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OBJECTIVES: We have previously described gestational-age-independent sonographic indices to assess fetal lung size in the right and left lungs: The Quantitative Lung Index for the right lung (QLI-R) and for the left lung (QLI-L), respectively. The purpose of this study was to evaluate the clinical cutoff point of the QLI-R to predict pulmonary hypoplasia and neonatal death. MATERIALS AND METHODS: Retrospective assessment of the QLI-R in patients with left-sided congenital diaphragmatic hernia (CDH-L) and other fetal conditions at risk for fetal pulmonary hypoplasia. Cross-section and longitudinal assessment of the behavior of the QLI-R in untreated and treated patients. ROC curve analysis to determine the optimal cutoff point of the QLI-R in predicting neonatal death. RESULTS: One hundred eighteen patients with CDH-L and other fetal conditions at risk for pulmonary hypoplasia had QLI-R measurements done. Seventeen patients were excluded for various reasons. Eleven patients with conditions other than CDH-L but at risk for pulmonary hypoplasia were used for intraclass coefficient measurements of the QLI-R. Ninety patients had CDH-L, of which 78 did not undergo antenatal intervention and in which the cutoff point for pulmonary hypoplasia and neonatal demise was assessed. Stent tracheal occlusion was performed in the remaining 12 patients with CDH-L, in which the behavior of the QLI after surgery was assessed. Analysis of the ICC showed an overall intra-rater reliability of 0.985 (Cronbach's Alpha-based). There was no correlation between gestational age and QLI-R (-0.73, Pearson correlation, p = .72). Twenty-six of the 78 patients (33%) with CDH-L managed expectantly had a neonatal demise. A QLI-R equal to or less than 0.45 was significantly predictive of neonatal demise (area under the curve 0.64, p = .046, sensitivity 77%). Nine of the 12 patients (75%) that underwent tracheal occlusion had neonatal survival. Of these, 10 had serial assessments of the QLI-R after surgery. An increase in the QLI-R of 0.11 was associated with a tendency for neonatal survival (p = .056). CONCLUSION: Our study confirms that the QLI-R is a gestational-age-independent measurement of fetal lung size, with a high degree of reproducibility. In a population of expectantly managed CDH-L patients, a cutoff value of the QLI-R of 0.45 or lower is predictive of neonatal death from pulmonary hypoplasia. The QLI-R can be used to monitor fetal lung growth after tracheal occlusion, and an increase in the QLI-R is suggestive of neonatal survival. Further prospective studies are needed to confirm these findings and to explore the use of the QLI in other populations at risk for pulmonary hypoplasia and consequent neonatal demise.
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Enfermedades Fetales , Hernias Diafragmáticas Congénitas , Muerte Perinatal , Recién Nacido , Humanos , Femenino , Embarazo , Reproducibilidad de los Resultados , Estudios Retrospectivos , Diagnóstico Prenatal , Pulmón/diagnóstico por imagen , Pulmón/anomalías , Hernias Diafragmáticas Congénitas/diagnóstico por imagen , Hernias Diafragmáticas Congénitas/cirugía , Ultrasonografía PrenatalRESUMEN
Feto-fetal hemorrhage (FFH) through placental vascular anastomoses is believed to be responsible for the death or damage of a "second twin" after the demise of a "first twin (co-twin)" in monochorionic twin pregnancies. However, the timing of FFH has been difficult to determine. The resulting anemia in the surviving twin can be suspected by the finding of an elevated middle cerebral artery peak-systolic velocity (MCA-PSV), but this elevation may lag for at least 4 h after the demise of the first twin. Knowledge of the timing of FFH may have important clinical implications, as it may dictate if and when attempts to prevent death or damage to the second twin by delivery or intrauterine fetal transfusion would be warranted. We present a case that supports the notion that FFH occurs before the actual demise of the first twin. A review of the literature was also conducted.
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Enfermedades Fetales , Transfusión Feto-Fetal , Embarazo , Femenino , Humanos , Placenta , Enfermedades Fetales/terapia , Gemelos , Embarazo Gemelar , Hemorragia , Transfusión Feto-Fetal/diagnóstico por imagen , Gemelos MonocigóticosRESUMEN
Open spina bifida is the most common congenital anomaly of the central nervous system compatible with life. Prenatal repair of open spina bifida via open maternal-fetal surgery has been shown to improve postnatal neurologic outcomes, including reducing the need for ventriculoperitoneal shunting and improving lower neuromotor function. Fetoscopic repair of open spina bifida minimizes the maternal risks while providing similar neurosurgical outcomes to the fetus. The following 2 fetoscopic techniques are currently in use: (1) the laparotomy-assisted approach, and (2) the percutaneous approach. The laparotomy-assisted fetoscopic technique appears to be associated with a lesser risk of preterm birth than the percutaneous approach. However, the percutaneous approach avoids laparotomy and uterine exteriorization and is associated with lesser anesthesia risk and improved maternal postsurgical recovery. The purpose of this article was to describe our experience with a modified surgical approach, which we call percutaneous/mini-laparotomy fetoscopy, in which access to the uterus for one of the ports is done via a mini-laparotomy, whereas the other ports are inserted percutaneously. This technique draws on the benefits of both the laparotomy-assisted and the percutaneous techniques while minimizing their drawbacks. This surgical approach may prove invaluable in the prenatal repair of open spina bifida and other complex fetal surgical procedures.
