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Objectives: Antenatal management of monochorionic pregnancies complicated by twin anemia polycythemia sequence (TAPS) remains sub‐optimally defined. Our objective was to evaluate the safety and efficacy of fetoscopic selective laser photocoagulation with respect to fetal and neonatal survival. Methods: A case series is reported with patients referred to the Texas Children's Fetal Center for evaluation and management of suspected spontaneous TAPS without concomitant twin‐to‐twin syndrome from 2014 to 2023. All evaluations were performed by our team and patients with stage II‐IV TAPS were offered expectant management, intrauterine transfusion, or laser therapy. Cases of post‐laser TAPS were excluded from this study. Pregnancy and neonatal outcomes were obtained from electronic medical records. Results: During a 10‐year time period, 18 patients presented to our center for the management of TAPS. Thirteen patients had stage II–IV TAPS (13/18, 72%) and elected to proceed with laser photocoagulation. All procedures were completed, and "solomonization" was performed for 12/13. Normalization of middle cerebral artery Dopplers in both fetuses was noted after all cases. There was one intrauterine fetal death of the 26 viable fetuses after laser treatment, which was complicated by selective growth restriction. Most patients (12/13) were delivered by Cesarean section at a mean gestational age of 29 ± 3 weeks. Subsequently, there was one ex‐donor neonatal death in an infant who had prenatal hydrops. Overall, 30‐day postnatal survival was 24/26 fetuses (92.3%). Conclusions: In the setting of spontaneous TAPS, laser therapy is feasible and appears to be an effective approach with overall favorable perinatal outcomes. Key points: What's already known about this topic? Optimal management of twin anemia polycythemia sequence (TAPS) remains a challenge and outcomes vary between spontaneous and post‐laser TAPS. What does this study add? We present a series of patients with spontaneous TAPS without concomitant twin‐to‐twin syndrome managed with fetoscopic laser photocoagulation. We show resolution of Doppler findings and >90% survival. Outcomes for TAPS managed with a fetoscopic laser appear favorable and may be considered definitive therapy targeting the underlying vascular pathology. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the prenatal diagnosis of closed dysraphism (CD) and its correlation with postnatal findings and neonatal adverse outcomes. Methods: A retrospective cohort study including pregnancies diagsnosed with fetal CD by prenatal ultrasound (US) and magnetic resonance imaging (MRI) at a single tertiary center between September 2011 and July 2021. Results: CD was diagnosed prenatally and confirmed postnatally in 12 fetuses. The mean gestational age of prenatal imaging was 24.2 weeks, in 17% the head circumference was ≤fifth percentile and in 25% the cerebellar diameter was ≤fifth percentile. US findings included banana sign in 17%, and lemon sign in 33%. On MRI, posterior fossa anomalies were seen in 33% of cases, with hindbrain herniation below the foramen magnum in two cases. Mean clivus‐supraocciput angle (CSA) was 74°. Additional anomalies outside the CNS were observed in 50%. Abnormal foot position was demonstrated prenatally in 17%. Neurogenic bladder was present in 90% of patients after birth. Conclusion: Arnold Chiari II malformation and impaired motor function can be present on prenatal imaging of fetuses with CD and may be associated with a specific type of CD. Prenatal distinction of CD can be challenging. Associated extra CNS anomalies are frequent and the rate of neurogenic urinary tract dysfunction is high. Key points: What is already known about this topic? Closed dysraphism poses a challenge in prenatal diagnosis.There is limited data on the prenatal findings and postnatal outcome. What does this study add? Cranial findings associated with Arnold Chiari II (AC II) malformation and impairment of motor function can be present on prenatal imaging of fetuses with closed spinal dysraphism and may depend on the specific type of closed dysraphism. MRI adds important information.Ventriculoperitoneal Shunt rate is very low and abnormal corpus callosum seems not to be a typical finding. Anomalies of the urogenital and skeletal systems are frequently associated. Neurogenic bladder is a common finding. [ABSTRACT FROM AUTHOR]

