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Objective: There are conflicting data on whether fetoscopic laser photocoagulation (FLP) of placental anastomoses for the treatment of twin‐to‐twin transfusion syndrome (TTTS) is associated with lower rates of overall survival. The objective of this study was to characterize twin survival and associated morbidity according to the gestational age at which FLP was performed. Methods: This was a secondary analysis of data collected prospectively on patients with a monochorionic diamniotic (MCDA) twin pregnancy who underwent FLP for TTTS at two centers between January 2011 and December 2022. Patients were divided into six groups according to gestational age at the time of FLP: < 18 weeks, 18 + 0 to 19 + 6 weeks, 20 + 0 to 21 + 6 weeks, 22 + 0 to 23 + 6 weeks, 24 + 0 to 25 + 6 weeks and ≥ 26 weeks. Demographic characteristics, sonographic characteristics of TTTS and operative characteristics were compared across the gestational age epochs. Outcomes, including overall survival, preterm delivery (PTD), preterm prelabor rupture of membranes (PPROM), intrauterine fetal demise (IUFD) and neonatal demise (NND), were also compared across gestational age epochs. Multivariate analysis was performed by fitting logistic regression models for these outcomes. Kaplan–Meier curves were constructed to compare the interval from PPROM to delivery between gestational age epochs. Results: There were 768 patients that met the inclusion criteria. The rate of dual twin survival was 61.3% for cases in which FLP was performed before 18 weeks, compared with 78.0%–86.7% when FLP was performed at ≥ 18 weeks' gestation. This appears to be driven by an increased rate of donor IUFD following FLP performed before 18 weeks (28.0%) compared with ≥ 18 weeks (9.3–14.1%). Rates of recipient IUFD and NND and donor NND were similar regardless of gestational age at FLP. The rate of PPROM was higher for FLP conducted at earlier gestational ages, ranging from 45.6% for FLP before 18 weeks to 11.9% for FLP performed at 24 + 0 to 25 + 6 weeks' gestation. However, gestational age at delivery was similar across gestational age epochs, with a median of 31.7 weeks. On multivariate analysis, donor twin loss was associated with FLP before 18 weeks, even after adjusting for selective fetal growth restriction, Quintero stage and other covariates. PPROM and PTD were also associated with FLP performed before 18 weeks after adjusting for cervical length, placental location, trocar size, laser energy and amnioinfusion. Conclusions: FLP performed at earlier gestational ages is associated with lower overall survival, which is driven by the increased risk of donor IUFD, as opposed to differences in the rate of PPROM or PTD. Parental counseling regarding twin survival should account for the gestational age at which patients present with TTTS. © 2024 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Utilizing a trait-based breeding approach is crucial for developing diverse materials with various agronomic traits, emphasizing a common focus on achieving high grain yield, as seen in many breeding programs. Genotype evaluation based on yield × trait combinations is essential, with yield as the primary variable. Genotype by yield × traits biplot analysis was used in pearl millet to assess associations among yield-trait combinations, trait profiles, and superiority rankings. The Biplot analysis reveals prevalent positive associations among yield-trait combinations, implying that selecting multiple traits can augment grain yield productivity. Notably, ICMV 221 and Dhanashakti exhibit elevated levels of YLD×Fe and YLD×Zn, while SOSAT C88, EC C6, Raj 171, and CZIC 618 excel in combining grain yield with traits such as plant height (PH), panicle length (PL), and days to maturity (DM). Based on overall superiority in yieldtrait combinations, populations were ranked as follows: AIMP 92901 > ICMV 221 > SOSAT C88 > CZIC 618 > Raj 171 > ICMP 87307 > EC C6. This study demonstrates the practical utility of the genotype by yield × traits biplot approach for selecting pearl millet germplasm with diverse trait combinations, enhancing the breeding program’s effectiveness. [ABSTRACT FROM AUTHOR]

