University of Oulu, Finland. Background: Intra-amniotic lipopolysaccharide (LPS) causes a fetal .... treatment of hypoplastic left heart syndrome with intact septum.
14th World Congress on Ultrasound in Obstetrics and Gynecology
Poster abstracts
This technique may be useful in the prenatal diagnosis of conotruncal anomalies and in the assessment of the spatial relationships of abnormal vascular connections in the upper mediastinum.
anemia, the MCA-PSV values at 3–7 days before the first FBS were < 1.29 MoM (2 cases), between 1.29–1.5 MoM (2 cases) and > 1.55 MoM (one case). No FBS was necessary in one case. Conclusions: Invasive procedures may be avoided by implementing MCA-PSV in the management of Kell isoimmunization. Delineating of appropriate intervals between reassessments and cutoff values for FBS performance awaits further study.
P01.34 Maternal lipopolysaccharide depresses fetal cardiovascular function in mouse ¨ anen, ¨ S. Rounioja, J. Ras H. Autio-Harmainen, M. Ojaniemi, ¨ V. Glumoff, K. Makikallio, M. Hallman University of Oulu, Finland Background: Intra-amniotic lipopolysaccharide (LPS) causes a fetal inflammatory response and cardiac dysfunction in mice. We hypothesized that the placenta serves as a barrier against bacterial toxins delaying the onset of a fetal inflammatory response and cardiac failure. Methods: At 14–15 days of gestation DBA strain mice were randomized to receive LPS (∼ 70 µg) or vehicle intraperitoneally. Doppler ultrasonography of fetal cardiovascular hemodynamics was performed before and six hours after LPS. The expression and production of cytokines and other inflammatory mediators were determined using ribonuclease protection assay and cytometric bead array. Histopathology and immunostaining of toll-like receptor (TLR) in placenta were carried out. Results: Six hours after LPS injection, there was no evidence of stasis in maternal lung or liver, although tumor necrosis factor´ and interleukin (IL)-6 were increased in serum alpha (TNF-a) (p < 0.05). In contrast, placenta showed severe dilatation and stasis ´ IL-1a´ most distinctly in maternal vessels. The expression of TNF-a, and IL-6 (p < 0.05) increased in placenta, whereas no inflammatory activation was evident in fetal tissues, and amniotic fluid revealed no increase in cytokines. The expression of TLR2 (p < 0.05) was increased in labyrinthine macrophages, which could serve as target for LPS. The fetal cardiac outflow mean velocity, was lowered (p < 0.005) in the LPS group. The pulsatility indices (PI) of the umbilical artery and the descending aorta and the PI for veins from the ductus venosus were higher after LPS. In the LPS group 65% of the fetuses had atrioventricular valve regurgitation, compared to only 4% in the vehicle group. Conclusions: Maternally administered LPS acutely induced cytokine expressions in placental tissue with histologic lesions. Inflammatory response was not evident in the fetal compartment. However, placental congestion increased the cardiac afterload, leading to fetal cardiovascular dysfunction.
P02: FETAL THERAPY AND FETAL SURGERY P02.01 The management of Kell isoimmunization- evaluation of conventional protocol and introduction of an MCA-PSV guided approach S. Lipitz1 , E. Rimon2 , R. Gamzu2 , S. Yagel2 , R. Peltz2 , B. Chyen2 1
Dept. of Ob&Gyn, Sheba Medical Center, Tel-Hashomer, Israel, 2 Israel Objective: To assess the role of peak systolic velocity in the middle cerebral artery (MCA-PSV) in the management of pregnancies complicated by Kell isoimmunization. Methods: Sixteen fetuses were monitored by conventional protocol (group 1) and six fetuses (group 2) by an MCA-PSV guided protocol. Results: No parameter emerged as a reliable predictor of isoimmunization severity in group 1. In group 2, all 10 measurements of MCA-PSV > 1.5 MoM were confirmed by the finding of fetal anemia in fetal blood sampling (FBS). In fetuses with severe
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P02.02 Accuracy of middle cerebral artery blood flow velocimetry in determining anemia in fetuses undergoing intrauterine transfusion P. Vasquez, J. Sanchez, J. Gutierrez, E. Carstens, R. Sandoval, W. Sepulveda San Jose Hospital, Chile Objective: To study the correlation between PSV-MCA and fetal hematocrit/hemoglobin in fetuses undergoing intrauterine transfusion (IUT). Methods: Fetuses at risk of anemia and treated by IUT at San Jose Hospital were identified from a prospectively collected computerized database. Medical records were reviewed for information on preand post-transfusion Doppler findings and hematological values. Doppler indices obtained after January 2000 were prospectively plotted against a Mari’s nomogram (N Engl J Med 2000, 342: 9–14) and used for pregnancy management. However, Doppler values obtained before that date were retrospectively analyzed for the purposes of this study. Results: During the study period from October 1996 to April 2002, a total of 25 women underwent 52 IUTs. Among them, 32 interventions had complete information for analysis. The primary indication for surveillance was Rh isoimmunization in all cases. In 5 (16%) the PSV-MCA was normal and in the remaining 27 (4%) above the 1.29 MoM for gestational age. In 8 cases (25%) the PSV-MCA indicated mild anemia, in 3 (9%) moderate anemia and in 15 (47%) severe anemia. Among the 5 fetuses with normal PSV-MCA values, 3 had mild anemia and 2 were not anemic. Of the 8 fetuses with mild anemia according to the PSV-MCA, 5 had mild, 1 moderate, and 2 severe anemia. Of the 3 fetuses with moderate anemia according to the PSV-MCA values, 1 had no anemia and 2 had severe anemia. Of the 15 fetuses with severe anemia according to the PSV-MCA values, 1 had mild anemia, 3 moderate anemia, and 11 severe anemia. After IUT, 23 fetuses showed normal values of PSV-MCA, 7 showed values consistent with mild anemia, and 1 showed values consistent with severe anemia. Conclusions: According to Mari’s nomogram, PSV-MCA shows a better correlation with fetal hematocrit/hemoglobin in cases of moderate and severe anemia than in cases with mild anemia. There was a significant reduction of the PSV-MCA in almost all fetuses undergoing IUT.
