The March issue of Ultrasound in Obstetrics & Gynecology includes a retrospective cohort study investigating the use of ultrasound features for predicting abnormal karyotype in first-trimester miscarriage, a systematic review and meta-analysis assessing the clinical features of twin pregnancy with complete hydatidiform mole and coexisting normal fetus, a retrospective cohort study evaluating prediction of survival after fetoscopic laser surgery for early-onset twin-to-twin transfusion syndrome, and a clinical and economic evaluation of PlGF-based first-trimester screening and aspirin prophylaxis for preterm pre-eclampsia.
Please see below a selection of articles from the March issue of the Journal chosen specially by the UOG team. To view all UOG content, become an ISUOG member today or login and upgrade.
Ultrasound features in early pregnancy for predicting abnormal karyotype in first-trimester miscarriage
Chromosomal abnormalities are found in approximately 60% of first-trimester miscarriages, yet reliable non-invasive methods for predicting abnormal karyotype prior to miscarriage remain limited. In this retrospective observational cohort study, Setty et al. investigated whether sonographic morphological features of live pregnancies that subsequently ended in a first-trimester miscarriage could be used to predict karyotype. Median gestational sac mean diameter (GSMD) centile and median crown–rump length (CRL) centile were found to be significantly lower in pregnancies with an abnormal karyotype, while bradycardia and enlarged yolk sac mean diameter (YSMD) were significantly more common in this group. It was also found that a specific combination of four abnormal morphological features (GSMD < 5th centile + YSMD ≥ 95th centile + CRL < 5th centile + bradycardia), termed the ‘tetrad of aneuploidy’, predicted an abnormal karyotype with a specificity of 100%, in cases last examined sonographically ≤ 10 weeks' gestation. As a result, the authors concluded that the recognition of this pattern on early sonographic assessment could enhance miscarriage risk stratification during early pregnancy, improving patient counseling and informing clinical decision-making.
Multiple pregnancy with complete hydatidiform mole and coexisting normal fetus: systematic review and meta-analysis of clinical outcomes from non-randomized studies
Twin pregnancy with complete hydatidiform mole and coexisting normal fetus (CHMCF) is exceptionally rare, meaning there is substantial heterogeneity in its diagnosis, counseling and management. In this systematic review and meta-analysis, Salmeri et al. summarized and quantified the prevalence of clinical outcomes in reported cases of CHMCF, with the aim of categorizing data based on relevant clinical features to aid prognostic evaluation. Across 19 studies and 417 cases of CHMCF, nearly half of pregnancies ended in elective termination, while slightly over half were continued. Of these continued pregnancies, the incidence of miscarriage was around 33% and the incidence of preterm birth < 37 weeks was around 68%, most of which were late preterm births. High rates of postpartum hemorrhage, pre-eclampsia and small-for-gestational age compared with the general population were also observed (43%, 18% and 41%, respectively). Meanwhile, the rate of gestational trophoblastic neoplasia among elective terminations, continued pregnancies and live births was 14.1%, 20.3% and 5.9%, respectively, suggesting that its risk was not clearly mitigated by early pregnancy termination. Overall, the high risk of maternal, obstetric and neonatal complications among CHMCF pregnancies highlight the importance of early diagnosis for timely intervention and outcome improvement.
Prediction of survival after fetoscopic laser surgery for early-onset twin-to-twin transfusion syndrome
Left untreated and managed expectantly, twin-to-twin transfusion syndrome (TTTS) in monochorionic diamniotic (MCDA) twin pregnancy is associated with a perinatal mortality rate of 80-90%. Although fetoscopic laser surgery (FLS) has been established as a standard of care for severe TTTS before 26 weeks’ gestation, evidence to guide management in cases diagnosed before 18 weeks remains limited. In this international multicenter retrospective cohort study, Prasad et al. investigated survival rates and predictors of survival for both twins and at least one twin following FLS in MCDA twin pregnancies with early-TTTS diagnosed before 18 weeks. Among 485 MCDA pregnancies treated with FLS, adverse Doppler parameters in the donor twin at the time of TTTS diagnosis, notably absent or reversed end-diastolic flow (AREDF) in the donor umbilical artery and absent or reversed a-wave in the donor ductus venosus, were independently associated with lower odds of dual-twin survival. Meanwhile, a higher gestational age at birth was associated with increased odds of both dual-twin survival and survival of at least one twin. While future research is warranted, these predictors may inform antenatal counselling and tailored management in cases of early-onset TTTS.
Implementation of PlGF-based first-trimester screening and aspirin prophylaxis for preterm pre-eclampsia: clinical and economic evaluation
Pre-eclampsia remains a major challenge in global maternal health, responsible for approximately 70 000 maternal deaths and more than 500 000 fetal and neonatal deaths worldwide each year. Therefore, effective screen-and-prevent strategies are integral for reducing maternal and perinatal morbidity and mortality. In this retrospective cohort study, Badr et al. assessed the clinical effectiveness and economic impact of implementing a first-trimester placental growth factor (PlGF)-based screening strategy followed by aspirin prophylaxis for the prevention of preterm pre-eclampsia. The incidence of preterm pre-eclampsia declined after the implementation of the strategy (1.1% in the preimplementation phase vs 0.6% in the postimplementation phase), along with similar reductions in the overall rate of pre-eclampsia (2.5% vs 1.4%) and preterm birth (5.9% vs 4.7%). The protective effect of aspirin was strongest in women identified as high-risk using a PlGF-based screening algorithm, while no significant effect was observed using an algorithm omitting PlGF. Overall, economic modeling projected that the screening strategy would save €27.7 million annually in a national cohort of 110 000 pregnancies. These results therefore support consideration of the widespread adoption of this preventive strategy in routine antenatal care.