Rogelio Cruz-Martínez

Objective: To report on perinatal outcomes and technical aspects of standardized fetal surgery technique with full laser coagulation of the feeding artery in fetuses with bronchopulmonary sequestration and large pleural effusion. Method: During a 14‐year period, a prospective cohort of fetuses with BPS and large pleural effusion were selected for laser coagulation in a single national reference center for fetal surgery. Feasibility, perinatal outcomes, complications, survival, respiratory morbidity, and need for neonatal lung mass resection are reported. Results: 29 fetuses were treated at a median gestational age of 28.4 weeks. Hydrops was present in 13 (44.8%) cases. In 2 fetuses (6.9%), an intrathoracic bleeding was observed during fetal intervention, one presenting with intrauterine demise at 23 weeks of gestation. Median gestational age at birth was 38.9 weeks. Two fetuses (6.9%) were born preterm (33 and 35 weeks). Neonatal respiratory morbidity was reported in 3 neonates requiring oxygen support and in 2 neonates requiring mechanical ventilation. One fetus required postnatal thoracic surgery. There were no neonatal deaths; hence, the overall survival rate was 96.6% (28/29). Conclusions: Fetuses with BPS and large pleural effusion treated by laser coagulation of the feeding vessel have good perinatal outcomes and low risk of complications.

Introduction: Fetuses with congenital diaphragmatic hernia (CDH) treated with fetal endoscopic tracheal occlusion (FETO) require a second procedure to reverse tracheal occlusion before birth. In this study, we aimed to report the feasibility and perinatal outcomes of a modified technique for ultrasound-guided balloon bursting used as a primary attempt. Methods: From January 2012 to December 2025 a prospective cohort of isolated CDH cases treated with FETO was included in a management protocol for balloon removal by a percutaneous balloon bursting using a 22-gauge needle in a transversal view of the fetal trachea under simultaneous 2D and color Doppler ultrasound guidance (dual imaging) to avoid vessels. The feasibility of this technique, procedure-related characteristics, complications, and outcomes were evaluated. Results: During the study period, 88 (74 left-sided, and 14 right-sided) CDH were treated with FETO at a mean GA of 29.6 weeks. The balloon was removed at a mean GA of 33.8 weeks and as an emergency procedure in up to 40.7% of the cases. Percutaneous ultrasound-guided balloon puncture was feasible in 80% of the cases. Our technique was technically successful and allowed balloon rupture in up to 98.5% of the selected cases. No cases of fetal bleeding or intrauterine fetal demise after balloon removal were observed and, in all cases, a patent airway was confirmed after birth. Conclusion: Implementing a modified technique for percutaneous ultrasound-guided balloon bursting is safe and feasible and allows balloon rupture, avoiding the need for a second fetoscopic procedure for the reversal of FETO.

Objectives: To establish normative reference ranges for diencephalon diameter, falx cerebri length, and the diencephalon/falx (D/F) ratio between 11 + 6 and 13 + 6 weeks of gestation and to evaluate their relationship with crown–rump length (CRL). Methods: This prospective observational study included 676 fetuses during routine first‐trimester screening; three fetuses were excluded from this study with major cerebral anatomical defects. Using a standardized mid‐sagittal plane, the diencephalon (maximum anteroposterior distance) and falx cerebri were measured. The D/F ratio was calculated, and quantile regression was used to generate 5th, 50th, and 95th percentile curves associated with CRL. Results: Diencephalon diameter increased progressively with CRL, while falx cerebri length showed modest growth. The D/F ratio demonstrated a slight inverse relationship with CRL. Two cases of midline defects (agenesis of the corpus callosum) were identified; the D/F ratio was abnormal in one case but remained within normal limits in the second. Conclusions: Diencephalon and falx measurements are reproducible during the first trimester. While the proposed quantile‐based nomograms provide a robust normative framework, the isolated use of the D/F ratio may have limitations in detecting certain midline anomalies. These landmarks should be regarded as adjunctive markers and should be interpreted as part of a comprehensive first‐trimester fetal neurosonographic assessment.