Objective: To assess the feasibility of using a novel device designed for minimally invasive suturing to anchor fetal membranes to the uterine wall and to close surgical defects after fetoscopy. Methods: We tested the WestStitch™ suturing device both ex vivo and in vivo. In the ex‐vivo studies, 12‐Fr trocar defects were created with a fetoscope in five specimens of human uterine tissue with fetal membranes attached. Specimens were examined for integrity of the anchoring stitch. For the in‐vivo studies, trocar defects were created in the two uterine horns of three pregnant ewes, each carrying twins at approximately 79–90 days' gestation. One trocar defect in each ewe was repaired using the suture device, and the other was left unrepaired as a control. The repair sites were examined for membrane‐anchoring integrity when the defect was created and at delivery. Results: Fetal membranes were anchored successfully to the uterine myometrium using the suture‐delivery device in all five experiments performed ex vivo. The in‐vivo experiments also revealed successful membrane anchoring compared with controls, both at the time of device deployment and 1–9 weeks after the procedure. Conclusions: We successfully anchored amniotic membranes to the underlying myometrium using a suturing device, both ex vivo and in vivo. Further studies are needed to evaluate the efficacy of the device and to determine whether it can successfully anchor fetal membranes percutaneously in human patients. © 2024 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objectives: To determine the association between elevated (> 1.5 multiples of the median (MoM)) middle cerebral artery (MCA) peak systolic velocity (PSV) and fetal demise of the donor twin in pregnancies complicated by twin–twin transfusion syndrome (TTTS) in the absence of twin anemia–polycythemia sequence (TAPS). Secondary objectives were to evaluate if donor or recipient MCA‐PSV is associated with a risk for their corresponding fetal death, and to compare the proportion of donor fetuses with low MCA pulsatility index (PI) among donor twins with high MCA‐PSV and those with normal MCA‐PSV to evaluate the contribution of blood‐flow redistribution to the fetal brain in donor twins with high MCA‐PSV. Methods: This prospective cohort study included TTTS cases that underwent laser surgery between 2011 and 2022 at a single center. TAPS cases were excluded from the study. Multivariable and Poisson regression analysis were performed to explore the association between isolated elevated donor MCA‐PSV and fetal demise, adjusted for TTTS stage, selective fetal growth restriction (sFGR) and other confounders. Results: Of 660 TTTS cases, donor MCA‐PSV was not recorded in 48 (7.3%) cases. Of the remaining 612 patients, nine (1.5%) were lost to follow‐up and 96 TAPS cases were excluded; thus, 507 cases were included in the study. High donor MCA‐PSV was seen in 6.5% (33/507) of cases and was an independent risk factor for donor fetal demise (adjusted relative risk (aRR), 4.52 (95% CI, 2.72–7.50)), after adjusting for confounders. Regression analysis restricted to each Quintero TTTS stage demonstrated that high donor MCA‐PSV was an independent risk factor for fetal demise of the donor in Quintero Stage II (aRR, 14.21 (95% CI, 1.09–186.2)) and Quintero Stage III (aRR, 3.41 (95% CI, 1.82–6.41)). Donor MCA‐PSV in MoM was associated with fetal demise of the donor (area under the receiver‐operating‐characteristics curve (AUC), 0.69; P < 0.001), but recipient MCA‐PSV in MoM was not associated with fetal demise of the recipient (AUC, 0.54; P = 0.44). A higher proportion of donor twins in the group with high MCA‐PSV had a low MCA‐PI compared to the group with normal MCA‐PSV (33.3% vs 15.5%; P = 0.016). Conclusions: Elevated donor MCA‐PSV without TAPS prior to laser surgery for TTTS is associated with a 4‐fold increased risk for donor fetal demise, adjusted for sFGR, TTTS stage and other confounders. Doppler evaluation of donor MCA‐PSV prior to laser surgery may help stratify TTTS staging to evaluate the risk of donor fetal demise. © 2024 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: Fetoscopic closure of spina bifida using heated and humidified carbon dioxide gas (hhCO2) has been associated with lower maternal morbidity compared with open closure. Fetal cardiovascular changes during these surgical interventions are poorly defined. Our objective was to compare fetal bradycardia (defined as fetal heart rate (FHR) < 110 bpm for 10 min) and changes in umbilical artery (UA) Doppler parameters during open vs fetoscopic closure. Methods: This was a prospective cohort study of 22 open and 46 fetoscopic consecutive in‐utero closures conducted between 2019 and 2023. Both cohorts had similar preoperative counseling and clinical management. FHR and UA Doppler velocimetry were obtained systematically during preoperative assessment, every 5 min during the intraoperative period, and during the postoperative assessment. FHR, UA pulsatility index (PI) and UA end‐diastolic flow (EDF) were segmented into hourly periods during surgery, and the lowest values were averaged for analysis. Umbilical vein maximum velocity was measured in the fetoscopic cohort. At each timepoint at which FHR was recorded, maternal heart rate and systolic and diastolic blood pressure were measured. Results: Fetal bradycardia occurred in 4/22 (18.2%) cases of open closure and 21/46 (45.7%) cases of fetoscopic closure (P = 0.03). FHR decreased gradually in both cohorts after administration of general anesthesia and decreased further during surgery. FHR was significantly lower during hour 2 of surgery in the fetoscopic‐repair cohort compared with the open‐repair cohort. The change in FHR from baseline in the final stage of fetal surgery was significantly more pronounced in the fetoscopic‐repair cohort compared with the open‐repair cohort (mean, −32.4 (95% CI, −35.7 to −29.1) bpm vs −23.5 (95% CI, −28.1 to −18.8) bpm; P = 0.002). Abnormal UA‐EDF (defined as absent or reversed EDF) occurred in 3/22 (13.6%) cases in the open‐repair cohort and 23/46 (50.0%) cases in the fetoscopic‐repair cohort (P = 0.004). There were no differences in UA‐EDF or UA‐PI between closure techniques at the individual stages of assessment. Conclusions: We observed a decrease in FHR and abnormalities in UA Doppler parameters during both open and fetoscopic spina bifida closure. Fetal bradycardia was more prominent during fetoscopic closure following hhCO2 insufflation, but FHR recovered after cessation of hhCO2. Changes in FHR and UA Doppler parameters during in‐utero spina bifida closure were transient, no cases required emergency delivery and no fetoscopic closure was converted to open closure. These observations should inform algorithms for the perioperative management of fetal bradycardia associated with in‐utero spina bifida closure. © 2024 International Society of Ultrasound in Obstetrics and Gynecology. Linked article: There is a comment on this article by Rychik. Click here to view the Editorial. [ABSTRACT FROM AUTHOR]