P02.03 Predictive value of middle cerebral artery peak systolic velocity to establish the interval between intrauterine transfusions in fetal red-cell alloimmunization ˜ J. E. Sanin-Blair, E. Hernandez-Andrade, B. Munoz-Abellana, J. Lopez, M. Medina, J. Sagala, E. Carreras, L. Cabero Hospital Universitari Vall d’Hebron, Spain Objective: middle cerebral artery peak systolic velocity (MCA-PSV) has been successfully used for identification of fetuses at risk for anemia requiring fetal blood sampling or intrauterine transfusion. Preliminary studies suggested that MCA-PSV could be as well a useful diagnostic tool to estimate the interval between transfusions. The present study describes the results of a prospective protocol for the management of fetuses with red cell alloimmunization after the first intrauterine transfusion, where the interval between transfusions was decide solely on the basis of MCA-PSV.
Ultrasound in Obstetrics & Gynecology 2004; 24: 269–372
31 August–4 September 2004, Stockholm, Sweden
Methods: A longitudinal prospective study including non-hydropic fetuses at 20–35 weeks’ gestational age (GA) with a previous intrauterine transfusion due to red-cell alloimmunization. MCA-PSV was assessed every 5 to 7 days. Intrauterine blood transfusion was indicated when the values were greater than 1.5 MoM. The value of the test to predict moderate to severe anemia (Hb levels < 0.65 MoM for GA) was evaluated with 2 × 2 tables statistical analysis. Results: During the study period 18 intrauterine transfusions were performed in 15 patients (range 0–3), with a median interval between transfusions of 20.3 days (range 7–28). At blood sampling, moderate to severe anemia was present in 14/18 (78%) and mild anemia (Hb 0.84–0.65 MoM for GA) in 4/18 (22%). None of the cases was found to have no anemia at blood sampling, and none developed hydrops during follow-up. Conclusion: MCA-PSV reliably predicts moderate/severe anemia in fetuses previously transfused in utero, allowing its use as a unique tool to establish the interval between transfusions. As compared to our previous protocol (15 days), MCA-PSV resulted in a 5-days gain in the interval between transfusions, avoiding unnecessary procedures.
P02.04 Endoscopic lysis of iatrogenic amniotic band after amniopatch E. K. Kontopoulos1 , R. A. Quintero2 Robert Wood Johnson-UMDNJ, USA, 2 Florida Institute for Fetal Diagnosis and Therapy, USA
1
This is a 34-year-old Caucasian female, gravida-2, para-1 with monochorionic, diamniotic twin pregnancy, with a posterior placenta, diagnosed with twin–twin transfusion syndrome (TTTS). At 166/7 weeks’ gestation, the patient underwent a decompression amniocentesis with removal of 1200cc of amniotic fluid. The procedure was complicated by membrane detachment with chorioamniotic separation. At 18 weeks, an amniopatch was performed at another institution, using doses several times higher than those recommended per protocol. The procedure restored the integrity of the amniotic cavity. The patient underwent selective laser photocoagulation of the communicating vessels at 194/7 weeks, for a diagnosis of Stage III TTTS. During surgery, the recipient fetus was noted to be encased with fibrous material around the neck, chest, both lower extremities as well as the umbilical cord. In particular, the left thigh was markedly edematous below the level of the constriction. The adhesions of fibrous material were cut and released endoscopically without complications. The edema of the left thigh was reversed completely in subsequent exams. The fetuses were delivered at 34 weeks’ gestation via elective cesarean section, had no gross abnormalities and did well. This is a case of iatrogenic amniotic bands following amniopatch. Although the optimal dosage of platelets and cryoprecipitate to be injected is unknown, adherence to current protocol (1/2 Unit of platelets, 1 Unit of cryoprecipitate) is recommended to decrease the risk of complications from the procedure. Endoscopic lysis of iatrogenic amniotic bands may avoid secondary complications from the amnniopatch.
