Affiliation(s)
- M A van Os
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - A J van der Ven
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - P M Bloemendaal
- Department of Surgery and Education, Leiden University Medical Center, Leiden, The Netherlands
| | - E Pajkrt
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - B W J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, SA, Australia
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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32
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Peeters SHP, Akkermans J, Slaghekke F, Bustraan J, Lopriore E, Haak MC, Middeldorp JM, Klumper FJ, Lewi L, Devlieger R, De Catte L, Deprest J, Ek S, Kublickas M, Lindgren P, Tiblad E, Oepkes D. Simulator training in fetoscopic laser surgery for twin-twin transfusion syndrome: a pilot randomized controlled trial. Ultrasound Obstet Gynecol 2015; 46:319-326. [PMID: 26036333 DOI: 10.1002/uog.14916] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 05/17/2015] [Accepted: 05/22/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the effect of a newly developed training curriculum on the performance of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS) using an advanced high-fidelity simulator model. METHODS Ten novices were randomized to receive verbal instructions and either skills training using the simulator (study group; n = 5) or no training (control group; n = 5). Both groups were evaluated with a pre-training and post-training test on the simulator. Performance was assessed by two independent observers and comprised a 52-item checklist for surgical performance (SP) score, measurement of procedure time and number of anastomoses missed. Eleven experts set the benchmark level of performance. Face validity and educational value of the simulator were assessed using a questionnaire. RESULTS Both groups showed an improvement in SP score at the post-training test compared with the pre-training test. The simulator-trained group significantly outperformed the control group, with a median SP score of 28 (54%) in the pre-test and 46 (88%) in the post-test vs 25 (48%) and 36 (69%), respectively (P = 0.008). Procedure time decreased by 11 min (from 44 to 33 min) in the study group vs 1 min (from 39 to 38 min) in the control group (P = 0.69). There was no significant difference in the number of missed anastomoses at the post-training test between the two groups (1 vs 0). Subsequent feedback provided by the participants indicated that training on the simulator was perceived as a useful educational activity. CONCLUSIONS Proficiency-based simulator training improves performance, indicated by SP score, for fetoscopic laser therapy. Despite the small sample size of this study, practice on a simulator is recommended before trainees carry out laser therapy for TTTS in pregnant women.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J Akkermans
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J Bustraan
- PLATO, Center for Research and Development in Education and Training, Faculty of Social Sciences, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - R Devlieger
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - L De Catte
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - S Ek
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - M Kublickas
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - P Lindgren
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - E Tiblad
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - D Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Adriaanse BME, Uittenbogaard LB, Tromp CHN, Schaefer SS, Heymans MW, van Vugt JMG, Haak MC. Prenatal examination of the area and morphology of the atrioventricular valves using four-dimensional ultrasound in normal and abnormal hearts. Prenat Diagn 2015; 35:741-7. [PMID: 26125132 DOI: 10.1002/pd.4569] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 01/23/2015] [Accepted: 01/25/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Our aim is to evaluate the feasibility to examine the morphology and area of the atrioventricular (AV) valves in normal fetuses and fetuses with cardiac defects using spatiotemporal image correlation (STIC). METHODS Atrioventricular valves were analyzed longitudinally in STIC volumes of 74 normal fetuses between the 15th and 36th week of pregnancy. The valve area was measured in a rendered view in diastole, the number of valve leaflets in systole. Longitudinal data analysis was performed using linear mixed models. Fifty fetuses with cardiac defects were examined. RESULTS Examination of 355 STIC volumes of normal fetuses showed in 82.5% sufficient quality. The tricuspid valve leaflets were seen in 200 (68.3%) volumes and the mitral valve leaflets in 219 (74.7%) volumes. The tricuspid valve showed in 61.1% a round, 29.0% rectangle, and 8.9% elliptical shape and the mitral valve in 60.1% round, 28.0% rectangle, and 10.9% elliptical. Regression analysis revealed a positive relationship of the valve area with gestational age (p < 0.0001). Most heart defects with stenosis showed an area below the 5th percentile. CONCLUSION Prenatal examination of the morphology and area of the AV valves using four-dimensional ultrasound is feasible. A rectangular valve opening is normal, which was visualized in about one third of the normal fetuses.
