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Introduction Preterm delivery is the leading cause for infant mortality and morbidity. Cervical incompetence is a recognised cause for both extreme prematurity and second trimester loss. Use of cervical sutures may reduce these risks. We present an assessment of cervical suture use in a busy regional centre. Method Women who had an attempted cervical suture insertion were identified from theatre records from 2010–2013. Case notes were reviewed retrospectively and index pregnancy was identified as the first attempt to insert a cervical suture. Cervical sutures were categorised as “elective” when there was no evidence of cervical change, “semi-elective” when cervical sutures were attempted following shortening / funnelling of the cervix was identified on transvaginal ultrasound, “rescue” when cervical dilatation was said to have occurred. Results 26 patients were identified. 25 sutures were attempted in singleton pregnancy and 1 in a DCDA twin pregnancy. 10/25 (40%) of women had a previous history of preterm birth. Elective cervical sutures were used in 11/26 (42.3%) cases, Semi-elective sutures in 7/26(26.9%) cases, Rescue sutures in 8/26 cases (30.8). 19/26 (73.1%) of pregnancies resulted in a live birth, of which 11/11 (100%) Elective sutures, 6/7 (85.7%) of Semi-elective sutures and only 2/8 (25%) Rescue sutures resulted in live birth (p 0.0005). Conclusion Survival in the “rescue” cervical suture group was significantly poorer in comparison to both “elective” and “semi-elective” groups. This data supports the use of early cervical length screening in high risk cases. Further studies are required to identify optima timing of serial cervical length.

Methods A retrospective case note review of monoamniotic monochorionic (MCMA) pregnancies identified from central pathology database (1996–2008). Results 23 cases were identified from seven referring units in the West of Scotland. 14 cases (1.16:28 000 deliveries/year) were diagnosed antenataly as MAMC. Three case notes were not retrieved. For six cases it is difficult to comment if these were misdiagnosed antenataly as diamniotic as pathology confirmed MAMC twin placenta. Antenatal monitoring involved combination of serial ultrasound (growth, liquor volume and umbilical artery doppler), serial CTGs (cardiotocograph) and Biophysical Profile. After fetal maturity, the frequency of monitoring varied between different unit (weekly to 3/week ultrasound scan and daily to 3/week CTG). Identification of cord entanglement, however, failed to alter antenatal management. 12 patients had outpatient antenatal monitoring. During the study period no new methods of fetal monitoring evolved but fetal surveillance became more intensive. One case was complicated by twin to twin transfusion syndrome and three cases by preterm labour. Growth discrepancy was suspected antenatally in six cases and confirmed in four cases postnatally. There were two cases of unexplained fetal demise. Cord entanglement was identified in three cases antenataly and eight cases at delivery. Two patients were offered sulindac but declined because of potential side effects. Eight sets of twins were delivered Conclusion Despite lack of general consensus and wide variation in practice, adverse perinatal outcome was less common in our case series than previously reported. This is probably due to intensive antenatal fetal monitoring and early intervention in our group of patients.

Introduction Mild intracranial ventriculomegaly (VM) is a common finding during routine and detailed anomaly scanning. It can be associated with congenital infection, aneuploidy, cerebral vascular insults and additional fetal abnormalities. It can also be of no pathological significance when found in isolation and therefore presents a diagnostic challenge to clinicians. Studies have shown that fetal MRI provides further important information in 6–10% of cases. The authors sought to examine the role of fetal brain MRI in our population. Methods The authors conducted a retrospective case review of fetal brain MRIs for isolated mild VM since November 2007. The aim was to determine (1) if MRI confirmed US findings, (2) if there were any additional abnormalities seen on MRI and (3) if additional MRI information altered parental counselling. Results 15 cases with known neonatal/postmortem outcomes fitted the criteria. MRI confirmed VM in 14 cases. No additional brain abnormalities were found on MRI however severe VM was identified in four cases. MRI altered counselling and parental choice in two cases; both opted for termination of pregnancy following reported severe VM on MRI. Postmortem identified a posterior fossa meningeal cyst in one case and an acardiac twin in the other, neither were diagnosed on antenatal US or MRI. Antenatal detection of lobar holoprosencephaly by either modality was missed in one case of mild VM. Conclusion In our small group of patients, MRI was useful in identifying severe VM in four cases (26%) and changed parental choice in two cases (13%).

