Prenatal repair of gastroschisis using partial carbon dioxide insufflation fetoscopy: lessons learned

ABSTRACT We report the long-term outcomes of a case of prenatal gastroschisis repair using a fully percutaneous fetoscopic approach with partial carbon dioxide insufflation. Surgery was performed as an experimental procedure before the scheduled elective birth. The fetal intestines were successfully returned to the abdominal cavity without any fetal or maternal complications. Ultrasonography performed 24 hours later revealed bowel peristalsis and no signs of fetal distress. After 48 hours, partial extrusion of the small bowel was observed, and the fetus was delivered. Gastroschisis repair was immediately performed upon delivery using the EXIT-like procedure as per our institutional protocol. The newborn did not require assisted mechanical ventilation, was discharged at 14 days of age and was then exclusively breastfed. At 3-year follow-up, the patient had no associated gastroschisis-related complications. This is the first case of prenatal repair of gastroschisis, which provides baseline knowledge for future researchers on the potential hurdles and management of prenatal repair.

Prenatal diagnosis and intrauterine treatment of a giant fetal hepatic hemangioma:a case report / 中华围产医学杂志

This article reported a case of fetal giant hepatic hemangioma with cardiomegaly managed with intrauterine treatment. At 23 weeks of gestation, the patient was referred to Guangdong Women and Children Hospital due to abnormal abdominal echogenicity of the fetus, which was suspected to be a hepatic hemangioma or a hepatic arteriovenous fistula. The prenatal ultrasound at 26 weeks of gestation revealed an enlarged fetal hepatic hemangioma of 45 mm×35 mm×42 mm and an enlarged heart (cardiothoracic area ratio of 0.50). So, with the patient's informed consent, the fetus was treated with intrauterine administration of propranolol and dexamethasone and closely monitored by ultrasound. The volume of the lump still increased at the beginning of the medication, but started to shrink in the 7th week. Besides, the fetal cardiac load was reduced and the condition was controlled. The patient delivered at 37 weeks of gestation. The baby received a CT examination on the fourth day after birth which revealed an abdominal mass of 40 mm×30 mm×44 mm requiring no treatment, and no abnormalities were reported during a one-year follow-up.

Fetoscopic laser coagulation for placental chorioangioma: a report of three cases and literature review / 中华围产医学杂志

Objective:To evaluate the outcome of laser coagulation under fetoscope for placental chorioangioma (CA).Methods:The clinical data of three pregnant women with giant CA treated by laser coagulation under fetoscope in Peking University Third Hospital from January 2018 to December 2020 were analyzed retrospectively. Relevant articles up to September 2022 were retrieved from Wanfang Database, China National Knowledge Infrastructure and PubMed, and the clinical data of all patients were retrospectively summarized. Indications and intervention effects of fetoscopic laser therapy were analyzed. Descriptive statistics was used to describe the data.Results:Thirteen patients were involved in this study including 10 cases retrieved from the databases. The average age of the pregnant women was (30.3±6.2) years old. There were 12 cases of single pregnancy and one case of twin pregnancy (monochorionic diamnionic twin pregnancy). Except for cases for which data were not available in the literatures, at the diagnosis of CA, the average gestational age was (19.9±4.5) weeks ( n=7) and the average maximum diameter of the mass was (6.1±4.1) cm ( n=6). The patients underwent fetoscopic laser therapy at an average gestational age of (25.0±2.0) weeks ( n=13) with the average maximum tumor diameter of (7.6±2.8) cm ( n=9). After treatment, the amniotic fluid volume of three cases decreased to normal. In one case, the amniotic fluid volume decreased but was still above the upper limit of the normal range. Moreover, the maximum tumor diameter decreased in four cases; the peak systolic velocity of the fetal middle cerebral artery decreased to normal in one case; fetal heart function became normal in two cases and fetal edema was relieved in one case. Among the three patients treated in our hospital, the blood supply of CA disappeared after treatment. Intrauterine fetal death occurred in two cases. The other 11 patients gave birth to live babies at the gestational age of (36.6±3.8) weeks with five through cesarean section (5/11), five through vaginal delivery (4/11) and two not reported. The birth weight of the neonates was (2 712±1 023) g and all of them survived. The gender of five neonates were reported and all were females, two of them were monochorionic diamnionic twins. No abnormality was found in the three neonates delivered in our hospital during a six-month follow-up. No abnormality was reported in the other neonates during ten days to six months of follow-up. Conclusions:Fetoscopic laser coagulation may help reduce the size of CA, decrease complications and improve pregnancy outcomes.