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Affiliation(s)
- B M E Adriaanse
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - L B Uittenbogaard
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - C H N Tromp
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - S S Schaefer
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - M W Heymans
- Department of Epidemiology & Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - J M G van Vugt
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M C Haak
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
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van de Mheen L, Everwijn SMP, Knapen MFCM, Haak MC, Engels MAJ, Manten GTR, Zondervan HA, Wirjosoekarto SAM, van Vugt JMG, Erwich JJHM, Bilardo CM, van Pampus MG, de Groot CJM, Mol BWJ, Pajkrt E. Pregnancy outcome after fetal reduction in women with a dichorionic twin pregnancy. Hum Reprod 2015; 30:1807-12. [PMID: 26093542 DOI: 10.1093/humrep/dev132] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 05/01/2015] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION What are the pregnancy outcomes for women with a twin pregnancy that is reduced to a singleton pregnancy? SUMMARY ANSWER Fetal reduction of a twin pregnancy significantly improves gestational age at birth and neonatal birthweight, however at an increased risk of pregnancy loss and preterm delivery. WHAT IS KNOWN ALREADY Women with a multiple pregnancy are at increased risk for preterm delivery. Fetal reduction can be considered in these women. STUDY DESIGN, SIZE, AND DURATION Retrospective cohort study of 118 women with a twin pregnancy reduced to a singleton pregnancy between 2000 and 2010. PARTICIPANTS/MATERIALS, SETTING, AND METHODS We compared the outcome of pregnancy in consecutive women with a dichorionic twin pregnancy that was reduced to a singleton pregnancy to that of women with a dichorionic twin pregnancy that was managed expectantly and women with a primary singleton pregnancy. Reductions were performed between 10-23(6/7) weeks' gestation by intracardiac or intrathoracic injection of potassium chloride, mostly for congenital anomalies. We compared median gestational age, pregnancy loss <24 weeks, preterm delivery <32 weeks, neonatal birthweight and perinatal deaths. MAIN RESULTS AND THE ROLE OF CHANCE We studied 118 women with a twin pregnancy that was reduced to a singleton, 818 women with an ongoing dichorionic twin pregnancy and 611 women with a primary singleton pregnancy. Loss of the entire pregnancy <24 weeks and preterm delivery occurred significantly more in the reduction group compared with the ongoing twin group (11.9 versus 3.1% <24 weeks, P< 0.001 and 18.6 versus 11.5% <32 weeks, respectively, P < 0.001). In the reduction group, the percentage of women without any surviving child was significantly higher compared with the ongoing twin and primary singleton group (14.4, 3.4 and 0.7%, respectively, P < 0.001). Median gestational age was 38.9 weeks (interquartile range (IQR) 34.7-40.3) for reduced pregnancies, 37.1 weeks (IQR 35.3-38.1) for ongoing twin pregnancies and 40.1 (IQR 39.1-40.9) for primary singletons (P < 0.001 for all comparisons). LIMITATIONS, REASONS FOR CAUTION The main limitations of the study were its retrospective character, and the fact that indications for reduction were heterogeneous. WIDER IMPLICATIONS OF THE FINDINGS In women with a dichorionic twin pregnancy fetal reduction increases median gestational age only at considerable risk of complete early pregnancy loss. STUDY FUNDING/COMPETING INTERESTS The study was not funded. None of the authors has conflicts of interest.
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Affiliation(s)
- L van de Mheen
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - S M P Everwijn
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - M F C M Knapen
- Department of Obstetrics and Prenatal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M C Haak
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - M A J Engels
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - G T R Manten
- Department of Obstetrics and Gynecology, University Medical Center, Utrecht, The Netherlands
| | - H A Zondervan
- Department of Obstetrics and Gynecology, Rijnstate Hospital, Arnhem, The Netherlands
| | - S A M Wirjosoekarto
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - J M G van Vugt
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J J H M Erwich
- Department of Obstetrics and Gynecology, University Medical Center, Groningen, The Netherlands
| | - C M Bilardo
- Department of Obstetrics and Gynecology, University Medical Center, Groningen, The Netherlands
| | - M G van Pampus
- Department of Obstetrics and Gynecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
| | - B W J Mol
- The Robinson Institute, School of Reproductive Health and Paediatrics, University of Adelaide, Adelaide, Australia
| | - E Pajkrt
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
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Boere I, Roest AAW, Wallace E, Ten Harkel ADJ, Haak MC, Morley CJ, Hooper SB, te Pas AB. Umbilical blood flow patterns directly after birth before delayed cord clamping. Arch Dis Child Fetal Neonatal Ed 2015; 100:F121-5. [PMID: 25389141 DOI: 10.1136/archdischild-2014-307144] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Delayed umbilical cord clamping (DCC) affects the cardiopulmonary transition and blood volume in neonates immediately after birth. However, little is known of blood flow in the umbilical vessels immediately after birth during DCC. The objective is to describe the duration and patterns of blood flow through the umbilical vessels during DCC. METHODS Arterial and venous umbilical blood flow was measured during DCC using Doppler ultrasound in uncomplicated term vaginal deliveries. Immediately after birth, the probe was placed in the middle of the umbilical cord, pattern and duration of flow in vein and arteries were evaluated until cord clamping. RESULTS Thirty infants were studied. Venous flow: In 10% no flow was present, in 57% flow stopped at 4:34 (3:03-7:31) (median (IQR) min:sec) after birth, before the cord was clamped. In 33%, flow continued until cord clamping at 5:13 (2:56-9:15) min:sec. Initially, venous flow was intermittent, increasing markedly during large breaths or stopping and reversing during crying, but then became continuous. Arterial flow: In 17% no flow was present, in 40% flow stopped at 4:22 (2:29-7:17) min:sec, while cord pulsations were still palpable. In 43% flow continued until the cord was clamped at 5:16 (3:32-10:10) min:sec. Arterial flow was pulsatile, unidirectional towards placenta or bidirectional to/from placenta. In 40% flow became continuous towards placenta later on. CONCLUSIONS During delayed umbilical cord clamping, venous and arterial umbilical flow occurs for longer than previously described. Net placental transfusion is probably the result of several factors of which breathing could play a major role. Umbilical flow is unrelated to cessation of pulsations.
