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Report on the 11 th World Congress in Fetal Medicine, 24-28 June 2012, Kos, Greece

2012; Wiley; Volume: 40; Issue: 4 Linguagem: Inglês

10.1002/uog.12295

1469-0705

Asma Khalil,

Autopsy Techniques and Outcomes

The World Congress in Fetal Medicine, a meeting organized by Professor Kypros Nicolaides, has established itself as the foremost international conference in fetal medicine. This year it was held on the island of Kos in Greece, the birth place of Hippokrates, and was attended by 1500 delegates. At a total cost of €400, which according to Kypros will not change for as long as he lives, the 12 hour-per-day 5-day program included over 150 lectures with extensive discussions and exciting social activities. The meeting kicked off with a workshop entitled ‘Born after ART: from the laboratory to the delivery room’, organized by Serono Symposia International Foundation. An outstanding review of ‘Preimplantation screening and diagnosis’ was presented by Dr Dagan Wells from Oxford, UK. He presented promising evidence that new approaches to preimplantation genetic screening (PGS), including biopsy of several cells at the blastocyst stage and use of microarray comprehensive genomic hybridization, provide accurate diagnosis with less risk of misdiagnosis due to mosaicism. Dr Wells suggested that PGS should be applied to all embryos to improve pregnancy outcome and reduce the rate of multiple pregnancies. Dr Antonio Pellicer from Spain reported that oocyte donation is a successful technique for patients with a low chance of pregnancy and that delivery rates can be as high as 97%. These rates are better when blastocysts are replaced and the results are similar with use of fresh or vitrified oocytes. Prognostic factors include the donor's age and the quality of the sperm. Maternal age over 45 years is associated with reduced chances of implantation. According to the available evidence, fibroids and endometriosis do not affect the outcome, but adenomyosis is associated with increased miscarriage rates. Pregnancies conceived using egg donation have a higher risk of obstetric complications, including pre-eclampsia (PE), fetal growth restriction (FGR) and postpartum hemorrhage. This session was followed by the Eurofoetus scientific meeting on fetal therapy. A wide range of topics was discussed, including intrauterine blood transfusion for fetal anemia, endoscopic laser surgery for twin-to-twin transfusion syndrome (TTTS) and selective FGR, endoscopic endotracheal placement of a balloon for severe congenital diaphragmatic hernia (CDH), vesicoamniotic shunting for obstructive uropathy, thoracoamniotic shunting for pleural effusions and fetal surgery for open spina bifida, either by hysterotomy or endoscopically. Irene Lindenburg from the Netherlands presented the results of the long-term follow-up after intrauterine transfusion (LOTUS2) study. The incidence of neurodevelopmental impairment was 7.3% and independent predictors of poor outcome were hydrops, severe neonatal morbidity and parental education. The incidence of cerebral palsy was 1.1%, which is comparable to that in the general population. Rohan D'Souza discussed pediatric outcome after pleuroamniotic shunting. In this study 64% of the fetuses shunted survived and 79% of these had normal neurodevelopment. Adverse outcomes were associated with late referral and delivery at an outside center. It was recommended that cases with pleural effusion should be tested for Noonan syndrome. Jacques Jani presented new data on the liver to thoracic cavity volume ratio (LITR) in CDH. He suggested that, rather than categorical use of intrathoracic position of the liver, LITR should be integrated in the prenatal decision-making for fetuses with CDH. A study on stomach position was presented by Anne Gael Cordier from Belgium. She concluded that in left-sided CDH, stomach grading is a simple and reproducible method for indirect evaluation of intrathoracic liver position. She proposed that stomach position might be an independent marker for prediction of postnatal survival in CDH. David Baud from Canada presented his group's experience of minimally invasive fetal therapy for massive hydropic bronchopulmonary sequestration. There were no survivors among cases which did not have fetal therapy. Several minimally invasive therapeutic options are available and feasible, for example laser coagulation, but the optimal fetal therapy is still to be determined. The results of the management of myelomeningocele study (MOMS) were presented by Alan Flake from the USA. He felt that open surgery is currently the best available approach, but expressed concerns regarding the performance of such surgery by less experienced centers as maternal and fetal outcomes are likely to be compromised. He suggested that the future is likely to lie in tissue engineering. On the other