Progress in antenatal magnesium sulfate exposure for neuroprotection in preterm infants / 中华围产医学杂志

Magnesium sulfate has been administered to pregnant women at imminent risk of preterm delivery for fetal neuroprotection, but its adverse effects and target population have not been fully studied. This paper summarizes the current protocols according to the existing guidelines and the latest research progress, including the gestational age at intervention, dose, duration of therapy and the need for re-administration, hoping to provide a reference for the clinical use of magnesium sulfate for fetal neuroprotection in China.

Terapia laser intrafetal para la secuencia perfusión arterial inversa en gemelos (TRAP). Comunicación de un caso y revisión de la literatura

Una primigesta de 41 años con gestación doble monocoriónica biamniótica, con diagnóstico de secuencia perfusión gemelar arterial reversa (TRAP, por sus siglas en inglés) y mal pronóstico perinatal fue intervenida mediante terapia laser intrafetal a las 18 semanas de gestación. Se complicó con rotura prematura de membranas que fue manejada en forma expectante hasta las 33 semanas 3 días, cuando se realizó cesárea electiva sin complicaciones. Se obtuvo un recién nacido vivo sano de 2,255 g que fue dado de alta hospitalaria el día 15 de nacido, sin complicaciones. Comunicamos el primer caso de terapia laser intrafetal realizado en nuestro país y resaltamos su eficacia, sencillez, bajo costo y abordaje ambulatorio en casos de secuencia TRAP.

A 41-year-old primigravida with double monochorionic biamniotic gestation, with a diagnosis of twin reverse arterial perfusion sequence (TRAP) and poor perinatal prognosis underwent intrafetal laser surgery at 18 weeks of gestation. It was complicated with premature rupture of membranes that was managed expectantly until 33 weeks 3 days, when elective caesarean section was performed without complications. A healthy live newborn of 2,255 g was obtained and was discharged from the hospital on the 15th day of birth without complications. We report the first case of intrafetal laser surgery performed in our country and highlight its efficacy, simplicity, low cost and ambulatory approach in cases of TRAP sequence.

¿Cuál es el rol actual de la toracocentesis en el hidrotórax fetal severo? Presentación de caso

Se llama hidrotórax a una efusión pleural primaria que ocurre durante la vida prenatal (denominado 'quilotórax primario' después del nacimiento). En ciertos casos, esta efusión es severa y produce compresión pulmonar y cardiaca, por lo cual, la mortalidad perinatal sigue siendo alta. Los recién nacidos con hidrotórax requieren, muchas veces, de drenaje, nutrición parenteral total y medicación específica para su recuperación. Sin embargo, las intervenciones prenatales, principalmente con derivaciones toraco-amnióticas, pueden mejorar estos resultados. Reportamos el caso de un feto con hidrotórax severo a quien se le realizó una toracocentesis y revisamos la literatura acerca de su rol en el tratamiento prenatal actual.

Hydrothorax is a primary pleural effusion that occurs during prenatal life (called "primary chylothorax" after birth). In certain cases, this effusion is severe and produces pulmonary and cardiac compression, and perinatal mortality remains high. Newborns with hydrothorax often require drainage, total parenteral nutrition and specific medication for their recovery. However, prenatal interventions, mainly with thoraco-amniotic shunts, can improve these results. We report the case of a fetus with severe hydrothorax who underwent thoracentesis and review the literature on its role in current prenatal management.

