368

Original Article

Vasa Praevia: Risk-Adapted Modification of the Conventional Management – a Retrospective Study Vasa praevia: eine risikoadaptierte Modifikation des konventionellen Managements – eine retrospektive Studie

Authors

M. Golic1, L. Hinkson1, C. Bamberg1, E. Rodekamp1, M. Brauer1, N. Sarioglu2, W. Henrich1

Affiliations

1

Klinik für Geburtsmedizin, Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin Institut für Pathologie, Campus Mitte, Charité – Universitätsmedizin Berlin

Key words

Zusammenfassung

Abstract

"

!

!

Ziel: Undiagnostizierte Vasa praevia haben eine hohe fetale Letalität und werden mit steigenden IVF-Maßnahmen zunehmen. Selbst wenn sie diagnostiziert werden, stellt sich die Frage, ob das pränatale Standardmanagement – die obligate Steroidapplikation zur fetalen Lungenreifeinduktion und eine geplante Sektio mit 35 SSW – die Risiken rechtfertigen. Wir präsentieren eine retrospektive Studie einer risikoadaptierten Modifikation des konventionellen Managements von Vasa praevia. Material und Methoden: Wir analysierten an unserem Perinatalzentrum 18 pränatal diagnostizierte Fälle von Vasa praevia. Jeder Fall wurde risikoadaptiert behandelt, wobei die Steroidapplikation und der Entbindungszeitpunkt von der Anamnese der Schwangeren und ihren Frühgeburtsbestrebungen abhingen. Ergebnisse: Es gab keine letalen Komplikationen der Kinder und Mütter. Die früheste Entbindung lag bei 34 + 1 SSW, die späteste bei 37 + 1 SSW. In mehr als der Hälfte der Fälle wurde in ≥ 36 SSW entbunden. Schlussfolgerung: Retrospektiv gesehen wäre in keinem Fall eine Steroidapplikation nötig gewesen, was unsere Methode der nicht obligaten Administration rechtfertigt. In 78 % unserer Fälle verschoben wir den Entbindungszeitpunkt um bis zu 2 Wochen hinter die üblicherweise empfohlenen 35 SSW, was zu keinen Komplikationen führte. Zusammenfassend empfehlen wir folgendes risikoadaptiertes Vorgehen bei Vasa praevia: 1. wöchentliche Evaluation der Frühgeburtsbestrebungen; 2. Steroidapplikation nur im Falle erhöhten Frühgeburtsrisikos; 3. Hospitalisierung in einer geeigneten Klinik ab 32 – 34 SSW; 4. primäre Sektio risikoadaptiert zwischen 35 und 37 SSW.

Purpose: Undiagnosed vasa praevia carries an imminent risk of fetal death and increases with IVF. When diagnosed, the question arises as to whether the conventional prenatal management of routine steroid administration for fetal lung maturation and elective caesarean section in week 35 is generally justified in face of the risks involved. We present a retrospective study of a risk-adapted modification of the conventional management of vasa praevia. Material and Methods: We analysed 11 years of records involving 18 cases of antenatally diagnosed vasa praevia at our perinatal centre. Each case was managed by a risk-adapted modification of the conventional treatment where both, the steroid administration and the timing of delivery, were dependent on the patient history and clinical signs for preterm birth. Results: There were no lethal fetal, neonatal, or maternal complications. The earliest caesarean section took place at 34 weeks 1 day, the latest at 37 weeks 1 day, and in more than half of the cases at ≥ 36 weeks. Conclusion: Steroid application is generally recommended for pregnancies before 34 weeks carrying a risk for preterm birth. Thus, retrospectively, none of our cases required steroid administration. This supports our protocol of not obligatorily administering steroids. Delaying the caesarean section up to two weeks beyond the conventionally recommended date of 35 weeks in 78 % of our cases resulted in no complications. This justifies the suitability of determining the timing of delivery based on our individual patient assessment. In conclusion, the following recommendations for a risk-adapted management of vasa praevia can be made: 1. weekly evaluation of risk factors for preterm delivery; 2. steroid administration only at risk for preterm birth; 3. admission to hospital with full obstetric and neonatal care facilities between 32 and 34 weeks; 4. elective caesarean section between 35 and 37 weeks, risk-adapted.