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Affiliation(s)
- I Boere
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - A A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - E Wallace
- The Ritchie Centre, Monash Institute for Medical Research, Monash University, Clayton, Victoria, Australia
| | - A D J Ten Harkel
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - M C Haak
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - C J Morley
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - S B Hooper
- The Ritchie Centre, Monash Institute for Medical Research, Monash University, Clayton, Victoria, Australia
| | - A B te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
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van Velzen CL, Haak MC, Reijnders G, Rijlaarsdam MEB, Bax CJ, Pajkrt E, Hruda J, Galindo-Garre F, Bilardo CM, de Groot CJM, Blom NA, Clur SA. Prenatal detection of transposition of the great arteries reduces mortality and morbidity. Ultrasound Obstet Gynecol 2015; 45:320-325. [PMID: 25297053 DOI: 10.1002/uog.14689] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/30/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the prenatal detection of transposition of the great arteries (TGA), after the introduction of a Dutch screening program in 2007, as well as the effect of prenatal detection on pre- and postsurgical mortality and morbidity. METHODS In a geographical cohort study, all infants with TGA who were born between 1 January 2002 and 1 January 2012 were included. The cases were divided into two groups: those with and those without a prenatal diagnosis. Pre- and postsurgical mortality was assessed, with a follow-up of 1 year. Presurgical morbidity was assessed in terms of cardiovascular compromise, metabolic acidosis, renal and/or hepatic dysfunction and closure of the duct before initiation of therapy. RESULTS Of all cases (n = 144), 26.4% were diagnosed prenatally, with detection rates of 15.7% and 41.0% in the first and last 5 years of the study period, respectively. First-year mortality was significantly lower in cases with a prenatal diagnosis of TGA than in those without (0.0% vs 11.4%, respectively). Presurgical mortality (4.9%) only occurred in undetected simple TGA cases. Closure of the duct before treatment, renal dysfunction and hypoxia occurred significantly more often in the group without a prenatal diagnosis. CONCLUSIONS The prenatal detection rate of TGA has increased significantly since the introduction of the screening program in 2007. Prenatal diagnosis is an important factor that contributes to survival of the infant in the first postnatal year. Furthermore, some morbidity indicators were significantly higher in the group without a prenatal diagnosis. These results justify efforts to improve prenatal screening programs.
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Affiliation(s)
- C L van Velzen
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
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van der Ven AJ, van Os MA, Kleinrouweler CE, de Groot CJM, Haak MC, Mol BWJ, Pajkrt E, Kazemier BM. Is cervical length associated with maternal characteristics? Eur J Obstet Gynecol Reprod Biol 2015; 188:12-6. [PMID: 25770842 DOI: 10.1016/j.ejogrb.2015.02.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/24/2014] [Accepted: 02/19/2015] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Women with a mid-trimester short cervical length (CL) are at increased risk for preterm delivery. Consequently, CL measurement is a potential screening tool to identify women at risk for preterm birth. Our objective was to assess possible associations between CL and maternal characteristics. STUDY DESIGN A nationwide screening study was performed in which CL was measured during the standard anomaly scan among low risk women with a singleton pregnancy. Data on maternal height, pre-pregnancy weight, ethnicity, parity and gestational age at the time of the CL measurement were collected from January 2010 to December 2012. Univariable and multivariable linear regression analyses were performed to assess the relationship between CL and maternal characteristics. RESULTS We included 5092 women. The mean CL was 44.3mm. No association was found between CL and maternal height or gestational age of the measurement. Maternal weight was associated with CL (p=0.007, adjusted R(2) 0.03). Separate analysis for BMI did not change these results. Ethnicity, known in 2702 out of 5092 women, was associated with CL (mean CL in Caucasian women 45.0mm, Asian 43.9mm, Mediterranean 43.1mm, and African 41.8mm, p=0.003), as well as parity (mean CL multiparous 45.3mm, nulliparous 43.5mm, p<0.0001). CONCLUSION Shorter mid-trimester cervical length is associated with higher maternal weight, younger maternal age, nulliparity and non-Caucasian ethnicity, but not with maternal height.