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Meningomielocele , Nacimiento Prematuro , Espina Bífida Quística , Femenino , Fetoscopios , Fetoscopía/métodos , Humanos , Recién Nacido , Laparotomía , Meningomielocele/cirugía , Embarazo , Espina Bífida Quística/cirugíaRESUMEN
OBJECTIVE: We have previously described a gestational age-independent sonographic parameter to assess fetal lung growth in the right lung (right quantitative lung index, or QLI-R). The purpose of this study was to develop a similar sonographic parameter to assess the growth of the left lung in the fetus, independent of gestational age, or QLI-L. STUDY DESIGN: A new index, the QLI-L was derived using published formulas for the head circumference (HC) and the area of the base of the left lung (LA), with the corresponding percentiles. RESULTS: Left lung growth can be expressed using the following formula: QLI-L=LAL(HC12)2. The 50th percentile of the QLI-L remained approximately constant at 1.0 for the GA between 16-32 weeks. A small left lung (<1st percentile) was defined as a QLI-L < 0.5. CONCLUSIONS: Fetal left lung growth can be adequately described independent of gestational age using the QLI-L. Further experience is needed to assess the clinical accuracy of the QLI-L in characterizing fetal left lung growth.
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Hernias Diafragmáticas Congénitas , Femenino , Edad Gestacional , Humanos , Pulmón , Embarazo , Ultrasonografía , Ultrasonografía PrenatalRESUMEN
BACKGROUND: Prenatal repair of open spina bifida via the percutaneous fetoscopic approach does not require maternal laparotomy, hysterotomy, or exteriorization of the uterus. This technique requires intrauterine partial CO2 insufflation. Limited data exist on the physiological effects of CO2 insufflation on human fetuses, with no data on open spina bifida repair performed using the entirely percutaneous fetoscopic surgical technique. OBJECTIVE: Our aim was to examine the effects of intrauterine partial CO2 insufflation on fetal blood gases after percutaneous fetoscopic open spina bifida repair. STUDY DESIGN: This was a prospective study of patients who underwent percutaneous fetoscopic open spina bifida repair from February 2019 to July 2020. Fetal cordocentesis of the umbilical vein was performed in cases with favorable access to the umbilical cord. The umbilical vein cord blood samples were obtained under ultrasound guidance immediately at the conclusion of the open spina bifida repair. Simultaneous maternal arterial blood gas samples were also obtained. The results are reported as median (range). RESULTS: Of the 20 patients who underwent percutaneous fetoscopic open spina bifida repair during the study period, 7 patients (35%) underwent fetal blood sampling. The gestational age at the time of surgery was 27.4 (24.0-27.9) weeks and the operative time was 183 (156-251) minutes. The CO2 exposure time was 122 (57-146) minutes with maximum pressure of 13.5 (12.0-15.0) mm Hg. Fetal umbilical vein results were as follows: pH 7.35 (7.30-7.39), partial pressure of O2 56.2 (47.1-99.9) mm Hg, partial pressure of CO2 43.8 (36.2-53.0) mm Hg, HCO3 23.9 (20.1-25.6) mmol/L, and base excess -2.2 (-4.5 to -0.4) mmol/L. Simultaneous maternal arterial blood gas results were as follows: pH 7.37 (7.28-7.42), partial pressure of O2 187.5 (124.4-405.2) mm Hg, partial pressure of CO2 36.6 (30.7-46.0) mm Hg, HCO3 21.3 (18.0-22.8) mmol/L and base excess -3.2 (-5.9 to -1.8) mmol/L. CONCLUSION: Despite prolonged CO2insufflation of the uterus, fetal umbilical vein pH and base excess values did not approach those associated with potentially pathologic fetal acidemia.