Effect of materal anti-Sj?gren's syndrome type A/Sj?gren's syndrome type B antibodies on fetal heart development and the management / 中华围产医学杂志

Anti-Sj?gren's syndrome type A（SSA) and anti-Sj?gren's syndrome type B（SSB) antibodies both belong to the antinuclear antibody spectrum and are common in patients with systemic lupus erythematosus, Sj?gren's syndrome and undifferentiated connective tissue disease as well as asymptomatic patients. Approximately 1% of pregnant women are positive for anti-SSA and anti-SSB antibodies and only 1%-3% of the fetuses carried by primiparae with anti-SSA and anti-SSB antibodies show immune-mediated cardiac conduction and structural abnormalities. Due to its low incidence and insidious onset, some pregnant women were diagnosed positive for antibodies against SSA and SSB for the first time only due to fetal heart block or structural abnormalities during pregnancy. Domestic and international research on the effects of anti-SSA and anti-SSB antibodies on fetal heart and the prenatal monitoring, diagnosis, intrauterine treatment and prognosis of fetal cardiac abnormalities related to anti-SSA and anti-SSB exposure are reviewed to guide the clinical work of obstetrics.

Development course of indications of intrauterine management for fetal hydrocephalus / 中华围产医学杂志

Surgical treatment of intrauterine hydrocephalus can prevent irreversible fetal brain damage through early decompression of the lateral ventricle. In 1980s, the prognosis of fetuses with hydrocephalus who received intrauterine treatment were poor due to non-specific surgical indications, lacking skilled operators, and underdeveloped imaging technology. We review the development of the surgical indications for fetal hydrocephalus in the following four stages: the introduction of surgical indications, the exclusion of extracranial malformations, the clear definition of isolated hydrocephalus, and the popularization of micro-array and gene sequencing techniques. The outcomes of fetuses with hydrocephalus who received intrauterine treatment with different selection criteria are summarized to explore the inclusion and exclusion criteria.

Actualización del diagnóstico prenatal y cirugía fetal del mielomeningocele / Update on prenatal diagnosis and fetal surgery for myelomeningocele

A partir del estudio seminal Management of Myelomeningocele Study en el año 2011, el cual demostró que la reparación prenatal del defecto del mielomeningocele antes de la semana 26 mejoraba los resultados neurológicos, la cirugía fetal fue incorporada dentro de las opciones de estándar de cuidado. Así, el diagnóstico prenatal del mielomeningocele dentro de la ventana terapéutica se convirtió en un objetivo obligatorio y, por ello, se intensificó la investigación de estrategias de tamizaje, sobre todo, en el primer trimestre. Además, se desarrollaron distintas técnicas de cirugía fetal para mejorar los resultados neurológicos y disminuir los riesgos maternos. El objetivo de la siguiente revisión es actualizar los avances en tamizaje y diagnóstico prenatal en el primer y segundo trimestre, y en cirugía fetal abierta y fetoscópica del mielomeningocel

A seminal study titled Management of Myelomeningocele Study, from 2011, demonstrated that prenatal myelomeningocele defect repaired before 26 weeks of gestation improved neurological outcomes; based on this study, fetal surgery was introduced as a standard of care alternative. Thus, prenatal myelomeningocele diagnosis within the therapeutic window became a mandatory goal; therefore, research efforts on screening strategies were intensified, especially in the first trimester. In addition, different fetal surgery techniques were developed to improve neurological outcomes and reduce maternal risks. The objective of this review is to provide an update on the advances in prenatal screening and diagnosis during the first and second trimesters, and in open and fetoscopic fetal surgery for myelomeningocele

Diagnóstico prenatal de peritonitis meconial fetal: Reporte de caso y revisión de la literatura Prenatal

Se comunica el diagnóstico ultrasonográfico prenatal de un caso de peritonitis meconial en un feto de 33 semanas, quien nació de parto pretérmino y se confirmó el diagnóstico con ultrasonografía, radiografía y cirugía. El neonato fue sometido a laparotomía exploratoria, en la cual se desbridó un pseudoquiste meconial, resecándose el área intestinal perforada, y se realizó anastomosis términoterminal. La evolución inicial fue tórpida, pero finalmente fue dado de alta con buen funcionamiento intestinal.

We report the prenatal ultrasonographic diagnosis of a case of meconium peritonitis in a 33-week fetus, who was born preterm and the diagnosis was confirmed with ultrasound, radiography and postnatal surgery. The neonate underwent exploratory laparotomy, in which a meconium pseudocyst was debrided, the perforated intestinal area was resected and end-to-end anastomosis was performed. The initial evolution was torpid, but he was finally discharged with good intestinal function.