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Affiliation(s)
- A J van der Ven
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands.
| | - M A van Os
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands.
| | - C E Kleinrouweler
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands.
| | - C J M de Groot
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands.
| | - M C Haak
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands.
| | - B W J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, 5000 SA, Australia.
| | - E Pajkrt
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands.
| | - B M Kazemier
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands.
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van Velzen CL, Clur SA, Rijlaarsdam MEB, Bax CJ, Pajkrt E, Heymans MW, Bekker MN, Hruda J, de Groot CJM, Blom NA, Haak MC. Prenatal detection of congenital heart disease--results of a national screening programme. BJOG 2015; 123:400-7. [PMID: 25625301 DOI: 10.1111/1471-0528.13274] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2014] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Congenital heart disease (CHD) is the most common congenital malformation and causes major morbidity and mortality. Prenatal detection improves the neonatal condition before surgery, resulting in less morbidity and mortality. In the Netherlands a national prenatal screening programme was introduced in 2007. This study evaluates the effects of this screening programme. DESIGN Geographical cohort study. SETTING Large referral region of three tertiary care centres. POPULATION Fetuses and infants diagnosed with severe CHD born between 1 January 2002 and 1 January 2012. METHODS Cases were divided into two groups: before and after the introduction of screening. MAIN OUTCOME MEASURES Detection rates were calculated. RESULTS The prenatal detection rate (n = 1912) increased with 23.9% (95% confidence interval [95% CI] 19.5-28.3) from 35.8 to 59.7% after the introduction of screening and of isolated CHD with 21.4% (95% CI 16.0-26.8) from 22.8 to 44.2%. The highest detection rates were found in the hypoplastic left heart syndrome, other univentricular defects and complex defects with atrial isomerism (>93%). Since the introduction of screening, the 'late' referrals (after 24 weeks of gestation) decreased by 24.3% (95% CI 19.3-29.3). CONCLUSIONS This is the largest cohort study to investigate the prenatal detection rate of severe CHD in an unselected population. A nationally organised screening has resulted in a remarkably high detection rate of CHD (59.7%) compared with earlier literature.
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Affiliation(s)
- C L van Velzen
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, the Netherlands
| | - S A Clur
- Department of Pediatric Cardiology, Academic Medical Centre, Emma Children's Hospital, Amsterdam, the Netherlands
| | - M E B Rijlaarsdam
- Department of Paediatric Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - C J Bax
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, the Netherlands
| | - E Pajkrt
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, the Netherlands
| | - M W Heymans
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, the Netherlands
| | - M N Bekker
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J Hruda
- Department of Paediatric Cardiology, VU University Medical Centre, Amsterdam, the Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, the Netherlands
| | - N A Blom
- Department of Pediatric Cardiology, Academic Medical Centre, Emma Children's Hospital, Amsterdam, the Netherlands.,Department of Paediatric Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M C Haak
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
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Jansen FAR, Blumenfeld YJ, Fisher A, Cobben JM, Odibo AO, Borrell A, Haak MC. Array comparative genomic hybridization and fetal congenital heart defects: a systematic review and meta-analysis. Ultrasound Obstet Gynecol 2015; 45:27-35. [PMID: 25319878 DOI: 10.1002/uog.14695] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 10/10/2014] [Accepted: 10/14/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Array comparative genomic hybridization (aCGH) is a molecular cytogenetic technique that is able to detect the presence of copy number variants (CNVs) within the genome. The detection rate of imbalances by aCGH compared to standard karyotyping and 22q11 microdeletion analysis by fluorescence in-situ hybridization (FISH), in the setting of prenatally-diagnosed cardiac malformations, has been reported in several studies. The objective of our study was to perform a systematic literature review and meta-analysis to document the additional diagnostic gain of using aCGH in cases of congenital heart disease (CHD) diagnosed by prenatal ultrasound examination, with the aim of assisting clinicians to determine whether aCGH analysis is warranted when an ultrasonographic diagnosis of CHD is made, and to guide counseling in this setting. METHODS Articles in PubMed, EMBASE and Web of Science databases from January 2007 to September 2014 describing CNVs in prenatal cases of CHD were included. Search terms were: 'array comparative genomic hybridization', 'copy number variants' and 'fetal congenital heart defects'. Articles regarding karyotyping or 22q11 deletion only were excluded. RESULTS Thirteen publications (including 1131 cases of CHD) met the inclusion criteria for the analysis. Meta-analysis indicated an incremental yield of 7.0% (95% CI, 5.3-8.6%) for the detection of CNVs using aCGH, excluding aneuploidy and 22q11 microdeletion cases. Subgroup results showed a 3.4% (95% CI, 0.3-6.6%) incremental yield in isolated CHD cases, and 9.3% (95% CI, 6.6-12%) when extracardiac malformations were present. Overall, an incremental yield of 12% (95% CI, 7.6-16%) was found when 22q11 deletion cases were included. There was an additional yield of 3.4% (95% CI, 2.1-4.6%) for detecting variants of unknown significance (VOUS). CONCLUSIONS In this review we provide an overview of published data and discuss the benefits and limitations of using aCGH. If karyotyping and 22q11 microdeletion analysis by FISH are normal, using aCGH has additional value, detecting pathogenic CNVs in 7.0% of prenatally diagnosed CHD, with a 3.4% additional yield of detecting VOUS.
