Anthony O. Odibo

Objective: To evaluate the characteristics and outcomes of pregnancies with a prenatally detected fetal or placental tumor with associated fetal anemia that underwent intrauterine transfusion (IUT). Methods: We searched PubMed, EMBASE, Web of Science, Scopus and Google Scholar databases for studies reporting on singleton pregnancies with a prenatally detected fetal or placental tumor complicated by fetal anemia that underwent IUT, published from inception to October 2024. Only articles written in the English language were considered eligible for inclusion. We excluded multiple gestations, fetuses with concomitant structural anomaly, cases that underwent IUT to treat fetal anemia secondary to intraoperative tumor bleeding and cases that received blood products other than red blood cells. Cases in which the tumor was detected postnatally, cases that underwent termination of pregnancy, studies with incomplete data and systematic reviews were also excluded. The primary outcome was perinatal death, defined as intrauterine fetal demise (IUFD) > 22 weeks' gestation or neonatal death within 28 days after birth. Secondary outcomes included IUFD, neonatal death, preterm labor (PTL), preterm prelabor rupture of membranes (PPROM), placental abruption, and spontaneous or medically indicated live preterm birth (PTB). We performed exploratory subgroup analyses, including differences in tumor size according to the presence or absence of additional non‐structural complications, as well as differences in baseline characteristics according to perinatal death status and differences in obstetric and perinatal outcomes according to whether the patient underwent prenatal tumor resection, embolization or ablation in addition to IUT. Results: We included 43 cases in our analysis, including 42 cases from 34 articles identified in the literature search and an additional case managed at our institution. The median hemoglobin level before the initial IUT was 7.0 (interquartile range, 6.0–8.8) g/dL. Most cases (92.5%) had an additional non‐structural complication at baseline. Prenatal tumor resection, embolization or ablation was performed as an adjunct to IUT in 40.0% of cases. PTL, PPROM or placental abruption complicated 43.2% of cases. PTB occurred in 81.1% of cases. Perinatal death occurred in 11 (25.6%) cases. We identified a higher likelihood of perinatal death in cases with fetal hydrops (odds ratio (OR), 6.3 (95% CI, 1.1–37.7); P = 0.04) or cardiomegaly (OR, 6.3 (95% CI, 1.1–36.9); P = 0.04), and a lower likelihood of perinatal death was associated with higher fetal hemoglobin after the initial IUT (OR, 0.4 (95% CI, 0.2–0.8), P = 0.01). Perinatal death rates were similar regardless of management strategy (12.5% for IUT as a standalone therapy vs 31.3% for IUT as an adjunct to tumor resection, embolization or ablation; P = 0.1). Conclusion: Pregnancies with a prenatally detected fetal or placental tumor, complicated by fetal anemia that underwent IUT, have a high rate of additional non‐structural complications. The rate of perinatal death in this population is high, likely due to the severity of the fetal condition at baseline and high rates of obstetric complications and PTB. IUT as a standalone therapy may be reasonable in selected cases. However, ideal candidates for this approach and the best management strategies remain to be determined. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To compare placental volumes between pregnancies with and without fetal CHD, including fetuses with CHD and genetic abnormalities, and to investigate the association between placental volume and regional fetal brain volumes. Method: Pregnant women carrying a fetus with critical CHD with or without a genetic abnormality (CHD Genetic or CHD Isolated) or a fetus without CHD (Control) had placental and fetal brain volumes measured from MRI. Mixed effects linear regression models examined the associations between study group and placental and fetal brain volumes. Results: Seventy‐one pregnant women/fetuses underwent 124 MRIs. In multivariate analysis, placental volume was 33% smaller among CHD Genetic males, 15% smaller among CHD Isolated males, and 7% smaller among CHD Genetic females compared to Control males. Adjusting for placental volume and confounders, CHD Genetic had smaller total and regional brain volumes compared to Controls. Fetal cortex was not smaller at baseline, but the difference grew over gestation. Reduced brain volumes were present, but less pronounced, for CHD Isolated. Placental volume was independently associated with subcortical gray matter, total brain, and intracranial volumes. Conclusion: Impaired placental and fetal brain development are most prominent for CHD fetuses with genetic abnormalities.

