Outcome of 12 antenatally diagnosed fetal arachnoid cysts: case series and review of the literature

OBJECTIVES

To investigate the natural history, associated abnormalities and outcome of 12 fetuses with arachnoid cyst diagnosed antenatally by ultrasound and magnetic resonance imaging and to compare the outcome with cases in the literature.

METHODS

A retrospective study of all cases of antenatally detected fetal arachnoid cysts was performed in patients referred to a tertiary unit between 2007 and 2013. Associated abnormalities, pregnancy outcome and postnatal follow-up were analyzed. All papers about prenatally diagnosed arachnoid cysts, of the last 30 years, were evaluated (search terms in Pubmed: "prenatal diagnosis", "Arachnoid Cysts").

RESULTS

Fetal arachnoid cysts were diagnosed in 12 fetuses, 9 were females. The mean gestational age of diagnosis was 28 1/7 (range 19 1/7-34 2/7 weeks). A total of 9 cases were supratentorial, 3 were located in the posterior fossa. In 10 cases a fetal MRI was performed which confirmed brain compression in 4 out of 5 supratentorial arachnoid cyst. MRI did not reveal other malformations nor signs of nodular heterotopia. Only one fetus presented with additional major anomalies (bilateral ventricumomegaly of >20 mm and rhombencephalosynapsis) leading to a termination of pregnancy. Two neonates underwent endoscopic fenestration of the arachnoid cyst in the first week of life with no additional intervention in childhood. All but one (10/11) had a favorable postnatal outcome. This child suffered from visual impairment at autism was diagnosed at the age of 5. One child had a surgical correction of strabismus later in childhood. In one child the infratentorial arachnoid cyst regressed spontaneously on ultrasound and MRI in the postnatal period.

CONCLUSIONS

The majority of arachnoid cysts in this series are of benign origin and remain stable. Based on the current series and the review of the literature, in the absence of other associated anomalies and when the karyotype is normal, the postnatal overall and neurological outcome is favorable. Large suprasellar arachnoid cysts however, may cause visual impairment and endocrinological disturbances. Rarely associated cerebral or cerebellar malformations are present. Modern postnatal management of suprasellar arachnoid cyst consists of endoscopic cystoventriculostomy.

Colostrum yield and piglet growth during lactation are related to gilt metabolic and hepatic status prepartum

It was hypothesized that colostrum production could be influenced by sow peripartum endocrine, metabolic, and hepatic status. The plant extract silymarin was shown to influence endocrine and hepatic status in several species. The aims of the present study were to investigate the effects of silymarin intake during late pregnancy on sow hormonal and hepatic status and to determine whether relations exist between sow hepatic and metabolic status during the peripartum period and colostrum yield and piglet performances during lactation. From d 107 of pregnancy until farrowing, nulliparous sows were either fed 12 g/d of silymarin (SIL; n = 15) or no treatment (Control; n = 12). Piglet BW was recorded directly after birth, 24 h after birth of the first piglet, and at 7, 14, and 21 d of lactation. Blood samples were collected from sows on d 107 and 109 of pregnancy, daily from d 111 of pregnancy until d 2 of lactation, and on d 7 and 21 of lactation. They were assayed for endocrine, metabolic, and hepatic variables. Colostrum yield was estimated during 24 h starting at the onset of farrowing. Silymarin did not influence colostrum yield (3.7 ± 0.3 kg) or gross composition (P > 0.10), nor did it affect serum prolactin concentrations or plasma concentrations of progesterone, estradiol-17β, or cortisol (P > 0.10). Mean litter BW gain was lower (P < 0.05) during the first week and tended (P < 0.10) to be lower during the second week of lactation in litters from SIL sows. Silymarin had no effect on plasma concentrations of aspartate transaminase, alanine transaminase, γ-glutamyl transferase (γ-GT), alkaline phosphatase, or total cholesterol (P > 0.10). Colostrum yield was positively correlated with urea (r = 0.50; P = 0.01) and creatinine (r = 0.43; P = 0.03) concentrations in sows on the day before farrowing. Mean litter BW gain over 2 wk was negatively correlated with concentrations of β-hydroxybutyric acid (r = -0.50; P = 0.01) and γ-GT (r = -0.42; P = 0.03) on the day before farrowing and was positively correlated with urea concentrations on the day before farrowing (r = 0.54; P = 0.01). In conclusion, at the dose of 12 g/d, silymarin did not influence prolactin concentrations or the hepatic status of sows, had no impact on colostrum production, and decreased litter BW gain in early lactation. Colostrum yield and litter performance during lactation were correlated with some markers of sow metabolic and hepatic status measured during the prepartum period.