Objective: Fetal Lower Urinary Tract Obstruction (LUTO) is associated with oligohydramnios and significant fetal morbidity, resulting in poor lung development and perinatal death. However, oligohydramnios may develop at different gestational periods, and the impact of timing on fetal outcomes remains unknown. Our objective was to characterize the impact onset of oligohydramnios had on prenatal outcomes. Methods: This study is a retrospective cohort study of all patients with a prenatal diagnosis of LUTO at our tertiary referral center from 2014 to 2023. All patients underwent detailed ultrasonography and interdisciplinary counseling and were subsequently delivered at our institution. Data were obtained from electronic medical records and complete extraction was required for final inclusion. Results: During the study time period, 93 patients met inclusion criteria of which 68 (73.1%) developed oligohydramnios during their pregnancy. 63 (93%) of these pregnancies resulted in livebirths with 28 (41.1%) perinatal deaths. Onset of oligohydramnios was earlier in pregnancies with perinatal death (23 vs. 28 weeks, p = 0.004) and associated with pulmonary hypoplasia. Conclusions: Our data show the impact of oligohydramnios timing in pregnancy on pulmonary hypoplasia and ultimately perinatal death. This allows for detailed patient counseling on the impact oligohydramnios may have on pregnancies by the gestational age of onset. Key points: What is already known about this topic? Fetal Lower Urinary Tract Obstruction may result in oligohydramnios, which results in increased perinatal morbidity and mortality. What does this study add? The gestational age onset of oligohydramnios prior to the completion of critical lung development results in pulmonary hypoplasia and increased perinatal mortality. [ABSTRACT FROM AUTHOR]

Objective: We evaluate survival of fetuses with severe Lower Urinary Tract Obstruction (LUTO) based on bladder morphology. We hypothesize that fetuses with a "floppy" appearing bladder on initial prenatal ultrasound will have worse infant outcomes than fetuses with full/rounded bladders. Method: We retrospectively reviewed all cases of LUTO evaluated in our fetal center between January 2013 and December 2021. Ultrasonographic assessment, renal biochemistry, and bladder refilling contributed to a "favorable" or "unfavorable" evaluation. Bladder morphology on initial ultrasound was classified as "floppy" or "full/rounded." Vesicoamniotic shunting was offered for favorably evaluated fetuses. Baseline demographics, ultrasound parameters, prenatal evaluations of fetal renal function, and infant outcomes were collected. Fetuses diagnosed with severe LUTO were included in analysis using descriptive statistics. The primary outcome measured was survival at 6 months of life. Results: 104 LUTO patients were evaluated; 24 were included in analysis. Infant survival rate at 6 months was 60% for rounded bladders and 0% for floppy bladders (p = 0.003). Bladder refill adequacy was lower in fetuses with floppy bladders compared with rounded bladders (p value < 0.00001). Conclusion: We propose that bladder morphology in fetuses with severe LUTO may be a prognostication factor for predicting infant outcomes and provides a valuable, noninvasive assessment tool. Key points: What is already known about this topic?Fetal urinary biochemistry and ultrasound have been useful in predicting when fetal intervention may be beneficial in cases of Lower Urinary Tract Obstruction (LUTO), but it remains difficult to determine prognosis prenatally and neither method has been found to be independently reliable. What does this study add?We propose that the addition of bladder morphology to the current LUTO evaluation methods provides a noninvasive method to prognosticate outcomes and determine candidacy for fetal intervention. [ABSTRACT FROM AUTHOR]

