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Objective: Preeclampsia often complicates pregnancies after maternal kidney transplantation. We aimed to assess whether preeclampsia is associated with kidney function decline either during the pregnancy or in the long term., Methods: We performed an international multicenter retrospective cohort study. Renal function at conception, pregnancy outcomes, and short- and long-term graft outcomes were collected for women who were pregnant after renal transplantation and had transplant and obstetric care at the participating centers. In women who had multiple pregnancies during the study period, only the last pregnancy was included. Univariate and multivariable analyses were performed., Results: We retrieved pregnancy outcomes and long-term renal outcomes for 52 women. Chronic hypertension was present at baseline in 27%. Mean estimated glomerular filtration rate (GFR) at start of pregnancy was 52.4±17.5 mL/min/1.73 m. Mean estimated GFR at delivery was 47.6±21.6 mL/min/1.73 m, which was significantly lower than at conception (P=.03). Twenty women (38%) developed preeclampsia. In multivariable analysis, women who developed preeclampsia had a 10.7-mL/min/1.73 m higher drop in estimated GFR between conception and delivery than women who did not develop preeclampsia (P=.02). Long-term estimated GFR follow-up was obtained at a median of 5.8 years (range 1.3-27.5 years). Mean estimated GFR at last follow-up was 38±23 mL/kg/1.73 m. Seventeen women (33%) experienced graft loss over the follow-up period. Incidence of graft loss was similar in women with and without preeclampsia in their last pregnancy (30% and 34%, respectively; P=.99). In multivariable analysis, the decrease in estimated GFR between conception and last follow-up was similar in women who experienced preeclampsia during pregnancy and those who did not (difference -2.69 mL/min/1.73 m, P=.65)., Conclusion: Preeclampsia commonly complicates pregnancies after renal transplantation but is not associated with long-term renal dysfunction or graft loss.

Purpose of Review: Although most fetal disorders can be treated after birth, a few conditions that predictably lead to fetal or neonatal death, or that progress significantly before birth, are ideally treated prenatally. The number of centers offering fetal therapeutic procedures is gradually increasing worldwide. Patients and caregivers should be aware of the potential maternal risks of these interventions., Recent Findings: For transplacental medical therapy (corticosteroids, antiarrhythmics and immunoglobulins), severe maternal adverse events are rare, when done in expert centers. Minimally invasive procedures carry a risk of maternal complications of about 5%, with 1% being severe complications (pulmonary edema or placental abruption). Open fetal surgery carries important risks to the mother, both in the index pregnancy (pulmonary edema, placental abruption, chorioamnionitis and scar dehiscence) and in subsequent pregnancies (uterine rupture), yet some of these risks are decreasing with surgical refinement and increasing experience of the surgical team., Summary: The information in this manuscript provides a base to counsel expectant mothers on risk of fetal therapy.

Objective: To assess maternal and fetal outcomes of pregnancies complicated by internal herniation after Roux-en-Y gastric bypass., Data Sources: Articles were identified through searches in online databases (ClinicalTrials.gov, MEDLINE, EMBASE, PubMed, and Google Scholar) from January 1980 to March 2015 for the following terms: [gastric bypass OR bariatric surgery] AND [pregnancy] AND [complication OR herniation OR obstruction]. Reference lists of relevant articles were hand-searched. Additionally, we searched our own hospital's obstetric database for cases of internal herniation after Roux-en-Y gastric bypass., Methods of Study Selection: Only articles in English and studies in humans were selected. Cases of internal herniation outside of pregnancy or internal herniation without a history of Roux-en-Y gastric bypass were excluded. Of 384 articles identified by the initial search, 22 were retained for further analysis., Tabulation, Integration, and Results: All retrieved articles were case reports or case series. There were no interventional studies. We retrieved 47 cases from the literature and five cases from our own database. The mean gestational age at diagnosis was 28.4±7.3 weeks. All women presented with abdominal pain. Nausea and vomiting were present in only 65%. Ultrasonography and laboratory results are usually noninformative, and computed tomography or magnetic resonance imaging confirmed the diagnosis in only 75% of cases. Nine of 52 women (17.3%) required bowel resections. There were two maternal deaths and three perinatal deaths, all in women treated later than 48 hours after onset of the symptoms., Conclusion: Internal herniation complicating pregnancy after Roux-en-Y gastric bypass typically presents with subtle signs in the third trimester of pregnancy. Timely recognition and early surgical intervention are associated with a reduced risk of bowel ischemia and maternal and fetal adverse outcomes.

Purpose of Review: This article reviews the potential benefits and downsides of early anatomy screening., Recent Findings: There is increasing evidence that about 50% of severe fetal anomalies can be diagnosed prior to 14 weeks of gestation. 'Red flags' such as an increased nuchal or intracranial translucency, tricuspid valve regurgitation, a small biparietal diameter, a single umbilical artery or an abnormal retronasal triangle should raise the sonographer's suspicion of a congenital defect and warrant a more thorough fetal assessment, which often includes transvaginal scanning. Care should, however, be taken not to overinterpret first-trimester findings as false-positive rates of 3-4% have been reported. With more subtle findings, and especially if a heart defect is suspected, a sonographic reassessment after 15 weeks' gestation is indicated. Patients should be counseled that findings could worsen but also improve with time., Summary: Basic fetal anomaly screening should be recommended, piggybacked on the routine first-trimester (aneuploidy screening) ultrasound, both for low and high-risk populations. First-trimester anatomy screening seems particularly useful in obese women, whose fetuses are difficult to screen at the midtrimester ultrasound and in multiple gestation. Noninvasive prenatal testing using cell-free fetal DNA can complement but should not replace first-trimester ultrasound.