Intrauterine transfusion (IUT) cases for Parvovirus B19 infection over 2002–2011 were reviewed. Our unit receives referrals from Scotland and Northern Ireland. Most were referred in 2008 ( n = 5) and 2009 ( n = 7). In other years there were Thirty patients underwent 48 IUTs (mean 1.6, range 1–3). Twenty-six fetuses had middle cerebral artery Doppler peak systolic velocity values documented. All were >1.5 multiples of median prior to first IUT. At initial assessment, 25 fetuses were hydropic and 4 had ascites. Pre-IUT haematocrit value was available in 27 pregnancies: n = 13) followed by 17–20 weeks gestation ( n = 9) (range 17–32 weeks). Intrauterine or neonatal death occurred in 9 hydropic fetuses that had bradycardia, thrombocytopenia, difficult procedure or severe anaemia. No reasons were identified in 2 cases. However, these did not have pre-transfusion haematocrit values. Seven procedures had other complications e.g. cord haematoma, technically difficult, bradycardia and spontaneous rupture of membranes. This pregnancy was conservatively managed with a live birth at 36 weeks gestation. Live births occurred in 14 pregnancies. Seven women were lost to follow-up. Improved capture of outcome data is required. Short term outcomes were available in 8 neonates: 6 required no treatment, 1 had phototherapy and 1 had a neonatal death. We conclude that poor outcomes following IUT can be predicted at the time of procedure and that IUT can rescue a fetus destined for intrauterine loss to a healthy outcome.

Scottish intrauterine transfusion (IUT) cases for severe Rhesus isoimmunisation over 2002–2011 were reviewed. One hundred and forty-one pregnancies underwent 437 IUTs (mean 3.09, range 1–8). One hundred and thirty-one fetuses had middle cerebral artery Doppler peak systolic velocity values documented. All were >1.5 multiples of median prior to the first IUT, except for one that was inactive with a pericardial effusion. Twelve fetuses were hydropic. The haematocrit value prior to initial IUT was 20–29% in 38% of cases, whilst 27% had a haematocrit between 10–19%. Initial IUT was most commonly performed between 29–32 weeks gestation (35%) followed by 25–28 (26%) and 21–24 (21%) weeks gestation (range 17–25 weeks). In the majority of cases, fetus was transfused via umbilical vein (80%). Fourteen percent of transfusions were performed intrahepatically, 3% intraperitoneally and 3% were undocumented. Complications occurred in 58 (13%) IUTs and include cord haematoma, difficult procedure, bradycardia or tachycardia necessitating unplanned delivery, and in utero death (5 fetuses). The procedure-related loss rate was 1%. Birth outcomes were documented in 108 cases with a 94% live birth rate (n = 102). One patient underwent termination of pregnancy for trisomy 21. Short term postnatal outcomes were available for 86 neonates: 33 neonates required phototherapy only, with 31 cases requiring top-up transfusions. Nine neonates had an exchange transfusion and 9 had immunoglobulin or erythropoietin. Four neonates did not require any treatment. We conclude that our live birth and procedure-related loss rates are consistent with other published series. Parents need to be aware of potential postnatal therapies.

