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Background: In type II vasa previa, fetoscopic laser ablation has the potential to avoid prolonged hospitalization, elective prematurity, and cesarean delivery associated with traditional conservative management.Objective: To assess the feasibility and to report perinatal outcomes of type II vasa previa patients treated via fetoscopic laser ablation.Study Design: This is a retrospective descriptive study of all women with vasa previa treated with laser at our center between 2006 and 2019. After 2010, laser ablation of vasa previa was only offered after 31 gestational weeks. Continuous variables are expressed as means ± SD.Results: 33 patients were evaluated for laser ablation of suspected vasa previa. Fifteen were not candidates (7 had type I vasa previa and 8 had no vasa previa), and the 18 remaining had type II vasa previa. Ten (56%) elected to undergo in utero laser ablation of the vasa previa vessel(s), which was successful in all patients. The mean gestational age (GA) at the time of the procedure was 28.8 ± 5.4 weeks, and the total operative time was 48.1 ± 21.3 min; there were no perioperative complications. The number of vessels lasered were distributed as follows: 1 (2 cases), 2 (5 cases), and 3 (3 cases). All patients except for 1 were subsequently managed as outpatients. The mean GA at delivery was 35.5 ± 3.2 weeks, and vaginal delivery occurred in 5 cases. The 5 patients with singletons who underwent laser ablation for primary diagnosis of type II vasa previa after the protocol change in 2010 had the following outcomes: mean GA of surgery was 32.5 ± 0.8 weeks, mean GA at delivery was 38.1 ± 1.4 weeks, vaginal delivery occurred in all cases, mean birth weight was 2,965 ± 596 g, and none were admitted to the neonatal intensive care unit.Conclusion: This cohort represents the largest number of vasa previa cases treated via in utero laser reported to date. Laser occlusion of type II vasa previa was technically achievable in all cases and resulted in favorable outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Incidental septostomy, or inadvertent perforation of the twins' dividing membranes, can create a functional monoamniotic twin pregnancy. Our aim was to describe the perinatal outcomes and antenatal management of patients with incidental septostomy after laser surgery for twin-twin transfusion syndrome (TTTS).Materials and Methods: Monochorionic diamniotic multiple gestations with a gestational age (GA) between 16 and 26 weeks that underwent laser surgery from March 2006 to December 2015 were studied retrospectively. Perinatal outcomes were compared for patients with and without an incidental septostomy. A subgroup analysis was performed to evaluate antenatal management.Results: Of 532 TTTS patients who underwent laser surgery, incidental septostomy occurred in 34 (6.4%). Compared to all others, patients with a septostomy had an earlier median (range) GA at delivery (30.8 [18.6-37.9] vs. 34.0 [19.3-40.4] weeks, p < 0.0001) and lower 30-day survival of at least one twin (85.3 vs. 94.6%, p = 0.0452). We found no evidence that inpatient fetal surveillance was protective.Discussion: Incidental septostomy in TTTS patients treated via laser surgery appeared to be associated with lower GA at delivery and perinatal survival of at least one twin. Further study is required to determine the optimal antenatal surveillance strategy. [ABSTRACT FROM AUTHOR]

Objective: To present outcomes of fetuses with congenital pulmonary airway malformation (CPAM) treated with sclerotherapy.Methods: Retrospective study of 8 patients with a prenatal diagnosis of CPAM type II or III with secondary hydrops treated with percutaneous sclerotherapy using 5% ethanolamine oleate (EO). All patients underwent ultrasonic measurement of the CPAM volume ratio. Results are expressed as median (range).Results: Gestational age at initial sclerotherapy was 22.0 weeks (19.6-31.4); 3 patients underwent 2 procedures. Intrauterine fetal demise (IUFD) occurred in 4 cases; 2 died on postoperative day #1 (one from inadvertent intravascular EO injection); 2 died >6 weeks after the procedure. Preoperative CPAM volume ratio was 3.6 (1.6-7.8) in survivors and 2.7 (1.7-4.7) in those with IUFD. The volume of EO at the initial sclerotherapy procedure was 3 mL (2-5) in survivors and 7 mL (6-10) in IUFD cases. The gestational age at delivery of the 4 survivors was 38.4 weeks (37.4-39.3); all underwent postnatal resection.Conclusion: The efficacy of percutaneous sclerotherapy for CPAM types II and III remains in question. Further studies are needed to determine the optimal dose of sclerotherapy agent and the safety and efficacy of this procedure. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to test the association between fetal intravenous anesthesia and the change in middle cerebral artery peak systolic velocity (MCA-PSV) in patients undergoing intrauterine transfusion (IUT) for suspected fetal anemia. Study Design We retrospectively examined data fromall patients who underwent IUT via umbilical cord route from 2007 to 2016. We calculated the change of the MCA-PSV multiple of median (MoM) as the difference in MCA-PSV MoM between the pre- and immediate postoperative measurements for the first IUT. The change in MCA-PSVMoM was compared between those who did and did not receive fetal anesthesia using Kruskal-Wallis' testing. Results Of 62 patients, 37 (59.7%) received intravenous fetal anesthesia and 25 (40.3%) did not. The change inMCA-PSV MoM did not differ between those who did and did not receive fetal anesthesia (median: 0.57 [interquartile range, IQR: +0.42 to +0.76] vs. median 0.57 [IQR: +0.40 to +0.81], p = 1.000). The relationship remained insignificant when stratifying by gestational age, length of procedure, initial MCA-PSV, and when excluding hydropic fetuses. Conclusion Among women undergoing IUT, there was no evidence that the use of fetal anesthesia was associated with a change in the pre- versus postoperative change in MCA-PSV MoM. [ABSTRACT FROM AUTHOR]