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Insuflación , Espina Bífida Quística , Dióxido de Carbono , Femenino , Sangre Fetal , Feto , Gases , Humanos , Insuflación/efectos adversos , Embarazo , Estudios Prospectivos , Espina Bífida Quística/cirugíaRESUMEN
OBJECTIVE: To compare the neurodevelopmental outcome of monochorionic-diamniotic twins (MCDA) with type II selective intrauterine growth restriction (SIUGR-II) managed in utero either expectantly or with laser. MATERIALS AND METHODS: Postnatal neurodevelopmental assessment was conducted on the children of patients that had been antenatally diagnosed with SIUGR-II between 16 and 26 weeks gestational age (GA) and that had been randomly assigned to expectant management (EM) versus laser therapy (LT). The assessment was conducted by trained specialists using the Battelle Developmental Inventory (BDI-2). BDI-2 total and domain (adaptive, personal-social, communication, motor, and cognitive) composite scores for the appropriately grown (AGA) and growth-restricted (IUGR) twins were compared by treatment arm. RESULTS: Twenty patients diagnosed with SIUGR had undergone block randomization between two centers to either expectant management (EM) (6) or laser therapy (LT) (14). The mean (SD) GA at diagnosis was no different between the EM and LT groups [21.5 (2.0) versus 21.1 (2.8) weeks, p = .7414, respectively]. However, GA at delivery was significantly lower in the EM versus LT groups [28.3 (1.8) versus 33.4 (3.8) weeks, p = .0039]. At 6 months, all 20 AGA babies were alive, whereas only 3/6 (50%) of the IUGR babies in the EM group and 4/14 (29%) in the LT group were alive (p = .6126). One family in the EM group and two families in the LT group declined BDI-2 assessment. The mean (SD) age at BDI-2 assessment was no different between the EM and LT groups [75.6 (14.4) versus 70.7 (18.2) months, p = .5618, respectively]. For the AGA children, there were no significant differences in total BDI-2 scores for the EM versus LT [97.4 (10.4) versus 98.0 (19.6), p = .8741], nor in any of the domain composite scores. For the IUGR children, no statistically significant differences were detected in total BDI-2 scores between the EM and LT [72.0 (31.1) versus 92.8 (22.1), p = .643], nor in any of the domain composite scores. The comparison of standardized scores between the AGA and IUGR pairs was significantly different, but within the normal range. CONCLUSIONS: Neurodevelopmental outcomes for SIUGR-II MCDA twins were similarly favorable, whether managed expectantly or with laser treated. However, the significantly different GA at delivery (28.3 versus 33.4 weeks, p = .0039, expectant versus laser, respectively) may suggest improved outcomes in laser-treated patients in a larger cohort.
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Retardo del Crecimiento Fetal , Espera Vigilante , Niño , Femenino , Retardo del Crecimiento Fetal/terapia , Humanos , Lactante , Rayos Láser , Embarazo , Embarazo Gemelar , Gemelos Monocigóticos , Ultrasonografía PrenatalAsunto(s)
Meningomielocele , Rotura Uterina , Femenino , Feto , Humanos , Recién Nacido , Embarazo , Resultado del Embarazo , Atención PrenatalRESUMEN
OBJECTIVE: The objective of this study was to assess whether the location of the trocar insertion site for laser treatment of twin-twin transfusion syndrome was associated with preterm-premature rupture of membranes (PPROM) and preterm birth (PTB). STUDY DESIGN: In this study trocar location was documented in the operating room. Lower uterine segment (LUS) location was defined as any insertion <10 cm vertically from the pubic symphysis. Lateral location was defined as ≥5 cm horizontally from the midline. Patient characteristics were tested against three outcomes: PPROM ≤ 21 days postoperative, PTB < 28 weeks, and PTB < 32 weeks. For each outcome, multiple logistic models were fitted to examine the effect of trocar location, controlling for potential risk factors. RESULTS: A total of 743 patients were studied. Patients with LUS location were twice as likely as those with a more superior location to have PPROM ≤ 21 days (OR = 2.33, 1.12-4.83, p = 0.0236). Patients with both a LUS and Lateral location were over six times more likely to have PPROM ≤ 21 days (OR = 6.66, 2.36-18.78, p = 0.0003). Trocar insertion site was not associated with PTB. CONCLUSION: We found that trocar insertion in the LUS, particularly the lateral LUS, was associated with an increased risk of PPROM.