hand, promising results were presented by Roland Axt-Fliedner from Germany. In a case–control study comparing outcome following fetoscopic repair of myelomeningocele and following standard postnatal treatment, he demonstrated a neuroprotective effect of the prenatal approach upon both muscle integrity and neurological motor and sensory function. Results of the randomized study on percutaneous shunting in lower urinary tract obstruction (PLUTO) were presented by Katie Morris from the UK. Unfortunately, the trial stopped early due to poor recruitment. Shunting was associated with a trend towards improved perinatal survival, but with an increased risk of pregnancy loss. The evidence for improvement of renal function was inconclusive. Divyesh Desai from the UK reported on the long-term outcome of fetuses with posterior urethral valve and the possible impact of PLUTO on outcome. He pointed out that normal amniotic fluid in male fetuses with features of lower urinary tract obstruction (LUTO) is not predictive of renal function at 1 year of age. He also proposed a randomized controlled trial (RCT) assessing the use of a percutaneous shunt in LUTO, with renal and bladder function as the outcomes. Dominique Luton presented preliminary results of the first RCT of amnioexchange in fetuses with gastroschisis. He concluded that the initial results are disappointing and that amnioexchange might also be associated with an increased risk of stillbirth. Case reports of new applications of fetoscopy in upper airway obstruction, ventriculocystostomy for increasingly compressive interhemispheric arachnoid cyst and bag placement in cases with gastroschisis were presented by Eduard Gratacos, Yves Ville and Kurt Hecher, respectively. Several lectures were presented by leading pediatric surgeons. Stefan Berge from the Netherlands discussed the surgical options for skull deformities, such as primary and secondary craniosynostosis, and the management of oropharyngeal and neck masses. Agostinho Pierro from London discussed postnatal and long-term management of anterior wall defects. A study by his group suggests that the absence of fetal bowel dilatation in gastroschisis excludes intestinal atresia. However, the sensitivity and specificity are poor. He also presented his experience with staged neonatal repair in cases of major exomphalos, highlighting its advantages, for example reduced hospitalization, avoidance of systemic toxicity and secondary operation for ventral hernia. Another talk by Agostinho Pierro focused on the postnatal management of necrotizing enterocolitis (NEC). He presented the randomized controlled Stoma Anastomosis Trial (STAT), which compares intestinal resection with stoma formation vs intestinal resection with primary anastomosis. He also presented a pilot study which suggests that cooling infants with NEC to as low as 33.5 °C for 48 hours appears feasible and safe. Several presentations provided new data on the best management of monochorionic (MC) twin pregnancies and the associated complications. Jeanine van Klink from the Netherlands presented favorable preliminary results on long-term neurodevelopment in cases of selective termination in MC pregnancies. Greg Ryan from Canada presented an overview of the various practices of twin delivery in different parts of the world and the controversies in management of cases of cotwin death. Liesbeth Lewis presented data suggesting that mortality is higher in MC twin pregnancies following assisted conception than in those conceived spontaneously. Kurt Hecher presented data on the effect of experience on the outcome of laser treatment for TTTS. While the overall survival rate after 1000 laser procedures was 80%, 70% of pregnancies had two survivors and 90% had one or more survivors. Data on neurological outcome after laser treatment for TTTS suggest that the increased survival rates do not lead to increased disability rates in survivors. Liesbeth Lewi reported that persistent anastomoses following laser surgery are common, leading to recurrence of TTTS and twin-anemia-polycythemia sequence. Ahmet Baschat recommended complete visualization of the vascular equator and coagulation of the entire chorionic plate to decrease the recurrence of TTTS. He presented data showing that equatorial dichorionization is associated with higher 6-month survival rates. Eduard Gratacos described the pathophysiology and clinical forms of selective FGR in monochorionic diamniotic (MCDA) twin pregnancies and reported that abnormal umbilical artery Doppler findings are associated with a poor prognosis. Active management improves the outcome of the larger twin, but worsens that of the smaller one. The decision is a balance between severity, parents' wishes and technical issues. He concluded that an RCT is unlikely to change current clinical practice. Reference ranges for amniotic fluid according to gestational age in