Objective: The aim of this study was to examine the performance of the Fetal Medicine Foundation (FMF) competing‐risks model for the prediction of a small‐for‐gestational‐age (SGA) neonate in a large, diverse, nulliparous cohort. Methods: This was a retrospective single‐center cohort study of nulliparous singleton pregnancies undergoing an ultrasound examination between 19 + 0 and 24 + 0 weeks' gestation. We calculated the risk of SGA at various birth‐weight thresholds using the FMF competing‐risks model, which utilizes maternal factors with or without ultrasound‐derived estimated fetal weight (EFW). The outcomes predicted by the model were compared with the actual outcomes of the included pregnancies using the area under the receiver‐operating‐characteristics curve (AUC) and detection rates at fixed false‐positive rates. These findings were compared with those of the original FMF model‐development study. Results: In our cohort of 8974 nulliparous patients, the FMF competing‐risks model had a higher predictive performance for SGA < 3 ^rd percentile compared with SGA < 10 ^th percentile. The model also performed better in the prediction of a SGA neonate requiring preterm delivery compared with a SGA neonate delivered at term. Utilization of both maternal factors and midgestation EFW improved the predictive performance of the model compared with using maternal factors alone. The AUC of the model including maternal factors and midgestation EFW was 0.740 for preterm SGA < 10 ^th percentile, 0.766 for preterm SGA < 3 ^rd percentile, 0.719 for term SGA < 10 ^th percentile and 0.734 for term SGA < 3 ^rd percentile. These values were significantly lower than those seen in the FMF model‐development cohort, which were 0.781 ( P = 0.01), 0.809 ( P = 0.04), 0.766 ( P < 0.01) and 0.790 ( P < 0.01), respectively, but similar to the AUCs seen in a subgroup of nulliparous patients in the FMF study. Conclusions: The FMF competing‐risks model for SGA performs well in a large independent cohort of nulliparous patients but appears to have better predictive performance in a population that includes parous patients. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To compare the accuracy of four published reference standards for the umbilical artery pulsatility index (UA‐PI) in predicting small‐for‐gestational age (SGA), adverse neonatal outcomes and obstetric complications in pregnancies at risk for fetal growth restriction.Methods: This was a secondary analysis of a prospective study of singleton pregnancies that underwent fetal growth assessment by ultrasound between 26 and 36 weeks' gestation. Pregnancies with estimated fetal weight or abdominal circumference < 20^th percentile with UA‐PI measurements available were included. We excluded fetuses with chromosomal anomaly or congenital malformation and those without delivery information. The predictive ability of UA‐PI > 95^th percentile according to the reference standards of Acharya et al., the INTERGROWTH‐21^st Project, the Fetal Medicine Foundation and Parra‐Cordero et al. for SGA, a composite of adverse neonatal outcomes and a composite of obstetric complications was compared using the area under the receiver‐operating‐characteristics curve (AUC). Sensitivity, specificity and positive and negative predictive values were calculated.Results: Of the 1054 pregnancies that underwent fetal growth evaluation by ultrasound, 207 were included in our analysis. SGA, adverse neonatal outcomes and obstetric complications were diagnosed in 94 (45.4%), 50 (24.2%) and 69 (33.3%) cases, respectively. All reference standards had similar and statistically significant but poor predictive accuracy for SGA (AUC of 0.55 to 0.56), adverse neonatal outcomes (AUC of 0.57 to 0.60) and obstetric complications (AUC of 0.55 for all).Conclusions: The reference standards for UA‐PI evaluated herein have poor predictive ability for SGA, adverse neonatal outcomes and obstetric complications. At present, no particular UA‐PI reference standard can be recommended over others. Larger trials are needed to answer this research question. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: Compared with postnatal repair, prenatal myelomeningocele (MMC) repair is associated with improved motor function and decreased need for cerebrospinal fluid (CSF) diversion. It is unknown how prenatal surgery alters neuroanatomical structures identifiable on magnetic resonance imaging (MRI). The purpose of this study was to use MRI to compare neurodevelopmental anatomy in patients undergoing fetal MMC repair compared with those undergoing postnatal repair.Methods: This was a retrospective review of neonates who underwent prenatal or postnatal MMC repair at our institution between 2016 and 2021. Imaging data, including prenatal ultrasound and pre‐ and postnatal MRI examinations, if available, were retrieved. We analyzed anatomical findings characteristically seen on MRI of the neuroaxis in patients with MMC and compared imaging findings between patients with prenatal vs postnatal MMC repair.Results: The study population included 61 patients who underwent surgical repair for MMC during the 6‐year study period, of whom 25 underwent prenatal repair and 36 postnatal repair. CSF diversion was required in 24% of the prenatally repaired cohort vs 67% of the postnatally repaired cohort (P = 0.001). On postnatal MRI, a syrinx was present in 13% of the prenatally repaired cohort vs 42% in the postnatally