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Rotura Prematura de Membranas Fetales/etiología , Transfusión Feto-Fetal/cirugía , Fetoscopía/efectos adversos , Instrumentos Quirúrgicos/efectos adversos , Femenino , Fetoscopía/métodos , Edad Gestacional , Humanos , Recién Nacido , Modelos Logísticos , Embarazo , Embarazo Gemelar , Nacimiento Prematuro/etiología , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Gemelos MonocigóticosRESUMEN
OBJECTIVE: Despite known racial disparities in obstetrics, as well as differences in magnesium pharmacodynamics according to race, the effect of race/ethnicity in magnesium sulfate (MgSO4) use during pregnancy has not been studied. Whether some mothers are at increased risk of side effects, or infants at decreased neuroprotective effects is unknown. We analyze the effect of race/ethnicity in maternal/infant outcomes after MgSO4 neuroprotection. STUDY DESIGN: Subgroup analysis of a multicenter clinical trial (BEAM trial) where pregnant women at risk of preterm birth were randomized to either MgSO4 or placebo. For this study, nonanomalous singleton pregnancies were studied. The effect of race in maternal/neonatal outcomes after MgSO4 was analyzed with Breslow-Day and multifactorial ANOVA. Logistic regression was used to calculate odds ratios (OR) of complications according to race. RESULTS: 922 MgSO4 and 972 placebo cases were included (45.0% African-American, 36.2% Caucasian, 17.8% Hispanics, and 1.0% Asians). Interaction analysis showed a significant effect of race/ethnicity (p = .043). Hispanics presented the highest frequency (88.3%, p < .001), as well as the highest odds of MgSO4 side effects [OR(95%CI) = 6.6 (1.3-33.8)]. CONCLUSION: Hispanics present increased risk of magnesium toxicity compared to other racial/ethnic groups. Whether specific racial/ethnic groups require closer surveillance for early signs of magnesium toxicity needs to be further explored.
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Etnicidad , Sulfato de Magnesio/uso terapéutico , Neuroprotección/efectos de los fármacos , Nacimiento Prematuro/etnología , Nacimiento Prematuro/prevención & control , Grupos Raciales , Adulto , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/etnología , Etnicidad/estadística & datos numéricos , Femenino , Humanos , Recién Nacido , Sulfato de Magnesio/efectos adversos , Placebos , Embarazo , Resultado del Embarazo/etnología , Nacimiento Prematuro/fisiopatología , Grupos Raciales/estadística & datos numéricos , Adulto JovenRESUMEN
OBJECTIVE: To quantify and assess potential risk factors for transplacental passage of fetal red blood cells (RBCs) into the maternal circulation (fetomaternal bleeding, FMB) after laser surgery for twin-twin transfusion syndrome (TTTS). STUDY DESIGN: A retrospective study of Rhesus-D negative patients that underwent laser surgery for TTTS. Patients with and without postoperative detectable fetal RBCs on Kleihauer-Betke (KB) testing were compared to determine risk factors for FMB. Patients were further sub-classified into those with a FMB < 20% and ≥20% of estimated fetoplacental blood volume. RESULTS: Of 60 studied patients, 26/60 (43%) had a positive postoperative KB test. The median fetal:adult RBC ratio was 0.00125, estimated to be a FMB volume of 6.25 mL. There were 17/26 (65%) of patients with FMB < 20% and 9/26 (35%) patients with ≥20% of the fetoplacental blood volume. Stage III-Recipient and III-Recipient/Donor patients were more likely to have a positive KB test (14/21 [66.7%] vs 12/39 [30.8%], OR = 4.50 [1.27-16.54], P = 0.0162). No other risk factors for FMB were apparent. CONCLUSIONS: Fetomaternal bleed appears to be a common finding after laser surgery for TTTS. TTTS Stage, particularly stage III-Recipient and III-Recipient/Donor, appears to be a risk factor for FMB.
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Transfusión Feto-Fetal/cirugía , Transfusión Fetomaterna/etiología , Terapia por Láser/efectos adversos , Femenino , Humanos , Embarazo , Estudios Retrospectivos , Factores de RiesgoAsunto(s)
Cateterismo Cardíaco , Corazón Fetal/cirugía , Defectos del Tabique Interatrial/cirugía , Síndrome del Corazón Izquierdo Hipoplásico/cirugía , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/mortalidad , Corazón Fetal/anomalías , Corazón Fetal/fisiopatología , Defectos del Tabique Interatrial/embriología , Defectos del Tabique Interatrial/mortalidad , Defectos del Tabique Interatrial/fisiopatología , Mortalidad Hospitalaria , Humanos , Síndrome del Corazón Izquierdo Hipoplásico/embriología , Síndrome del Corazón Izquierdo Hipoplásico/mortalidad , Síndrome del Corazón Izquierdo Hipoplásico/fisiopatología , Lactante , Mortalidad Infantil , Nacimiento Vivo , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Stents , Mortinato , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: Amniopatch is a proposed treatment of iatrogenic preterm premature rupture of membranes (iPPROM). We studied characteristics associated with successful amniopatch treatment of iPPROM after fetoscopic laser surgery for twin-twin transfusion syndrome. METHODS: Patients with iPPROM within 15 days of laser surgery treated with an amniopatch were studied. Factors associated with amniopatch success (i.e. cessation of leakage with normalization of amniotic fluid volume) were tested univariately and in multivariate logistic regression models. Continuous variables are expressed as median (range). RESULTS: Of 1124 patients undergoing laser surgery, 19 (1.7%) had iPPROM and subsequent amniopatch. Twelve (63.2%) were successful. Latency in days from iPPROM to delivery was greater in the successful group (114.0 [87.0-141.0]) versus (44.0 [3.9-88.0], p = 0.0005), which translated into greater gestational age (GA) (weeks) at delivery (35.1 [30.9-39.4] versus 28.1 [22.0-31.0], p = 0.0005). The 30-day survival of the affected recipient twin was improved (100% versus 57.1%, p = 0.0361). After multivariate testing, GA < 20 weeks at the time of the amniopatch placement was the only variable that remained associated with successful sealing of the membranes. CONCLUSIONS: Treatment of iPPROM via amniopatch was successful in almost two-thirds of cases and was associated with higher GA at delivery and improved perinatal survival.
