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Objectives: To compare the ambulatory status of a cohort of children who had undergone prenatal repair of an open neural tube defect (ONTD) using one of two different methods (fetoscopic or open hysterotomy) with that of a cohort who had undergone postnatal repair, and to identify the best predictors of ambulation at 30 months of age. Methods: This was a retrospective review of a cohort of children who underwent ONTD repair either prenatally (n = 110), by fetoscopic surgery (n = 73) or open hysterotomy surgery (n = 37), or postnatally (n = 51), in a single tertiary hospital between November 2011 and May 2023. The cohort comprised a consecutive sample of cases who had undergone ONTD repair in‐utero following Management of Myelomeningocele Study (MOMS) trial criteria and cases who had undergone postnatal repair, meeting the same criteria, which were also followed up after birth at the same institution. Motor function assessment by ultrasound was recorded at referral, 6 weeks after prenatal repair, or after referral in postnatally repaired cases, and at the last ultrasound scan before delivery. Clinical examinations to assess motor function at birth and at 12 months were retrieved from records. Intact motor function was defined as first sacral myotome (S1) motor function. Ambulatory status data at each follow‐up visit were collected. The proportion of children who were able to walk independently after 30 months of age was compared between those who had undergone fetoscopic vs open prenatal surgery and between prenatal (by either fetoscopic or open surgery) and postnatal ONTD repair. Logistic regression analyses were performed to identify predictors for independent ambulation. Results: After 30 months, the proportion of infants who were able to walk independently was higher in prenatally vs postnatally repaired cases (51.8% vs 15.7%, P < 0.01), and there was no difference between those with fetoscopic (52.1%) vs open (51.4%) prenatal repair (P = 0.66). In the prenatally repaired group, having intact motor function at 12 months (adjusted odds ratio (aOR), 9.14 (95% CI, 2.64–31.63), P < 0.01) and at birth (aOR, 4.50 (95% CI, 1.21–16.80), P = 0.02) were significant predictors of independent walking at 30 months; an anatomical level of lesion below L2 at referral (aOR, 1.83 (95% CI, 1.30–2.58), P = 0.01) and female gender (aOR, 3.51 (95% CI, 1.43–8.61), P < 0.01) were also predictive for this outcome. Conclusions: Prenatally repaired cases of ONTD have a better chance of being able to walk independently at 30 months than do those who undergo postnatal repair. In patients with prenatally repaired ONTD, ambulatory status at 30 months can be predicted by observing a low lesion level at referral (below L2) and intact motor function postnatally. These results have implications for parental counseling and planning for supportive therapy in pregnancies affected by ONTD. © 2024 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: Prenatal open neural tube defect (ONTD) repair is performed to decrease the risk of needing treatment for hydrocephalus after birth and to preserve motor function. Some centers may not consider patients to be candidates for surgery if severe ventriculomegaly is present and there is no expected benefit in risk for hydrocephalus treatment. This study sought to compare the postnatal outcome of fetuses with ONTD and severe ventriculomegaly (ventricular width ≥ 15 mm) that underwent prenatal repair with the outcome of fetuses with severe ventriculomegaly that underwent postnatal repair and fetuses without severe ventriculomegaly (< 15 mm) that underwent prenatal repair. Methods: This was a retrospective study of fetuses with ONTD that underwent prenatal or postnatal repair between 2012 and 2021 at a single institution. The cohort was divided into two groups based on preoperative fetal ventricular size: those with severe ventriculomegaly (ventricular width ≥ 15 mm) and those without severe ventriculomegaly (< 15 mm). Fetal ventricular size was measured by magnetic resonance imaging before surgery using the standardized approach and the mean size of the left and right ventricles was used for analysis. Motor function of the lower extremities was assessed at the time of referral by ultrasound and if flexion–extension movements of the ankle were seen it was considered as preserved S1 motor function. Postnatal outcomes, including motor function of the lower extremities at birth and the need for a diversion procedure for hydrocephalus treatment during the first year after birth, were collected and compared between groups. Multivariate regression analysis was used to adjust for potential confounders. Results: In this study, 154 patients were included: 145 underwent fetal surgery (101 fetoscopic and 44 open hysterotomy) and nine with severe ventriculomegaly underwent postnatal repair. Among the 145 patients who underwent fetal surgery, 22 presented with severe ventriculomegaly. Fetuses with severe ventriculomegaly at referral that underwent prenatal repair were significantly more likely to need hydrocephalus treatment by 12 months after birth than those without severe ventriculomegaly (61.9% vs 28.9%, P < 0.01). However, motor function assessment at birth was similar between both prenatal repair groups (odds ratio, 0.92 (95% CI, 0.33–2.59), P = 0.88), adjusted for the anatomical level of the lesion. The prenatal repair group with severe ventriculomegaly had better preserved motor function at birth compared to the postnatal repair group with severe ventriculomegaly (median level, S1 vs L3, P < 0.01; proportion with S1 motor function, 68.2% vs 11.1%, P < 0.01). Fetuses with severe ventriculomegaly that underwent prenatal repair had an 18.9 (95% CI, 1.2–290.1)‐times higher chance of having intact motor function at birth, adjusted for ethnicity, presence of club foot at referral and gestational age at delivery, compared with the postnatal repair group. There was no significant difference in the need for hydrocephalus treatment in the first year after birth between prenatal and postnatal repair groups with severe ventriculomegaly (61.9% vs 87.5%, P = 0.18). Conclusions: Although fetuses with ONTD and severe ventriculomegaly do not seem to benefit from fetal surgery in terms of postnatal hydrocephalus treatment, there is an increased chance of preserved motor function at birth. Results from this study highlight the benefit of prenatal ONTD repair for cases with severe ventriculomegaly at referral to preserve motor function. © 2024 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