● vasa praevia ● obstetric management ● prenatal ultrasound ● diagnosis " " "

received accepted

20.10.2011 25.7.2012

Bibliography DOI http://dx.doi.org/ 10.1055/s-0032-1313167 Published online: September 21, 2012 Ultraschall in Med 2013; 34: 368–376 © Georg Thieme Verlag KG Stuttgart · New York · ISSN 0172-4614 Correspondence Dr. Michaela Golic Department of Obstetrics, Charité – CVK Augustenburger Platz 1 13353 Berlin Germany Tel.: ++ 49/30/4 50 66 40 72 Fax: ++ 49/30/4 50 56 49 01 [email protected]

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Original Article

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Velamentous umbilical cord insertion (VCI) is diagnosed when the umbilical cord inserts into the placental membranes before entering the placental tissue [1], which occurs in approximately 1 % of pregnancies [2]. Vasa praevia is a variant of VCI, where foetal umbilical vessels run within the amniotic membranes overlying the internal cervical os. In the case of vasa praevia, rupture of the membranes often leads to the simultaneous rupture of the vulnerable vessels, causing fetal mortality due to exsanguination [3, 4] in 50 to 100 % [4, 5]. More than 50 % of these survivors require neonatal blood transfusions. The approximate incidence of vasa praevia is 1 in 3000 to 1 in 5000 pregnancies [4, 6, 7] and is described as being higher in multiple pregnancies and in pregnancies after in-vitro fertilisation (IVF) [2, 4, 8]. The incidence of vasa praevia following IVF is described as 1 in 293 IVF pregnancies [9]. With the global rise in use of assisted fertility techniques, the overall incidence of vasa praevia is expected to increase significantly. In cases with vasa praevia, the best outcome critically depends on prenatal diagnosis by ultrasound and subsequent elective delivery prior to rupture of membranes and onset of labour. In the literature, there have been no cases of severe foetal or maternal complications following antenatal diagnosis. Conventional management of patients with vasa praevia includes the obligatory use of antenatal corticosteroids for foetal lung maturation [10] as well as prolonged hospital admission, bed rest, and planned caesarean section at 35 weeks of gestational age, as recommended by the Vasa Praevia Foundation and Oyelese et al. [4]. However, planned caesarean section at 35 weeks of gestational age induces late preterm infants (34 weeks to 36 weeks) with their increased risks for severe respiratory disorders [11], infections [12], hypoglycaemia [13], and hyperbilirubinaemia [14] leading to prolonged hospitalisation and increased neontatal mortality compared to term infants [15]. Antenatal corticosteroids do have – apart from their efficiency in reducing incidence and severity of neonatal respiratory distress syndrome and intracranial haemorrhage [16] – potentially long-term side effects for the child such as restricted birth weight, brain growth [17], impaired neurological development [18], and problematic behaviour [19]. In the present article, we present a retrospective study of a risk-adapted modification of the conventional management of vasa praevia with administration of corticosteroids and decision on delivery date depending on the patient history and clinical signs for preterm birth.

Materials and methods !

