Third-trimester fetoscopic ablation therapy for types II and III vasa previa.

BACKGROUND: Vasa previa is an obstetrical condition in which fetal vessels located near the cervix traverse the fetal membranes unprotected by underlying placenta. Type I vasa previa arises directly from a velamentous cord root, whereas types II and III arise from an accessory lobe or a distal lobe of the same placenta, respectively. Fetoscopic laser ablation for types II and III vasa previa is a novel therapeutic option with benefits that include surgical resolution of the vasa previa, avoidance of prolonged hospitalization, and opportunity for a term vaginal delivery. The potential risks of fetoscopy can be mitigated by delaying laser surgery until a gestational age of 31 to 33 weeks, immediately before anticipated hospitalized surveillance. OBJECTIVE: This study aimed to assess feasibility and outcomes of types II and III vasa previa patients treated via fetoscopic laser ablation in the third trimester. STUDY DESIGN: This is a retrospective study of singleton pregnancies with types II and III vasa previa treated with fetoscopic laser ablation at a gestational age ≥31 weeks at a single center between 2006 and 2022. Pregnancy and newborn outcomes were assessed. Continuous variables are expressed as mean±standard deviation. RESULTS: Of 84 patients referred for vasa previa, 57 did not undergo laser ablation: 19 either had no or resolved vasa previa, 25 had type I vasa previa (laser-contraindicated), and 13 had type II or III vasa previa but declined laser treatment. Of the remaining 27 patients who underwent laser ablation, 7 were excluded (laser performed at <31 weeks and/or twins), leaving 20 study patients. The mean gestational age at fetoscopic laser ablation was 32.0±0.6 weeks, and total operative time was 62.1±19.6 minutes. There were no perioperative complications. All patients had successful occlusion of the vasa previa vessels (1 required a second procedure). All patients were subsequently managed as outpatients. The mean gestational age at delivery was 37.2±1.8 weeks, the mean birthweight was 2795±465 g, and 70% delivered vaginally. Neonatal intensive care unit admission occurred in 3 cases: 1 for respiratory distress syndrome and 2 for hyperbilirubinemia requiring phototherapy. There were no cases of neonatal transfusion, intraventricular hemorrhage, sepsis, patent ductus arteriosus, or death. CONCLUSION: Laser ablation for types II and III vasa previa at 31 to 33 gestational weeks was technically achievable and resulted in favorable outcomes.

Management of Late Twin-to-Twin Transfusion Syndrome beyond 26 Weeks: Comparison between Fetoscopic Laser Therapy versus Traditional Management.

INTRODUCTION: A proportion of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) can present after 26 weeks of gestation. The aim of this study was to compare perinatal outcomes of late TTTS treated by fetoscopic laser coagulation versus traditional management with amniodrainage and/or emergency preterm cesarean delivery (CD). METHODS: Retrospective cohort from January 2012 to January 2023 of consecutive MCDA twin pregnancies complicated by TTTS after 26 weeks and evaluated in our referring centers. We analyzed perinatal outcomes of cases treated with fetoscopic laser surgery at our national referral fetal surgery center in Queretaro, Mexico, and compared them with those managed with traditional management (amniodrainage and/or emergency preterm CD). The primary outcome was survival at discharge and the secondary outcome was gestational age (GA) at birth. RESULTS: Among the study population, 46 TTTS cases were treated by fetoscopy at 27+6 (26+0-31+0) weeks+days and were compared with a group of 39 cases who underwent emergency preterm CD. In comparison to the group who underwent traditional management, the group treated by laser fetoscopy showed a significantly higher GA at birth (32+3 vs. 29+1 weeks+days, p < 0.001), lower frequency of preterm delivery below 37 weeks (91.3% vs. 100%, p = 0.06), 34 weeks (63.0% vs. 100%, p < 0.001), 32 weeks (50% vs. 74.4%, p = 0.02), or 30 weeks (28.3% vs. 53.8%, p = 0.01), and significantly higher perinatal survival (89.1% vs. 71.8%, p < 0.05 of at least one twin; and 65.2% vs. 38.5%, p = 0.01 of both twins, respectively). CONCLUSION: MCDA twins complicated with TTTS can be treated with fetoscopic laser surgery between 26 and 31 weeks of gestation, which is a feasible and safe option, and such cases are associated with a higher GA at birth and better perinatal survival than those managed with amniodrainage and/or emergency preterm CD.