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Affiliation(s)
- F A R Jansen
- Leiden University Medical Center, Department of Obstetrics and Fetal Medicine, Leiden, The Netherlands
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Adriaanse BME, Bartelings MM, van Vugt JMG, Chaoui R, Gittenberger-de Groot AC, Haak MC. Differential and linear insertion of atrioventricular valves: a useful tool? Ultrasound Obstet Gynecol 2014; 44:568-574. [PMID: 24515626 DOI: 10.1002/uog.13326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 12/25/2013] [Accepted: 01/28/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The differential insertion of the atrioventricular valves is the ultrasonographic representation of the more apical attachment of the tricuspid valve to the septum with respect to the mitral valve. A linear insertion is present when both valves form a linear continuum and has been suggested as a marker for atrioventricular septal defects (AVSDs). The objective of this study was to evaluate the anatomical substratum of differential and linear insertions of the atrioventricular valves in normal fetal hearts and fetal hearts with an AVSD. METHODS The extent and position of the fibrous skeleton and attachment of the atrioventricular valves to the septum were studied in histological sections of 17 normal hearts and four hearts with an AVSD from 10 + 0 weeks' gestation to 3 days postpartum with various immunohistochemical tissue markers. In addition, spatiotemporal image correlation (STIC) volumes of 10 normal hearts and STIC volumes of eight hearts with an AVSD at 13 + 6 to 35 + 5 weeks' gestation were examined. RESULTS The differential insertion of the atrioventricular valves was visible in normal hearts in the four-chamber plane immediately beneath the aorta, but nearer the diaphragm a linear insertion was found. In hearts with an AVSD, a linear appearance was observed in the four-chamber plane immediately beneath the aorta. Towards the diaphragm, however, first a differential insertion and, more caudally, a linear insertion was found. CONCLUSIONS Both differential and linear insertions can be found in normal fetal hearts and fetal hearts with AVSD, depending on the plane in which the four-chamber view is visualized. Therefore, measurement of the differential insertion is likely to be useful only in experienced hands.
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Affiliation(s)
- B M E Adriaanse
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands; Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
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Adriaanse BME, Schats J, Tromp CHN, Uittenbogaard LB, Heymans MW, van Vugt JMG, Haak MC. Differential insertion of the atrioventricular valves: measurement protocol to detect various congenital heart defects. Prenat Diagn 2014; 34:935-9. [PMID: 24760486 DOI: 10.1002/pd.4395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 01/30/2014] [Accepted: 04/20/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The objectives of this study were to develop reference values for the distance between the atrioventricular valves, called differential insertion of the atrioventricular valves (DIAVV), in normal fetuses using four-dimensional ultrasound with spatio-temporal image correlation and to explore if DIAVV measurement can differentiate between normal hearts and hearts with cardiac defects. METHODS The DIAVV was analysed longitudinally following a measurement protocol in 74 fetuses between 15 and 36 weeks gestational age. The DIAVV was measured in an apical four-chamber view of the heart in end-diastole. Furthermore, the DIAVV was measured in 70 fetuses with cardiac defects. RESULTS In total, 337 normal and 70 abnormal spatio-temporal image correlation volumes were examined. Longitudinal regression analysis revealed a positive relationship of the DIAVV with gestational age and fetal biometry (p < 0.0001). The DIAVV of fetuses with double outlet right ventricle, truncus arteriosus, atrioventricular septal defects, Ebstein and tetralogy of Fallot all differed from normal fetuses (p < 0.05). CONCLUSION Measurement of the DIAVV is a promising tool; however, a well-defined measurement protocol should be followed to accomplish the correct plane and exact moment in the cardiac cycle. This study presents new nomograms following this measurement protocol and reports an abnormal DIAVV in a wide spectrum of congenital heart disease.