We analysed the records of all cases of antenatally diagnosed vasa praevia in our perinatal centre from January 1999 through July 2010, meaning a study of 18 pregnancies in total. Each case received, at the time, a risk-adapted modification of the conventional treatment with administration of corticosteroids and decision on delivery date depending on the patient history and clinical signs for preterm birth. We did not obligatorily administer corticosteroids, but rather in case of contractions, vaginal bleeding and rupture of membranes after exclusion of foetal bleeding before 34 weeks of gestational age. We aimed for prolongation of pregnancies over 35 weeks. Non-elective caesarean sections were performed due to labour, vaginal bleeding, and/or rupture of membranes. In all 18 cases, vasa praevia was confirmed by an ultrasound specialist antenatally: there were 12

cases with foetal vessels lying directly over the internal cervical os, 4 cases with vasa praevia 1 centimetre from the internal cervical os, and 2 cases with total bipartite placenta praevia having an interconnecting vessel in front of the internal cervical os. We did exclude cases with total placenta praevia or marginal placenta praevia without foetal vessels overlying the internal cervical os. Birth weights were classified according to weight percentiles [20]. With a total of 39 870 deliveries (annual deliveries ranging from 3274 to 3586), the incidence of antenatally diagnosed vasa praevia was 1 in 2215 pregnancies at our perinatal centre during the observed time.

Results !

In all 18 pregnancies with antenatally diagnosed vasa praevia " Table 1, 2, " Fig. 1 – 10), there were no lethal foetal, neonatal, (● ● or maternal complications. The average Apgar scores after 1, 5, and 10 minutes were 8, 9, and 10 and the average pH value of the umbilical artery was 7.29. None of the babies required blood transfusions postnatally and the average birth weight was 2729 g (50th percentile). The earliest caesarean section took place at 34 weeks and 1 day, the latest at 37 weeks and 1 day, and more than half the cases (10) at 36 weeks and later (median 36 weeks and 1 day). From all cases with vasa praevia, 56 % (10) of the babies had been delivered by elective caesarean section and 44 % (8) by nonelective caesarean section. On average, elective caesarean sections took place at 36 weeks and 3 days, non-elective caesarean sections at 35 weeks and 2 days. Non-elective caesarean sections were indicated because of labour (2 cases with bleeding, 2 cases without bleeding), heavy vaginal bleeding (comparable to menstrual bleeding, 2 cases) and/or rupture of membranes (2 cases). Seven women (39 %) received corticosteroids for foetal lung maturation at an average gestational age of 29 weeks and 5 days. Four of these 7 women (57 %) received corticosteroids because of vaginal maternal bleeding (after exclusion of foetal bleeding), 1 woman because of premature rupture of membranes without bleeding. In 2 cases the exact reason for administration of corticosteroids was not clear. The average gestational age of hospital admission for observation was 31 weeks and 6 days. One woman refused admission. In 83 % (15) of pregnancies with vasa praevia, we found placental abnormalities (53 % (8) had a low lying placenta, 33 % (5) had a marginal placenta praevia and 13 % (2) had a total bipartite placenta praevia). Thirty-three per cent (6) of pregnancies with vasa praevia were observed following IVF or ICSI. We had one case of antenatally undiagnosed vasa praevia where a woman at 38 weeks of gestational age was admitted to our hospital with loss of bloody amniotic fluid for the last 30 minutes and intrauterine death. The foetal demise was secondary to exsanguination. The woman delivered in our hospital. The pla" Fig. 11). centa revealed the ruptured vasa praevia (●

Discussion !

In our perinatal centre, we conducted a retrospective study of a risk-adapted modification of the conventional management of vasa praevia: both, the antenatal administration of corticosteroids and the delivery date were chosen depending on the patient history and clinical signs for preterm birth. It is crucial to note that in our analysed 18 pregnancies, all babies and mothers survived. This finding is supported by a large retrospective study,

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Introduction

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Outcomes of pregnancies antenatally diagnosed with vasa praevia. We observed 18 cases. 1

Table 1

case

age

GA

conc.

deliv.

sex

weight

admission

steroids

Apgar

pH

placental anomaly

31 + 1

31 + 1/2

8/8/8

7.29

total bipartite p. praevia, interconnecting vessel

1

1

32

35 + 2

spon.

2 3

e. C/S

m

2860 g (71.p)

42

35 + 4

/

e. C/S

m

2035 g (8.p)

34 + 3

/

10/10/10

7.28

low lying bipartite p.