MCDA twin pregnancies were presented by Philip DeKoninck from Belgium. He reported that the deepest vertical pocket is gestational-age dependent, with a gradual increase reaching a peak at 26 weeks. The findings of this study support the use of the European cut-offs to define polyhydramnios in the recipient twin. Ozhan Turan from the USA presented a small study on fetal cardiovascular parameters for prediction of outcome after fetoscopic treatment in cases with TTTS. He reported that these cardiovascular parameters did not improve prediction in either the recipient or the donor. Yves Ville proposed a new method for mapping the vascular equator prior to laser surgery as well as reporting preliminary findings of a study on the use of Foley's catheter to prevent iatrogenic membrane rupture following laser treatment in TTTS. He also presented data on brain lesions, including atrophy, schizencephaly, periventricular leukomalacia, intraventricular hemorrhage and ischemia, seen in fetuses following laser treatment for TTTS. On the third day, the International Society for Prenatal Diagnosis chaired an extremely successful workshop on molecular techniques for both invasive and non-invasive prenatal diagnosis (NIPD). Rossa Chiu from Hong Kong presented an excellent overview of NIPD. Her group, led by Dennis Lo, carried out pioneering studies in this field. The key points summarized were that NIPD of fetal sex, Rhesus status and common chromosomal aneuploidies is now possible and the principles of NIPD for single gene disorders and for fetal genome assembly have already been established. Several commercial companies currently involved in NIPD, including Ariosa Diagnostics, Beijing Genome Institute, LifeCodexx, Natera, NIPD Genetics, Sequenom and Verinata, presented their results from the clinical implementation of NIPD of aneuploidies. This was followed by an animated discussion during which the presenters faced a barrage of stimulating questions from the audience. Several issues were raised, including the following: how to achieve better, more accurate, cheaper sequencing; selective use of the most informative sequences; and how to perfect a faster process with lower failure rates. The perspective of patients and healthcare professionals was presented by Lyn Chitty from the UK and the discussion was led by Howard Cuckle. Ron Wapner from the USA presented the results of the NIH study on the use of microarrays in the investigation of amniocentesis and chorionic villus samples and argued that the high incidence of clinically significant abnormalities may lead to a need to offer invasive testing rather than NIPD to a much larger proportion of the population. In his cohort, 17% of euploid pregnancies had copy number variance (CNV) not detectable by karyotyping; of which 60% would not be detected by 22q fluorescent in situ hybridization. He concluded that, if available, microarray should be the first-tier test for evaluation of fetal structural anomalies. This would potentially lead to increased genomic information on causes of birth defects and provide a cost-effective service. Rabih Chaoui presented an elegant review of genetic abnormalities in cardiac defects, including Di George, Williams-Beuren (del 17q11), Noonan and CHARGE syndromes and tuberous sclerosis complex. He also shared his own protocol for investigating cases of fetal cardiac defects; he routinely performs karyotyping and testing for 22q11 deletion. Increasingly, he tests for del 17q11 in cases with defects affecting the left ventricle outflow, del 1p36 if there are additional findings and del 4p (Wolf–Hirschhorn syndrome) if the fetus has FGR with facial dysmorphism. After genetic counseling, targeted investigations for monogenic disease, e.g. Noonan syndrome, or array comparative genomic hybridization (aCGH) can be offered. Lyn Chitty presented molecular diagnosis of fetal skeletal anomalies. She shared her NIPD experience in achondroplasia and thanatophoric dysplasia. She also suggested alternative approaches, in particular next-generation sequencing and gene panels, for example Sanger sequencing to screen 54 exons of the COL21A gene (osteogenesis imperfecta, kneist, spondyloepiphyseal dysplasia congenita and achondrogenesis) and a panel covering multiple mutations in the FGFR3 gene (achondroplasia, thanatophoric dysplasia and SADDAN (severe achondroplasia with developmental delay and acanthosis nigricans)). Eugene Pergament from the USA proposed that aCGH should be applied in all cases of brain malformation detected in the first trimester. He demonstrated the additional value of aCGH through real-time examples and showed that in central nervous system abnormalities its use can increase the detection rate by 7%. Richard Choy from China presented the results of the multicenter study, ‘Detection of chromosomal copy number variants by aCGH among fetuses with increased nuchal translucency’ (NT) and reported an extra 3.3% yield compared with karyotyping for diagnosing submicroscopic chromosomal abnormalities in fetuses with increased NT. Howard Cuckle emphasized the need for ‘conceptual change’ in carrier screening. Matthew Rabinowitz from the USA presented on high throughput carrier screening. He proposed that genetic testing is more than just testing and stressed the importance of pre- and post-test patient education. Sylvie Langlois from Canada presented promising results on the validation of a novel approach for assessing Fragile X syndrome locus repeats that is applicable to population carrier screening. The assay was amenable to high throughput, with quick turnaround time, and had high sensitivity for permutations and full mutations. On the same day, Rabih Chaoui and Simcha Yagel held a comprehensive course on fetal echocardiography, which kept the audience in the conference center and away from the dangers of swimming in the sun! On the fourth day Eugene Pergament led with an overview of the ‘Big Bang’ theory of the origin of increased NT. He argued that increased NT is a common endpoint of a diverse number of genetic and developmental disorders as a consequence of defects in neural crest cells in terms of their movement, differentiation and regulation. Therefore, it is anticipated that there may be multiple etiologies giving rise to increased NT. Jiri Sonek from the USA discussed the impact of Fetal Medicine Foundation (FMF) accreditation status and operator experience on NT distributions in the USA. As expected, FMF accredited sonographers outperform non-FMF accredited sonographers, and sonographers with greater experience outperform those with less experience. Elena Casals Font from Spain reported the results of implementation of first-trimester combined screening in Catalonia. Her group detected 94% of cases of Down syndrome and 88% of other aneuploidies at a false-positive rate (FPR) of 3%. Oliver Kagan from Germany reported that addition of serum placental growth factor (PlGF) in first-trimester screening improved the detection rate of trisomy 21 by 2%. Jo-Ann Johnson from Canada showed that addition of serum PlGF and alpha-fetoprotein (AFP) enhances the performance of first-trimester screening. Nerea Maiz from Spain presented data on the use of ductus venosus pulsatility index for veins (DV-PIV) for major improvement of first-trimester screening for aneuploidies. She showed that there are two distributions of DV-PIV multiples of the median: one which is crown–rump length (CRL)-dependent and another that is CRL-independent. There followed three abstracts on second-trimester screening. The first was presented by Alvaro Sepulveda-Martinez from Chile, on the biparietal diameter (BPD) to nasal bone (NB) ratio in a low-risk population and concluded that this ratio is unlikely to improve on the currently used soft markers. Waldo Sepulveda showed that the frontonasal fold to NB ratio is a strong marker of trisomy 21 and suggested that this ratio should be incorporated into the routine sonographic examination. Oliver Kagan reported that the prefrontal space ratio is below the 5th centile (0.5) in 80% of fetuses with trisomy 21. Apostolos Athanasiadis from Greece reported the results of a randomized study demonstrating that there was no significant difference in perinatal outcome after amniocentesis using a 20G vs a 22G needle. The second session on the fourth day was dedicated to impaired placentation. The session started with a talk on prevention of obstetric complications using low-dose aspirin by Emmanuel Bujold from Canada. His recently published meta-analysis claimed approximately 40% reduction in PE using low-dose aspirin and he concluded that its use reduced the risk of PE, FGR, preterm birth (PTB) and perinatal death. This effect was more obvious in the severe and preterm forms of PE. Two abstracts then focused on the prenatal changes seen in FGR. Gabriela Egana from Spain demonstrated that term FGR fetuses show different patterns of brain development, mainly deeper fissures, smaller intracranial brain and opercular volumes, and more pronounced right asymmetry. More importantly, these cortical developmental differences are associated with neurobehavioral performance. The second abstract was presented by Monica Cruz-Lemini from the same group and showed encouraging results of the prenatal prediction of postnatal cardiovascular risk due to FGR using fetal echocardiography. Elisa Llurba from Spain presented the results of an RCT to evaluate uterine artery Doppler screening at 20 weeks to improve maternal and perinatal outcome (UTOPIA study). She reported that the use of uterine artery Doppler followed by targeted intervention failed to show an improvement in short-term maternal or neonatal complications. She also presented novel data on the change in uterine artery Doppler between the first and third