Objectives: To provide further evidence on the outcomes associated with fetal malformations of cortical development (MCD), currently informed by data from symptomatic pediatric cohorts, providing a new classification system. Design: Multicenter retrospective cohort study. Setting: Fetal medicine units of three tertiary centers in United Kingdom and Italy. Population: 118 fetuses diagnosed with MCD by ultrasound and/or magnetic resonance imaging included. Methods: The cases were classified according to their presumed etiology (genetic, hemorrhage, dysgenesis, infection) and imaging findings (focal, diffuse, mantle, sulcation). Neurodevelopmental delay was classified as mild, moderate or severe. Cases with missing information on pregnancy or postnatal outcome were excluded. Main Outcome Measures: Postnatal neurodevelopmental outcome ascertained from the infant’s neurological assessments according to International performance scales, depending on the age. Results: There were 52 (44%) livebirths, 64 (54.2%) terminations of pregnancy (TOP) and two (1.6%) intrauterine demises . 24 of 46 cases (54.3 %, 95% CI 39.01 -79.10) that survived the neonatal period had a normal or mildly delayed neurological development. The commonest etiology was genetic and the most frequent radiological finding was reduced sulcation. The best neurological outcome was found in children with focal lesions, and those with diffuse hemispheric lesions had the worst one. Conclusion: This is the largest cohort of fetuses diagnosed with MCDs systematically classified using etiology and radiological findings. Fetal MCDs have a better than previously expected postnatal neurodevelopmental outcome that is related to both the etiological classification and radiological findings: these results should be considered when counselling for a prenatal diagnosis of MCD.

Objective: To assess whether combining estimated fetal weight (EFW) and fetal Doppler ultrasound parameters would provide information to optimise timing of birth in monochorionic twin pregnancies and prevent adverse perinatal outcomes. Study design: Retrospective multicentre cohort study. Setting: Three tertiary centres in the UK, Italy and Belgium. Population: 624 monochorionic twin pregnancies managed between 2013 and 2023. Methods: Univariable and multivariable analyses assessed the association between EFW and Doppler indices taken within two weeks of birth. Main Outcome Measures: Stillbirth or iatrogenic preterm birth before 34 weeks for non-reassuring fetal status. Results: The primary outcome occurred in 143 (22.9%) pregnancies with 70 cases of early PTB for fetal reasons and 73 cases of at least one IUD. Significant associations between biometric and Doppler parameters and adverse perinatal outcomes were found. The best-performing prediction models incorporated EFW discordance and umbilical artery pulsatility index (UA PI) discordance, achieving an AUC of 0.85 (95% CI 0.78-0.91) and EFW discordance and absent or reverse end diastolic flow of UA PI with an AUC of 0.86 (95% CI 0.80-0.92) . The model incorporating EFW and UA PI discordance could be applied to the largest proportion of pregnancies and outperformed the currently clinical sFGR classification in predicting adverse outcomes. Conclusion: A model incorporating intertwin EFW discordance and UA PI discordance outperforms the current clinical classification for prediction of adverse perinatal outcomes in monochorionic pregnancies. If confirmed by further external validation studies, these findings could contribute to build a tailored risk assessment in these pregnancies.

Objective: To assess the clinical effectiveness of the TRUFFLE monitoring protocol in a routine clinical setting. Secondary objectives were evaluating timing and indications for delivery, stratified by gestational age at Fetal Growth Restriction (FGR) diagnosis. Design: Retrospective cohort study. Setting: Tertiary Fetal Medicine Unit. Population or Sample: Singleton pregnancies diagnosed with FGR between 2013 and 2024. Methods: FGR was defined as an estimated fetal weight or abdominal circumference <10th centile with an elevated umbilical artery pulsatility index >95th centile, diagnosed before 36 weeks’ gestation. Exclusion criteria were multiple pregnancies, major fetal anomalies, delivery before 26 weeks, and absence of TRUFFLE protocol monitoring. Main outcome measures: Perinatal survival, interval from diagnosis to delivery, and delivery indications. Results: 196 pregnancies met inclusion criteria. Median gestational age at FGR diagnosis was 28 +1 (26 +2-30 +3) weeks and 30 +6 (28 +3-33 +3) at delivery. Overall intact survival was 92.3%, with 2.6% stillbirths and 5.2% neonatal deaths. Diagnosis prior to 26 weeks allowed longer pregnancy prolongation (31 days compared to 10.5 days; p<0.001). Below 32 weeks, the predominant trigger for delivery was abnormal computerised CTG (low STV). Above 32 weeks, abnormal umbilical artery Doppler and maternal indications became more frequent. Conclusions: The TRUFFLE monitoring protocol is clinically effective in managing early-onset FGR outside a trial environment, achieving comparable perinatal outcomes. Routine integration of both Doppler and cCTG STV monitoring, is crucial for optimal timing of delivery. Further research is needed to assess if more frequent or remote fetal monitoring to improve outcomes. Funding: No funding was received.