37

36 + 1

ICSI

e. C/S

f

2970 g (63.p)

33 + 2

/

8/9/10

7.30

low lying p.

4

30

36 + 2

spon.

e. C/S

m

3205 g (78.p)

denied

/

8/9/9

7.23

marginal p. praevia, UCI over ICO

5

38

36 + 3

ICSI

e. C/S

f

2620 g (34.p)

32 + 1

/

9/10/10

7.28

low lying p., UCI over ICO

6

35

36 + 3

/

e. C/S

m

3450 g (90.p)

26 + 5

26 + 5/6

9/9/9

7.28

marginal p. praevia

7

41

36 + 6

spon.

e. C/S

f

2980 g (50.p)

33 + 1

/

8/9/10

7.28

low lying p.

8

41

36 + 6

ICSI

e. C/S

m

3040 g (55.p)

34 + 0

/

9/10/10

7.31

low lying p.

9

37

37 + 0

IVF

e. C/S

m

2820 g (38.p)

36 + 3

/

9/10/10

7.32

marginal p. praevia

10

15

37 + 1

spon.

e. C/S

m

3060 g (51.p)

28 + 6

/

9/10/10

7.20

/

11

36

34 + 1

spon.

n.-e. C/S

m

2470 g (61.p)

32 + 1

33 + 1/2

9/10/10

7.31

/

12

32

34 + 3

/

n.-e. C/S

f

2180 g (34.p)

33 + 1

/

6/7/8

7.33

low lying p.

13

36

34 + 4

ICSI

n.-e. C/S

f

2755 g (76.p)

32 + 6

/

9/10/10

7.36

marginal p. praevia

14

34

34 + 6

/

n.-e. C/S

f

2600 g (57.p)

32 + 0

32 + 1/2

6/6/8

7.34

total bipartite p. praevia, interconnecting vessel

15

32

35 + 2

/

n.-e. C/S

m

2450 g (40.p)

33 + 5

27 + 1/2

9/9/10

7.34

low lying p.

16

31

35 + 4

spon.

n.-e. C/S

m

2430 g (33.p)

28 + 1

/

9/10/10

7.29

uci over ico

17

29

36 + 2

IVF

n.-e. C/S

m

2690 g (40.p)

27 + 0

24 + 2/3

7/9/10

7.28

marginal p. praevia

18

26

37 + 1

spon.

n.-e. C/S

f

2500 g (16.p)

33 + 3

33 + 3/4

9/9/10

7.23

low lying bipartite p.

From left to right: case number; maternal age; gestational age in weeks (GA); way of conception (conc.), spontaneously (spont.); delivery mode (deliv.), caesarean section (C/S), elective (e.), non-elective (n.-e.); sex of the baby, female (f), male (m); birth weight of baby in grams (g) and by percentile (perc.); in case of hospital admission beginning of admission at gestational age in weeks; in case of steroid application date of application at gestational age in weeks; Apgar scores; pH values; anomalies of the placenta (p.), umbilical cord insertion (UCI), internal cervical os (ICO).

elective caesarean section

all pregnancies with

elective caesarean

non-elective caesarean

vasa praevia (18 cases)

section (10 cases)

section (8 cases)

56 %

non-elective caesarean section

44 %

average Apgar scores at 1/5/10 min

8/9/10

9/9/10

8/9/10

average pH value of the umbilical artery

7.29

7.28

7.31

average gestational age

35 weeks 6 days

36 weeks 3 days

35 weeks 2 days

median gestational age

36 weeks 1 day

36 weeks 3 days

35 weeks 0 days

steroids (fetal lung maturation)

39 %

20 %

63 %

average time of steroid application

29 weeks 5 days

29 weeks 0 days

30 weeks 0 days 31 weeks 4 days

average time of hospital admission

31 weeks 6 days

32 weeks 2 days

placental abnormalities

83 %

90 %

75 %

IVF/ICSI

33 %

40 %

25 %

average birth weight

2729 g

2904 g

2509 g

average birth weight (percentile)