The objective of this study was to describe the management and perinatal outcomes of patients with twin-twin transfusion syndrome (TTTS) and an extremely short cervical length (CL). This retrospective study examined 17 patients with TTTS and a preoperative CL ≤1.0 cm who had undergone laser surgery and perioperative cervical cerclage placement successfully. In this subset of patients, the median interval between surgery and delivery was 9.6 (range 2.1-13.9) weeks and only one patient had PPROM within 3 weeks of surgery. The median gestational age at delivery was 30.9 (range 23.1-37.6) weeks, 30-day survival of at-least-one twin was 88.2% and dual survivorship was 82.4%. Overall, patients with TTTS and a preoperative CL ≤1.0 cm who were able to undergo successful laser surgery and emergent cerclage placement had favourable outcomes. Impact statement The management of patients with twin-twin transfusion syndrome (TTTS) and extremely short cervical length (CL) varies between foetal surgery centres. This study demonstrates that laser surgery and cerclage placement in such patients are not only technically feasible, but also can result in favourable perinatal outcomes. Patients with an extremely short CL should not be uniformly excluded from laser surgery for TTTS. [ABSTRACT FROM AUTHOR]

Objectives: Amniopatch is a proposed treatment of iatrogenic preterm premature rupture of membranes (iPPROM). We studied characteristics associated with successful amniopatch treatment of iPPROM after fetoscopic laser surgery for twin-twin transfusion syndrome.Methods: Patients with iPPROM within 15 days of laser surgery treated with an amniopatch were studied. Factors associated with amniopatch success (i.e. cessation of leakage with normalization of amniotic fluid volume) were tested univariately and in multivariate logistic regression models. Continuous variables are expressed as median (range).Results: Of 1124 patients undergoing laser surgery, 19 (1.7%) had iPPROM and subsequent amniopatch. Twelve (63.2%) were successful. Latency in days from iPPROM to delivery was greater in the successful group (114.0 [87.0-141.0]) versus (44.0 [3.9-88.0], p = 0.0005), which translated into greater gestational age (GA) (weeks) at delivery (35.1 [30.9-39.4] versus 28.1 [22.0-31.0], p = 0.0005). The 30-day survival of the affected recipient twin was improved (100% versus 57.1%, p = 0.0361). After multivariate testing, GA < 20 weeks at the time of the amniopatch placement was the only variable that remained associated with successful sealing of the membranes.Conclusions: Treatment of iPPROM via amniopatch was successful in almost two-thirds of cases and was associated with higher GA at delivery and improved perinatal survival. [ABSTRACT FROM AUTHOR]

Objectives. We examined trends in maternal comorbidities in California. Methods. We conducted a retrospective cohort study of 1 551 017 California births using state-linked vital statistics and hospital discharge cohort data for 1999, 2002, and 2005. We used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify the following conditions, some of which were preexisting: maternal hypertension, diabetes, asthma, thyroid disorders, obesity, mental health conditions, substance abuse, and tobacco use. We estimated prevalence rates with hierarchical logistic regression models, adjusting for demographic shifts, and also examined racial/ethnic disparities. Results. The prevalence of these comorbidities increased over time for hospital admissions associated with childbirth, suggesting that pregnant women are getting sicker. Racial/ethnic disparities were also significant. In 2005, maternal hypertension affected more than 10% of all births to non-Hispanic Black mothers; maternal diabetes affected nearly 10% of births to Asian/Pacific Islander mothers (10% and 43% increases, respectively, since 1999). Chronic hypertension, diabetes, obesity, mental health conditions, and tobacco use among Native American women showed the largest increases. Conclusions. The prevalence of maternal comorbidities before and during pregnancy has risen substantially in California and demonstrates racial/ethnic disparity independent of demographic shifts. [ABSTRACT FROM AUTHOR]