Fetoscopic cord laser therapy in management of monochorionic monoamniotic twin pregnancies / 中华围产医学杂志

Objective:To analyze fetoscopic cord laser therapy for management of monochorionic monoamniotic (MCMA) twin pregnancies.Methods:The clinical data of fetoscopic cord laser therapy, including cord occlusion, transection, and disentanglement in three pairs of MCMA twins from January 2020 to January 2021 in Peking University Third Hospital were summarized. Literature on cord occlusion and/or transection in MCMA twins were retrieved from Cochrane Library, PubMed, EMBASE, CBM, WanFang, and CNKI from the time at establishment to December 2020. The clinical conditions, surgical indications and methods, disease progression, and maternal and infant prognosis were analyzed.Results:Three cases of MCMA twins in this study period received fetoscopic cord laser therapy between 17-24 weeks, among which two cases gave birth at full-term without any maternal or infant complications, and one was terminated due to fetal malformation. Seven English articles including 29 MCMA twin pregnancies were retrieved. In addition to the three cases reported in this article, a total of 32 cases were analyzed. The indication of cord occlusion and/or transection included twin-reversed arterial perfusion sequence (21.9%, 7/32), fetal malformation (46.9%, 15/32), selective fetal growth restriction (sFGR) (21.9%, 7/32), twin-to-twin transfusion syndrome (TTTS) (3.1%, 1/32), TTTS combined with sFGR (3.1%, 1/32), single intrauterine death (3.1%, 1/32). Gestational age at surgery was between 14 +1 to 27 +3 weeks. No maternal complication due to the operation was reported. After exclusion of two cases who did not receive cord transection and one case was terminated due to fetal malformation, all the other 29 co-twins were born alive at the gestational age between 24 +3 to 40 weeks and birth weight between 800-3 800 g. Among the 29 live born babies, four died soon after birth with unclarified reasons in the literature and one was born with multiple malformations which were detected prenatally, and the other 24 neonates were healthy during the follow-up from 1 month to 9 years old. Conclusions:For MCMA twin pregnant women with umbilical cord entanglement or other indications for fetal reduction, cord occlusion, transection, and disentanglement using fetoscopic cord laser is safe and effective for protecting the surviving fetus.

Cirurgias intrauterinas: alternativa de intervenção para as cardiopatias congênitas / Intrauterine surgeries: intervetion alternative for congenital cardiopathies

As cardiopatias congênitas são anormalidades estruturais ou funcionais do sistema cardiovascular, advindas desde o nascimento, mesmo que diagnosticadas posteriormente. Entre as malformações congênitas, as cardiopatias são as principais causas de mortalidade infantil nos Estados Unidos e em outros países desenvolvidos. Com o intuito de reduzir os efeitos progressivos dessas patologias, a intervenção intrauterina tem se destacado como opção terapêutica diante de resultados iniciais satisfatórios. O presente artigo teve por objetivo demonstrar a evolução da cirurgia intrauterina para correção cardíaca, a partir da avaliação dos benefícios ao feto e visando a riscos mínimos e aceitáveis para a mãe. Foi realizada uma pesquisa na base de dados Publisher Medline (PubMed), Scientific Electronic Library Online (SciELO) e Biblioteca Virtual da Saúde (BVS), incluindo artigos publicados entre 2008 e 2018; além da pesquisa efetuada no Manual de Medicina Fetal da SOGIMIG ­ 2018. Os critérios de elegibilidade são amplos. São necessários equipe multidisciplinar, equipamentos sofisticados e aperfeiçoamento da técnica, dessa forma dificulta-se a realização das cirurgias. Entretanto, diante dos resultados já demonstrados, a cirurgia intrauterina apresenta-se como alternativa terapêutica promissora.(AU)