This article discusses the management of fetal cardiac resuscitation during fetal cardiac intervention (FCI) in cases of severely obstructed left heart and a restrictive or intact atrial septum. The study reports on five fetal cases that underwent cardiac compressions, including one fetus that required resuscitation after ventricular fibrillation. The authors describe their institutional resuscitation strategy, which involves using ultrasound guidance to assess the depth and quality of compressions. The article also highlights the success of cardiac compressions in restoring normal sinus rhythm in all five fetuses. The authors recommend standardized dilutions of resuscitative drugs for fetal resuscitation during FCI. [Extracted from the article]

Objective: In‐utero repair of an open neural tube defect (ONTD) reduces the risk of developing severe hydrocephalus postnatally. Perforation of the cavum septi pellucidi (CSP) may reflect increased intraventricular pressure in the fetal brain. We sought to evaluate the association of perforated CSP visualized on fetal imaging before and/or after in‐utero ONTD repair with the eventual need for hydrocephalus treatment by 1 year of age. Methods: This was a retrospective cohort study of consecutive patients who underwent laparotomy‐assisted fetoscopic ONTD repair between 2014 and 2021 at a single center. Eligibility criteria for surgery were based on those of the Management of Myelomeningocele Study (MOMS), although a maternal prepregnancy body mass index of up to 40 kg/m2 was allowed. Fetal brain imaging was performed with ultrasound and magnetic resonance imaging (MRI) at referral and 6 weeks postoperatively. Stored ultrasound and MRI scans were reviewed retrospectively to assess CSP integrity. Medical records were reviewed to determine whether hydrocephalus treatment was needed within 1 year of age. Parametric and non‐parametric tests were used as appropriate to compare outcomes between cases with perforated CSP and those with intact CSP as determined on ultrasound at referral. Logistic regression analysis was performed to assess the predictive performance of various imaging markers for the need for hydrocephalus treatment. Results: A total of 110 patients were included. Perforated CSP was identified in 20.6% and 22.6% of cases on preoperative ultrasound and MRI, respectively, and in 26.6% and 24.2% on postoperative ultrasound and MRI, respectively. Ventricular size increased between referral and after surgery (median, 11.00 (range, 5.89–21.45) mm vs 16.00 (range, 7.00–43.5) mm; P < 0.01), as did the proportion of cases with severe ventriculomegaly (ventricular width ≥ 15 mm) (12.7% vs 57.8%; P < 0.01). Complete CSP evaluation was achieved on preoperative ultrasound in 107 cases, of which 22 had a perforated CSP and 85 had an intact CSP. The perforated‐CSP group presented with larger ventricles (mean, 14.32 ± 3.45 mm vs 10.37 ± 2.37 mm; P < 0.01) and a higher rate of severe ventriculomegaly (40.9% vs 5.9%; P < 0.01) compared to those with an intact CSP. The same trends were observed at 6 weeks postoperatively for mean ventricular size (median, 21.0 (range, 13.0–43.5) mm vs 14.3 (range, 7.0–29.0) mm; P < 0.01) and severe ventriculomegaly (95.0% vs 46.8%; P < 0.01). Cases with a perforated CSP at referral had a lower rate of hindbrain herniation (HBH) reversal postoperatively (65.0% vs 88.6%; P = 0.01) and were more likely to require treatment for hydrocephalus (89.5% vs 22.7%; P < 0.01). The strongest predictor of the need for hydrocephalus treatment within 1 year of age was lack of HBH reversal on MRI (odds ratio (OR), 36.20 (95% CI, 5.96–219.12); P < 0.01) followed by perforated CSP on ultrasound at referral (OR, 23.40 (95% CI, 5.42–100.98); P < 0.01) and by perforated CSP at 6‐week postoperative ultrasound (OR, 19.48 (95% CI, 5.68–66.68); P < 0.01). Conclusions: The detection of a perforated CSP in fetuses with ONTD can reliably identify those cases at highest risk for needing hydrocephalus treatment by 1 year of age. Evaluation of this brain structure can improve counseling of families considering fetal surgery for ONTD, in order to set appropriate expectations about postnatal outcome. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the outcome of monochorionic diamniotic (MCDA) twins complicated by Type‐II selective fetal growth restriction (sFGR) who underwent fetoscopic laser photocoagulation and to validate a previously proposed subclassification system for Type‐II sFGR in a large multicenter cohort. Methods: This retrospective multicenter cohort study included all MCDA twins complicated by Type‐II sFGR who underwent laser photocoagulation of placental anastomoses at four large tertiary fetal‐care centers between 2006 and 2020. Cases were subclassified according to a recently proposed system based on Doppler evaluation of the ductus venosus (DV) and middle cerebral artery (MCA) into Type‐IIA (normal DV flow and MCA peak systolic velocity (PSV) of the growth‐restricted fetus) or Type‐IIB (absent or reversed flow in the DV during atrial contraction and/or MCA‐PSV ≥ 1.5 multiples of the median of the growth‐restricted fetus). Demographic characteristics and pregnancy outcomes were compared between the groups. Data are presented as mean ± SD or n (%) as appropriate. P‐values < 0.05 were considered statistically significant. Results: A total of 98 patients with MCDA twins met our inclusion criteria, with 56 subclassified as Type IIA and 42 as Type IIB. Demographic characteristics were similar between the groups; however, Type‐IIB cases had a significantly earlier gestational age at diagnosis and at laser surgery, as well as larger intertwin estimated fetal weight discordance, which may be a reflection of disease severity. Postnatal survival of the growth‐restricted fetus to 30 days of age was significantly lower in Type‐IIB compared to Type‐IIA cases (23.8% vs 46.4%; P = 0.034). Conclusions: In MCDA twins complicated by Type‐II sFGR and treated with laser photocoagulation of placental anastomoses, preoperative Doppler assessment of the DV and MCA helped identify a subset of patients at increased risk of demise of the growth‐restricted fetus following intervention. This study provides valuable information for guiding surgical management and patient counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

This article discusses the use of ultrasound in predicting perinatal morbidity in fetal sacrococcygeal teratoma (SCT), the most common tumor in neonates. The study aimed to develop a model for predicting perinatal outcomes in SCT using parameters obtained from mid-trimester ultrasound examinations. The study found that several sonographic characteristics, such as tumor volume, tumor volume-to-fetal weight ratio, and the presence of hydrops fetalis and hepatomegaly, were significantly associated with perinatal death in SCT cases. Abnormal ductus venosus waveforms and fetal hepatomegaly were identified as independent predictors of perinatal death. The findings suggest that incorporating the assessment of these characteristics into perinatal SCT work-up may help guide protocols for antenatal intervention and improve outcomes. [Extracted from the article]