Magnesium sulfate titration reduces maternal complications following fetoscopic closure of spina bifida.

OBJECTIVE: To evaluate if magnesium sulfate (MgSO4 ) titration following fetoscopic spina bifida closure is associated with fewer maternal complications than the Management of Myelomeningocele Study (MOMS) tocolytic regimen. METHODS: This prospective cohort study included 73 consecutive patients undergoing fetoscopic closure of spina bifida between 2015 and 2020. A policy of using the MgSO4 regimen per the MOMS trial was changed to a flexible one in which MgSO4 was titrated according to the frequency of the uterine contractions following surgery. The frequency of maternal pulmonary edema, low maternal oxygen saturation requiring oxygen supplementation, atelectasis, hypocalcemia, and preterm delivery was compared before and after the policy was changed. RESULTS: A higher proportion of women in the group that used the MOMS MgSO4 regimen had pulmonary edema compared to those in the flexible one (26.1% [6/23] vs. 6% [3/50]; p = 0.024). Multivariate analysis showed that the MOMS tocolytic regimen was independently associated with a higher risk of pulmonary edema (adjusted odds ratio: 8.57; 95% confidence interval: 1.54-47.7; p = 0.014) than a flexible one. There was no difference in the rate of preterm delivery. CONCLUSION: Following fetoscopic closure of spina bifida, the MOMS MgSO4 regimen is associated with an increased risk of pulmonary edema than a more flexible regimen.

Potential sealing and repair of human FM defects after trauma with peptide amphiphiles and Cx43 antisense.

OBJECTIVE: We examined whether peptide amphiphiles functionalised with adhesive, migratory or regenerative sequences could be combined with amniotic fluid (AF) to form plugs that repair fetal membrane (FM) defects after trauma and co-culture with connexin 43 (Cx43) antisense. METHODS: We assessed interactions between peptide amphiphiles and AF and examined the plugs in FM defects after trauma and co-culture with the Cx43antisense. RESULTS: Confocal microscopy confirmed directed self-assembly of peptide amphiphiles with AF to form a plug within minutes, with good mechanical properties. SEM of the plug revealed a multi-layered, nanofibrous network that sealed the FM defect after trauma. Co-culture of the FM defect with Cx43 antisense and plug increased collagen levels but reduced GAG. Culture of the FM defect with peptide amphiphiles incorporating regenerative sequences for 5 days, increased F-actin and nuclear cell contraction, migration and polarization of collagen fibers across the FM defect when compared to control specimens with minimal repair. CONCLUSIONS: Whilst the nanoarchitecture revealed promising conditions to seal iatrogenic FM defects, the peptide amphiphiles need to be designed to maximize repair mechanisms and promote structural compliance with high mechanical tolerance that maintains tissue remodeling with Cx43 antisense for future treatment.

A Comparison of Spinal Anesthesia Versus Monitored Anesthesia Care With Local Anesthesia in Minimally Invasive Fetal Surgery.

BACKGROUND: Minimally invasive fetal surgery is commonly performed to treat twin-to-twin transfusion syndrome with selective fetoscopic laser photocoagulation and twin-reversed arterial perfusion sequence using radiofrequency ablation. Although an increasing number of centers worldwide are performing these procedures, anesthetic management varies. Both neuraxial anesthesia and monitored anesthesia care with local anesthesia are used at different institutions. We sought to determine the efficacy and outcomes of these 2 anesthetic techniques for fetal procedures at our institution. METHODS: All patients undergoing minimally invasive fetal surgery for twin-to-twin transfusion syndrome or twin-reversed arterial perfusion sequence over a 6-year time period (2011-2016) were reviewed. Patients receiving monitored anesthesia care with local anesthesia were compared with those receiving spinal anesthesia in both selective fetoscopic laser photocoagulation and radiofrequency ablation fetal procedures. The primary outcome examined between the monitored anesthesia care and spinal anesthesia groups was the difference in conversion to general anesthesia using a noninferiority design with a noninferiority margin of 5%. Secondary outcome measures included use of vasopressors, procedure times, intraoperative fluids administered, maternal complications, and unexpected fetal demise within 24 hours of surgery. RESULTS: The difference in failure rate between monitored anesthesia care and spinal was -0.5% (95% CI, -4.8% to 3.7%). Patients receiving monitored anesthesia care plus local anesthesia were significantly less likely to need vasopressors, had a shorter presurgical operating room time, and received less fluid (P < .001). Operative time did not differ significantly. CONCLUSIONS: Monitored anesthesia care plus local anesthesia is a reliable and safe anesthetic choice for minimally invasive fetal surgery. Furthermore, it decreases maternal hemodynamic instability and reduces preincision operating room time.