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Rotura Prematura de Membranas Fetales/cirugía , Transfusión Feto-Fetal/cirugía , Fetoscopía/efectos adversos , Terapia por Láser/efectos adversos , Femenino , Edad Gestacional , Humanos , Enfermedad Iatrogénica , Recién Nacido , Modelos Logísticos , Embarazo , Resultado del Embarazo , Embarazo Gemelar , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: The purpose of this article is to review the definition of twin-to-twin transfusion syndrome (TTTS) and the sonographic diagnostic assessment of these cases prior to therapy. MATERIALS AND METHODS: The article addresses the terminology used to refer to the condition and describes the systematic ultrasound assessment of the condition, including the ultrasound diagnosis, the staging of the disease, cervical assessment and pre-operative mapping. RESULTS: From an etymologic and medical point of view, the term 'fetofetal transfusion' is more appropriate than 'TTTS'. However, as the latter, and its attendant acronym TTTS, have been widely adopted in the English language, it is impractical to change at this point. TTTS is defined sonographically in the combined presence of a maximum vertical pocket (MVP) of 8 cm or greater in one sac and 2 cm or less in the other sac, regardless of the gestational age at diagnosis. Staging of the condition using the Quintero staging system is practical, reproducible, and accepted. Transvaginal cervical length assessment should be an integral part of the ultrasound evaluation. Pre-operative mapping to anticipate the location of the placental vascular anastomoses and avoid injuring the dividing membrane is also discussed. CONCLUSIONS: The term 'TTTS' can continue to be used in the English medical literature. The condition can be diagnosed and assessed following a systematic ultrasound methodology. The use of such ultrasound methodology breaks the examination into a distinct set of components, assuring a comprehensive examination and proper communication among caregivers.
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Transfusión Feto-Fetal/diagnóstico , Placenta/diagnóstico por imagen , Embarazo Gemelar , Femenino , Transfusión Feto-Fetal/diagnóstico por imagen , Transfusión Feto-Fetal/fisiopatología , Transfusión Feto-Fetal/cirugía , Edad Gestacional , Humanos , Coagulación con Láser , Placenta/irrigación sanguínea , Placenta/fisiopatología , Embarazo , UltrasonografíaRESUMEN
OBJECTIVE: Laser ablation of all placental vascular anastomoses is the optimal treatment for twin-twin transfusion syndrome (TTTS). However, two important controversies are apparent in the literature: (a) a gap between concept and performance, and (b) controversy regarding whether all the anastomoses can be identified endoscopically and whether blind lasering of healthy placenta is justified. The purpose of this article is: (a) to address the potential source of the gap between concept and performance by analyzing the fundamental steps needed to successfully accomplish the surgery, and (b) to discuss the resulting competency benchmarks reported with the different surgical techniques. MATERIALS AND METHODS: Laser surgery for TTTS can be broken down into two fundamental steps: (1) endoscopic identification of the placental vascular anastomoses, (2) laser ablation of the anastomoses. The two steps are not synonymous: (a) regarding the endoscopic identification of the anastomoses, the non-selective technique is based upon lasering all vessels crossing the dividing membrane, whether anastomotic or not. The selective technique identifies and lasers only placental vascular anastomoses. The Solomon technique is based on the theory that not all anastomoses are endoscopically visible and thus involves lasering healthy areas of the placenta between lasered anastomoses, (b) regarding the actual laser ablation of the anastomoses, successful completion of the surgery (i.e., lasering all the anastomoses) can be measured by the rate of persistent or reverse TTTS (PRTTTS) and how often a selective technique can be achieved. Articles representing the different techniques are discussed. RESULTS: The non-selective technique is associated with the lowest double survival rate (35%), compared with 60-75% of the Solomon or the Quintero selective techniques. The Solomon technique is associated with a 20% rate of residual patent placental vascular anastomoses, compared to 3.5-5% for the selective technique (p < .05). Both the Solomon and the selective technique are associated with a 1% risk of PRTTTS. Adequate placental assessment is highest with the selective technique (99%) compared with the Solomon (80%) or the 'standard' (60%) techniques (p < .05). A surgical performance index is proposed. CONCLUSION: The Quintero selective technique was associated with the highest rate of successful ablation and lowest rate of PRTTTS. The Solomon technique represents a historical backward movement in the identification of placental vascular anastomoses and is associated with higher rate of residual patent vascular communications. The reported outcomes of the Quintero selective technique do not lend support to the existence of invisible anastomoses or justify lasering healthy placental tissue.