Fifty-five fetuses with pleural effusion were seen in our unit over last 9 years. Twenty-six cases (47%) did not have associated anomaly and were of uncertain aetiology. Twelve (22%) had associated structural anomalies without evidence of abnormal karyotypes. Cardiac anomalies were most common, while abnormalities in brain, kidneys and bones were also seen. Twelve fetuses had abnormal karyotypes (Trisomy 21 and Turner9s syndrome), 2 had parvovirus B19 and 1 had listeria. One fetus had supraventricular tachycardia and another had cardiac rhabdomyomas. There appears to be some seasonal trend for pleural effusions in those uncertain aetiology (n=26). They presented most frequently in November, October and July. Proven parvovirus cases (n=2) presented in June and October. Overall, 15/55 (27%) had termination of pregnancy: 5 had hydrops and 10 had associated anomalies. Four patients (7%) were delivered shortly after presentation whilst 21 (38%) had conservative sonographic surveillance. Three IUDs occurred in this group, 2 due to worsening hydrops or rhabdomyomas at 28 weeks and 1 was unexplained at 35 weeks despite postmortem examination. Eight patients (15%) were lost to follow-up. Fifteen cases underwent fetal therapy i.e. pleuro-amniotic shunt, pleural tap, intrauterine transfusion (IUT) or maternal flecainide. Of these, 2 losses occurred post IUT and the remainder had live births or were discharged to referring hospitals for follow-up. We conclude that in the absence of karyotypic or structural anomalies, fetal pleural effusion can have good outcomes with live births as in 36% (20/55) of our cohort.

During 2010, an audit of monochorionic twin management was undertaken in Glasgow and Clyde hospitals with 15,000 annual deliveries. Practice was compared against RCOG guideline.1 Thirty-seven MCDA and three MCMA cases were identified. All women had ultrasound examination for chorionicity, which was performed ≤13 weeks in 36 women (90%). Twenty-three patients (58%) had recorded photographic confirmation of this. Thirty cases (75%) were offered NT assessment, of which 14 declined. Of the 7 patients not offered, 2 were too late in gestation whilst 1 requested amniocentesis. All cohorts had detailed ultrasound scan. Only 1 case did not have extended cardiac views. Thirty-two women (80%) had ultrasound examinations from 16 weeks and 36 patients (90%) had scans every 2-3 weeks. Three women had single fetal death, of which 2 had selective reduction. Following this, all were assessed in a tertiary centre and had fetal MRI performed. Six cases of TTTS were identified. All were diagnosed ≤24 weeks. Two patients had stage 3 TTTS and were treated with laser ablation. One patient booked at 19 weeks with TTTS and IUDs, otherwise all resulted in live births. Overall, 32 MCDA pregnancies (86%) had at least one live birth, 23 (72%) delivered before 37 weeks, with 21 of these (91%) having received steroids. The remainder delivered between 37-38 weeks. Three MCMA pregnancies were delivered by Caesarean section at 32 weeks after steroid administration, and all had live births. We conclude that most RCOG recommendations have been implemented into practice, with some scope for improvement.

An 18 year old para1+0 was referred to our fetal medicine unit with an intraoral cystic structure (22mm×19mm) detected at routine anomaly scan. Fetal MRI confirmed a large thin walled cyst (25mm×24mm×18mm) in the midline filling the entire oral cavity and inseparable from the tongue. Differential diagnosis included congenital ranula, epidermoid cyst, unilocular lymphatic malformation and enteric duplication cyst. Multidisciplinary team counselling was performed involving fetal medicine specialists, neonatologists, paediatric ENT surgeons and paediatric anaesthetists and a management plan formulated. Ultrasound monitoring through the course of the pregnancy revealed no significant change in the size of the cyst. Development of polyhydramnios suggested that the cyst was beginning to interfere with fetal swallowing raising the possibility of potential problems with securing and maintaining airway at delivery. Hence delivery was arranged by elective caesarean section at 38+ weeks under steroid cover. Operation On Placental Support (OOPS) procedure was done at the time of delivery with the cyst being decompressed and intubation done while placental circulation was maintained. Excision of the lesion was performed on day 2 and histology confirmed a thyroglossal duct cyst. The baby did well in the neonatal period and was discharged home in the first week of life. With this case report we seek to highlight management of this extremely rare congenital cystic malformation of the oral cavity and the crucial role of combined imaging and multidisciplinary input to ensure a good outcome.