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Affiliation(s)
- B M E Adriaanse
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, The Netherlands
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Adriaanse BME, Tromp CHN, Simpson JM, Van Mieghem T, Kist WJ, Kuik DJ, Oepkes D, Van Vugt JMG, Haak MC. Interobserver agreement in detailed prenatal diagnosis of congenital heart disease by telemedicine using four-dimensional ultrasound with spatiotemporal image correlation. Ultrasound Obstet Gynecol 2012; 39:203-209. [PMID: 21611994 DOI: 10.1002/uog.9059] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To evaluate the clinical accuracy of four-dimensional (4D) echocardiography in the detailed prenatal diagnosis of congenital heart disease (CHD) in a telemedicine setting. METHODS Ten second-trimester spatiotemporal image correlation (STIC) volumes were sent to three observers in different tertiary care centers with expertise in 4D echocardiography. The 10 volumes were selected based on the type of diagnosis to cover a wide spectrum of CHD anomalies, and also included one normal fetal heart. Observers were asked to provide the diagnosis, the postprocessing modalities used and the time spent on examination, and to give a rating of the confidence for the diagnosis on a 5-point Likert scale. They were free to consult other colleagues, including pediatric cardiologists, but were blinded to the prenatal diagnosis and the neonatal outcome. A diagnostic scoring system was used to evaluate different aspects of the heart defects. The results were compared with neonatal echocardiography or postmortem findings ('gold standard'). RESULTS In two cases all observers correctly diagnosed all details of the volume datasets. The observer with the best performance reached perfect agreement in six cases and nearly perfect agreement in three. The volumes were most frequently studied by sectional planes and were analyzed in a median time of 11.0 (range, 2.5-30.0) min. The median confidence score was 4.0 (range, 1.0-5.0). CONCLUSIONS In a telemedicine setting using STIC volumes, fetal cardiac anomalies can be diagnosed correctly by an expert. However, details required for adequate counseling and planning of postnatal care may be missed. STIC by telemedicine is a promising modality, although not accurate enough for exclusive use in clinical decision making regarding treatment, prognosis or termination of pregnancy.
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Affiliation(s)
- B M E Adriaanse
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands.
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van Velzen CL, Hruda J, Rammeloo LAJ, Haak MC. Supraventricular tachycardia in a neonate with the prenatal diagnosis of a single left superior vena cava. Ultrasound Obstet Gynecol 2011; 38:731-732. [PMID: 21710663 DOI: 10.1002/uog.9080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Keizer AL, Deurloo KL, van Vugt JMG, Haak MC. A prenatal diagnosis of a thyroglossal duct cyst in the fetal anterior neck. Prenat Diagn 2011; 31:1311-2. [DOI: 10.1002/pd.2872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 07/01/2011] [Accepted: 07/05/2011] [Indexed: 11/08/2022]
Affiliation(s)
- A. L. Keizer
- Onze Lieve Vrouwe Gasthuis; Amsterdam the Netherlands
| | - K. L. Deurloo
- Vrije Universiteit Medisch Centrum; Amsterdam the Netherlands
| | | | - M. C. Haak
- Leids Universitair Medisch Centrum; Leiden the Netherlands
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Uittenbogaard LB, Haak MC, Tromp CHN, Terwee CB, Van Vugt JMG. Reliability of fetal cardiac volumetry using spatiotemporal image correlation: assessment of in-vivo and in-vitro measurements. Ultrasound Obstet Gynecol 2010; 36:308-314. [PMID: 20131339 DOI: 10.1002/uog.7582] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To assess the reliability of measurement of fetal cardiac ventricular volume, stroke volume, and ejection fraction with four-dimensional ultrasound using spatiotemporal image correlation (STIC). METHODS Volume datasets were collected from two sources: 24 from fetuses over a range of gestational ages and 12 from a miniature balloon model. Datasets were analyzed by three observers, repeatedly in 12 fetal datasets and all balloon datasets. Volume calculations were obtained by manually tracing multiple parallel slices (three-dimensional (3D) slice method). Measurement error was assessed by calculating standard errors of measurement (SEM) and coefficients of variation (CV). Reliability was assessed by calculating interobserver and intraobserver intraclass correlation coefficients (ICC). RESULTS Measurement errors of balloon volumes were small and reliability was good (SEM <or= 0.07 mL, ICC 0.98-1.00). Fetal ventricle volume measurement error ranged from 0.09 to 0.20 mL and CV from 14.6 to 28.3%. Ventricular volume reliabilities for intra- and interobserver comparisons were greater than or equal to 0.94 and 0.75, respectively. Fetal stroke volume measurement error (SEM 0.17 mL), CV (21.9%) and reliability were measured (intraobserver ICC: left ventricle stroke volume (LVSV), 0.93 vs. right ventricle stroke volume (RVSV), 0.88; interobserver ICC: LVSV, 0.75 vs. RVSV, 0.86). The measurement error decreased with increasing operator experience. The reliability of ejection fraction calculations was poor (ICC < 0.7) for intra- and interobserver comparisons. CONCLUSIONS Volume measurements obtained with STIC and 3D slice methods using a balloon model were reliable. In the fetus, measurement errors decreased with increasing operator experience, and reliability was better for stroke volume than for ejection fraction.
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Affiliation(s)
- L B Uittenbogaard
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands.