Objective Shoulder dystocia (SD) and brachial plexus palsy (BPP) are complications of childbirth that can result in significant long-term sequelae. The purpose of the present study was to analyze risk factors in cases of SD and BPP. Methods We performed a retrospective study of laboring women who delivered a singleton, term, live-born infant at the Los Angeles County + University of Southern California Medical Center from 1995 to 2004. Multivariable logistic regression models were used to analyze risk factors among SD cases with and without BPP. Results Of the 13,998 deliveries that met inclusion criteria, 221 (1.6%) had SD. Of these, 42 (19.0%) had BPP. After testing for association with multiple potential risk factors, including maternal demographic variables, diabetes, hypertension, prior cesarean delivery, uterine abnormalities, induction of labor, prolonged second stage (adjusted by parity and epidural use), assisted vaginal delivery, and neonatal birth weight, no statistical association of BPP with any specific risk factor was identified. Conclusion In the present study, we were unable to identify any reliable risk factors for BPP among deliveries with or without SD. SD and BPP remain unpredictable complications of childbirth. [ABSTRACT FROM AUTHOR]

Objective: To determine the composite risk of maternal and neonatal morbidity in pregnancies with suspected fetal macrosomia. Methods: In a retrospective study of laboring women delivering singleton, term neonates, we defined 3 groups of patients by estimated fetal weight (EFW) in grams, using ultrasound: (1) <4000, (2) 4000-4499, and (3) 4500+, and tested them for association with a composite outcome using multivariable logistic regression models. The measure of composite morbidity included: shoulder dystocia, third/fourth degree perineal laceration, postpartum hemorrhage, maternal length of stay (LOS)≥ 5 days, neonatal birth trauma, meconium aspiration syndrome, perinatal infection, and neonatal LOS ≥ 5 days. Because of potential interactions between diabetes and birthweight, women with maternal diabetes were examined separately. Results: Of 8,843 deliveries, the proportion with composite morbidity by group was: (1): 26.2%, (2): 41.2%, and (3): 63.6% ( p < 0.0001). The OR (95% CI) for groups (2) and (3) were: 1.9 (1.2-2.9) and 2.1 (0.6-7.2), for diabetics (9.7% of the final study population), and 2.3 (1.9-2.7) and 3.9 (2.2-6.9), for non-diabetics. Conclusions: Suspected fetal macrosomia appeared associated with increased risk for a composite measure of childbirth morbidity. [ABSTRACT FROM AUTHOR]

Objective. Multiple observational studies have emphasized the increased risk of elective induction versus spontaneous labor. We estimated the risks of elective induction before 39 weeks compared to expectant management. Methods. Using a single institution's delivery data (1996--2004), we identified women with uncomplicated term gestations who underwent elective induction before 39 weeks (Early Induction Group). A comparison group of women eligible for elective induction before 39 weeks but who were managed expectantly was created by identifying the remaining deliveries ≥≥39 weeks and excluding women with ''established'' pregnancy complications such as diabetes or heart disease (Expectant Management Group), but retaining women with complications that may have developed while waiting, e.g. gestational hypertension or abruption. Results. Pregnancies in the Early Induction Group were generally not at increased risk for morbidity when compared to the entire Expectant Management Group, in whom 49%% developed pregnancy complications or went postdates. These pregnancies had poorer maternal and neonatal outcomes when compared to patients who remained uncomplicated with spontaneous labor onset, thus reducing the overall benefit of expectant management. Conclusions. Failure to account for the large proportion of women who develop late pregnancy complications can falsely elevate the estimated risk of elective induction prior to 39 weeks. [ABSTRACT FROM AUTHOR]