50th

54th

45th

multiple pregnancies

0%

0%

0%

male babies

61 %

70 %

50 %

female babies

39 %

30 %

50 %

average maternal age

33.6 years

34.8 years

32 years

which collected 155 cases of vasa praevia [4]. Our results confirm the positive correlation of vasa praevia with placental anomalies [2, 4, 7] and IVF and ICSI [2, 4, 8]. However, we cannot reproduce the association of vasa praevia with multiple pregnancies [1, 4, 21] and lower birth weights [1].

Recommendations for the management of vasa praevia In our study, the earliest gestational age of delivery was 34 weeks and 1 day. Antenatal administration of corticosteroids is recommended and commonly used for all pregnancies of 24 to 34 gestational weeks when there is increased risk of preterm birth

Golic M et al. Vasa Praevia: Risk-Adapted … Ultraschall in Med 2013; 34: 368–376

Table 2 Outcomes of pregnancies with vasa praevia; all cases and cases divided in groups according to delivery by elective or non-elective caesarean section.

[22]. Since potentially long-term side effects of corticosteroids have been described [17 – 19], the antenatal administration thereof should be used restrictively in situations with high risk of preterm birth. In retrospect, none of the cases encountered in our hospital over the past eleven years required the administration of corticosteroids. This lends strong support to our method of not obligatorily administering corticosteroids. Delaying the caesarean section up to two weeks beyond the standard recommended date of 35 weeks in 78 % (14) of our cases resulted in no complications. This speaks for the adequacy of determining the delivery date by the individual, risk-adapted assessments em-

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(perc.)

Fig. 1 Vasa praevia: insertion of the umbilical cord directly over the internal cervical os. Conventional B-mode ultrasound, transabdominal view, 24 weeks of gestational age.

Fig. 3 Vasa praevia: insertion of the umbilical cord directly over the internal cervical os. Conventional B-mode ultrasound, transvaginal sagittal view, 24 weeks of gestational age.

Abb. 1 Nabelschnuransatz direkt über dem inneren Muttermund. Konventioneller B-Mode-Ultraschall, transabdominale Aufnahme, 24 Schwangerschaftswochen.

Abb. 3 Nabelschnuransatz direkt über dem inneren Muttermund. Konventioneller B-Mode-Ultraschall, transvaginale sagittale Aufnahme, 24 Schwangerschaftswochen.

Fig. 2 Vasa praevia: insertion of the umbilical cord directly over the internal cervical os. Colour-mode ultrasound, transabdominal view, 24 weeks of gestational age.

Fig. 4 Vasa praevia: insertion of the umbilical cord directly over the internal cervical os. Colour-mode ultrasound, transvaginal sagittal view, 24 weeks of gestational age. Without colour-mode, it would have been difficult to diagnose vasa praevia.

Abb. 2 Nabelschnuransatz direkt über dem inneren Muttermund. ColourMode-Ultraschall, transabdominale Aufnahme, 24 Schwangerschaftswochen.

ployed in the cases underlying our study. In our opinion, every woman with vasa praevia should be seen by a doctor weekly starting with the 23rd week of gestation for measurement of cervical length, evaluation of risk for preterm delivery, and psychological support. Risk factors for preterm birth are a history of preterm delivery, vaginal bleeding, shortening of cervical length, contractions, and a positive tocograph. In the absence of risk factors for preterm birth, we propose the optimal time of hospital admission to be between 32 and 34 weeks of gestation lasting until delivery. In these cases, we recommend the abandonment of corticosteroid application for foetal lung maturation, as deliv-

Abb. 4 Nabelschnuransatz direkt über dem inneren Muttermund. ColourMode-Ultraschall, transvaginale sagittale Aufnahme, 24 Schwangerschaftswochen. Ohne Colour-Mode-Ultraschall hätte man die Vasa praevia nur sehr schwer entdeckt.