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Uittenbogaard LB, Haak MC, Peters RJH, van Couwelaar GM, Van Vugt JMG. Validation of volume measurements for fetal echocardiography using four-dimensional ultrasound imaging and spatiotemporal image correlation. Ultrasound Obstet Gynecol 2010; 35:324-331. [PMID: 20084644 DOI: 10.1002/uog.7561] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To assess the accuracy and reliability of four-dimensional (4D) ultrasound imaging using spatiotemporal image correlation (STIC) employing three different techniques to measure volumes in vitro. METHODS Customized miniature balloons attached to a pump system were used to mimic fetal cardiac chambers. After the balloon model had been immersed in a bath filled with viscous gel, 4D datasets were acquired and three methods were used for volume analysis: three dimensional (3D) slice method, Virtual Organ Computer-aided AnaLysis (VOCAL) and VOCAL combined with inversion mode. Accuracy and measurement error were measured as the difference between the volume measurements and the actual volumes. Intraobserver reliability was assessed by computing coefficients of variation (CV) and intraclass correlation (ICC). RESULTS Measurement of 76 different volumes, ranging from 0.30 to 4.95 mL, resulted in a total of 912 measurements. The 3D slice method had a mean error of -3.3%, the inversion method underestimated the volumes with a mean error of -6.1%, and VOCAL had a mean error of -2.9%. The 3D slice method had the best agreement (95% limits of agreement (LOA), -11.2 to 4.7%), followed by VOCAL (95% LOA, -14.1 to 8.3%); the inversion mode demonstrated the worst agreement (95% LOA, -21.4 to 9.2%). All three methods were reliable with CV < 10% and ICC > 0.95. CONCLUSIONS 4D ultrasonography with STIC is a feasible and accurate method for calculating volumes of 0.30 mL upwards. In an in-vitro model the 3D slice method proved accurate, was the least time consuming, had the best reliability and had the smallest LOA. This method may prove useful when applied to in-vivo investigations.
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Affiliation(s)
- L B Uittenbogaard
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands.
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Uittenbogaard LB, Haak MC, Spreeuwenberg MD, van Vugt JMG. Fetal cardiac function assessed with four-dimensional ultrasound imaging using spatiotemporal image correlation. Ultrasound Obstet Gynecol 2009; 33:272-281. [PMID: 19212969 DOI: 10.1002/uog.6287] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES The goal of this study was to use spatiotemporal image correlation (STIC) to provide reference values for left and right ventricle volumes, and indices of fetal cardiac function. METHODS In this prospective longitudinal study, STIC volumes were acquired periodically from 12 weeks of gestation onwards. The STIC volumes were frozen in end-systole and end-diastole, and volumetric data were measured by manual tracing and summation of multiple slices. These ventricle volumes were used to calculate stroke volume, ejection fraction and cardiac output. RESULTS Some 202 STIC volumes of 63 fetuses were included in the analysis. Mean left and right ventricle stroke volume increased from 0.02 mL at 12 weeks to 1.41 mL and 1.46 mL, respectively, at 30 weeks, while the mean right to left stroke volume ratio remained stable at around 1.2. Mean left and right ventricle cardiac output increased from 2.40 mL/min and 2.60 mL/min at 12 weeks to 197.74 mL/min and 204.81 mL/min, respectively, at 30 weeks. Both left and right mean ejection fraction remained constant at around 0.45 with advancing gestational age. Bland-Altman analysis showed a coefficient of variation for measured stroke volume of 13.7%. CONCLUSIONS This study establishes reference values for fetal cardiac volumes and indices for fetal cardiac function from 12 to 30 weeks of gestation using STIC. STIC seems to overcome many of the pitfalls of conventional ultrasound methods and has the potential to become the method of choice.
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Affiliation(s)
- L B Uittenbogaard
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands.
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Uittenbogaard LB, Haak MC, Spreeuwenberg MD, Van Vugt JMG. A systematic analysis of the feasibility of four-dimensional ultrasound imaging using spatiotemporal image correlation in routine fetal echocardiography. Ultrasound Obstet Gynecol 2008; 31:625-632. [PMID: 18504769 DOI: 10.1002/uog.5351] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To investigate the feasibility of incorporating spatiotemporal image correlation (STIC) into a tertiary fetal echocardiography program. METHODS During the study period all pregnant women fitting our inclusion criteria were enrolled consecutively. Four sonographers participated in the study, one of whom had substantial previous experience of STIC volume acquisition and three of whom did not. STIC volumes were acquired within the time slot allocated for the usual examination and all attempts were recorded. STIC volumes were assessed on acquisition conditions, the quality (as defined by a checklist of cardiac structures that could be visualized), and the rendering abilities. Furthermore, possible learning effects and the influence of experience with STIC on volume acquisition were studied. RESULTS STIC volume acquisition was successful in 75.7% (112/148) of cases in which it was attempted. The more experienced sonographer had a higher success rate in STIC volume acquisition (experienced vs. less experienced, 88.4% vs. 70.5%, P = 0.02). Of all analyzed STIC volumes, 64.8% were of high or sufficient quality. STIC volume quality and rendering ability correlated strongly with the acquisition conditions. High-quality STIC volumes successfully rendered the intracardiac septa in 84.6% of cases. The coronal atrioventricular plane was rendered in 12/26 cases (46.2%). CONCLUSIONS This study shows that incorporation of STIC volume acquisition into the daily practice of a tertiary fetal echocardiography program is feasible. Sonographers do not have to be specifically experienced in three- or four-dimensional ultrasound imaging to acquire high-quality STIC volumes. For successful STIC acquisition and subsequent successful analysis, correct acquisition conditions are of major importance. Finally, our results demonstrate that STIC is as susceptible as conventional two-dimensional ultrasound imaging to individual variations and limitations in scanning windows.