Reduced feed intake of lactating primiparous sows is associated with increased insulin resistance during the peripartum period and is not modified through supplementation with dietary tryptophan

The aim of this experiment was to investigate whether insulin resistance is related to the dietary concentration of Trp and the ADFI of primiparous sows having similar body conditions. Twenty-four primiparous sows were catheterized on d 97 of pregnancy. Blood samples were collected during 3 tests: after the ingestion of 1.5 kg of feed (meal test), after the intravenous infusion of 0.5 g of glucose/kg of BW (glucose tolerance test), and during an euglycemic hyperinsulinemic clamp with an infusion rate of 100 ng of insulin x kg of BW(-1) x min(-1). Both tests were performed at 4 stages at approximately d 103 and 110 of pregnancy and at d 3 and 10 of lactation. Sows were fed a diet containing 0.16 or 0.26% of total Trp (suboptimal vs. slight excessive Trp supply according to recommendations for lactating sows) from d 104 of pregnancy after the first clamp until weaning. The dietary treatment did not result in differences in ADFI, BW, and backfat changes, and growth of piglets during lactation. Plasma Trp concentration was greater for the sows allocated to the slight excessive Trp diet than for the sows allocated to the suboptimal Trp diet (P < 0.05). Plasma glucose, NEFA, and urea profiles during the meal tests were not affected by the dietary treatment. At d 3 of lactation, the insulin concentration at 105 (P = 0.03) and 120 min (P = 0.04) after meal intake was less for the sows allocated to the slight excessive Trp diet than for the sows allocated to the suboptimal Trp diet. On d 10 of lactation, the glucose half life (P = 0.03) and the time needed to reach 25% of the area under the insulin curve (P = 0.04) during the tolerance test were less for the sows allocated to the slight excessive Trp diet than for the sows allocated to the suboptimal Trp diet. The glucose infusion rate during euglycemic hyperinsulinemic clamps was similar in the 2 Trp groups of sows. Irrespective of the dietary treatment, the ADFI of the sows was negatively related to the glucose half life during the glucose tolerance test and positively related to the glucose infusion rate during the clamp (P < 0.05). This relationship observed with the tests performed during early lactation was already found with the tests performed during late pregnancy (P < 0.02). Present findings indicate that a dietary Trp supply of 0.26% does not increase feed intake in lactating primiparous sows. This result indicates that the interest in a Trp supplementation during the peripartum period can be questioned. Irrespective of the dietary treatment, the reasons why sows with similar rearing conditions develop different rates of insulin resistance during pregnancy remain to be elucidated.

[First trimester ultrasound screening for structural and chromosomal anomalies in multiple pregnancy]

AIM OF THE STUDY

To assess the feasibility of first trimester ultrasound screening for structural and chromosomal fetal anomalies in multiple gestations.

METHODS

An observational prospective follow up study was carried out in 32 cases of multiple pregnancies. Two scans were scheduled in each case--the first, between 6-9 weeks of gestation (w.g.) and the second, between 11-14 w.g. The aim was assessment of fetal number, viability, chorionicity/amnionicity and fetal biometry. In addition, nuchal translucency [NT] measurement, assessment of risk for chromosomal anomalies and fetal anatomy survey were always performed. Increased NT > or = 95 percentile and/or detection of structural anomaly were considered indications for invasive prenatal diagnosis and fetal karyotyping. Selective fetocide was considered in cases of chromosomal or structural anomalies and in high-order multiple gestations (> or = 3 fetuses). Pregnancy outcome was ascertained by the physical examination of the fetuses, placentas and membranes postpartum, the hospital records, the referring physicians or the parents.

RESULTS

From 32 cases of multiple pregnancies included in the study, 28 were twins, and 4--triplets. 68% (19/28) of the twin pregnancies were bichorionic-biamniotic [Bi-Bi], 25% (7/28)--monochorionic-biamniotic [Mo-Bi] and 7% (2/28)--monochorionic-monoamniotic [Mo-Mo]. 4 cases of increased NT in one of the twins (1--associated with trisomy 21) were observed, as well as 2 cases of structural fetal anomalies (1--discordant for exencephaly, and 1--with conjoint twins), 2 cases of feto-fetal transfusion syndrome that developed in the second trimester (1--associated with increased NT between 11-14 w.g.), 1 case of TRAP syndrome [twin-reversed arterial perfusion] and 1 case of cord entanglement in monoamniotic twins. In addition, there were 4 cases of a vanishing twin in the first trimester, and in 2 other cases spontaneous miscarriage of both twins occurred before 24 w.g. In two of the triplet pregnancies selective fetocide was performed, one was successfully delivered at 33 w.g. and in the last case the parents chose to terminate the pregnancy.