trimesters. She reported that third-trimester uterine artery Doppler was a better predictor of third-trimester PE and FGR than was first-trimester uterine artery Doppler. She also showed that first-trimester low-dose aspirin in high-risk patients was associated with a decrease in uterine artery Doppler resistance towards the third trimester, and that third-trimester placental dysfunction could emerge independent of first-trimester vascular development. This was followed by a study on the prediction of PE at 30–34 weeks' gestation, presented by Jonathan Lai from the UK. He demonstrated that uterine artery pulsatility index (PI) and mean arterial pressure (MAP) were increased, serum PlGF was decreased and soluble fms-like tyrosine kinase 1, endoglin and activin A were increased in pregnancies that subsequently developed PE. The altered marker levels were inversely related to the gestational age at delivery. Leona Poon from the UK reported that while stillbirth before 32 weeks is predictable but currently not preventable, stillbirth at 32–36 weeks was mostly predictable and preventable, and stillbirth after 37 weeks was partly predictable and preventable. Based on the findings, proposed strategies to prevent stillbirth include screening at 11–13 weeks, low-dose aspirin administration, a third-trimester scan and better intrapartum care. Yasmine Kacem from Belgium reported that estimation of fetal weight using magnetic resonance imaging (MRI) was more precise than was estimation using ultrasound. However, the impact of these results remains to be determined. A third session on the 11–13-week assessment started with Kypros presenting the new FMF algorithm. In the event of failed audit, the licence will be renewed for only 3 months, instead of 1 year. The online course, including the criteria for correct NT measurement, scoring of NT images and placement of calipers in images, should be passed within 1 week. The new data (> 30 cases) should be submitted and copies of all the images should be kept to present to The FMF on request. Oliver Kagan presented a study on the impact of errors in CRL measurement on first-trimester screening for trisomy 21. His findings showed that the intra- and interoperator reliability of CRL measurements is around ± 5 mm or ± 2.5 days. An error of ± 5 mm can substantially alter the patient-specific risks; random errors have little effect on screening performance, while systematic errors can alter the screening performance substantially. Merel Bakker from the Netherlands presented a study on the comparison between manual and semi-automated NT measurement. She concluded that manual measurement according to The FMF guidelines is sufficiently reliable for NT measurement but that less experienced operators should benefit from use of semi-automated Sono-NT. This presentation was followed by a review by Katia Bilardo of the implications of increased NT. The take-home messages were that around 20% of fetuses with increased NT and normal karyotype have a poor perinatal outcome. However, if the translucency resolves and detailed scanning shows no abnormalities, there is a high chance of a favorable outcome. Genetic syndromes with developmental delay may occur in 1–2% of cases. aCGH in cases with NT > 99th centile reveal an extra 3–5% of pathogenic CNV. Noonan syndrome, with variable but mostly favorable prognosis, is the most frequent monogenic syndrome (6%). Dr Bilardo's advice was to restrict additional testing to Noonan syndrome and only in cases of clinical suspicion, and to reassure the parents about the good neurodevelopmental outcome of structurally normal fetuses after increased NT, even in the pre-aCGH era. Rabih Chaoui argued that the first-trimester scan, in addition to screening for chromosomal abnormalities, should be a comprehensive early anomaly scan. He demonstrated through examples that many anomalies are easily detectable and proposed an efficient management approach. Luxmimalar Velauthar from the UK assessed the accuracy of first-trimester uterine artery Doppler in predicting PE and FGR in a meta-analysis of 55 091 pregnancies. The results suggest that the specificity is high for early-onset PE and FGR and that abnormal uterine artery Doppler in the first trimester ‘rules in’ the disease. She concluded that the use of first-trimester uterine artery Doppler provides an opportunity to target high-risk women early. A prospective study to evaluate the performance of The FMF algorithm for first-trimester screening for PE was presented by Adolfo Etchegaray from Argentina. The MAP and uterine artery PI at 11–13 weeks were increased in women who later developed PE. The detection rate for early-onset PE was 88% for a 15% FPR. This was followed by a presentation by Ranjit Akolekar from the UK on early screening for PE using the competing risk model combining maternal demographic characteristics, MAP, uterine artery