Objective: In‐utero repair of open neural tube defects (ONTD) is an accepted treatment option with demonstrated superior outcome for eligible patients. While current guidelines recommend genetic testing by chromosomal microarray analysis (CMA) when a major congenital anomaly is detected prenatally, the requirement for an in‐utero repair, based on the Management of Myelomeningocele Study (MOMS) criteria, is a normal karyotype. In this study, we aimed to evaluate if CMA should be recommended as a prerequisite for in‐utero ONTD repair. Methods: This was a retrospective cohort study of pregnancies complicated by ONTD that underwent laparotomy‐assisted fetoscopic repair or open‐hysterotomy fetal surgery at a single tertiary center between September 2011 and July 2021. All patients met the MOMS eligibility criteria and had a normal karyotype. In a subset of the pregnancies (n = 77), CMA testing was also conducted. We reviewed the CMA results and divided the cohort into two groups according to whether clinically reportable copy‐number variants (CNV) were detected (reportable‐CNV group) or not (normal‐CMA group). Surgical characteristics, complications, and maternal and early neonatal outcomes were compared between the two groups. The primary outcomes were fetal or neonatal death, hydrocephalus, motor function at 12 months of age and walking status at 30 months of age. Standard parametric and non‐parametric statistical tests were employed as appropriate. Results: During the study period, 146 fetuses with ONTD were eligible for and underwent in‐utero repair. CMA results were available for 77 (52.7%) patients. Of those, 65 (84%) had a normal CMA and 12 (16%) had a reportable CNV, two of which were classified as pathogenic. The first case with a pathogenic CNV was diagnosed with a 749‐kb central 22q11.21 deletion spanning low‐copy‐repeat regions B–D of chromosome 22; the second case was diagnosed with a 1.3‐Mb interstitial deletion at 1q21.1q21.2. Maternal demographics, clinical characteristics, operative data and postoperative complications were similar between those with normal CMA results and those with reportable CNVs. There were no significant differences in gestational age at delivery or any obstetric and early neonatal outcome between the study groups. Motor function at birth and at 12 months of age, and walking status at 30 months of age, were similar between the two groups. Conclusions: Standard diagnostic testing with CMA should be offered when an ONTD is detected prenatally, as this approach has implications for counseling regarding prognosis and recurrence risk. Our results indicate that the presence of a clinically reportable CNV should not a priori affect eligibility for in‐utero repair, as overall pregnancy outcome is similar in these cases to that of cases with normal CMA. Nevertheless, significant CMA results will require a case‐by‐case multidisciplinary discussion to evaluate eligibility. To generalize the conclusion of this single‐center series, a larger, multicenter long‐term study should be considered. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

This article discusses the outcomes of cytogenetic analysis during fetoscopic selective laser photocoagulation (FSLP) for Twin-Twin Transfusion Syndrome (TTTS) in monochorionic twin pregnancies. The study found that 78% of patients undergoing FSLP consented to amniotic fluid cytogenetic analysis, with 2% of karyotypes showing abnormal results and 3% of CMA analysis showing abnormal results. The study also encountered six confirmed parental variants. The authors conclude that cytogenetic analysis during FSLP is feasible and may provide additional information to parents, but the potential benefits should be weighed against the identification of unidentified parental variants and unknown consanguinity. [Extracted from the article]

This article, published in the journal Ultrasound in Obstetrics & Gynecology, examines amniotic fluid abnormalities in monochorionic diamniotic (MCDA) twins that do not meet the criteria for Twin–twin transfusion syndrome (TTTS). The study reviewed MCDA twins at a tertiary fetal center between 2018 and 2022. The results show that cases with fluid abnormalities not diagnostic for TTTS had more complications, fetal intervention, fetal demise, and longer hospital stays compared to the control group. The study suggests that such cases often become apparent within four weeks. [Extracted from the article]