The congenital cardiopathies are structural or functional abnormalities of the cardiovascular system, originated from birth, even when previously diagnosed. Among the congenic malformations, the cardiopathies are the main causes of infant mortality in the United States and in other developed countries. In order to reduce the progressive effects of these pathologies, intrauterine intervention has been highlighted as a therapeutic option in contempt of satisfactory initial results. This article has as goal to demonstrate the evolution of the intrauterine surgery for cardiac correction, based on the evaluation of the benefits to the fetus and aiming at minimum and acceptable risks to the mother. A research was made based on the Publisher Medline (PubMed) data base, Scientific Electronic Library Online (SciELO) and Biblioteca Virtual da Saúde (BVS), including published articles between 2008 and 2018. Beyond the research made on The fetal medicine manual from SOGIMIG ­ 2018. The eligibility criteria are broad. It is necessary a multidisciplinary team, sophisticated equipments and technique improvement, therefore interfering in the performance of surgeries. However, in contempt of the already demonstrated results the intrauterine surgery presents itself as a therapeutic promising alternative.(AU)

Promotion of basic research in fetal medicine supported by National Natural Science Foundation of China / 中华围产医学杂志

We systematically analyzed the progress on basic research in fetal medicine in China funded by National Natural Science Foundation of China since 1987.Aiming to promote basic research in fetal medicine,a series of effective measures has been implemented by National Natural Science Foundation of China in recent years,such as defining specific research goals and keywords under the application code of fetal medicine,launching emergent management projects and organizing strategic discussion with experts.Despite the wide gap between domestic and foreign researches,we have some advantages and have already made great achievements.Here are some suggestions on future basic research in fetal medicine from the perspective of funding application in China.

Fetoscopic laser surgery for twin to twin transfusion syndrome

Twin to twin transfusion syndrome (TTTS) is a complication of circa 10% of all monochorionic pregnancies (MC). A predominantly unidirectional, net intertwin blood flow through placental vascular anastomoses triggers a variety of complex renal and cardiovascular disturbances in both fetuses. Left untreated, severe TTTS leads to a mortality rate above 80% and 15-50% morbidity in the survivors. Fetoscopic laser coagulation (FLC) of the placental anastomoses is the first line treatment for severe cases before 27 weeks and it has been shown to improve perinatal outcomes. The risk of preterm premature rupture of membranes (PPROM) and prematurity associated with FLC has to be balanced with the risk of adopting expectant management in every particular case. Since there is no accurate way to predict the evolution of the disease, and no effective method to prevent post-procedure PPROM has been described, the indication of FLC is as challenging as the procedure itself.

El síndrome de transfusión de gemelo a gemelo (TTTS) complica alrededor del 10% de todos los embarazos monocoriónicos (MC). Un flujo sanguíneo intergemelar neto, predominantemente unidireccional, a través de anastomosis vasculares placentarias, desencadena una variedad de alteraciones renales y cardiovasculares complejas en ambos fetos. Sin tratamiento, el TTTS grave conduce a una mortalidad superior al 80% y una morbilidad del 15 a 50% en los sobrevivientes. La coagulación láser fetoscópica (CLF) de las anastomosis placentarias es el tratamiento de elección para casos graves antes de las 27 semanas y ha demostrado mejorar los resultados perinatales. El riesgo de rotura prematura de membranas (RPM) y de prematuridad asociada a CLF se debe sopesar con el riesgo de la conducta expectante en cada caso particular. Dado que no hay una manera precisa de predecir la evolución de la enfermedad, y no se ha descrito aun ningún método eficaz para prevenir la RPM posterior al procedimiento, la indicación de la CLF es tan desafiante como el procedimiento en sí mismo.

Outcomes of severe primary fetal hydrothorax treated by prenatal intervention / 中华妇产科杂志