PI, serum pregnancy-associated plasma protein-A and PlGF to identify 95% of pregnancies that will develop early PE, at a FPR of 10%. The session ended with Kypros presenting the new FMF algorithm for screening for PE and FGR. Promising results of a study of metabolomics, measured at 11–13 weeks, in aneuploidies and PE was presented by Ray Bahado-Singh from the USA. Interesting data on the use of cell-free plasma RNA in pregnancy complications were presented by Carl Weiner from the USA. Based on his results, he predicted that a single maternal blood sample at 12 weeks will identify common fetal trisomies, gender, several fetal structural malformations and pregnancies destined to develop spontaneous PTB, PE and FGR. The day ended with an exciting session on PTB. Elena Carreras from Spain presented her recent Lancet paper: ‘RCT of Arabin pessary for prevention of PTB in singletons’. She showed that the Arabin pessary was associated with a 78% reduction in PTB before 34 weeks. Jesus Calvo from the UK had disappointing results when the Arabin pessary was used in twin pregnancies; the rate of spontaneous PTB before 34 weeks was the same in both arms. Jacques Jani presented an MRI observational follow-up study to elucidate the mechanism of action of the Arabin pessary. The results suggest that the mechanism of action is at least partly mediated by a change in the uterocervical angle, which becomes more acute. Ozhan Turan from the USA presented the findings of a study on fetal adrenal gland enlargement for the prediction of PTB. The results suggest that both two-dimensional (2D) and three-dimensional (3D) ultrasound of the fetal adrenal gland provide optimal prediction of PTB within 7 days and that this was superior to the use of cervical length. A study on the use of proteomics as novel markers for the prediction of PTB was presented by Mark Evans from the USA. The results suggest that these panels outperform fetal fibronectin. Two abstracts on the use of proteomics and pulsation of the fetal splenic vein to predict infection in cases of premature rupture of the membranes (PPROM) were presented by Marian Kacerovsky and Ivana Musilova, respectively. The final talk of the day was given by Roberto Romero. The audience were so impressed by his review that they were willing to carry on until past 9.30 pm! He gave an overview entitled ‘Great obstetric syndromes’ in which he included PTB, PPROM, PE, small-for-gestational age (SGA) and fetal death. Highlights of his talk included the angiogenic/antiangiogenic markers in PE, the potential role of statins and the recent meta-analysis on the role of progesterone in the prevention of PTB. On the last day of the conference, George Haddad's group from France presented an overview of fetal eye defects and demonstrated examples of how the fetal eye can represent a simple window to a more complex diagnosis. They recommended the inclusion of a transverse view of the fetal face through the fetal orbits and called for larger studies to assess the incidence of ocular dysplasia. This was followed by a feasibility study by Laurent Salomon of MRI and ultrasound fusion imaging for prenatal examination. Using this technology, a live scan is feasible using the Volume Navigation system. Real-time Doppler signal can also be added to the MRI images. However, a major limitation is that any significant fetal movement required repeat registration, which occurred in 60% of cases. The results suggest that the different modalities complement each other and that this new technology may prove very useful in assessing normal and abnormal fetal anatomy. Jean-Pierre Bernard from France presented data on effective first-trimester screening for open spina bifida by a combination of BPD (low) and serum AFP (high). They achieved a detection rate of 72% for a FPR of 10%. Athena Souka from Greece presented her multicenter experience on the posterior brain appearances at 11–13 weeks in cases with spina bifida and concluded that this assessment is achievable without additional scanning time. Novel findings were then presented by Robert Lachmann from Germany from his study on midbrain and falx at 11–13 weeks in fetuses with absent corpus callosum. He reported increased midbrain diameter–falx diameter ratio, increased midbrain diameter and decreased falx diameter. Efstathios Varvarigos from Italy presented data on the distinction between Blake's pouch and Dandy–Walker complex using various imaging modes. Eldad Katorza from Israel compared 3D ultrasound, 2D ultrasound and MRI in the prenatal assessment of vermian biometry, measurement of the lateral ventricles and differential diagnosis in cases with absent septum pellucidum. He demonstrated that volume contrast imaging in the C-plane allows assessment of the cerebellar vermis when the 2D-US midsagittal plane is difficult to obtain. The advantages and limitations of each tool were discussed. The