Both the vasa previa artery (blue arrows) and vein (red arrows) were ablated and appeared thrombosed without dye entering the vessel on dye injection testing. Vasa previa (VP) is defined as the presence of extraplacental fetal blood vessels traversing through the amniotic membranes over the cervix[1]. The placental cotyledon with vasa previa was ablated (white dotted circle), but a small tributary (small red arrows) can be seen branching off from the larger vasa previa vein near the internal os site (white circle with red border). [Extracted from the article]

This article, published in the journal Ultrasound in Obstetrics & Gynecology, examines the uterine circulation in women with severe placenta accreta spectrum (PAS) who undergo conservative management. The study monitored 27 patients who chose either to preserve their uterus or undergo a delayed hysterectomy. Doppler velocimetry of the uterine arteries was performed at regular intervals, and the results showed that patients who experienced bleeding complications or were unable to retain their uterus had lower mean pulsatility index (PI) and higher velocities in the uterine artery (UtA) compared to those without complications. The findings suggest that Doppler velocimetry may be a useful tool in managing PAS. [Extracted from the article]

This article, published in the journal Ultrasound in Obstetrics & Gynecology, discusses a study that proposes a semi-quantitative approach for evaluating cervical vascularisation in women with placenta accreta spectrum (PAS) using transvaginal ultrasound. The study found that there was a significant difference in quantitative vascularisation (QV) between patients without PAS and those with placenta increta (PI) and placenta percreta (PP), but not with placenta accreta (PA). However, QV of the cervix cannot accurately predict blood loss at birth, as this is influenced by various factors. [Extracted from the article]

This article, published in the journal Ultrasound in Obstetrics & Gynecology, examines the effects of serial amnioinfusions (AI) on fetal lung size/volume and intrapulmonary circulation in fetuses diagnosed with anhydramnios before 22 weeks of gestation. The study involved nine fetuses with anhydramnios due to renal agenesis or renal dysplasia, who received serial AI to maintain an amniotic fluid index (AFI) of 15-17 cm until 32 weeks or preterm premature rupture of membranes (PPROM). The results showed that there was an increase in lung size and improvement in intrapulmonary circulation after the AI, but the lung measurements remained below the expected mean for gestational age. [Extracted from the article]

This article, titled "Comparing ultrasound and magnetic resonance imaging in predicting perinatal mortality among fetuses with left-sided congenital diaphragmatic hernia," explores the challenges of prenatal risk stratification in congenital diaphragmatic hernia (CDH). The study evaluates the association between different ultrasound and MRI predictors and neonatal mortality in fetuses with CDH. The findings suggest that MRI parameters and herniation of the stomach into the thorax may be better predictors of perinatal mortality than the observed-to-expected lung to head ratio (O/E LHR). However, further research is needed to improve prenatal risk stratification in predicting postnatal outcomes for CDH. [Extracted from the article]

This article compares the outcomes of standard management (SM) versus fetoscopic laser ablation (FLA) for types II and III vasa previa (VP). Vasa previa is a condition where fetal blood vessels cross the cervix, which can lead to serious complications during childbirth. The study found that FLA allowed for a higher rate of vaginal delivery and resulted in shorter maternal hospital stays and a lower need for neonatal blood transfusions compared to SM. These findings suggest that FLA may be a beneficial treatment option for vasa previa. [Extracted from the article]