The first national survey of anesthesia techniques for fetal therapies in Japan.

PURPOSE: The aim of this study was to survey the frequency of various anesthetic techniques used in the anesthetic management of both the mother and fetus during fetal therapies in Japan. METHODS: We sent a postal survey to the institutions with physicians who held membership of the Japan Society of Fetal Therapy to describe maternal and fetal anesthetic management during fetal therapies performed from January 2016 to March 2017. The therapies included were thoracoamniotic shunting (TAS), intrauterine transfusion (IUT), radiofrequency ablation (RFA), fetoscopic laser photocoagulation (FLP), fetoscopic endotracheal occlusion (FETO), and ex utero intrapartum treatment (EXIT). Survey respondents were asked to specify the standard anesthetic technique used in each of these procedures done during the study period. RESULTS: The most common anesthetic techniques used in each therapy were sedation/analgesia with local anesthesia in TAS (31%), local anesthesia alone in IUT (47%), neuraxial anesthesia in RFA (50%), FLP (66%) and FETO (100%), and general endotracheal anesthesia in EXIT. Fetal analgesia was utilized in 61% of TAS, 33% of IUT, 10% of RFA, 22% of FLP, 100% of FETO, and 50% of EXIT. In all fetal therapies, the most common route of administration for fetal anesthesia was maternal administration. CONCLUSION: In this first published description of the frequency of various anesthetic techniques used during fetal therapies in Japan, we found that anesthetic techniques varied depending on the degree of invasiveness to the mother and fetus. Fetal anesthesia was not always performed, and the most common route for fetal anesthesia was maternal administration.

Fetal and Neonatal Circulatory Disorders in Twin to Twin Transfusion Syndrome (The Secondary Publication).

Twin to twin transfusion syndrome (TTTS) is a major complication of monochorionic diamniotic (MD) twins, and its onset is known to be associated with placental vascular anastomoses and blood flow imbalance. In a typical case of TTTS, the recipient develops polyhydramnios, weight gain, cardiomegaly and hydrops fetalis in the uterus. In contrast, the donor develops oligohydramnios and intrauterine growth restriction. Recently, the significance of the renin-angiotensin-aldosterone system (RAAS) that transfers from the donor to the recipient has attracted interest in the fetal circulation of TTTS. The donor has decreased renal blood flow due to decreased circulating blood volume. For this reason, the secretion of RAAS hormones is augmented in the fetal kidneys of the donor. In TTTS, these RAAS hormones from the donor transfer to the recipient through the anastomosed vessels. In addition to excess preload, the recipient heart is exposed to excess afterload due to systemic vasoconstriction through RAAS hormones. Commonly occurring complications in the recipient include myocardial hypertrophy, atrioventricular valve regurgitation, and pulmonary valve stenosis or pulmonary atresia. Fetoscopic laser photocoagulation (FLP) has been introduced recently because neither mortality nor neurological morbidity have been satisfactorily improved with conventional treatment. FLP is a curative method that may improve the prognosis of TTTS. In Japan, this procedure has been performed frequently, and positive neurological outcomes have been achieved.

Midwives' perceptions on using a fetoscope and Doppler for fetal heart rate assessments during labor: a qualitative study in rural Tanzania.

BACKGROUND: The Doppler is thought to be more comfortable and effective compared to the fetoscope for assessing the fetal heart rate (FHR) during labor. However, in a rural Tanzanian hospital, midwives who had easy access to both devices mostly used fetoscope. This study explored midwives' perception of factors influencing their preference for using either a Pinard fetoscope or a FreePlay wind-up Doppler for intermittent FHR monitoring. METHODS: Midwives who had worked for at least 6 months in the labor ward were recruited. Focus group discussion (FGD) was used to collect data. Five FGDs were conducted between December 2015 and February 2016. Qualitative content analysis was employed using NVivo 11.0. RESULTS: Three main themes emerged as factors perceived by midwives as influencing their preference; 1) Sufficient training and experience with using a device; Midwives had been using fetoscopes since their midwifery training, and they had vast experience using it. The Doppler was recently introduced in the maternity ward, and midwives had insufficient training in how to use it. 2) Ability of the device to produce reliable measurements; Using a fetoscope, one must listen for the heartbeat, count using a watch, and calculate, the Doppler provides both a display and sound of the FHR. Fetoscope measurements are prone to human errors, and Doppler measurements are prone to instrumental errors. 3) Convenience of use and comfort of a device; Fetoscopes do not need charging, and while it is possible to "personalize/hide" the measurements, and may be painful for mothers. Dopplers need charging and do not cause pain, but provide limited privacy. CONCLUSION: Midwives' preferences of FHR monitoring devices are influenced by the level of device training, experience with using a device, reliable measurements, and convenience and comfort during use. Fetoscopes and Dopplers should be equally available during midwifery training and in clinical practice.