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Anastomosis Arteriovenosa/cirugía , Transfusión Feto-Fetal/cirugía , Coagulación con Láser , Placenta/cirugía , Anastomosis Arteriovenosa/fisiopatología , Femenino , Transfusión Feto-Fetal/fisiopatología , Humanos , Placenta/irrigación sanguínea , Placenta/fisiopatología , Embarazo , Tasa de SupervivenciaRESUMEN
INTRODUCTION: We examined placental weight characteristics associated with donor selective intrauterine growth restriction (SIUGR) among patients with twin-twin transfusion syndrome (TTTS) who underwent laser surgery. MATERIALS AND METHODS: Fresh placental specimens were studied. Pregnancies with higher-order multiples, fetal demise, or disrupted or nonsubmitted placental specimens were excluded. Placental characteristics prospectively collected included total placental weight, individual placental weight, and placental share. Data were compared between pregnancies with SIUGR (TTTS + SIUGR group) and those without SIUGR (TTTS-only group). RESULTS: Of 369 consecutive patients who underwent laser surgery for TTTS, 155 (42%) met inclusion criteria: 91 with TTTS + SIUGR and 64 with TTTS-only. Compared to the TTTS-only group, patients in the TTTS + SIUGR group had a lower total placental weight (608 ± 163 vs. 687 ± 224 g, p = 0.012), with a lower donor individual placental weight (237 ± 91 vs. 291 ± 124 g, p = 0.002), but no apparent difference in the individual placental weight of recipient twins (371 ± 109 vs. 396 ± 133 g, p = 0.211). Donor placental share was smaller in those pregnancies affected by SIUGR (38.7 ± 9.6 vs. 42.3 ± 9.8%, p = 0.029). DISCUSSION: TTTS patients with SIUGR had a lower total placental weight and a lower donor individual placental weight compared to those without SIUGR. These findings suggest that differences in donor individual placental weights for SIUGR gestations may not solely be related to differences in placental share.
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Retardo del Crecimiento Fetal/patología , Transfusión Feto-Fetal/patología , Placenta/patología , Femenino , Humanos , Coagulación con Láser , Modelos Logísticos , Oportunidad Relativa , Tamaño de los Órganos , EmbarazoRESUMEN
Selective reduction (SR) via intravascular potassium chloride (KCl) injection is contraindicated in monochorionic twins due to the presence of placental vascular communications, which may serve as a conduit for inter-twin passage of KCl or allow exsanguination of the living twin into the demised twin. After successful selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS), the twins' circulatory systems are rendered independent. Theoretically, intravascular KCl injection into one twin after successful SLPCV should not result in passage of the feticidal agent nor cause hemodynamic alterations in the co-twin. We describe 3 cases of 1,069 patients (0.3%) that underwent SLPCV for TTTS between 2003 and 2013 and subsequent SR. SLPCV was successfully completed at 180, 226, and 230 weeks' gestational age for Quintero stages III, IV, and III TTTS, respectively. SR via intravascular KCl injection was later performed at maternal request due to the risk of neurological compromise in one twin at 226, 254, and 236 weeks' gestational age. All co-twins survived after SR, and no neurological sequelae were suspected after birth. Further study is necessary before SR can be routinely considered after laser surgery for TTTS.
