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Immune Hydrops Fetalis

Introduction The fetal-maternal interface in pregnancy does not act as a barrier to the passage of fetal cells into the maternal circulation, and the passage of fetal deoxyribonucleic acid into the maternal compartment is one proposed mechanism for preventing immunologic rejection of the fetus with its paternally derived foreign antigen. The transfer of fetal red blood cells into the maternal circulation, however, has the ability to…

Nonimmune Hydrops Fetalis

Introduction Nonimmune hydrops fetalis (NIHF) was first explained by Potter, who described fetal hydrops in the nonanemic fetuses of Rh-positive women. With the advent of anti-D immunoglobulin and the decreased incidence of immune-mediated hydrops, NIHF now comprises 90% of all fetal hydrops cases. NIHF presents a diagnostic dilemma for the treating physician secondary to the myriad etiologies that result in NIHF. Although overall fetal mortality remains…

Lymphedema and Lymphatic Malformations

Background Dysregulation of the lymphatic system is a key factor in a variety of disorders, and may be associated with aneuploidy (especially monosomy X), autosomal, or X-linked genetic disorders, and/or multiple other conditions. Lymphatic disorders can be classified as primary or secondary. Primary or congenital lymphedema is most commonly associated with cystic hygroma (CH), and often leads to hydrops fetalis and fetal demise. Secondary lymphedema is…

Oligohydramnios

Introduction Oligohydramnios, a reduced amount of amniotic fluid, is associated with increased perinatal morbidity and mortality. Its presence should prompt fetal and maternal evaluation. Disease Definition The definition of oligohydramnios varies. It may be described subjectively, but accuracy is dependent on operator experience and gestational age; precise objective measurement requires invasive study and is difficult to assess clinically. In practice, the amniotic fluid volume is usually…

Polyhydramnios

Introduction Polyhydramnios (also called hydramnios ) is defined as an excessive amount of amniotic fluid. Although idiopathic in more than 50% of cases, it may be associated with maternal and fetal disorders. Polyhydramnios should prompt a detailed fetal anatomic ultrasound (US) scan and maternal evaluation. Disease Definition An amniotic fluid volume greater than 2000 mL constitutes polyhydramnios, but accurate measurement requires invasive study and is difficult to…

Open Fetal Surgery

Introduction Development of fetal surgery would not have been possible without advances in prenatal imaging, understanding the natural history of diseases, experimental animal models, and above all, the vision, innovation, and discipline of a dedicated group of surgeons, maternal-fetal medicine specialists, and anesthesiologists. The first human open fetal intervention was performed in 1982, with bilateral ureterostomies to manage a lower urinary tract obstruction (LUTO). Fetal surgery…

Multifetal Pregnancy Reduction

Introduction Multiple gestations are at risk for perinatal morbidity and mortality that increase with higher-order pregnancies, primarily caused by complications of prematurity. The risk of preterm delivery increases as the number of fetuses increases. In 2014, preterm delivery <32 weeks occurred in 1% of singletons, 11% of twins, 39% of triplets, and 72% of quadruplets. Infant mortality increases fourfold in twins, 12-fold in triplets, and 26-fold…

Fetal Shunts

Introduction Intrauterine fetal shunts provide continuous drainage of fluid accumulations that are associated with a high risk of death or profound morbidity without decompression. The shunts are flexible plastic catheters that are percutaneously guided to a fetal location in utero under continuous ultrasound (US) guidance. Although shunt placement is considered to be minimally invasive, procedural risks and uncertain long-term prognosis despite technical success limit this therapy…

Selective Laser Photocoagulation

Introduction Monochorionic twin gestations are at increased risk of perinatal morbidity and mortality related to a shared placental circulation. They are uniquely susceptible to the development of twin-twin transfusion syndrome (TTTS), with an incidence of approximately 10% to 15%. TTTS involves unbalanced shunting of blood between twins across vascular anastomoses within the placental bed. Without intervention, early-onset TTTS has a mortality rate that can approach 95%;…

Radiofrequency Ablation

Introduction The use of radiofrequency energy to create focal thermal tissue injury was first studied in the liver in the early 1990s. In 1996 the first radiofrequency ablation (RFA) procedure was performed on a patient with a liver tumor at Massachusetts General Hospital. RFA has since been used for various indications including unresectable tumors and cardiac arrhythmias. This technology has also been successfully applied to selective…