Role of adjunctive medical therapy in the fetoscopic surgical treatment of twin-twin transfusion syndrome.

The underlying etiology of twin-twin transfusion syndrome (TTTS) is unknown, but our growing understanding of the cardiovascular features of TTTS suggests this may be a disease that could respond to transplacental medical therapy. Adjunctive medical therapy in TTTS with the calcium channel blocker nifedipine has been shown to improve recipient survival while having no effect on the donor. There is no significant difference in recipient survival from postoperative day 5 to birth suggesting that the survival benefit is confined to the effects of nifedipine in the perioperative period. Also, there is no significant effect of nifedipine on gestational age at delivery suggesting the survival benefit was unrelated to the tocolytic effects of nifedipine and more likely a result of hemodynamic effects in the recipient twins' cardiovascular system during the perioperative period. TTTS remains poorly understood but there appears to be good evidence suggesting twin-twin hypertensive cardiomyopathy is a large component of the pathophysiology in recipient twins. The initial findings of nifedipine's effectiveness as a targeted medical therapy to address TTTS cardiomyopathy and improve survival of recipient twins opens the door for further research for adjunctive medical therapies in TTTS.

Maternal hypotension during fetoscopic surgery: incidence and its impact on fetal survival outcomes.

In this retrospective cohort study, we aimed to determine the incidence of intraoperative maternal hypotension during fetoscopic surgery for twin-twin transfusion syndrome (TTTS) and to evaluate the impact of intraoperative hypotension on fetal survival. A total of 328 TTTS patients with recipient twin cardiomyopathy who underwent fetoscopic surgery under epidural anesthesia were included. The exposure of interest was maternal medical therapy with nifedipine for the treatment of fetal cardiomyopathy. We found that intraoperative hypotension occurred in 53.4% (175/328 patients). There was no statistically significant difference in incidence of hypotension between nifedipine exposure and nonexposure groups (54.8% versus 50.8%, P = 0.479). However, the nifedipine exposure group received a statistically significant higher dose of phenylephrine (7.04 ± 6.38 mcg/kg versus 4.70 ± 4.14 mcg/kg, P = 0.018) and higher doses of other vasopressor, as counted by number of treatments (6.06 ± 4.58 versus 4.96 ± 3.42, P = 0.022). There were no statistically significant differences in acute fetal survival rate (within 5 days) and fetal survival rate at birth between hypotensive and nonhypotensive patients. We concluded that preoperative exposure to nifedipine resulted in increased intraoperative maternal vasopressor requirement during fetoscopic surgery under epidural anesthesia. In patients who had intraoperative maternal hypotension, there was no correlation between the presence of maternal hypotension and postoperative fetal survival.

Successful fetoscopic laser coagulation for twin-to-twin transfusion syndrome under local anaesthesia.

A review of the efficacy and outcome of fifteen fetoscopic laser ablations under local anaesthesia for twin to twin transfusion syndrome (TTTS) in the National Maternity Hospital Dublin was undertaken. The mean gestation at laser was 19.7 weeks (range 16-25 weeks) with a mean gestation at delivery of 29.1 weeks (range 20-35 weeks). The overall liveborn birth rate was 79% (22 infants) and one pregnancy was still ongoing. There were four neonatal deaths secondary to complications of prematurity. The surviving eighteen infants (64%) undergo regular paediatric review. The procedure was performed successfully in all cases with local anaesthesia. In no case was there maternal discomfort that warranted the procedure to be abandoned and good visual access of the vascular anastamoses was obtained in all cases. Local anaesthesia therefore offers a safe effective anaesthetic option for fetoscopic laser coagulation in monochorionic pregnancies complicated by TTTS.