repaired cohort (P = 0.02). Postnatal corpus callosal (CC) morphology was abnormal in 54% of the prenatally repaired cohort vs 53% of the postnatally repaired cohort (P = 0.92), while falx morphology was normal in 92% of the prenatally repaired cohort vs 34% of the postnatally repaired cohort (P < 0.001). On postnatal MRI, patients in the prenatally repaired cohort had a shorter tentorium‐to‐foramen‐magnum distance compared with those in the postnatally repaired cohort (mean, 18.43 mm vs 22.42 mm; P = 0.01), a larger foramen magnum diameter (mean, 22.87 mm vs 18.94 mm; P < 0.001) and a smaller degree of hindbrain herniation (mean, 1.53 mm vs 8.72 mm; P < 0.001). The cerebral aqueduct was patent in 79% of the prenatally repaired cohort vs 100% of the postnatally repaired cohort on postnatal MRI (P = 0.008). Between the two cohorts, at postnatal MRI there was no significant difference in the presence of gray‐matter heterotopia, presence of the septum pellucidum or size of the massa intermedia.Conclusions: We report variations in developmental neuroanatomy in patients with MMC, including rates of CC dysgenesis, gray‐matter heterotopia and additional cranial and spinal MRI findings. Compared to postnatal surgery, prenatal surgery is associated with changes to infratentorial anatomy, with minimal effect on supratentorial brain development. This information will be useful in counseling parents affected by fetal MMC and in understanding how prenatal repair of MMC affects brain development. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: Fetoscopic laser photocoagulation (FLP) is a well‐established treatment for twin–twin transfusion syndrome (TTTS) between 16 and 26 weeks' gestation. High‐quality evidence and guidelines regarding the optimal clinical management of very early (prior to 16 weeks), early (between 16 and 18 weeks) and late (after 26 weeks) TTTS are lacking. The aim of this study was to construct a structured expert‐based clinical consensus for the management of early and late TTTS.Methods: A Delphi procedure was conducted among an international panel of experts. Participants were chosen based on their clinical expertise, affiliation and relevant publications. A four‐round Delphi survey was conducted using an online platform and responses were collected anonymously. In the first round, a core group of experts was asked to answer open‐ended questions regarding the indications, timing and modes of treatment for early and late TTTS. In the second and third rounds, participants were asked to grade each statement on a Likert scale (1, completely disagree; 5, completely agree) and to add any suggestions or modifications. At the end of each round, the median score for each statement was calculated. Statements with a median grade of 5 without suggestions for change were accepted as the consensus. Statements with a median grade of 3 or less were excluded from the Delphi process. Statements with a median grade of 4 were modified according to suggestions and reconsidered in the next round. In the last round, participants were asked to agree or disagree with the statements, and those with more than 70% agreement without suggestions for change were considered the consensus.Results: A total of 122 experts met the inclusion criteria and were invited to participate, of whom 53 (43.4%) agreed to take part in the study. Of those, 75.5% completed all four rounds. A consensus on the optimal management of early and late TTTS was obtained. FLP can be offered as early as 15 weeks' gestation for selected cases, and can be considered up to 28 weeks. Between 16 and 18 weeks, management should be tailored according to Doppler findings.Conclusions: A consensus‐based treatment protocol for early and late TTTS was agreed upon by a panel of experts. This protocol should be modified at the discretion of the operator, according to their experience and the specific demands of each case. This should advance the quality of future studies, guide clinical practice and improve patient care. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Objectives Most human in-vivo placental imaging techniques are unable to distinguish and characterize various placental compartments, such as the intervillous space (IVS), placental vessels (PV) and placental tissue (PT), limiting their specificity. We describe a method that employs T2* and diffusion-weighted magnetic resonance imaging (MRI) data to differentiate automatically placental compartments, quantify their oxygenation properties and identify placental lesions (PL) in vivo. We also investigate the association between placental oxygenation patterns and fetal brain oxygenation.Methods This was a prospective study conducted between 2018 and 2021 in which dual-contrast clinical MRI data (T2* and diffusion-weighted MRI) were acquired from patients between 20 and 38 weeks' gestation. We trained a fuzzy clustering method to analyze T2* and diffusion-weighted MRI data and assign placental voxels to one of four clusters, based on their distinct imaging domain features. The new method divided automatically the placenta into IVS, PV, PT and PL compartments and characterized their oxygenation changes throughout pregnancy.Results A total of 27 patients were recruited, of whom five developed pregnancy complications. Total placental oxygenation level and T2* did not demonstrate a statistically significant temporal correlation with gestational age (GA) (R-2 = 0.060, P = 