This article, published in the journal Ultrasound in Obstetrics & Gynecology, compares two methods of estimating fetal lung size in fetuses with Congenital Diaphragmatic Hernia (CDH) who underwent Fetoscopic Endoluminal Tracheal Occlusion (FETO). The first method, observed/expected lung to head ratio (O/E LHR), is measured using ultrasound scans, while the second method, observed/expected Total Fetal Lung Volume (O/E TFLV), is measured using MRI scans. The study found that there was no significant difference in the predictive value of O/E TFLV and O/E LHR for 6 months survival. [Extracted from the article]

This article discusses a study that aimed to evaluate the use of a post-processing technique called Slice-to-Volume registration (SVR) in assessing lung volume in fetuses with congenital diaphragmatic hernia (CDH) who underwent Fetoscopic Enlolunial Tracheal Occlusion (FETO). The study found that there was a good correlation between lung volume measurements obtained using original MRI volumes and after motion artifact correction using SVR. Additionally, the prediction of postnatal survival after FETO based on lung volume measurements using original MRI volumes and SVR volumes showed similarities. Overall, SVR appears to be a useful tool in assessing lung volume in CDH fetuses. [Extracted from the article]

This article, published in the journal Ultrasound in Obstetrics & Gynecology, discusses the natural history of elevated middle cerebral artery (MCA) peak systolic velocity (PSV) in monochorionic/diamniotic (MCDA) twins that do not meet the criteria for twin-anemia-polycythemia sequence (TAPS). The study reviewed MCDA twin pairs undergoing TAPS screening at a tertiary care center between 2018 and 2022. The results showed that elevated MCA PSVs not meeting TAPS criteria did not change outcomes in the absence of twin-twin transfusion syndrome (TTTS) or selective fetal growth restriction (sFGR). The study suggests that while providers should be aware of the risk of TTTS or TAPS and closely monitor these cases, families can be reassured that the risks are low. [Extracted from the article]

This article, titled "Diffusion weighted imaging of the spinal cord in infants with prenatally repaired spina bifida and its association with neurological outcomes," examines the use of MRI-diffusion weighted imaging (DWI) analysis to assess spinal cord microstructure in infants who underwent prenatal spina bifida repair. The study found that infants with favorable neurological outcomes, including independent ambulation, better motor and sensory function, and improved bladder control, had significant differences in spinal microstructure compared to those with unfavorable outcomes. The research suggests that DWI analysis may be a useful tool for predicting neurological outcomes in infants with spina bifida. [Extracted from the article]

This article, titled "Association between fetal brain diffusion weighted imaging and postnatal neurodevelopmental outcomes after prenatal spina bifida repair," examines the relationship between fetal brain imaging and postnatal neurodevelopmental outcomes in infants who underwent prenatal spina bifida repair. The study involved 73 infants and used diffusion weighted imaging (DWI) scans to measure brain microstructure. The results showed that infants with delayed cognition and communication skills had significant differences in their fetal brain microstructure measured 6 weeks after the surgery. This research provides valuable insights into the potential impact of prenatal spina bifida repair on neurodevelopmental outcomes. [Extracted from the article]

This article, published in the journal Ultrasound in Obstetrics & Gynecology, examines the significance of abnormal ductus venosus Doppler waveforms on delivery indications and outcomes in monochorionic pregnancies with type III selective fetal growth restriction (sFGR). The study, conducted at a tertiary center from 2015 to 2023, found that abnormal ductus venosus Dopplers were a common finding in type III sFGR pregnancies. While it did not indicate immediate fetal compromise, it was associated with earlier gestational age at delivery and an increased risk of fetal distress leading to emergency delivery compared to type III sFGR cases with normal DV Doppler waveforms. [Extracted from the article]

This article discusses a study that aimed to compare different methods of predicting survival in fetuses with congenital diaphragmatic hernia (CDH). The researchers compared the use of observed/expected total fetal lung volume (O/E TFLV) normalized by gestational age (GA) using first trimester Crown-Rump Length (CRL) versus using fetal size determined at the time of MRI. The study found that there were no differences in the prediction of survival using either method. The findings suggest that both methods can be used to predict survival in CDH fetuses. [Extracted from the article]