Objective: To compare the difference in lung size measurement in fetuses with left‐sided congenital diaphragmatic hernia (L‐CDH) by means of the observed/expected lung‐to‐head ratio (O/E‐LHR) in two different fetal positions. Method: Prospective cohort of L‐CDH fetuses, with O/E‐LHR measurements by one experienced investigator but with the fetus in two positions: with the contralateral lung close and one with the lung away from the ultrasound probe. A Bland‐Altman analysis was performed to assess the agreement between lung measurements in both fetal positions. Results: 49 L‐CDH fetuses underwent paired assessments of lung size at a mean gestational age of 28.8 (17.7–37.7) weeks. Lung size estimation with the lung distant to the probe consistently underestimates the O/E‐LHR values compared to measurements obtained using the lung close to the probe. On average, O/E‐LHR values were 11.3% (95% confidence intervals (CI), 7.5%–15.0%) higher when the lung was close to the probe. When the lung was distant to the probe, a higher proportion of CDH fetuses were classified in a more severe group than when it was evaluated close to the probe ( p < 0.01). A consistently lower survival rate was expected when the lung was evaluated distant to the ultrasound probe. Conclusions: Lung size estimation in L‐CDH fetuses may be affected by fetal position, which may affect postnatal prognosis, prediction of survival and eligibility for fetal therapy.

Introduction: To describe the perinatal and neurological outcomes of fetuses with occipital encephalocele treated with intrauterine repair by open microneurosurgery. Methods: Between 2021 and 2025, a consecutive cohort of fetuses with occipital encephalocele referred to two fetal surgery centers in Nicaragua and Mexico were selected for intrauterine correction by open fetal microneurosurgery. Inclusion criteria were fetuses at less than 28 weeks with isolated occipital encephalocele, Chiari III malformation (obliteration of the cisterna magna with protrusion of cerebral tissue), and microcephaly. We report the procedure-related characteristics, perinatal and neurological outcomes (hydrocephalus, meningitis, seizures, cognitive delay, motor dysfunction, and visual impairment) within the first 12 months of age. Results: Twelve cases were evaluated during the study period but only 6 cases were selected for fetal intervention. Open fetal microneurosurgery was successfully performed in all cases at a median gestational age (GA) of 25+2 weeks+days, with a median surgical time of 93 minutes. Regression of Chiari and reversal of microcephaly was observed in 4/6 and 6/6 cases, respectively. The median GA at birth was 36+5 weeks+days. Preterm rupture of the membranes and preterm delivery was reported in 3/6 cases. No cases of perinatal death were reported. Within the first 12 months of age, none of the children developed meningitis, cognitive delay, or hydrocephalus requiring ventriculoperitoneal shunting. Motor dysfunction, seizures and visual disorders were reported in 1/6, 1/6 and 3/6 cases, respectively. Conclusion: In fetuses with occipital encephalocele, open fetal microneurosurgery is feasible and is associated with good perinatal and neurological outcomes.

Objective: To describe the pregnancy and postnatal outcomes of a large, retrospectively analyzed case–cohort series of pregnancies complicated by congenital heart disease (CHD) and fetal hydrops that were assessed for potential for fetal cardiac intervention (FCI). Methods: The International Fetal Cardiac Intervention Registry (IFCIR) collects diagnostic and procedure‐related data on maternal–fetal dyads with CHD that are considered by fetal specialists to be potentially capable of benefiting from FCI, with data submitted voluntarily by local institutions. For this retrospective analysis, the IFCIR database was searched for all case entries of pregnancies with a diagnosis of CHD and coexistent non‐immune fetal hydrops, defined as abnormal fluid or edema involving at least two compartments, between January 2001 and September 2024. Data on the underlying cardiac diagnosis, procedures performed and pregnancy and postnatal outcomes were collated. Results: At the time of data extraction, the IFCIR contained 864 recorded maternal–fetal dyads, of which 91 (10.5%) had fetal hydrops at initial evaluation. Of these, 73 (80.2%) underwent FCI, including aortic ( n = 61) or pulmonary ( n = 5) balloon valvuloplasty, atrial septal intervention and/or stent placement ( n = 4) and other FCI ( n = 3), at a median gestational age of 28.3 (range, 19.6–34.7) weeks. The overall rate of procedure‐related fetal loss was 20.5% (15/73). There were an additional 10 intrauterine fetal deaths, and two cases were either terminated ( n = 1) or lost to follow‐up ( n = 1). Overall, 21 neonates were liveborn preterm (< 37 weeks) and 25 were liveborn at term (≥ 37 weeks), with a median latency post‐procedure to delivery of 8.9 (range, 0.3–18.4) weeks. Of the 73 cases that underwent FCI, 26 (35.6%) survived to first hospital discharge, including 39.3% (24/61) of patients who underwent aortic valvuloplasty, one patient who underwent atrial septal intervention and one patient who underwent pulmonary valvuloplasty. The majority of survivors had biventricular circulation (15/20 with available outcome) at the last follow‐up. No procedure‐related maternal complications were recorded. Only 1/18 patients managed expectantly without FCI survived to hospital discharge. Conclusions: Our findings suggest a potential benefit of FCI in patients with hydrops, although the procedure‐related loss rate of 1 in 5 was significant. While the survival rate was lower than that reported in non‐hydropic cohorts with FCI, approximately one‐third of hydropic fetuses that underwent FCI included in our analysis survived to hospital discharge. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To evaluate the survival outcomes of fetuses with severe left congenital diaphragmatic hernia (CDH) treated with fetal endoscopic tracheal occlusion (FETO) in Latin American centers. Method: A retrospective cohort including fetuses with isolated left CDH and severe pulmonary hypoplasia (observed/expected lung area to head ratio (O/E‐LHR) < 35% with liver herniation) treated with FETO in five Latin‐American countries was compared to a contemporary control group with similar lung size but managed expectantly during pregnancy. Propensity score matching and multivariate logistic regression were used to compare survival outcomes between cases with and without FETO. Results: 360 fetuses with severe left CDH were included, 180 treated with FETO were compared with 180 contemporaneous cases managed expectantly during pregnancy with similar O/E‐LHR values (25.2 vs. 25.7, p = 0.50). FETO was performed at a mean GA of 28.4 (ranges, 24.0–32.0) weeks. Balloon removal was performed at a mean GA of 33.8 (ranges, 28.4–38.0) weeks. The mean duration of tracheal occlusion was 37.5 (ranges, 2.0–84.0) days. The FETO group showed significantly lower GA at delivery (35.2 vs. 37.0 weeks, respectively, p < 0.001), and higher incidence of preterm prelabor rupture of membranes (47.8% vs. 20.0%, p = < 0.001). The neonatal survival rate was significantly higher in the FETO group compared with the expectant care group (39.4% vs. 8.9%, respectively, p < 0.001) (odds ratio: 14.8; 95% confidence interval [CI]: 7.1–30.9; p < 0.001). Conclusions: In Latin American centers, FETO was associated with a significant increase in survival among fetuses with left CDH and severe lung hypoplasia.