next session, which was on fetal cardiac defects, started with an ectopia cordis case series presented by Waldo Sepulveda. He highlighted the fact that the diagnosis of ectopia cordis can be established easily in the first trimester and that, due to the strong association between ectopia cordis and abdominal wall defects, first-trimester fetuses with a large exomphalos should be examined carefully to determine the exact location of the heart. Carmela Votino from Belgium presented data on the use of spatiotemporal image correlation (STIC) in the first trimester. She demonstrated that visualization of the four-chamber view and the great vessels was possible in over 90% and 75% of cases, respectively. This was related to the quality of the STIC volume and to the probe used. There was concordance between STIC volume diagnosis and the diagnosis at follow-up in over 80% of cases. Greg Ryan then presented his experience of stenting of the atrial septum in left atrial hypertension. In six cases he showed that atrial stenting is feasible and seems to be an effective treatment in cases of left heart obstruction and type-A restrictive atrial septum. This technique seems preferable to balloon, laser or radiofrequency ablation septostomy. In his opinion, the benefits include the option of awaiting spontaneous labor instead of undergoing elective delivery and a stable condition in the immediate neonatal period. Christian Enzensberger from Germany presented his center's experience of diagnosis and assessment of hypoplastic left heart. In his retrospective study there was a difference between the prenatal and postnatal outcome data, a finding which is important to consider when counseling parents. Robert Lachmann, on behalf of Christoph Berg, then presented their center's experience of premature obstruction of the foramen ovale (POFO). The results suggest that POFO is associated with a high mortality rate despite intrauterine intervention. They failed to identify criteria to determine which fetuses are likely to profit from intrauterine intervention and, in contrast to the Canadian experience, stents in the atrial septum had a high rate of occlusion. Sifa Turan from the USA presented evidence that congenital heart defects are associated with abnormal fetal head growth that is distinct in timing and follows a pattern specific to the type of lesion. She proposed that central switching of the circulation could produce early and consistent reduction in fetal brain growth. However, the relationship of the brain growth patterns seen in this study and subsequent abnormal neurodevelopment requires further studies. Yves Ville gave a comprehensive review of the management of cytomegalovirus (CMV) in pregnancy. In this lecture he focused on the value of first-trimester IgG avidity index (AI). The take-home message was that, in women with positive IgM at 11–14 weeks, CMV serology should include measurement of both IgM and IgG. High AI, which is found in about 60% of cases, is reassuring. In cases with low or intermediate AI, an individual risk should be derived from a combination of AI and serum viremia (by PCR). Shlomo Lipitz from Israel presented data on the use of fetal ultrasound and MRI in primary CMV infection. In his experience, the outcome of congenital primary CMV infection is favorable when the prenatal ultrasound and MRI are normal. He warned that the prognostic value of subtle MRI findings is limited and does not justify termination. Special lectures included a review of the outcomes and management of pregnancies after solid organ transplantation by Miroslaw Wielgos from Poland and an inspiring new opinion of the difference between SGA and FGR by Eduard Gratacos. The final session of this excellent conference was chaired by Gerry Visser and Ahmet Baschat. Ebru Celik from Turkey showed that in women with gestational diabetes mellitus (GDM) maternal and fetal serum salusins are decreased. Julia Murlewska from Poland demonstrated that the fetal liver length is a marker of macrosomia, but does not have a better prognostic value than does a large abdominal circumference. Ahmet Baschat presented a comprehensive overview on the management of diabetes in pregnancy. Gerry Visser gave an outstanding review in which he provided convincing evidence that an abnormal intrauterine environment induces diabetes mellitus and obesity in the offspring. However, most studies failed to control for maternal body mass index, so it remains uncertain whether GDM or obesity is the factor most strongly related to obesity in the offspring. His final recommendation was that prevention of metabolic syndrome in the offspring equates to prevention of childhood obesity. All in all, this was an extremely enjoyable, educational and entertaining conference. The delegates left for home counting the days until next year's event, which will be held in Sitges, Spain, on 23–27 June 2013.