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Transfusión Feto-Fetal/cirugía , Cloruro de Potasio/uso terapéutico , Reducción de Embarazo Multifetal/métodos , Adulto , Femenino , Humanos , Fotocoagulación , Cloruro de Potasio/administración & dosificación , EmbarazoRESUMEN
BACKGROUND: A recent randomized clinical trial named Management of Myelomeningocele Study (MOMS trial) showed that prenatal correction of open spina bifida (OSB) via open fetal surgery was associated with improved infant neurological outcomes relative to postnatal repair, but at the expense of increased maternal morbidity. OBJECTIVE: We sought to report the final results of our phase I trial (Cirurgia Endoscópica para Correção Antenatal da Meningomielocele [CECAM]) on the feasibility, safety, potential benefits, and side effects of the fetoscopic treatment of OSB using our unique surgical technique. STUDY DESIGN: Ten consecutive pregnancies with lumbosacral OSB were enrolled in the study. Surgeries were performed percutaneously under general anesthesia with 3 ports and partial carbon dioxide insufflation. After appropriate surgical positioning of the fetus, the neuroplacode was released with scissors and the skin was undermined to place a biocellulose patch over the lesion. The skin was closed over the patch using a single running stitch. Preoperative, postoperative, and postnatal magnetic resonance imaging were performed to assess hindbrain herniation. Neurodevelopmental evaluation was performed before discharge and at 3, 6, and 12 months. All cases were delivered by cesarean delivery, at which time the uterus was assessed for evidence of thinning or dehiscence. RESULTS: The median gestational age at the time of surgery was 27 weeks (range 25-28 weeks). Endoscopic repair was completed in 8 of 10 fetuses. Two cases were unsuccessful due to loss of uterine access. The mean gestational age at birth was 32.4 weeks with a mean latency of 5.6 weeks between surgery and delivery (range 2-8 weeks). There was 1 fetal and 1 neonatal demise, and 1 unsuccessful case underwent postnatal repair. Of the 7 infants available for analysis, complete reversal of hindbrain herniation occurred in 6 of 7 babies. Three babies required ventriculoperitoneal shunting or third ventriculostomy. Functional motor level was the same or better than the anatomical level in 6 of 7 cases. There was no significant maternal morbidity and no evidence of myometrial thinning or dehiscence. However, surgeries were complicated by premature rupture of membrane and prematurity. CONCLUSION: Our study suggests that the antenatal treatment of OSB using a fetoscopic approach and our unique surgical technique can result in a watertight seal, reversal of the hindbrain herniation, and better than expected motor function. Our technique differs substantially from the classic repair of OSB used in prior open fetal surgery and fetoscopic studies, in which the dura mater is dissected and the defect is closed in multiple layers. Instead, we use a biocellulose patch placed over the lesion and simple closure of the skin. As such, our technique is an alternative to the current paradigms in the antenatal treatment of OSB. Our clinical outcomes are in line with the results of our extensive prior animal work. Maternal benefits of our approach and technique include minimal morbidity and no myometrial legacy. Current limitations of the approach include potential loss of access, premature rupture of membranes, and attendant prematurity. Phase II trials are needed to prevent these complications and to further assess the risks and benefits of our distinct surgical approach and technique.
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Fetoscopía/efectos adversos , Fetoscopía/métodos , Meningomielocele/cirugía , Disrafia Espinal/cirugía , Adulto , Femenino , Rotura Prematura de Membranas Fetales/etiología , Edad Gestacional , Humanos , Recién Nacido , Imagen por Resonancia Magnética , Meningomielocele/diagnóstico , Muerte Perinatal/etiología , Embarazo , Nacimiento Prematuro/etiología , Disrafia Espinal/diagnóstico , Derivación Ventriculoperitoneal , Ventriculostomía , Adulto JovenRESUMEN
OBJECTIVE: To assess fetal growth after laser surgery for TTTS at the time of prenatal diagnosis, birth, and at 2years of age. DESIGN/METHODS: Growth data were collected from surviving children treated between 2007 and 2010 as part of a study to assess neurodevelopment at 24months (±6weeks) corrected age. Fetal weights were obtained via ultrasound using Hadlock's formula at the time of preoperative assessment for laser surgery. Birth weights were recorded by the staff at the delivering institutions. Weights at 2years corrected age were recorded at the time of neurodevelopmental testing. Weights were converted into percentiles according to standard growth curves. Growth restriction was defined as <10th percentile for given age. Multilevel latent growth curve models in Mplus (twins nested in families) examined weight change over time as a function of donor status, and repeated measures ANOVA was utilized to assess in donor-recipient weight discordance over time for twin pairs. RESULTS: 99 of 206 children (56 of 130 families) were studied. There were no differences between enrolled and non-enrolled patients in donor/recipient status and survival rates, fetal demise, intrauterine growth restriction, Quintero stage, and gestational age of surgery or delivery. 48.5% were donors. The median fetal, birth, and 2-year weights for all twins were 288g, 1.9kg, and 11.8kg, respectively, and the overall prevalence of growth restriction was 28%, 22%, and 3%, respectively. Growth restriction rates at prenatal diagnosis were 56% in donors vs. 2% in recipients (OR=64.3, p<0.001); at birth, 35% vs. 10% (OR=5.0, p<0.01); and at 2years, 6% vs. 0%. Donors showed significant gains in weight percentile (B=13.1, p<0.001) and a significant decrease in growth restriction rates over time (B=-1.6, p<0.001). Weight discordance between donor and recipient pairs also significantly decreased over time (linear F(1,42)=54.34, p<0.001). CONCLUSIONS: After laser surgery for TTTS, donor twins exhibit significant catch-up growth by two years of age.