Objective Antenatal diagnosis of placenta accreta spectrum (PAS) is critical to reduce maternal morbidity. While clinical outcomes of women with PAS have been extensively described, little information is available regarding the women who undergo cesarean delivery with a presumptive PAS diagnosis that is not confirmed by histopathologic examination. We sought to examine resource utilization and clinical outcomes of this group of women with a false-positive diagnosis of PAS. Study Design This is a retrospective analysis of patients with prenatally diagnosed PAS cared for between 2015 and 2020 by our multidisciplinary PAS team. Maternal outcomes were examined. Univariate analysis was performed and a multivariate model was employed to compare outcomes between women with and without histopathologically confirmed PAS. Results A total of 162 patients delivered with the preoperative diagnosis of PAS. Of these, 146 (90%) underwent hysterectomy and had histopathologic confirmation of PAS. Thirteen women did not undergo the planned hysterectomy. Three women underwent hysterectomy but pathologic examination did not confirm PAS. In comparing women with and without pathologic confirmation of PAS, the false-positive PAS group delivered later in pregnancy (34 vs. 33 weeks of gestation, p = 0.015) and had more planned surgery (88 vs. 47%, p = 0.002). There was no difference in skin incision type or hysterotomy placement for delivery. No significant difference in either the estimated blood loss or blood components transfused was noted between groups. Conclusion Careful intraoperative evaluation of women with preoperatively presumed PAS resulted in a 3/149 (2%) retrospectively unnecessary hysterectomy. Management of women with PAS in experienced centers benefits patients in terms of both resource utilization and avoidance of unnecessary maternal morbidity, understanding that our results are produced in a center of excellence for PAS. We also propose a management protocol to assist in the avoidance of unnecessary hysterectomy in women with the preoperative diagnosis of PAS. Key Points Evaluation and delivery planning of patients with suspected placenta accreta spectrum in experienced centers provides acceptable outcomes. Under specific circumstances, delivery of placenta may be attempted if placenta accreta is suspected. Patients with suspected placenta accreta rarely undergo unindicated hysterectomy. [ABSTRACT FROM AUTHOR]

This article includes Author Insights, a video abstract available at: https://vimeo.com/758012058 [ABSTRACT FROM AUTHOR]

Introduction: Preeclampsia (PE) is a hypertensive disorder during pregnancy associated with elevated levels of soluble FMS-like tyrosine kinase (sFLT-1) and increased vascular sensitivity to angiotensin II (ATII). Calcitonin gene-related peptide (CALCA) is a potent vasodilator that inhibits the ATII-induced increase in blood pressure and protects against ATII-induced increases in oxidative stress through a mitochondrial-dependent pathway in male mice. In rodent pregnancy, CALCA facilitates pregnancy-induced vascular adaptation. Most of the vascular effects of CALCA are mediated by vascular smooth muscle cells (VSMCs). We recently reported that CALCA treatment inhibits sFLT-1-induced decreases in cAMP synthesis in omental artery smooth muscle cells (OASMCs) isolated from pregnant women and has relaxant effects in omental arteries (OAs) isolated from pregnant women with preeclamptic (PE) pregnancies. The current study was designed to assess the effects of sFLT-1 on mitochondrial bioenergetics in OASMCs isolated from pregnant women in the presence or absence of CALCA and assess the development of vascular dysfunction in sFLT-1 using a mouse model of PE pregnancy. Methods: OASMCs were isolated from pregnant women to assess the effects of sFLT-1 on mitochondrial bioenergetics and oxidative stress using the Seahorse assay and quantitative PCR. Pregnant mice overexpressing sFLT-1 via adenoviral delivery were used to assess the effects of CALCA infusion on the sFLT-1-induced increase in blood pressure, ATII hypersensitivity, fetal growth restriction, and the elevated albumin--creatinine ratio. Systemic blood pressure was recorded in conscious, freely moving mice using implantable radio telemetry devices. Results: CALCA inhibited the following sFLT-1-induced effects: 1) increased oxidative stress and the decreased oxygen consumption rate (OCR) in response to maximal respiration and ATP synthesis; 2) increases in the expression of mitochondrial enzyme complexes in OASMCs; 3) increased mitochondrial fragmentation in OASMCs; 4) decreased expression of mitophagy-associated PINK1 and DRAM1 mRNA expression in OASMCs; and 5) increased blood pressure, ATII hypersensitivity, fetal growth restriction, and the albumin--creatinine ratio in sFLT-1-overexpressing pregnant mice. Conclusion: CALCA inhibits sFLT-1-induced alterations in mitochondrial bioenergetics in vascular smooth muscle cells and development of maternal vascular dysfunction in a mouse model of PE. [ABSTRACT FROM AUTHOR]