Objective: To evaluate antenatal surveillance strategies and the optimal timing of delivery for monoamniotic twin pregnancies., Methods: Obstetric and perinatal outcomes were retrospectively retrieved for 193 monoamniotic twin pregnancies. Fetal and neonatal outcomes were compared between fetuses followed in an inpatient setting and those undergoing intensive outpatient follow-up from 26 to 28 weeks of gestation until planned cesarean delivery between 32 and 35 weeks of gestation. The risk of fetal death was compared with the risk of neonatal complications., Results: Fetal deaths occurred in 18.1% of fetuses (70/386). Two hundred ninety-five neonates from 153 pregnancies were born alive after 23 weeks of gestation. There were 17 neonatal deaths (5.8%), five of whom had major congenital anomalies. The prospective risk of a nonrespiratory neonatal complication was lower than the prospective risk of fetal death after 32 4/7 weeks of gestation (95% confidence interval 32 0/7-33 4/7). The incidence of death or a nonrespiratory neonatal complication was not significantly different between fetuses managed as outpatients (14/106 [13.2%]) or inpatients (15/142 [10.5%]; P=.55). Our statistical power to detect a difference in outcomes between these groups was low., Conclusions: The in utero risk of a monoamniotic twin fetus exceeds the risk of a postnatal nonrespiratory complication at 32 4/7 weeks of gestation. If close fetal surveillance is instituted after 26-28 weeks of gestation and delivery takes place at approximately 33 weeks of gestation, the risk of fetal or neonatal death is low, no matter the surveillance setting., Level of Evidence: II.

Background: Pregnancy provides a unique model to study the adaptation of the heart in a physiological situation of transient load changes. The aim of this study was to assess the performance of the left ventricle (LV) in normal, uncomplicated pregnancies while considering the actual LV load and shape., Methods and Results: Serial echocardiographic examinations were performed in 51 women in each pregnancy trimester and 3 to 6 months after delivery. Data from 10 nulliparous, age-matched women were used as the control. Conventional parameters of LV function (ejection fraction) as well as myocardial deformation (strain) were interpreted, taking into consideration maternal hemodynamics and LV shape. Cardiac output increased during pregnancy because of a higher stroke volume in early pregnancy and a late increase in heart rate, whereas total vascular resistance decreased. Progressive development of eccentric hypertrophy was observed, which subsequently recovered postpartum. Sphericity index decreased from the first to the third trimester (1.92±0.17 versus 1.71±0.17) and returned postpartum to values comparable to the control. Although higher LV stroke work was noted toward the third trimester (5.9±1.1 versus 5.3±1.0 Newton meter, P<0.001), ejection fraction showed no significant changes. LV strain decreased significantly in late pregnancy (-19.5±2% to -17.6±1.6%, P<0.001) and returned to baseline values after delivery (-19.5±2%)., Conclusions: Pregnancy is a physiological process associated with increased cardiac performance and progressive LV remodeling. These changes are not directly reflected by parameters traditionally considered to describe systolic function, such as ejection fraction and longitudinal deformation. While ejection fraction was insensitive to the functional changes, the transient decrease in longitudinal deformation becomes only plausible when considering the changes in LV geometry.

Background: Restrictive bariatric surgery decreases obesity-related morbidity and mortality. With the widespread use of these interventions, an increasing number of women who have undergone bariatric surgery become pregnant., Case: A women, pregnant 2 years after laparoscopic gastric banding, presented with prolonged vomiting due to slippage of the gastic band resulting in gastric outlet obstruction. Parenteral feeding was initiated for 3 weeks until the patient was delivered because of a nonreassuring fetal heart rate pattern. A postnatal diagnosis of an extensive intracranial fetal hemorrhage due to maternal vitamin K deficiency was made., Conclusion: Although restrictive bariatric surgery is generally considered safe, we want to warn of possible severely adverse outcomes related to the intervention. In case of food intolerance, early vitamin substitution is indicated.

Purpose of Review: We aimed to review the current clinical status and advances in endoscopic and open surgical interventions on the fetus in terms of indications, technical aspects and reported outcomes., Recent Findings: In numbers, there has been a move away from open toward fetoscopic surgery. The indications for each access modality are, however, different, and hence cannot substitute each other. Complications of monochorionic twinning are the leading indication today. Other increasingly frequent indications are severe congenital diaphragmatic hernia and myelomeningocele, and to a certain extent valvuloplasty by needle puncture. Although maternal safety is not at stake, rupture of the membranes and preterm delivery remain a problem. Today, there is level I evidence that fetoscopic laser surgery for twin-to-twin-transfusion syndrome is the preferred therapy. This has triggered the interest of several units to embark on fetoscopic surgery, although the complexity and the overall rare indications act as a limitation to sufficient turnover., Summary: Fetal surgery seems safe and has therefore become a clinical reality. With the current state of technology, open and endoscopic interventions do not compete, each having their indications. Although the stage of technical experimentation is over, most interventions remain investigational. Inclusion of patients into trials whenever possible should be encouraged rather than building up casuistic experience. Healthcare providers and individual centers should be encouraged to consider viability and efficacy of new treatment programs.