Objective@#To investigate the effect of intrauterine intervention on severe primary fetal hydrothorax.@*Methods@#Twelve cases with severe fetal primary hydrothorax who underwent prenatal intervention from January 2014 to December 2017 in Guangdong Women and Children Hospital were retrospectively reviewed.@*Results@#The median gestational age of prenatal diagnosis was 30.8 weeks (24.0-33.0 weeks) . All cases were excluded congenital chromosomal abnormalities by prenatal diagnosis, and had no complications of pregnancy during prenatal diagnosis and had hydrothorax. Three cases (3/12) were right hydrothorax, the other 9 cases (9/12) were bilateral. Thoracoamniotic shunting was performed in 7 cases (7/12) . Thoracentesis was performed in 5 cases (5/12) , and the hydrothorax reappeared soon after operation in 4 cases, shunt placement was performed again. The hydrothorax was dissolved in 2 cases, released in 6 cases.Tube falling off occurred in 1 case,treatment was abandoned in 1 case and intrauterine fetal death happened in 1 case, and 1 case wasn′t rechecked by ultrasonic due to premature birth following thoracentesis. In 10 cases who had deliveries, 5 newborns (5/10) were premature, 6 newborns (6/10) underwent assisted mechanical ventilation, 8 newborns (8/10) underwent thoracic close drainage, all of them were discharged when hydrothorax resolved.@*Conclusions@#Antenatal intervention may improve the chance of survival in severe primary fetal hydrothorax. Thoracoamniotic shunting is the first-choice for the primary severe fetal hydrothorax.

Clinical outcomes of non-immune hydrops fetalis in the era of intrauterine intervention: a single centered retrospective analysis / 中华围产医学杂志

Objective To investigate the pregnancy outcomes of non-immune hydrops fetalis (NIHF) in the era of intrauterine intervention. Methods We reviewed the medical records of 149 patients who were referred for NIHF and delivered at Fetal Medicine Unit, Shanghai First Maternity and Infant Hospital between March 2012 and March 2017. After systematic evaluation and consultation, 102 cases chose to terminate their pregnancies, 47 cases (31.5％) chose to continue their pregnancies, among which two cases were lost to follow-up. The rest 45 cases were divided into two groups according to whether they received intrauterine interventions or not, the intrauterine intervention group (n=18) and the control group (n=27), and the clinical characteristics and pregnancy outcomes were compared. Independent samples t-test or Kruskal-Wallis test, Chi-square test or Fisher exact test were applied for statistical analysis. Results The mean gestational age of the intervention group at diagnosis of NIHF was lower than that of the control group [26.5(23.4-30.0) weeks vs 30.3(29.0-32.0) weeks, χ2=7.427, P=0.006]. Compared with the control group, the intrauterine fetal death rate was slightly lower [25.9％(7/27) vs 1/18], the neonatal survival rate was slightly higher [37.0％(10/27) vs 11/18] in the intrauterine intervention group, although no statistically significance was observed (Fisher exact, P>0.05). In the intrauterine intervention group, the incidence of low Apgar score (<4) at both 1 and 5 min was 1/17 and 0/17, respectively, which was much lower than those of the control group [45％(9/20) and 35％(7/20), Fisher exact, both P<0.05]. Conclusions After overall prenatal evaluation, appropriate intrauterine interventions may improve the pregnancy outcomes in NIHF.

Novel multidisciplinary approach to monitor and treat fetuses with gastroschisis using the Svetliza Reducibility Index and the EXIT-like procedure / Nova abordagem multidisciplinar para monitorizar e tratar fetos com gastrosquise utilizando o Svetliza Reducibility Index e o procedimento EXIT-like

ABSTRACT Objective: To describe our initial experience with a novel approach to follow-up and treat gastroschisis in "zero minute" using the EXITlike procedure. Methods: Eleven fetuses with prenatal diagnosis of gastroschisis were evaluated. The Svetliza Reductibility Index was used to prospectively evaluate five cases, and six cases were used as historical controls. The Svetliza Reductibility Index consisted in dividing the real abdominal wall defect diameter by the larger intestinal loop to be fitted in such space. The EXIT-like procedure consists in planned cesarean section, fetal analgesia and return of the herniated viscera to the abdominal cavity before the baby can fill the intestines with air. No general anesthesia or uterine relaxation is needed. Exteriorized viscera reduction is performed while umbilical cord circulation is maintained. Results: Four of the five cases were performed with the EXIT-like procedure. Successful complete closure was achieved in three infants. The other cases were planned deliveries at term and treated by construction of a Silo. The average time to return the viscera in EXIT-like Group was 5.0 minutes, and, in all cases, oximetry was maintained within normal ranges. In the perinatal period, there were significant statistical differences in ventilation days required (p = 0.0169), duration of parenteral nutrition (p=0.0104) and duration of enteral feed (p=0.0294). Conclusion: The Svetliza Reductibility Index and EXIT-like procedure could be new options to follow and treat gastroschisis, with significantly improved neonatal outcome in our unit. Further randomized studies are needed to evaluate this novel approach.