ery with more than 34 weeks of gestation is highly probable. The Vasa Praevia Foundation recommends hospital admittance for all patients with vasa praevia in the third trimester, which could mean starting with the 26th week of gestation. Based on our experience, an individual counselling and management plan for optimal timing of admission can prevent an unnecessarily long hospital stay with potential loss of quality of life and mental stress for the pregnant woman. From a medicolegal point of view, patients should be fully informed and consent to the plan of management. Of course, in cases of bleeding, contraction, or prema-

Golic M et al. Vasa Praevia: Risk-Adapted … Ultraschall in Med 2013; 34: 368–376

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Fig. 5 Vasa praevia: insertion of the umbilical cord directly over the internal cervical os. Colour-mode ultrasound, transvaginal sagittal view, demonstrating the course of the vessels overlying the internal cervical os to the anterior wall of the uterus, 24 weeks of gestational age. Abb. 5 Nabelschnuransatz direkt über dem inneren Muttermund. ColourMode-Ultraschall, transvaginale sagittale Aufnahme, den Verlauf der Gefäße über den inneren Muttermund zur Uterusvorderwand verlaufend zeigend, 24 Schwangerschaftswochen.

Fig. 6 Vasa praevia: insertion of the umbilical cord directly over the internal cervical os. 3D-colour-TUI-mode, transvaginal sagittal view, demonstrating the course of the vessels overlying the internal cervical os to the anterior wall of the uterus, 24 weeks of gestational age. (TUI – Tomographic Ultrasound Imaging – enables visualization in several different slices similar to CT or MRI). Knowing the course of vessels is important for the uterine incision during caesarean section. Abb. 6 Nabelschnuransatz direkt über dem inneren Muttermund. 3DColour-TUI-Mode, transvaginale sagittale Aufnahme, den Verlauf der Gefäße über den inneren Muttermund zur Uterusvorderwand verlaufend zeigend, 24 Schwangerschaftswochen. (TUI – Tomographic Ultrasound Imaging – ermöglicht die Visualisierung in vielen verschiedenen Schichten ähnlich CT oder MRT). Die Kenntnis des Gefäßverlaufs ist wichtig für die uterine Inzision im Rahmen der Sektio.

ture rupture of membranes an earlier hospital admission and application of corticosteroids (before 34 weeks gestational age) are absolutely necessary. In terms of the optimal timing of planned elective caesarean section we propose this to be risk-adapted between 35 and 37 weeks of gestational age. In the absence of

Golic M et al. Vasa Praevia: Risk-Adapted … Ultraschall in Med 2013; 34: 368–376

Fig. 7 Vasa praevia: insertion of the umbilical cord directly over the internal cervical os. Glass body mode, transvaginal sagittal view, demonstrating the course of the vessels overlying the internal cervical os to the anterior wall of the uterus, 24 weeks of gestational age. Abb. 7 Nabelschnuransatz direkt über dem inneren Muttermund. GlassBody-Mode, transvaginale sagittale Aufnahme, den Verlauf der Gefäße über den inneren Muttermund zur Uterusvorderwand verlaufend zeigend, 24 Schwangerschaftswochen.

Fig. 8 Vasa praevia: insertion of the umbilical cord directly over the internal cervical os. 3D-Rendered-Scan, transabdominal view, 24 weeks of gestational age, perspective from the uterine fundus with view to the internal cervical os where the umbilical cord inserts into the amniotic membranes. Abb. 8 Nabelschnuransatz direkt über dem inneren Muttermund. 3-DRender-Scan, transabdominale Aufnahme, 24 Schwangerschaftswochen, Blickwinkel vom Uterusfundus auf den inneren Muttermund, wo die Nabelschnur in die Eihäute inseriert.

shortening cervical length, bleeding, or other risks of preterm birth, elective caesarean section with 37 gestational weeks is possible and precludes prematurity with its associated risks [11 – 15]. Women with vasa praevia should be admitted to a perinatal centre or at least a hospital with round-the-clock obstetric and neonatal care for the possibility of performing non-elective caesarean section at any time. We have summarised our recommendations of a risk-adapted management of vasa praevia in ●" Fig. 12. Obstetricians performing the caesarean section should be aware of possible umbilical vessels at the area of the uterine

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Abb. 9 Makroskopisches Bild einer Plazenta mit Vasa praevia nach primärer Sektio in 35 Schwangerschaftswochen.