0.27). In contrast, the oxygenation level reflected by T2* values in the placental IVS (R-2 = 0.51, P = 0.0002) and PV (R-2 = 0.76, P = 1.1 x 10(-7)) decreased significantly with advancing GA. Oxygenation levels in the PT did not show any temporal change during pregnancy (R-2 = 0.00044, P = 0.93). A strong spatial-dependent correlation between PV oxygenation level and GA was observed. The strongest negative correlation between PV oxygenation and GA (R-2 = 0.73, P = 4.5 x 10(-7)) was found at the fetal-vessel-dominated region close to the chorionic plate. The location and extent of the placental abnormality were automatically delineated and quantified in the five women with clinically confirmed placental pathology. Compared to the averaged total placental oxygenation, placental IVS oxygenation level best reflected fetal brain oxygenation level during fetal development.Conclusion Based on clinically feasible dual-MRI, our method enables accurate spatiotemporal quantification of placental compartment and fetal brain oxygenation across different GAs. This information should improve our knowledge of human placenta development and its relationship with normal and abnormal pregnancy. (c) 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Objective To evaluate the hypothesis that patients with opioid use disorder (OUD), who receive prenatal care in a multidisciplinary, prenatal OUD clinic, have comparable postpartum breastfeeding rates, prenatal and postpartum visit compliance, and postpartum contraceptive use when compared with matched controls without a diagnosis of OUD. Study Design This was a retrospective, matched, cohort study that included all patients who received prenatal care in a multidisciplinary, prenatal OUD clinic—Clinic for Acceptance Recovery and Empowerment (CARE)—between September 2018 and August 2020. These patients were maintained on opioid agonist therapy (OAT) throughout their pregnancy. CARE patients were matched to controls without OUD in a 1:4 ratio for mode of delivery, race, gestational age ± 1 week, and delivery date ± 6 months. The primary outcome was rate of exclusive breastfeeding at maternal discharge. Secondary outcomes included adherence with prenatal care (≥4 prenatal visits), adherence with postpartum care (≥1 postpartum visit), postpartum contraception plan prior to delivery, and type of postpartum contraceptive use. Conditional multivariate logistic regression was used to account for possible confounders in adjusted calculations. Results A total of 210 patients were included (42 CARE and 168 matched controls). Despite having lower rates of adequate prenatal care, 40 CARE patients (95%) were exclusively breastfeeding at discharge resulting in CARE patients being significantly more likely to be breastfeeding at discharge (adjusted relative risk (aRR): 1.28, 95% confidence interval [CI]: 1.05–1.55). CARE patients and controls demonstrated no difference in postpartum visit compliance (86 vs. 81%, aRR: 1.03, 95% CI: 0.76–1.40) or effective, long-term contraception use (48 vs. 48%; aRR: 0.81, 95% CI: 0.36–1.84). Conclusion In the setting of multidisciplinary OUD prenatal care during pregnancy, patients with OUD were more likely to be breastfeeding at the time of discharge than matched controls, with no difference in postpartum visit compliance or effective, long-term contraception. Key Points

Objective The objective of our study was to compare the maternal and neonatal complications of periviable birth by the delivery route. Study Design A retrospective cohort study of periviable deliveries (220/7–256/7weeks) from 2013 to 2020 at a tertiary teaching institution was conducted. Deliveries were grouped by the mode of delivery. Excluded deliveries included pregnancy termination, anomaly, or undesired neonatal resuscitation. The primary composite maternal outcome included death, intensive care admission, sepsis, surgical site infection, unplanned operation, or readmission. Secondary outcomes included maternal blood loss, length of stay, neonatal survival, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), and retinopathy of prematurity (ROP). Outcomes were compared using Student's t-test, Wilcoxon–Mann–Whitney and Chi-squared tests. Relative risk (RR) and 95% confidence intervals were calculated with log-binomial regression. p-Values <0.05 were considered significant. Demographic and intervention variables associated with the outcome and the exposure were included in an adjusted relative risk (aRR) model. Subgroup analyses of singleton pregnancies and 220/7 to 236/7 weeks deliveries were conducted. Results After exclusion, 230 deliveries were included in the cohort. Maternal characteristics were similar between cohorts. For the primary outcome, cesarean delivery was associated with a trend toward increased maternal morbidity (22.6 vs. 10.7%, RR = 2.11 [1.03–4.43], aRR = 1.95 [0.94–4.03], p-value 0.07). Administration of magnesium sulfate, antenatal corticosteroids, and tocolytics were similar between cohorts. Neonatal survival to discharge was not different between the groups (54/83, 65.1% vs. 118/191, 61.8%, aRR = 0.93 [0.77–1.13]). Among the 172 neonates discharged alive, there was no difference in BPD, IVH, NEC, PDA, ROP, or intact survival. Conclusion Periviable birth has a high rate of maternal morbidity with a trend toward the highest risk among women undergoing cesarean delivery. These risks should be included in shared decision-making. Key Points