RESUMO Objetivo: Descrever a experiência inicial com a nova técnica cirúrgica EXIT-like para acompanhamento e correção de gastrosquise no "minuto zero". Métodos: Foram avaliados onze fetos com diagnóstico pré-natal de gastrosquise. O Svetliza Reducibility Index foi usado prospectivamente para avaliar cinco casos, e seis foram utilizados como controles. O índice foi calculado dividindo-se o diâmetro do defeito da parede abdominal pela maior alça intestinal que coubesse neste espaço. O procedimento EXIT-like compreendeu cesárea programada, analgesia fetal e redução da víscera herniada para a cavidade abdominal, antes da deglutição de ar pelo recém- nascido. Não são necessários anestesia geral e nem relaxamento uterino. A redução da víscera exteriorizada é realizada enquanto se mantém a circulação do cordão umbilical. Resultados: Quatro casos, dos cinco, foram submetidos ao EXIT-like. A correção foi completa em três casos. Os demais casos foram partos a termo planejados, e a correção do defeito foi feita com Silo. O tempo médio de redução da víscera foi de 5,0 minutos no grupo submetido ao procedimento EXITlike, e a oximetria foi mantida dentro dos valores de variação normal em todos os casos. No período perinatal, foram observadas diferenças estatisticamente significativas no tempo de ventilação mecânica (p=0,0169), duração da nutrição parenteral (p = 0,0104) e da nutrição enteral (p=0,0294). Conclusão: O Svetliza Reducibility Index e o procedimento EXIT-like podem ser novas opções para acompanhar e tratar gastroquise, com desfecho neonatal significativamente melhor em nossa unidade. Novos estudos randomizados são necessários para avaliar esta nova abordagem.

First reported case of fetal aortic valvuloplasty in Asia

Prenatal intervention of severe fetal aortic valve stenosis by ultrasound-guided percutaneous balloon valvuloplasty has been performed to prevent the progression to hypoplastic left heart syndrome, and achieve biventricular circulation in neonates. Here we report a case of fetal aortic valvuloplasty prenatally diagnosed with aortic stenosis at 24 weeks of gestation and showed worsening features on a follow-up echocardiography. Prenatal aortic valvuloplasty was performed at 29 weeks of gestation, and was a technical success. However, fetal bradycardia sustained, and an emergency cesarean delivery was performed. To the best of our knowledge, this is the first reported case of fetal aortic valvuloplasty which was performed in Asia.

Prenatal diagnosis and intervention to fetal hydrothorax:five cases analysis / 中华妇产科杂志

Objective To research the important of prenatal diagnosis and effect of intervention to fetal hydrothorax. Methods The cases of fetal hydrothorax (n=5) were obtained from the Shengjing Hospital,China Medical University between December 2014 and May 2015. All pregnancies were uncomplicated, excluded congenital organic and chromosomal abnormalities during prenatal diagnosis and with a 37 average gestational weeks. The case 1, 2, 4 were unilateral hydrothorax and the case 3, 5 were bilateral. We performed an antenatal thracocentesis to case 1, 2, 3. In case1, the hydrothorax increased rapidly after 5 days, and the patient underwent a cesarean section and ex utero intrapartum treatment (EXIT);in case 2, the fetal heart rate was decreased to 40-50 bpm suddenly during thracocentesis, and we performed an emergent cesarean section and EXIT for the patient; in case 3, the patient underwent thracocentesis and a meanwhile cesarean section and EXIT procedure. We performed a conservative management to case 4, 5, the hydrothorax resolved spontaneously during the pregnancy and after birth, both patients underwent cesarean section. Results All fetuses were survived, the neonates of case 1, 2 and 3 underwent assited mechanical ventilation, thoracic close drainage, then discharged after hydrothorax resolved and feeding tolerance;in case 4, there was no respiratory distress and hospital treatment;in case 5, the neonate underwent assited mechanical ventilation and conservative management, the hydrothorax has resolved gradually. Conclusions The prenatal diagnosis and antenatal intervention (thracocentesis) may play an important role in fetal hydrothorax treatment. In clinical, we should choose different plan according to the gestation weeks and classification of hydrothorax of the patient.