Open spina bifida (OSB) is a congenital, non-lethal malformation with multifactorial etiology. Fetal therapy can be offered under certain conditions to parents after accurate prenatal diagnostic and interdisciplinary counseling. Since the advent of prenatal OSB surgery, various modifications of the original surgical techniques have evolved, including laparotomy-assisted fetoscopic repair. After a two-year preparation time, the team at the University of Giessen and Marburg (UKGM) became the first center to provide a three-port, three-layer fetoscopic repair of OSB via a laparotomy-assisted approach in the German-speaking area. We point out that under the guidance of experienced centers and by intensive multidisciplinary preparation and training, a previously described and applied technique could be transferred to a different setting. [ABSTRACT FROM AUTHOR]

Objective As the awareness of the accompanying morbidity of placenta accreta spectrum (PAS) has increased over recent decades. We sought to analyze the precision and reliability of the currently available content regarding PAS on YouTube. Study Design A YouTube search was performed on June 17, 2019 by using the search terms "placenta accreta," "PAS," and "invasive placentation." Search results were sorted by relevance, and up to 200 videos per search term were systematically evaluated by four independent reviewers. A quality assessment checklist relating to aspects of PAS was developed with a Likert's scale from 0 to 12 points to quantify video content. Videos were classified as poor educational quality (grade 0 to ≤4), moderate quality (grade >4–8), and high quality (grade >8–12). Results Of the 318 videos identified, 99 videos met inclusion criteria. The majority of videos (61.6%) were produced by a professional source, that is, appearing to be from a hospital, university, or educational service. Of the remaining videos, 16.2% were classified as personal, that is, posted from personal YouTube accounts and depicting a personal or family member experience, and 22.2% were classified as other. The majority of the "other" category consisted of news segments and short clips from talk shows. Overall, 60.6% of videos were of poor educational quality, 32.3% were of moderate quality, and 7.1% were deemed high quality. All seven of the high-quality videos were produced by a professional source and intended for an audience of medical professionals. There were neither high-quality videos intended for the general public nor the likely affected and relevant patient population. Conclusion This study suggests that the currently available videos on YouTube regarding PAS are poor educational sources for patients seeking information, and demonstrates a need for high-quality content videos produced by medical professionals specifically focused on meeting the needs of patient population. Key Points Awareness of the accompanying morbidity of placenta accreta spectrum has increased over recent decades. YouTube videos are poor educational sources for patients seeking information regarding PAS. YouTube videos and all social media warrant improvements regarding patient's information. [ABSTRACT FROM AUTHOR]

The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. Key Points The surgical management of PAS requires careful planning and expertise. Multidisciplinary team care for pregnancies complicated by PAS can decrease morbidity and mortality. Careful surgical techniques can minimize risk of significant hemorrhage by avoiding pitfalls. [ABSTRACT FROM AUTHOR]