Changes in umbilical venous volume flow after fetoscopic laser occlusion of placental vascular anastomoses in twin-to-twin transfusion syndrome.

OBJECTIVE: To examine effects of fetoscopic laser occlusion of placental vascular anastomoses on umbilical venous volume flow in twin-to-twin transfusion syndrome. STUDY DESIGN: Absolute umbilical venous volume flow, measured preoperatively and 48 hours after fetoscopic laser occlusion was related to Doppler studies, bladder filling in donors, and anastomoses. RESULTS: Among 45 patients, recipients had decreased ductus venosus pulsatility index (ductus venosus-pulsatility index for veins, 1.16 vs 1.01; P < .001) and unchanged umbilical venous volume flow after fetoscopic laser occlusion (74.7 vs 74.5 mL; P = .407). Donors had decreased umbilical artery pulsatility (1.34 vs 1.11; P = .008), increased ductus venous-pulsatility index for veins (0.75 vs 0.91; P < .014), and significantly increased umbilical venous volume flow per kilogram by 52.3% (136.6 vs 208.0 mL/Kg/min; P < .001). Donor bladder filling occurred at higher umbilical venous volume flow per kilogram (142.7 vs 221.4 mL/Kg/min; P < .012). Increase in umbilical venous volume flow per kilogram correlated with the net difference in arteriovenous anastomoses (Pearson r = 0.403, P = .006). CONCLUSION: Fetoscopic laser occlusion in twin-to-twin transfusion syndrome corrects intertwin differences in umbilical venous volume flow by predominant effects in the donor. Reappearance of donor bladder filling correlates with correction of volume flow.

Improved recipient survival with maternal nifedipine in twin-twin transfusion syndrome complicated by TTTS cardiomyopathy undergoing selective fetoscopic laser photocoagulation.

OBJECTIVE: The purpose of this study was to evaluate the effect of maternal nifedipine on fetal survival when started 24-48 hours before selective fetoscopic laser photocoagulation (SFLP). STUDY DESIGN: We conducted a case control study of consecutive cases of twin-twin transfusion syndrome (TTTS) in which TTTS cardiomyopathy was treated with maternal nifedipine 24-48 hours before SFLP, compared with gestational age and stage-matched control cases. The primary outcome was recipient and donor survival. RESULTS: One hundred forty-one cases of TTTS were treated with nifedipine, and 152 gestational age- and stage-matched control cases were analyzed. There was a significant increase in overall fetal survival in nifedipine-treated cases compared with control cases (237/284 [83%] vs 232/308 [75%]; P = .015). There is an increase in survival of recipients who were treated with nifedipine in stage IIIA (100% vs 81%; P = .021) and IIIB (93% vs 71%; P = .014); however, there was no difference in donor survival. CONCLUSION: Maternal nifedipine is associated with improved recipient survival in TTTS that undergoes SFLP. This is the first study to suggest a benefit of adjunctive maternal medical therapy in patients with TTTS who undergo SFLP.

Management of Stage I twin-to-twin transfusion syndrome: an international survey.

OBJECTIVE: To determine practice patterns for evaluation and treatment of Stage I twin-to-twin transfusion syndrome (TTTS) among international physicians. METHODS: An e-mail cross-sectional survey of members from the IFMSS, NAFTNet and SMFM societies and participants at a Eurofoetus-sponsored TTTS meeting was undertaken between May 2008 and November 2008. Questionnaires consisted of physician demographics and their recommendations for managing Stage I TTTS. Alternative therapies to expectant management were assessed based on the following special circumstances of the patient: residence more than 200 miles from the center, severe symptoms, or a cervical length of

Evolución de los perímetros del iris y de la pupila fetal durante la gestación / Evolution of the perimeters of the iris and of the fetal pupil throughout gestation

Objetivo: La actividad pupilar depende del sistema nervioso autónomo y su regulación llega a alcanzar el córtex cerebral. En este artículo se estudia la evolución funcional del iris fetal en condiciones basales.Sujetos y métodos: Se examinaron mediante ultrasonidos 192 pupilas de fetos humanos desde las semanas 15 hasta la 42. Las imágenes eran digitalizadas para la medición informática de los perímetros de la pupila y del iris.Resultados: El perímetro del iris presenta un progreso lineal durante la gestación. El perímetro de la pupila muestra una evolución variable. A partir de la semana 23, el perímetro pupilar con relación al del iris es menor al 30 por 100. Esta relación, perímetro pupilar/iris, presenta una variación estadísticamente significativa a lo largo de la gestación (test de Kruskal-Wallis).Conclusiones: La actividad pupilar manifiesta una integridad de determinadas vías neurológicas y puede permitir un nuevo control neurológico de los fetos humanos (AU)

Techniques of chorion villus sampling.