Comparação entre duas técnicas cirúrgicas para correção intra-uterina de meningomielocele em feto de ovelha / Comparison between two surgical technique for prenatal correction of meningomyelocele in sheep

Introdução: A incidência de defeitos do tubo neural é de cerca de 1/1000 nascimentos. Na mielomenngocele, o tratamento intra-uterino utilizando a técnica neurocirúrgica clássica, apresenta melhor prognóstico neurológico, do que o tratamento pós natal, mas está associado a complicações maternas e fetais. Novas técnicas de correção estão sendo estudadas para diminuir a morbidade materna e fetal. Objetivo: Comparar os efeitos sobre a medula de duas técnicas cirúrgicas de correção intra-uterina de um defeito semelhante à mielomeningocele , em fetos de ovelha. Métodos: Em 15 fetos foi criado um defeito semelhante à mielomeningocele (laminectomia e excisão de dura-máter) no 90° dia de gestação. O tipo de correção foi randomizado. No grupo 1, o defeito foi corrigido usando a técnica neurocirúrgica clássica, com a sutura de três camadas (dura-máter, músculo e pele), realizada por um neurocirurgião. No grupo 2, um especialista em Medicina Fetal, utilizou uma técnica simplificada, colocando um fragmento de celulose Biosintética sobre a medula e suturando apenas a pele sobre a celulose. Próximo ao termo da gestação (132° dias), os fetos foram sacrificados para análise anatomopatológica. Resultados: Ocorreram 1 morte materna, 3 casos de trabalho de parto precoce e 4 tardios. Um total de 10 casos foram viáveis para avaliação anatomopatológica 10 casos, 6 no grupo 1 e 4 no grupo 2. No grupo 1, todos os casos mostraram aderência da medula à cicatriz (meningoadesão) e perda da arquitetura medular por destruição do funículo posterior e 5 de 6 casos apresentaram perda da visualização da substância cinzenta. No grupo 2, observamos em todos os casos, a formação de uma neoduramater, separando o tecido nervoso do músculo adjacente, sendo que o funículo posterior e a substância cinzenta estavam preservados. Conclusão: A técnica simplificada foi superior à técnica neurocirúrgica, com maior preservação da medula e evitando as aderências do tecido nervoso. Nossos...

Introduction: The incidence of neural tube defects is about 1/1000 births. In myelomeninocele, the intrauterine treatment with the classical neurosurgical technique suggest better neurological prognosis for the fetus, than postnatal treatment, but it is associated with maternal and fetal complications. New correction techniques are being studied to decrease maternal and fetal morbidity. Objective: To compare the effects on the medulla of two surgical techniques for intrauterine correction of myelomeningocele-like defect in sheep. Methods: In 15 pregnant sheep a myelomeningocele -like defect (laminectomy and dural excision) was created in the lumbar region in 90o day gestation. The type of correction was randomized. In group 1 the defect was corrected using the classic neurosurgical technique of three layers suture (dura-mater, muscle and skin closure) performed by a neurosurgeon. In group 2, a fetal medicine specialist used a biosynthetic cellulose patch to protect the medulla and only the skin was sutured above it. Near term (132o day gestation) fetuses were sacrificed for pathological analysis. Results: One maternal death occurred, early preterm labour, and late preterm labour occurred in 3 and 4 cases, respectively. A total of 10 cases were available for pathological analysis, 6 in group 1 and 4 in group 2. In group 1, all the cases showed a adherence of the medulla to the scar (meningoneural adhesion) and a destruction of the normal architecture of nervous tissue, whithout view of posterior funiculus and in 5 of 6 cases without view of grey matter. In group 2, in all the cases were observed a formation of an organized tissue involving the cellulose patch, a neoduramater, separating the nervous tissue of adjacent muscle, preserving the posterior funicullus and grey matter. Conclusion: The simplified new technique was better than the classical neurosurgical technique. It preserved the nervous tissued and avoided the adherence of the medulla to the scar....