Objective: To evaluate the impact of twin dating by ultrasound-measured crown-rump length (CRL) of the larger (CRL-L), smaller (CRL-S) or mean twin measurement (CRL-M) on the rates of preterm birth (PTB) and detection of fetal growth restriction. Design: A cohort study. Setting: A tertiary fetal medicine centre (London, UK). Population or sample: All twin pregnancies between 1998 and 2023 who underwent ultrasound assessment of first trimester CRL and fetal growth. Methods: Data collection included CRL measurement, estimated fetal weight (EFW), pregnancy outcome and birthweight (BW) for each twin. Pregnancies were retrospectively re-dated by CRL-S, CRL-L and CRL-M. Main outcome measures: Small for gestational age (SGA) <10 th centile and PTB rates. Results: Of the 1129 twin pairs median CRL was 61mm (IQR:56.0-66.0) and 63mm (IQR:58.4-68.9) for the smaller and larger twin respectively with a mean discordance of 4.0%. Prenatal SGA diagnosis occurred in 19.8% and 23.1% of smaller twins when dated by CRL-S and CRL-L respectively. When pregnancies were dated by CRL-M versus CRL-S or CRL-L there was no difference in prenatal SGA diagnosis (p=0.275 and p=0.419); SGA at birth (p=0.132 and p=0.325); or PTB (p=1.00 and p=0.765 respectively). Conclusions: Dating by the smaller, larger or mean-twin CRL doesn’t significantly alter rates of extreme preterm birth, SGA detection or SGA birth. Dating by the mean twin CRL reduces stigmatisation of the smaller twin, alleviating parental anxiety, whilst retaining the utility of accurate gestational age assessment without impacting on clinical outcomes.

Objective To determine whether home cervical ripening is associated with acceptable safety margins compared to in-hospital cervical ripening during induction of labour. Design A prospective multicentre observational cohort study using routinely collected data. Setting Twenty-six UK maternity units; 18 offering only in-hospital cervical ripening and 8 offering both in-hospital and home cervical ripening. Population Women with singleton pregnancies, no previous caesarean section, at or beyond 37 weeks gestation having induction with details of cervical ripening method and location recorded. Methods Home cervical ripening using a balloon catheter was compared to in-hospital cervical ripening using prostaglandin. Multivariable logistic regression was performed for the primary outcome. Exposure: Cervical ripening at home using balloon catheter. Main outcome measures Primary outcome: neonatal unit admission within 48 hours of birth for 48 hours or more. Additional neonatal, maternal, labour progress and process outcomes were reported. Results Of 17,530 eligible women, 515 had balloon cervical ripening at home and 4332 had prostaglandin cervical ripening in a hospital that did not offer home cervical ripening. The primary outcome following home cervical ripening with balloon was not higher {16/515 (3.1%) vs 208/4332 (4.8%)}, but with substantial uncertainty on adjusted analysis consistent with a 64% lower risk through to an 81% higher risk. Conclusions Home cervical ripening using balloon catheter may be as safe for babies as using prostaglandin in hospital in low and moderate-risk groups, but further safety data are required.

A document by Becky Liu. Click on the document to view its contents.

BJOG mini-commentary on BJOG-22-0097This manuscript by McCall et al reports that UK and France have very different approaches to managing women with PAS. More women in France received a uterus conserving approach. Major haemorrhage was more common in the UK series. The authors speculate that this may be related to treatment modality. The ACOG/SMFM committee opinion (Obstet Gynecol 2018;132:e259–75) recommends caesarean hysterectomy as the most generally accepted approach. Does this report imply that we should stop offering hysterectomies and recommend conservative treatment?Before we make up our mind, it is important to consider what else was different in the two cohorts. The case definitions used by UK OSS and PACCRETA investigators were different. However, the authors of the current report have included only those cases that satisfied a harmonised definition. UK prevalence (1.7/10 000) was significantly lower as compared to that from France (4.2/10 000). This raises the question: Is UK under-reporting or is France over-reporting? Screening studies may give some idea about the ‘true’ prevalence. A prevalence of 5.8/10 000 (Panaiotova et al, Ultrasound Obstet Gynecol 2019; 53: 101–106) was reported with screening for Caesarean scar pregnancies. Coutinho et al (Ultrasound Obstet Gynecol 2021; 57: 91–96) reported a prevalence of 3.8/10 000 with screening for PAS in late pregnancy. In both these reports all women had either placenta previa or a low-lying placenta. In contrast, placenta previa was present in 64% and 63% of women from UK and France, respectively. In this light, one would expect a higher, rather than lower prevalence of PAS as compared to the two screening studies. One explanation could be increasing Caesarean section rate and better awareness with time.A systematic review reported high (>90%) sensitivity for the detection of PAS using ultrasound in women at high risk of PAS (D’Antonio et al, Ultrasound Obstet Gynecol 2013; 42: 509–517). The prenatal detection was disappointingly low at < 50% in both UK and France. Before we begin to berate ourselves, it is noteworthy that these are 7-12 year-old data. The current study took place between May 2010 - April 2011(UK) and November 2013 - October 2015(France).What about the differences in median blood loss? Manual removal of the placenta was attempted in fewer women in France. Even then, unplanned hysterectomy was more common in the French group. The blood loss may be lower with conservative management, but this advantage should be weighed against the uncertainty about the possibility and timing of developing major haemorrhage in the post-operative period. Moreover, it is possible that the UK series had particularly severe cases as compared to the French cohort given the significantly lower prevalence. A head-to-head comparison of the two treatment modalities has never been reported. This will necessitate a unified definition and accurate prenatal detection. Such a study would be extremely challenging given the strong views of women regarding fertility preservation and of physicians regarding ongoing uncertainty with complications and personal experience. The jury is still out on this one.

Letter to the Editor, BJOG Exchange

Mini-commentary on BJOG- 19-1590.R1: Obstetric outcomes of twin pregnancies presenting with a complete hydatidiform mole and coexistent normal fetus: A systematic review and meta-analysis