CONCLUSIONS

First trimester ultrasound is a method of choice for detection of major structural fetal anomalies in multiple gestations. Increased NT between 11-14 w.g. in multiple pregnancies is a useful screening tool for detection of chromosomal fetal anomalies, while in monochorionic twins its presence might predict the development of fetofetal transfusion syndrome. First trimester selective fetocide in high-order multiple gestations or in affected twins is one of the options in pregnancy management.

[Ultrasound screening and diagnosis of fetal structural abnormalities between 11-14 gestational weeks]

AIM OF THE STUDY

To assess the feasibility of ultrasound screening and diagnosis of structural fetal anomalies at the 11-14 week scan.

METHODS

An observational prospective follow up study from March 2000 till May 2003 was performed at three referral centers by seven experienced sonographers with high-resolution ultrasound equipment. 1135 singleton pregnancies between 11+0 and 14+6 weeks gestation (w.g.) participated in the study. The first trimester scan included assessment of fetal number, viability and biometry, nuchal translucency [NT] measurement and fetal anatomy survey performed according to standardized published protocols. Increased NT > or = 95th centile and/or diagnosis of structural fetal anomaly was considered as indication for invasive prenatal diagnosis, early fetal echocardiogram and follow-up scans, including a detailed fetal anomaly scan at 18-22 w.g. and a third scan at 28-32 w.g. Pregnancy outcome was ascertained from hospital records, referring physicians or the patients themselves.

RESULTS

The overall prevalence of structural fetal anomalies in the present study was 4.6% (53/1135). 22% (12/53) of the structural anomalies were detected between 11-14 w.g. 9 of those had normal karyotype, and 3 were associated with chromosomal anomalies. Furthermore, 10 cases of increased NT, with or without non-immune hydrops fetalis, were associated with congenital heart disease, rare genetic syndromes and adverse pregnancy outcome later in gestation. The ultrasound detection rate of structural fetal anomalies in the present study increased from 22% (12/53), to 69% (37/53) and 79% (42/53) for the first trimester scan, the first and second trimester scans, and the combination of all three scans, respectively. 21% (11/53) of all structural fetal anomalies were missed by prenatal ultrasound.

CONCLUSIONS

The first trimester scan is a method of choice for the diagnosis of major structural fetal anomalies. NT measurement is a useful screening test for chromosomal anomalies. In cases with increased NT subsequent development of congenital heart disease, rare genetic syndromes or adverse pregnancy outcome should be ruled out. At present, the second trimester scan constitutes an indispensable tool for the detection of most structural abnormalities. Even in advanced gestation the prenatal diagnosis of certain anomalies is difficult and often unfeasible.

Second trimester maternal dimeric inhibin-A in the multiple-marker screening test for Down's syndrome

The aim of this study was to evaluate the additional value of dimeric inhibin-A serum concentration in second trimester multiple-marker screening tests for pregnancies affected by Down's syndrome. We anticipated that second trimester maternal serum dimeric inhibin-A concentrations would be altered in pregnancies complicated by fetal Down's syndrome and that dimeric inhibin-A would perform better than one of the three substances analysed in the multiple-marker screening test currently in use. A total of 1156 serum samples were screened for dimeric inhibin-A in parallel with the routine classic triple test screening programme performed on a random obstetric population. Classic triple test performance was compared with detection rates obtained after substitution of unconjugated oestriol by inhibin-A and with the performance of inhibin-A and alpha-fetoprotein alone. Absolute dimeric inhibin-A maternal serum concentrations of Down's syndrome pregnancies were indeed significantly higher than those of normal pregnancies in our screened population. The performance of dimeric inhibin-A in combination with the multiple-marker screening test, however, is limited because of its strong correlation with intact human chorionic gonadotrophin.

Dimeric inhibin serum values as markers of ovarian activity in pill-free intervals

Levels of inhibin A and B as well as other hormones in serum samples obtained during the pill-free interval in women taking combined oral contraceptives (OC) were measured to asses the extent of ovarian activity during that period. Type of pill and day of pill-free interval were recorded during routine gynecologic check-ups, if patients were in the pill-free period and had taken their pills regularly in the previous cycle. In addition to inhibin A and B, serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), and progesterone were also quantified. Inhibin B levels rise significantly in parallel with rising levels of FSH, LH, and E2. Progesterone levels were completely suppressed and inhibin A levels rose slightly but insignificantly. Inhibins are sensitive biochemical markers of ovarian activity in pill-free intervals.