Fig. 10 Vasa praevia next to the internal cervical os, transvaginal ultrasound, sagittal view, conventional B-mode, 35 weeks of gestational age. Abb. 10 Vasa praevia neben dem inneren Muttermund, transvaginale sagittale Aufnahme, konventioneller B-Mode-Ultraschall, 35 Schwangerschaftswochen.

incision running along the anterior wall of the lower uterine segment. In such cases, an atypical uterine incision and/or keeping the membranes intact might be helpful. Clear communication with the neonatal team is crucial for the prompt resuscitation of the potentially anaemic foetus.

Recommendations for diagnosing vasa praevia For the optimal management of vasa praevia, early detection is crucial. It is known that women with risk factors will benefit from routine prenatal determination of the placental cord insertion site [4, 6]. However, there remains a shortage of routine screening. In a questionnaire conducted in the UK, 85 % of the responding consultants admitted not to investigate velamentous cord insertions during the anomaly scan [23]. Because of the worldwide increase of vasa praevia, we recommend an ultra-

Fig. 11 Placenta with ruptured vasa praevia. The vasa praevia was not diagnosed antenatally, after rupture of membranes, the baby died of exsanguination, 38 weeks of gestational age. Patient admitted with intrauterine death. Picture is a courtesy of K. Kalache, Department of Obstetrics, Charité, Berlin. Abb. 11 Plazenta mit rupturierten Vasa praevia. Die Vasa praevia waren pränatal nicht diagnostiziert worden. Nach Blasensprung verblutete das Kind, 38 Schwangerschaftswochen. Die Schwangere hatte sich mit einem intrauterinen Fruchttod in unserer Klinik vorgestellt. Bild freundlicherweise zur Verfügung gestellt von K. Kalache, Klinik für Geburtsmedizin, Charité, Berlin.

sound screening in every pregnant woman meaning, first and foremost, the documentation of the umbilical cord insertion in the first trimester screening via transabdominal and/or transva" Fig. 13). This ginal B-mode and/or colour-mode ultrasound (● " early detection of VCI is possible [24] (● Fig. 14) and supported by a study, which showed the feasibility of screening for VCI during the 11 to 14-week scan with the addition of less than 30 seconds to the overall scan time of about 15 minutes [21]. Secondly, we recommend the performance of a B-mode and colour-mode transvaginal and transabdominal ultrasound in every pregnant woman during the 20 week scan to detect VCI and vasa praevia [25, 26]. A few years ago, some authors claimed that threedimensional scanning may provide additional information for the localisation of the abnormal vessels [27, 28]. Three-dimensional scanning can help to map out the course of the vessels preoperatively and thereby help the surgeon to determine the ideal uterine incision in order to avoid lacerating foetal vessels [28]. However, in our opinion two-dimensional scanning combined with colour mode is entirely sufficient for the initial detection of " Fig. 1 – 4, 10, 14). By diagnosing vasa VCI and vasa praevia (● praevia und VCI, Doppler sonography can contribute to further reduction of perinatal mortality in addition to the management of intrauterine growth restriction and foetal anaemia [29]. Increased training in the diagnosis of VCI und vasa praevia should be promoted and encouraged, as it seems there is a need for it. Half of the consultants responding to the questionnaire survey mentioned above admitted that they have never had the experience of diagnosing vasa praevia through ultrasound scan or managing it antenatally before rupture [23]. Besides diagnosing vasa praevia, professional training is required to distinguish between vasa praevia and its differential diagnoses such as umbili" Fig. 15, 16) and the presence of maternal cal cord presentation (● vessels at the internal cervical os in proximity to a low lying placenta. It is also necessary to differentiate between uterine and " Fig. 17). In the case of lower placentaretrochorionic vessels (● Golic M et al. Vasa Praevia: Risk-Adapted … Ultraschall in Med 2013; 34: 368–376

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Fig. 9 Macroscopic picture of a placenta with vasa praevia after elective caesarean section at 35 weeks of gestational age.