Introduction: The aim of the study was to describe the anatomical features of the fetal facial blood circulation during the first trimester of pregnancy. Methods: Blood flow circulation of the fetal face was assessed a prospective cohort of fetuses during routine sonographic screening at 11+0 to 13+6 weeks+days of gestation in a single Fetal Medicine Center in Colombia. In a coronal view of the fetal face, the orofacial circulation was assessed using micro vascular flow mode (MV-Flow™). Results: A total of 162 fetuses with no structural abnormalities were evaluated at a mean gestational age of 12+6 weeks+days. Eight pairs of orofacial arteries could be identified in all cases showing the “face on fire” sign, which includes the supratrochlear, supraorbital, temporal, angular, dorsal nasal, superior labial, labiomental, and the ascending branches of the facial arteries. The perilabial circulation forming the fetal “labial rectangle” sign was successfully identified in all cases and was delimited anteriorly by the superior labial arteries, laterally by the ascending branches of the facial arteries and posteriorly by the labiomental arteries. Conclusion: Evaluation of orofacial circulation was feasible during the first trimester of pregnancy. The utility of facial blood trajectory for early detection of lip and palate defects requires assessment in further studies.

Introduction: The aim of this study was to assess the longitudinal intrathoracic changes after pleuroamniotic shunting (PAS) in fetuses with massive unilateral or bilateral hydrothorax. Methods: The presence of intrafetal fluid effusions and the observed/expected lung-to-head ratio (O/E-LHR) of both lungs were weekly evaluated in a cohort of fetuses with severe hydrothorax treated PAS in a single reference center in Mexico. Severe fetal hydrothorax was diagnosed as an accumulation of fluid within the fetal pleural space accompanied with severe bilateral lung compression, mediastinal shift, polyhydramnios, and/or hydrops. The longitudinal changes in intrafetal fluid effusions, and pulmonary growth were analyzed by survival and multilevel analysis against weeks after fetal intervention. Results: Fifty-six pregnancies with severe fetal hydrothorax were treated with PAS at a median gestational age of 30.1 (range, 20.8–36.1) weeks. After shunting, all cases were longitudinally analyzed and in whom a total of 332 scans were performed (median 6, range 2–16). A complete disappearance of hydrops and hydrothorax was observed at a median interval of 1.6 and 5.9 weeks after PAS, respectively. A progressive increase in lung growth was observed, becoming normal O/E-LHR at on average 7.0 weeks after PAS. Conclusion: Fetal PAS promotes disappearance of all fetal fluid effusions and a normalization of the pulmonary growth after fetal intervention.