MRI for evaluating CNS anomalies detected on antenatal sonography has not become standard practice in our unit. This pilot study was carried out to determine the frequency at which MRI provides additional information in this setting. Going back from August 2010 a retrospective review of available case notes of 16 consecutive patients who attended our unit with fetal CNS abnormalities diagnosed on ultrasonography and then went on to have an MRI was done. The most common abnormality on sonography was ventriculomegaly (10 out the 16 cases) followed by cerebellar abnormality and suspected corpus callosum agenesis in 2 cases each. There was one case each of cortical cyst and megacisterna. Analysis of findings revealed that the MRI findings concurred with ultrasound findings in 10 of the 16 cases (62.5%) although additional information which did not influence counselling was obtained in 6 out of these 10 patients. In 6 of the 16 patients (37.5%) the MRI findings yielded information altered the counselling patients received. Magnetic resonance imaging findings not found by ultrasound included periventricular cavitation with subcortical white matter injury, agenesis of the corpus callosum, septum pellucidum agenesis, fine intraventricular adhesions suggestive of congenital CMV infection and cortical gyral abnormality. In conclusion when a CNS anomaly is detected by sonography, MRI findings might lead to altered diagnosis and patient counselling. Larger studies are needed to justify additional funding for fetal MRI examination to be made part of standard examination on sonographic diagnosis of a CNS abnormality.

Background Parvovirus infection may affect 1–5% of pregnant women. Clinical impact of maternal infection on the fetus is diverse (uncomplicated pregnancy, fetal anaemia, hydrops or intrauterine death). In mothers with proven fetal parvovirus B19 infection ultrasound monitoring of middle cerebral artery peak systolic velocity (MCA-PSV) is used to assess need for intrauterine transfusion (IUT). Objectives To confirm the correlation between MCA-PSV and fetal anaemia, and evaluate outcome following IUT. Methodology 10-year retrospective case note analysis of patients with parvovirus B19 infection referred to the fetal medicine at the Queen Mother9s hospital, Glasgow. Results 24 cases were identified from various units within Scotland and Northern Ireland. Data were available in 21 cases. Median age was 29 years. Median gestational age at referral was 21 weeks. All of the patients had positive serology for Parvovirus B19. Ultrasound confirmed hydrops in most patients (pleural effusion, pericardial effusion and ascites). IUT was attempted when MCA-PSV was >1.5 MoMs (19 patients; 1 twin pregnancy). There was a good correlation between MCA PSV and foetal anaemia (sensitivity 81.2% and PPV 100%). No complications occurred in 84% and cord haematoma and bradycardia occurred in 16%. Overall live birth rate was 53%. In one case conservative management was associated with spontaneous resolution of hydrops. Conclusion MCA-PSV is a reliable predictor of fetal anaemia in cases of fetal parvovirus infection. Overall survival was 55%. Regular monitoring and timely IUT is the key to management when anaemia is suspected.

Introduction Congenital diaphragmatic hernia (CDH) has an incidence of 1 in 2500 and around 30% of babies with isolated CDH die from pulmonary hypoplasia. There have been several techniques describing prediction of postnatal outcome in antenatally diagnosed isolated CDH based on the estimation of residual lung capacity by US and MRI. Recently, the observed to expected lung head ratio (O/E LHR) has been validated as a reliable method of lung estimation by 2D ultrasound and is a marker of postnatal morbidity and mortality.1 The authors sought to determine if the O/E LHR predicts survival in our West of Scotland population. Methods The authors conducted a retrospective analysis of antenatally diagnosed isolated left-sided CDH cases referred to the Ian Donald Fetal Medicine unit, Queen Mother9s Hospital, Glasgow from 2002 to 2009. Results 58 patients had an antenatal diagnosis of isolated fetal left-sided CDH, lung head ratios were available for 25 cases. The mortality was 29%, none of these patients underwent in utero fetal tracheal occlusion. There was no significant difference in conventional LHRs between the neonates that survived (n=18) and those that did not (n=7), p=0.11. Using the O/E LHRs however the neonates that survived had a significantly higher O/E ratio than those that did not (p=0.03). The liver position (being in the fetal chest or abdomen) did not affect the O/E ratios in the group of survivors (p=0.26) or non-survivors (p=0.44). Conclusion The authors have shown that the O/E LHR is a good predictor of mortality in our population of antenatally diagnosed CDH.