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Recommendations for diagnosing vasa praevia 1st trimester screening: transabdominal and/or transvaginal B-mode and/or colour-mode ultrasound: documentation of the insertion of the umbilical cord

2nd trimester screening: transabdominal and transvaginal Bmode and colour-mode ultrasound: confirmation of the insertion of the umbilical cord and screening for vasa praevia

Fig. 12

Recommendations for the management of vasa praevia.

Abb. 12

Empfehlungen für das Management von Vasa praevia.

generally: increased training of doctors in diagnosing vasa praevia, velamentous cord insertion, and its differential diagnoses

Table 3 Recommendations for diagnosing vasa praevia.

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Fig. 13 Unremarkable insertions of the umbilical cords into anterior wall placentas, dichorionic twins, 3D-ultrasound, 13 weeks of gestational age.

Fig. 14 VCI at the anterior uterine wall. The placenta is located at the posterior uterine wall, colour-mode ultrasound, 13 weeks of gestational age.

Abb. 13 Unauffällige Nabelschnurinsertionen in die Vorderwandplazenten dichorioner Gemini, 3-D-Ultraschall, 13 Schwangerschaftswochen.

Abb. 14 Insertio velamentosa an der Uterusvorderwand. Die Plazenta liegt an der Uterushinterwand, Colour-Mode-Ultraschall, 13 Schwangerschaftswochen.

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Fig. 15 Umbilical cord next to the internal cervical os and the fetal skull, transvaginal ultrasound, sagittal view, colour-mode, 27 weeks of gestational age. Abb. 15 Nabelschnur neben dem inneren Muttermund und fetalen Schädel, transvaginaler Ultraschall, sagittale Aufnahme, Colour-Mode, 27 Schwangerschaftswochen.

Abb. 17 Hinterwandplazenta praevia mit teilweiser Überlappung des inneren Muttermunds und retrochorialem Blutfluss, transvaginaler Ultraschall, sagittale Aufnahme, Colour-Mode, 21 Schwangerschaftswochen. Unkomplizierte Vaginalgeburt nach 38 Schwangerschaftswochen aufgrund Uteruswachstums und Apoptose marginalen Plazentagewebes.

marised our recommendations for diagnosing vasa praevia in

● Table 3. Although our retrospective observational study rests "

on a comparatively small number of 18 cases, our new risk-adapted modification of the conventional management of vasa praevia was successfull in all cases (we had not a single delivery before 34 weeks of gestation and no foetal, neonatal, or maternal complications due to delaying the delivery time up to 2 weeks beyond the standardly recommended 35 weeks of gestation), and thus provides the strongest possible statistical imperative for further studies involving a higher number of cases.

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Fig. 16 Umbilical cord next to the internal cervical os, fetus in breech presentation, transvaginal ultrasound, sagittal view, 3D-colour-TUI-mode, 34 weeks of gestational age. This scan was done after rupture of membranes followed by a non-elective caesarean section to prevent umbilical cord prolapse. Abb. 16 Nabelschnur neben dem inneren Muttermund, Fetus in Steißlage, transvaginaler Ultraschall, sagittale Aufnahme, 3-D-Colour-TUI-mode, 34 Schwangerschaftswochen. Dieses Bild war nach Blasensprung aufgenommen worden. Anschließend war eine sekundäre Sektio durchgeführt worden um einen Nabelschnurvorfall zu vermeiden.

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