Objectives: To evaluate if fetal endoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia (CDH) using a 1.0-mm fetoscope improves neonatal outcome. Method: Between January 2006 and December 2008, a controlled study was conducted at a single center in which FETO was proposed for fetuses with severe isolated CDH (lung-to-head ratio <1.0) and liver herniation to the thoracic cavity but no other detectable anomalies at diagnosis (<26 weeks). FETO was performed under maternal epidural and fetal intramuscular anesthesia, guided by ultrasonography and 1.0-mm fetoscope between 26 and 30 weeks. All cases submitted to FETO were delivered by ex utero intrapartum therapy procedure. Postnatal therapy was the same for both treated fetuses and controls. The primary outcome was neonatal survival (up to 28 days after birth). Results: A total of 35 women met the inclusion criteria, and in 17 of them, fetal intervention was intended. However, in 1 case, it was not possible to insert the balloon inside the fetal trachea because of placental bleeding. FETO was therefore successfully performed in 16 fetuses with severe CDH. Eighteen cases received no prenatal intervention and served as the control group. Mean gestational age at diagnosis was similar in both groups (p > 0.05). Delivery occurred at 35.6 (range: 28–38) weeks in the FETO group and at 37.5 (range: 31–40) weeks (p = 0.18) among controls. Nine of 17 (52.9%) infants in the FETO group and 1 of 18 (5.6%) in the control group survived (p < 0.01). Severe pulmonary arterial hypertension was present in 8/17 (47.1%) infants from the FETO group and in 16/18 (88.9%) controls (p = 0.01). Conclusion: The present study shows that FETO using a 1.0-mm fetoscope is feasible and may improve neonatal outcome in severe CDH.

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Fetal cystoscopy may be an option for the treatment of severe lower urinary tract obstruction 1 -7 . In the present case the use of four-dimensional (4D) ultrasonography was helpful in the identification of the urethral obstruction and guidance of percutaneous cystoscopy.A 34-year-old pregnant woman, gravida 2 para 1 (one previous vaginal delivery), was referred at 20 weeks' gestation because her male fetus presented with distended bladder, dilated proximal urethra ('keyhole sign') ( Figure 1a), bilateral hydroureters and hyperechogenic kidneys with severe hydronephrosis, ascites and anhydramnios. Amniocentesis was performed and normal fetal karyotype was observed. Renal function (sodium concentration of 120 mEq/L, chloride concentration of 95 mEq/L and osmolarity of 255 mOsm) was assessed by percutaneous puncture of the fetal right kidney. At 22 weeks' gestation fetal cystoscopy was performed under maternal epidural anesthesia and fetal anesthesia (15 µg/kg of fentanyl and 2 mg/kg pancuronium), after the parents' informed consent and the approval of the local ethics committee were obtained. A 2.2-mm slightly curved operating sheath was introduced into the fetal dilated bladder through the maternal abdomen, uterine walls and amniotic cavity under two-dimensional (2D) Figure 1 (a) Two-dimensional ultrasound image (parasagittal section) revealing a distended bladder (DB) and dilated urethra (DU) at 20 weeks' gestation. (b) Three-dimensional surface-rendered ultrasound image of fetal distended bladder (DB), dilated upper posterior urethra (DU), hydroureters (HyUr) and a septum (s) that seemed to obstruct bladder drainage. P, placenta.

Pregnancies complicated by hypertensive disorders are associated with reduced placental vascularity but not with reduced placental volumes. These findings are independent of changes in uterine artery Doppler studies. Future studies of the prediction of preeclampsia may focus on placental vascularity in combination with results of Doppler studies of the uterine arteries.

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Objectives: To evaluate the potential use of the lung-head ratio (LHR) for the prediction of neonatal outcome in severe left congenital diaphragmatic hernia (CDH) after fetal tracheal occlusion (FETO). Methods: Between January 2006 and December 2009, 20 fetuses with severe, isolated left CDH (LHR < 1.0 and liver-up) were submitted to FETO between 26-30 weeks of gestation. The LHR was evaluated before (26-28 ws) and after (32 ws) FETO procedure and then correlated with neonatal outcome (deaths). Results: Neonatal deaths occurred in 9/20 (45.0%) cases. Significantly lower values of LHR were observed in those cases that died before (0.6 ± 0.3) and after (0.9 ± 0.4) FETO procedures in comparison to those that survived (0.8 ± 0.3 and 1.6 ± 0.4; respectively, P < 0.05). Conclusions: The LHR may be useful to predict neonatal outcome in fetuses with severe left CDH submitted to FETO procedures.