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Affiliation(s)
- L B Uittenbogaard
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands.
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Haak MC, Twisk JWR, Bartelings MM, Gittenberger-de Groot AC, van Vugt JMG. First-trimester fetuses with increased nuchal translucency do not show altered intracardiac flow velocities. Ultrasound Obstet Gynecol 2005; 25:246-252. [PMID: 15719441 DOI: 10.1002/uog.1810] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To study intracardiac flow velocities in first-trimester fetuses with normal nuchal translucency thickness (NT) and those with increased NT. METHODS Ultrasound examinations were performed in 85 normal fetuses and 45 fetuses with NT > 95(th) percentile. Follow-up was complete and postmortem examination was performed on terminated pregnancies. Flow velocities during the early (e-wave) and late (a-wave) peaks across the tricuspid and mitral valves were measured and compared, using multilevel analysis, between the fetuses with normal and those with increased NT. In the group with increased NT, fetuses with and without a heart defect irrespective of the karyotype were compared, and in this group, euploid and aneuploid fetuses were compared, irrespective of the presence of a heart defect. RESULTS No difference in intracardiac flow velocities was found between fetuses with normal and those with increased NT. Within the group of fetuses with increased NT, there was no difference between the fetuses with and without a cardiac defect. However, comparison of aneuploid with euploid fetuses within the group with increased NT showed that both the e-wave and a-wave peaks were decreased significantly by 3.03 cm/s and 5.95 cm/s, respectively, across the tricuspid valve, and by 3.47 cm/s and 5.92 cm/s, respectively, across the mitral valve (P < 0.05). The most common cardiac malformations were septal defects. CONCLUSION There is no difference in intracardiac blood flow velocities between normal fetuses and those with increased NT. This contradicts the theory that NT is caused by impaired atrial contraction or cardiac failure. In fetuses with increased NT, those with aneuploidy show a decreased e-wave and a-wave compared with euploid fetuses. This cannot, however, be explained by the presence of cardiac defects, because there is no difference between fetuses with and without a cardiac defect. Therefore, we hypothesize that the relationship between enlarged NT and cardiac defects can only be explained by a developmental process that coexists at this period of gestation and is linked to cardiovascular development.
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Affiliation(s)
- M C Haak
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands.
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Bekker MN, Haak MC, Rekoert-Hollander M, Twisk J, Van Vugt JMG. Increased nuchal translucency and distended jugular lymphatic sacs on first-trimester ultrasound. Ultrasound Obstet Gynecol 2005; 25:239-245. [PMID: 15736181 DOI: 10.1002/uog.1831] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To investigate the presence and volume of jugular lymphatic sacs (JLS) in first-trimester fetuses with normal nuchal translucency thickness (NT) and in those with increased NT. METHODS This was a prospective study of 26 fetuses with NT > 95(th) percentile, which were compared with 137 fetuses with normal NT. Following crown-rump length (CRL) and NT measurement the neck region of the fetus was studied by transvaginal ultrasound. The JLS presented as spheroidal translusencies in the anterolateral region of the neck. RESULTS The prevalence of JLS differed significantly between fetuses with enlarged NT and the control group (P < 0.0001). In the group of 26 fetuses with increased NT, 22 had clearly visible JLS. Chorionic villus sampling revealed aneuploidy in 10 and euploidy in 16 fetuses. In the control group two fetuses, with NT values of 2.8 mm and 2.9 mm, had JLS; pregnancy outcome was normal in both cases. Logistic regression analysis in the total study group showed that an increase in NT was associated with a greater probability of JLS being present (for NT = 3-3.5 mm, probability = 0.67; for NT > 3.5 mm, probability = 0.93). In fetuses with JLS, an increase in CRL was associated with a significant increase in right JLS volume (r = 0.51; P-value = 0.01) and a non-significant increase in left sac volume (r = 0.40; P-value = 0.09). Increase in NT was not associated with a significant increase in JLS volume. CONCLUSION There is a significant association between increased NT and the presence of JLS on first-trimester ultrasound. In our opinion, the pathophysiological explanation for increased NT lies in a disturbance in lymphangiogenesis.
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Affiliation(s)
- M N Bekker
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands.
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