This article, published in the journal Ultrasound in Obstetrics & Gynecology, examines the effect of different entry techniques on chorioamniotic membrane separation (CAS) in fetoscopic laser photocoagulation (FLP) for Twin-twin transfusion syndrome (TTTS). The study, which included 508 cases of FLP for TTTS, compared the outcomes of using the Seldinger technique versus the sharp trocar entry technique. The results showed that the sharp trocar entry technique was associated with lower rates of CAS, lower rates of preterm delivery at less than 32 weeks, and a longer interval between intervention and delivery. However, further research is needed due to the retrospective nature of the study. [Extracted from the article]

This article compares the neurodevelopmental outcomes of infants who underwent prenatal open neural tube defect repair (ONTD) with those who had a postnatal repair. The study included 132 infants, with 93 undergoing prenatal repair (69 fetoscopic and 24 open hysterotomy) and 39 undergoing postnatal repair. Neurodevelopmental outcomes were evaluated using standardized tests and interviews. The results showed that infants who had prenatal repair had better neurodevelopmental outcomes compared to those who had postnatal repair. Additionally, fetoscopically repaired infants had similar outcomes to those who had open fetal surgery, except for higher visual and non-verbal problem-solving skills. [Extracted from the article]

This article discusses the management of a rare condition called heterokaryotypic monochorionic twin pregnancy, which involves genetic discordance between twins. Depending on the severity of associated malformations, management options can range from observation to termination of pregnancy. However, in some areas of the USA, termination of pregnancy is limited by legislation. The article presents a case study of a patient with this condition who opted for fetoscopic laser photocoagulation (FLP) as an alternative to termination. The FLP procedure was successful, resulting in the delivery of a healthy neonate. The article concludes that FLP can be a safe and feasible alternative for managing complex monochorionic pregnancies. [Extracted from the article]

Objective: To evaluate the efficacy of long‐term indomethacin therapy (LIT) in prolonging pregnancy and reducing spontaneous preterm birth (PTB) in patients undergoing fetoscopic laser surgery (FLS) for the management of twin‐to‐twin transfusion syndrome (TTTS). Design: Retrospective cohort study of prospectively collected data. Setting: Collaborative multicentre study. Population: Five hundred and fifty‐seven consecutive TTTS cases that underwent FLS. Methods: Long‐term indomethacin therapy was defined as indomethacin use for at least 48 hours. Log‐binomial regression was used to estimate the relative risk of PTB in the LIT group compared with a non‐LIT group. Cox regression was used to evaluate the association between LIT use and FLS‐to‐delivery survival. Main outcome measures: Gestational age (GA) at delivery. Results: Among the 411 pregnancies included, a total of 180 patients (43.8%) received LIT after FLS and 231 patients (56.2%) did not. Median GA at fetal intervention did not differ between groups (20.4 weeks). Median GA at delivery was significantly higher in the LIT group (33.6 weeks) compared with the non‐LIT group (31.1 weeks; P < 0.001). FLS‐to‐delivery interval was significantly longer in the LIT group (P < 0.001). The risks of PTB before 34, 32, 28 and 26 weeks of gestation were all significantly lower in the LIT group compared with the non‐LIT group (relative risks 0.69, 0.51, 0.37 and 0.18, respectively). The number needed to treat with LIT to prevent one PTB before 32 weeks of gestation was four, and to prevent one PTB before 34 weeks was five. Conclusion: Long‐term indomethacin after FLS for TTTS was found to be associated with prolongation of pregnancy and reduced risk for PTB. Long‐term indomethacin used after fetoscopic laser surgery for twin‐to‐twin transfusion syndrome is effective in prolonging pregnancy and reducing the risk for preterm birth; especially extreme preterm birth. Long‐term indomethacin used after fetoscopic laser surgery for twin‐to‐twin transfusion syndrome is effective in prolonging pregnancy and reducing the risk for preterm birth; especially extreme preterm birth. Linked article This article is commented on by Y Ville pp. 607 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471-0528.17015. [ABSTRACT FROM AUTHOR]