Chorionic Villus Sampling

Introduction Chorionic villus sampling (CVS) is a procedure in which small samples of placental tissue are obtained for prenatal diagnosis of aneuploidy or for DNA analysis. CVS is an outpatient procedure usually performed between 10 and 14 weeks' gestation. The main advantage of CVS compared with amniocentesis is that the results are available earlier in pregnancy, allowing for earlier and safer methods of pregnancy termination if…

Cordocentesis and Fetal Transfusion

Introduction Cordocentesis is a procedure that has both diagnostic and therapeutic value in fetal medicine, and is used for fetal blood sampling (FBS) and administration of fetal transfusions. Sir William Liley described the first successful intraperitoneal transfusion in 1963 with x-ray assistance. Almost 20 years later, Rodeck et al. reported using a fetoscopic approach to gain direct fetal vascular access. Ultrasound (US) guided percutaneous umbilical sampling (PUBS)…

Amniocentesis

Introduction Amniocentesis is a procedure in which a transabdominally placed needle is used to withdraw amniotic fluid from the amniotic sac. “Early amniocentesis” (<15 weeks' gestation) should be avoided because of increased complications, including a higher fetal loss rate and an increased risk of talipes equinovarus. Procedure You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If…

Intrauterine Growth Restriction

Introduction Intrauterine growth restriction (IUGR) is a significant pregnancy complication that has both short-term and long-term implications for the fetus and the neonate. A growth-restricted fetus is at increased risk of perinatal morbidity and mortality, and the risks are carried into adulthood with an increased risk of cardiovascular disease, hypertension, obesity, diabetes, and osteoporosis, regardless of the gestational age at delivery. Disease Definition IUGR is generally…

Beckwith-Wiedemann Syndrome

Introduction Beckwith-Wiedemann syndrome (BWS) was first described in 1963 and 1964 by Beckwith, an American pediatric pathologist, and Wiedemann, a German geneticist. Since the first descriptions, more than 500 cases have been reported. Prenatal diagnosis of BWS was first reported in 1980. With the increased knowledge of the clinical features and possible causes of BWS, the diagnosis is now often suspected prenatally, allowing for genetic testing,…

Fetal Macrosomia

Introduction The term macrosomia is used to describe a fetus or neonate with excessive growth. However, during pregnancy, as the fetus cannot be weighed directly, the term fetal macrosomia is intended to convey a suspicion of excessive fetal growth beyond a specified threshold, based on indirect assessment such as physical examination or ultrasound (US) assessment. Because of the increased risk of labor dystocia, birth trauma, and…

Vasa Previa

Introduction Vasa previa is a condition in which the umbilical vessels course through the membranes within the lower uterine segment and traverse over, or near, the endocervical os. These vessels can rupture spontaneously without rupture of the membranes, and result in fetal exsanguination and demise. In addition, since the vessels are not protected by the umbilical cord, they are at increased risk of cord compression. Disease…

Placenta Previa

Introduction Placenta previa is a leading cause of antepartum bleeding. Diagnosis of this condition prenatally by ultrasound (US) is key in preventing the significant maternal and fetal morbidity that can occur as a result of this condition. Disease Definition Placenta previa refers to a placenta located either fully or partially in the lower uterine segment and covering the internal cervical os. Historically, terms such as complete,…

Limb–Body Wall Complex

Introduction Limb–body wall complex (LBWC) refers to a combination of multiple malformations involving the craniofacial structures, thoracoabdominal wall, extremities, and spine. LBWC is almost uniformly lethal and associated with a very poor outcome because of, among other factors, pulmonary hypoplasia. The associated anomalies can be significantly disfiguring, often involving extensive lesions of the thoracoabdominal region with visceral herniation, a short or absent umbilical cord, and exteriorization…

Gestational Trophoblastic Disease

Introduction Gestational trophoblastic disease (GTD) is a spectrum of disorders arising from abnormal proliferation of the trophoblastic epithelium of the placenta. There are several histologically distinct types of GTD that range from premalignant, complete, and partial hydatidiform moles (HMs), to malignant diseases, also known as gestational trophoblastic neoplasia (GTN), which includes persistent/invasive GTN, placental site trophoblastic tumors, epithelioid trophoblastic tumor (ETT), and choriocarcinoma. Choriocarcinoma is discussed…