Whilst randomized studies into the safety of chorionic villus sampling (CVS) are already under way the technique is now offered as an acceptable alternative to amniocentesis in many diagnostic centres. In counselling, the obstetrician can now quote a risk to the pregnancy of 2-4% which, even if the inevitable losses before 16 weeks are excluded, represents probably at least twice the risk of amniocentesis. The evolution of the obstetric procedures has meant that the transcervical approach to CVS has been the most popular to date but there is now increasing interest in transabdominal aspiration as it minimizes the possibility of infection. The two best known transcervical methods are aspiration with a plastic or metal cannula and biopsy with rigid forceps. The majority of aspirations have been performed using the Portex cannula technique. Using this, three centres (Milan, Chicago and Philadelphia) have had experience of over 5000 cases with a failure rate of less than 1% and a minimal fetal loss of 2.2%. However, the proportion of fetal losses may be between 4 and 7% by the time complete obstetric follow-up is available (Brambati et al, 1985). A similar technique has been used with a variety of cannulae. The experience of the first 1000 cases from San Francisco (Hogge et al, 1986) led them to conclude that CVS by this technique was acceptably safe but that continuing investigation was needed before CVS was offered routinely as an alternative to amniocentesis. The only other transcervical technique that is practical for routine use is biopsy with rigid forceps. The failure and fetal loss rates associated with this method are comparable to the aspiration technique. The pioneering work of Hahnemann and his colleague Smidt-Jensen has established transabdominal aspiration as a reliable alternative approach. Its main advantage should be to minimize the risk of infection which is inherent in all transcervical techniques. In addition, it does not need to be confined to 9-11 weeks gestation and thus offers couples the possibility of diagnosis between 12 and 14 weeks rather than waiting for amniocentesis at 16 weeks. The quality and quantity of the sample depends on the size of the needle used and the technique is said to have high patient acceptability. Nevertheless, fetal losses occur following the procedure (1.8-3.2%) and it may not always be successful (failure rate 1.9-4.2%).

[Clinical experience with fetoscopy (author's transl)]. / Klinische Erfahrung mit der Fetoskopie.

From December 1975 to July 1979 28 fetoscopies were made in the I. UFK Munich, 25 in local anaesthesia and under ultrasonic control using the real time scanner. 20 fetoscopies were made up to the 24th week of pregnancy, preceding an interruptio for medical or genetic reasons. 8 fetoscopies were made between the 26th and 38th week of pregnancy for diagnostic reasons. The best results were obtained before the 20th week of pregnancy, following a special fetoscopy score, developed by us. In consideration of the present state of the art, fetoscopy cannot be recommended as a clinical routine method for diagnosing external malformations. An application of substances directly into the fetal blood circulation by fetoscopy methods is not yet possible. Up to the 24th week of pregnancy fetoscopy methods can be used in specialised centres after properly weighing the risks, for the purpose of fetal blood sampling from the vessels of the chorionicplate or from umbilical vessels near the insertion of the chord to the placenta, for diagnosing genetical enzyme defects.

[Fetoscopy under ultrasound control (author's transl)]. / Fetoskopie unter Sichtkontrolle mit Ultraschall.

Under local anaesthesia and ultrasound control (beta-mode; Vidoson) the fetoscope was introduced into the amniotic cavity in 23 women, 13-20 weeks pregnant. Used before planned surgical abortion the method decisively reduced the dangers of damage to the fetus. In 21 women introduction of the fetoscope was without problem, but twice obesity made it difficult. Placental surface, umbilical cord, fetal head and fetal limbs were more commonly seen than other fetal parts. In one instance fetoscopy made it possible to exclude Mohr's syndrome. Preliminary attempts to obtain fetal blood by puncture of placental vessels under fetoscopy were successful. The described technique seems highly promising. Further experience will demonstrate whether it is without danger and simple enough to be used routinely in the prenatal diagnosis of congenital anomalies.