Asunto(s)
Peso al Nacer/fisiología , Desarrollo Infantil/fisiología , Desarrollo Fetal/fisiología , Peso Fetal/fisiología , Transfusión Feto-Fetal/cirugía , Terapia por Láser , Preescolar , Femenino , Transfusión Feto-Fetal/fisiopatología , Edad Gestacional , Humanos , Masculino , EmbarazoRESUMEN
BACKGROUND: Invasive fetal cardiac intervention (FCI) has been reported in single-institution series, promoting technical and physiologic success. OBJECTIVES: This study describes the creation of an international registry of cases presenting for FCI, intended to compile technical and outcome data from a multicenter cohort. METHODS: For this initial analysis, the entire database of the International Fetal Cardiac Intervention Registry (IFCIR) was queried for details of diagnoses, procedures, and outcomes. Maternal-fetal dyads from January 2001 through June 2014 were included. RESULTS: Eighteen institutions submitted data by data harvest. Of 370 cases entered, 245 underwent FCI: 100 aortic valvuloplasties from a previous single-center report (excluded from additional reporting here), an additional 86 aortic and 16 pulmonary valvuloplasties, 37 atrial septal cases, and 6 unclassified cases. FCI did not appear to affect overall survival to hospital discharge. Among live-born infants with a fetal diagnosis of aortic stenosis/evolving hypoplastic left heart syndrome, more than twice as many were discharged with biventricular circulation after successful FCI versus those meeting institutional criteria but without any or successful FCI (42.8% vs. 19.4%, respectively). When fetal deaths were counted as treatment failures, the percentages were similar: biventricular circulation at discharge was 31.3% versus 18.5% for those discharged with univentricular palliation. Survival to discharge for live-born fetuses with atrial restriction was similar to that of those undergoing technically successful versus unsuccessful FCI (63.6% vs. 46.7%, respectively), although criteria for diagnosis were nonuniform. CONCLUSIONS: We describe the contents of the IFCIR and present post-natal data to suggest potential benefit to fetal therapy among pregnancies considered for possible intervention and support proposals for additional work.
Asunto(s)
Enfermedades Fetales/cirugía , Terapias Fetales/estadística & datos numéricos , Cardiopatías Congénitas/cirugía , Cooperación Internacional , Resultado del Embarazo/epidemiología , Sistema de Registros , Femenino , Enfermedades Fetales/diagnóstico , Enfermedades Fetales/epidemiología , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/epidemiología , Humanos , Recién Nacido , EmbarazoRESUMEN
OBJECTIVES: In twin-twin transfusion syndrome (TTTS), persistent absent or reversed end-diastolic flow in the umbilical artery is a rare finding in the recipient twin, and the clinical implications of this finding are not well characterized. We sought to study the clinical importance of abnormal umbilical artery Doppler waveforms in recipient twins and determine the perinatal survival of these twins after laser surgery. METHODS: A retrospective study of patients with TTTS treated with laser surgery between 2006 and 2012 was conducted. Recipient twins with absent or reversed umbilical artery end-diastolic flow on preoperative sonography were identified, and clinical and perinatal outcomes were compared to the remaining cohort. Statistical analyses were performed with Fisher exact and χ(2) tests. RESULTS: Of 369 consecutive TTTS cases, 14 (3.8%) had absent or reversed umbilical artery end-diastolic flow in the recipient twin. The rate of hydrops was higher in this group compared to those without absent or reversed flow (35.7% [5 of 14] versus 10.1% [36 of 355]; P = .0125). The rate of recipient twin growth restriction was also higher in the absent or reversed flow group (28.6% [4 of 14] versus 3.9% [14 of 355]; P = .0029). There was an increased rate of recipient fetal demise within 24 hours after surgery in those with absent or reversed flow (21.4% [3 of 14] versus 2.5% [9 of 355]; P = .0078), although there was no statistical difference in 30-day survival between the groups (78.6% [11 of 14] versus 89.9% [319 of 355]; P = .1751). CONCLUSIONS: Doppler findings of absent or reversed umbilical artery end-diastolic flow are rare in recipient twins. Although immediate post-laser surgery survival is relatively decreased in this group, overall perinatal survival rates appear to be favorable.