P02.05 Percutaneous fetal aortic valvotomy with intracardiac endoscopy for the treatment of critical aortic valve stenosis R. Quintero1 , E. Suh2 , J. Huhta2 , R. Chmait1 , J. Angel1 , S. Lichtenstein2 1 2
Florida Institute for Fetal Diagnosis and Therapy, USA, Pediatric Cardiology Associates, USA
Critical aortic stenosis (AS) occurs in approximately 2% of fetuses with congenital heart disease, and may lead to hypoplastic left
Ultrasound in Obstetrics & Gynecology 2004; 24: 269–372
Poster abstracts
heart syndrome (HLHS) or hydrops. In utero ultrasound-guided balloon aortic valvotomy (IUBAV) has been reported, but has been associated with both technical failures and intraoperative mortality. The differential diagnosis of aortic atresia (AA) versus AS may be beyond the resolution of ultrasound in selected cases. We describe intracardiac fetal endoscopy (ICFE) to document AS. A 34 year old, G2 P1, was diagnosed with a fetus with AS at 18 weeks’ gestation. Echocardiogram also showed mitral regurgitation, an ascending aorta which measured 1.7 mm which showed no discernible antegrade flow, and a dilated-akinetic left ventricle with an echogenic endocardium. A normal 46, XY karyotype was obtained. The patient gave written informed consent. Under ultrasound guidance and local anesthesia, an 18-gauge needle was inserted percutaneously into the left ventricle. An attempt to negotiate the aortic valve failed twice. The possibility of aortic atresia was contemplated. A 0.8 mm angioscope threaded through the 18-gauge needle confirmed a unicommissural aortic valve with a lumen of approximately 5 mm. A 014’’ soft-tip wire guide was passed through the lumen of the aortic valve. A 3 mm × 1 cm coronary angioplasty balloon was dilated across the aortic valve, achieving approximately 130% of the aortic valve anulus. Color and pulsed Doppler showed forward and regurgitant flow through the aortic valve. Ventricular function improved significantly post-op. Forward flow through the valve persists after surgery. Minimal scalp edema resolved within 72 hours. Percutaneous ICFE and IUBAV are technically feasible. ICFE may aid in the differential diagnosis of AA versus AS. Further experience is needed to determine the risks and benefits of these procedures in the management of fetuses with AS.
P02.06 Percutaneous fetal interatrial laser septotomy for the treatment of hypoplastic left heart syndrome with intact septum R. Quintero1 , J. Huhta2 , E. Suh2 , R. Chmait1 , S. Lichtenstein2 1 2
Florida Institute for Fetal Diagnosis and Therapy, USA, Pediatric Cardiology Associates, USA
Objective: Hypoplastic left heart syndrome (HLHS) accounts for 22% of all deaths from congenital heart disease. Approximately 5.7% of HLHS fetuses have an intact atrial septum (IAS). IAS results in pulmonary congestion, parenchymal lung damage, and is associated with a perinatal survival rate of only 30%. We describe the performance of in utero laser interatrial laser septotomy (IALS) in a fetus with HLHS and IAS. Methods: The patient was a 20 year old, G2 P1 diagnosed with HLHS at 24 6/7 weeks’ gestation. Mitral and aortic atresia, as well as IAS were present. Pulmonary drainage occurred via the vertical vein, which was also obstructed. Large, tortuous pulmonary veins were noted. The right atrium measured 3 cm and the left atrium measured. 5 cm in diameter. The patient was informed of the poor prognosis for the fetus and she gave written informed consent for an attempt at IALS. Under ultrasound guidance, local anesthesia and using a percutaneous approach, an 18-gauge needle was inserted into the right atrium. A 600 µ contact Nd : YAG laser fiber was passed through the lumen of the needle and placed against the atrial septum. The septum was opened with short bursts of 5–10 Watts of energy. Color Doppler confirmed flow of blood from the left to the right atrium. A hemopericardium of 6 cc was drained with a 22-gauge needle without complications. Results: Pulmonary venous decongestion was sonographically documented. Left-to-right interatrial blood flow as shown with color Doppler persisted until birth. The patient was delivered vaginally at 37 weeks. The baby underwent a Norwood I operation on the first day of life. The baby is intubated, on room air. Conclusions: IALS is technically feasible through a minimallyinvasive ultrasound-guided approach. Further experience is needed to determine the risks and benefits of this novel fetal therapeutic intervention.
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