Selective fetal growth restriction (sFGR) complicates 10%–26% of monochorionic twins. Treatment options include cord coagulation, expectant management, and fetoscopic laser photocoagulation. This review compared laser to expectant management for situations when cord coagulation is not an option. The MEDLINE, EMBASE, and Cochrane databases were queried for studies that compared laser to expectant management for sFGR. GRADE was used to assess quality prior to meta‐analysis. A random‐effects model was used to generate relative risks. Six studies were included, encompassing 299 pregnancies. One study was randomized and the remainder were retrospective cohorts. Laser is associated with more fetal deaths of the FGR twin compared to expectant management (risk ratio [RR] 2.5, 95% confidence interval [CI] 1.43–4.37, p = 0.001, I2 = 48%). Neonatal deaths and gestational age at delivery did not differ. Laser was associated with decreased abnormal neuroimaging in the AGA twin (RR 0.25, 95% CI 0.07–0.97, p = 0.05). Neurodevelopmental outcomes did not differ, although these data are limited. Laser causes more fetal deaths of the FGR twin without altering gestational age at delivery or rates of neonatal death. The literature is heterogeneous and the level of bias is high. Randomized trials that address laser for type II sFGR are needed and should include long‐term neurological outcomes. Key points: What is already known about this topic? Selective fetal growth restriction (sFGR) is a complication in 10%–26% of monochorionic twins. This can be associated with fetal death of one twin and devastating neurological effects on the surviving co‐twin. Fetoscopic laser therapy can separate the placenta, an attractive possible solution that has been successful in other conditions. But, laser may leave the small twin with little placental tissue for vital functions, even as it protects the larger twin from neurological effects of co‐twin demise. Given this mix of effects, laser therapy is not clearly superior to expectant management. What does this study add? Compared to expectant management, fetoscopic laser photocoagulation for sFGR is associated with a greater relative risk of fetal death of the FGR twin and a lower relative risk of abnormal neonatal neuroimaging findings in the AGA twin. Across six studies, laser does not alter gestational age at delivery or rates of neonatal death of either twin. For providers in areas with restrictions on cord coagulation, or for parents who do not desire selective feticide, fetoscopic laser is an option that may preserve two twins and prevent some consequences of co‐twin demise as measured by neonatal ultrasound findings in the normally grown twin. There is insufficient evidence on long‐term outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Perinatal depression and anxiety are major causes of maternal morbidity, and are more common in high-risk pregnancies compared to low-risk pregnancies. This study used validated screening tools to assess the prevalence of depression and anxiety symptoms in pregnant patients who transferred their obstetric care to a specialized fetal center for fetal anomaly. Methods: This is a prospective cohort of patients with a fetal anomaly prompting transfer of obstetric care to Texas Children's Hospital Fetal Center between January 2021 and February 2022. The primary outcome was a self-assessed Edinburgh Postnatal Depression Scale score of 13 or higher, either antepartum or postpartum ("ever-positive EPDS"). Secondary outcomes included self-assessed Perinatal Anxiety Screening Scale (PASS) scores of 21 or higher ("ever-positive PASS"), obstetric outcomes, and neonatal outcomes. A frequentist analysis was performed. Results: Of 149 women who transferred to Texas Children's Hospital during the study period, 94 enrolled in this study. Twenty-six percent of women had an ever-positive EPDS; 20% of patients had an ever-positive PASS. Patients were more likely to have an ever-positive EPDS if they were single (46% compared to 20%, p = 0.025). Women who had an ever-positive EPDS were more likely to be referred to psychiatry (46% compared to 14%, p = 0.004) and psychotherapy (29% compared to 1%, p < 0.001). Surprisingly, patients were more likely to have an ever-positive PASS if they reported good social support (p = 0.03). Antepartum EPDS and PASS scores had no relationship with postpartum EPDS scores. Conclusion: Women who transfer care to a tertiary setting have positive EPDS scores at double the rate of the general population, but tend to experience this either antepartum or postpartum (not both). Fetal centers should be prepared to screen for mental health symptoms before and after delivery and provide appropriate referral or treatment. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to identify predictors of 'intrauterine fetal renal failure' in fetuses with severe congenital lower urinary tract obstruction (LUTO). Methods We undertook a retrospective study of 31 consecutive fetuses with a diagnosis of LUTO in a tertiary Fetal Center between April 2013 and April 2015. Predictors of 'intrauterine fetal renal failure' were evaluated in those infants with severe LUTO who had either a primary composite outcome measure of neonatal death in the first 24 h of life due to severe pulmonary hypoplasia or a need for renal replacement therapy within 7 days of life. The following variables were analyzed: fetal bladder re-expansion 48 h after vesicocentesis, fetal renal ultrasound characteristics, fetal urinary indices, and amniotic fluid volume. Results Of the 31 fetuses included in the study, eight met the criteria for 'intrauterine fetal renal failure'. All of the latter had composite poor postnatal outcomes based on death within 24 h of life (n = 6) or need for dialysis within 1 week of life (n = 2). The percentage of fetal bladder refilling after vesicocentesis at time of initial evaluation was the only predictor of 'intrauterine fetal renal failure' (cut-off Conclusion We propose the concept of 'intrauterine fetal renal failure' in fetuses with the most severe forms of LUTO. Fetal bladder refilling can be used to reliably predict 'intrauterine fetal renal failure', which is associated with severe pulmonary hypoplasia or the need for dialysis within a few days of life., Author(s): Rodrigo Ruano[sup.1] [sup.7] , Adnan Safdar[sup.2] [sup.7] , Jason Au[sup.3] [sup.7] , Chester J. Koh[sup.3] [sup.7] , Patricio Gargollo[sup.3] [sup.7] , Alireza A. Shamshirsaz[sup.1] [sup.7] , Jimmy Espinoza[sup.1] [sup.7] [...]