Background: Controversy exists regarding the threshold of recipient twin polyhydramnios required to diagnose twin-twin transfusion syndrome at a gestational age of ≥20 weeks. One criterion set (Quintero staging) requires the amniotic fluid maximum vertical pocket for the recipient twin to measure ≥8 cm, whereas another (European) system uses a maximum vertical pocket for the recipient twin of ≥10 cm.Objective: This study aimed to characterize the patients with twin-twin transfusion syndrome who were treated with laser surgery and would be excluded from laser surgery according to the European criteria.Study Design: A total of 366 monochorionic diamniotic twins diagnosed with twin-twin transfusion syndrome from 20 to 26 weeks' gestation who underwent laser surgery at our center were studied. A maximum vertical pocket for the recipient twin of ≥8 cm was used to diagnose twin-twin transfusion syndrome. Patients were retrospectively divided into the following 2 groups: group A with a maximum vertical pocket for the recipient twin of ≥8 cm and <10 cm and group B with a maximum vertical pocket for the recipient twin of ≥10 cm. The association of each of the groups with the survivorship outcomes was tested. Bivariate associations between the patient characteristics and the 30-day donor twin and dual survivorship outcomes were evaluated. Tests used in the analysis were chi-square or Fisher exact tests as appropriate for categorical variables and Kruskal-Wallis tests for continuous variables. Multiple logistic regression models for each of the survivorship outcomes were then assessed. The results are reported as mean±standard deviation.Results: Of the 366 studied patients, 53 (14.5%) had a maximum vertical pocket for the recipient twin of ≥8 and <10 cm (group A) and 313 (85.5%) had a maximum vertical pocket for the recipient twin of ≥10 cm (group B). Groups A and B did not differ in the Quintero stage. Notably, 60.4% (32 of 53) of group A patients were stage III or IV. When compared with group B, group A was diagnosed with twin-twin transfusion syndrome at an earlier gestational age (21.7±1.6 vs 22.3±1.6 weeks; P=.0037) and had a higher prevalence of donor growth restriction (81.1% [43 of 53] vs 65.5% [205 of 313]; P=.0260). Rates of at least 1 twin and dual twin survival between group A and B were similar (98.1% [52 of 53] vs 95.8% [300 of 313]; P=.7023, and 79.2% [42 of 53] vs 83.4% [261 of 313]; P=.4369, respectively). Logistic regression models adjusted for perioperative characteristics showed no difference in the outcomes between the groups (group B as reference) (donor twin survival odds ratio, 0.64; 95% confidence interval, 0.29-1.42; P=.2753; and dual survivor odds ratio, 0.90; 95% confidence interval, 0.42-1.91; P=.7757).Conclusion: Restriction of the definition of twin-twin transfusion syndrome to a maximum vertical pocket for the recipient of ≥10 cm beyond 20 weeks gestational age would potentially exclude 14.5% of patients from laser surgery, the majority of whom had advanced stage twin-twin transfusion syndrome. A unifying criterion of a maximum vertical pocket for the recipient of ≥8 cm regardless of gestational age would allow inclusion of these patients and access to surgical management. [ABSTRACT FROM AUTHOR]

Objective To identify risk factors for development of twin-twin transfusion syndrome (TTTS) in monochorionic diamniotic multiple gestations complicated by midtrimester isolated polyhydramnios (iPoly). Study Design A retrospective study of patients referred for possible TTTS between 16 and 26 gestational weeks was performed. IPoly was defined as a maximum vertical pocket of ≥8 cm in the iPoly twin's sac and >2 and <8 cm in the co-twin's sac on the consultative ultrasound. Results Of 628 consecutive patients referred for possible TTTS, 74 were diagnosed with iPoly. The majority of these patients (n = 52, 70.3%) were not subsequently diagnosed with TTTS, and of these, 40 were managed expectantly and 12 had amnioreductions because of symptomatic iPoly; 30-day perinatal survival of at-least-one twin in the non-TTTS group was 93.0% (40/43). TTTS developed in the 22 remaining patients, of which 63.6% were of advanced Quintero Stage. Nineteen underwent laser surgery; 30-day perinatal survival of at-least-one twin was 84.2% (16/19). In a multivariate logistic regression model, 2 characteristics were associated with the development of TTTS: (1) gestational age <20 weeks at the time of diagnosis of iPoly (odds ratio, 13.48; 95% confidence interval, 3.40–53.48; P = .0002); and (2) intrauterine growth restriction of the co-twin (odds ratio, 7.28; 95% confidence interval, 1.72–30.88; P = .0071). Conclusion Among referred patients with midtrimester iPoly, 29.7% subsequently developed TTTS. Early diagnosis (<20 weeks) and/or co-twin intrauterine growth restriction were significant risk factors for development of TTTS in these patients. [ABSTRACT FROM AUTHOR]