Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 1.204
Filtrar
1.
Curr Opin Anaesthesiol ; 33(3): 368-373, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32324666

RESUMO

PURPOSE OF REVIEW: This review describes maternal and fetal anesthetic management for noncardiac fetal surgical procedures, including the management of lower urinary tract obstruction, congenital diaphragmatic hernia (CDH), myelomeningocele, sacrococcygeal teratoma, prenatally anticipated difficult airway and congenital lung lesions. RECENT FINDINGS: Fetal interventions range from minimally invasive fetoscopic procedures to mid-gestation open surgery, to ex-utero intrapartum treatment procedure. Anesthetic management depends on the fetal intervention and patient characteristics. Anesthesia for most minimally invasive procedures can consist of intravenous sedation and local anesthetic infiltration in clinically appropriate maternal patients. Open fetal and ex-utero intrapartum treatment procedures require maternal general anesthesia with volatile anesthetic and other medications to maintain uterine relaxation. Tracheal balloons are a promising therapy for CDH and can be inserted via minimally invasive techniques. Management of the prenatally anticipated difficult airway during delivery and removal of tracheal balloons from patients with CDH during delivery can be clinically dynamic and require flexibility, seamless communication and a high-functioning, multidisciplinary care team. SUMMARY: Maternal and fetal anesthetic management is tailored to the fetal intervention and the underlying health of the fetus and mother.


Assuntos
Anestesia/métodos , Doenças Fetais/cirurgia , Transfusão Feto-Fetal/cirurgia , Fetoscopia/métodos , Hérnias Diafragmáticas Congênitas/terapia , Placenta/irrigação sanguínea , Feminino , Doenças Fetais/diagnóstico , Doenças Fetais/terapia , Fetoscopia/efeitos adversos , Feto/cirurgia , Hérnias Diafragmáticas Congênitas/cirurgia , Humanos , Doenças Placentárias/cirurgia , Gravidez , Cuidado Pré-Natal , Diagnóstico Pré-Natal
2.
Dev Med Child Neurol ; 62(4): 417-425, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31840814

RESUMO

Fetal myelomeningocele (fMMC) closure (spina bifida aperta) has become a care option for patients that meet inclusion criteria, but it is clear that fetal intervention, while improving outcomes, is not a cure. This review will: (1) focus on the rationale for fMMC surgery based on preclinical studies and observations that laid the foundation for human pilot studies and a randomized controlled trial; (2) summarize important clinical outcomes; (3) discuss the feasibility, efficacy, and safety of recent developments in fetal surgical techniques and approaches; and (4) highlight future research directions. Given the increased risk of maternal and fetal morbidity associated with prenatal intervention, accompanied by the increasing number of centres performing interventions worldwide, teams involved in the care of these patients need to proceed with caution to maintain technical expertise, competency, and patient safety. Ongoing assessment of durability of the benefits of fMMC surgery, as well as additional refinement of patient selection criteria and counselling, is needed to further improve outcomes and reduce the risks to the mother and fetus. WHAT THIS PAPER ADDS: High-quality prospective studies are needed to broaden the indication for fetal surgery in the general myelomeningocele population. Innovative minimally invasive approaches have had promising results, yet lack comprehensive and robust experimental or clinical evaluation. Important information to help families make informed decisions regarding fetal surgery for myelomeningocele is provided.


Assuntos
Fetoscopia , Feto/cirurgia , Meningomielocele/cirurgia , Feminino , Humanos , Gravidez
3.
J Urol ; 203(1): 194-199, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31479395

RESUMO

PURPOSE: In utero myelomeningocele closure is a valid alternative to postnatal repair with unclear benefits to bladder function. We compared bladder status in patients who underwent fetal myelomeningocele surgery versus postnatal repair. MATERIALS AND METHODS: We retrospectively reviewed our database, with group 1 consisting of in utero surgery and group 2 consisting of postnatal repair. Group 3 was a subgroup of group 2, including patients initially presenting at age less than 12 months. We recorded medical history, radiological investigation with renal ultrasonography, voiding cystourethrography, urodynamic evaluation and clinical outcome of the bladder pattern after treatment. RESULTS: We identified 88 patients in group 1, 86 in group 2 and 38 in group 3. The incidence of urinary tract infection was higher in the postnatal period (45% vs 20%). Hydronephrosis occurred in 20.7%, 22.6% and 28.9% of patients in groups 1, 2 and 3, respectively. Vesicoureteral reflux was diagnosed in 15% in all groups. Urodynamic data showed a higher prevalence of detrusor overactivity in group 1 and no difference in other urodynamic parameters. The high risk bladder pattern at initial evaluation occurred in 56%, 50% and 46% of patients in groups 1, 2 and 3, respectively. There was a trend to decrease the percentages of the high risk bladder pattern and to increase the normal pattern after treatment in all groups. CONCLUSIONS: In utero repair did not improve urological parameters compared to repair in the postnatal period.


Assuntos
Feto/cirurgia , Meningomielocele/cirurgia , Complicações Pós-Operatórias/epidemiologia , Feminino , Humanos , Hidronefrose/epidemiologia , Lactente , Recém-Nascido , Masculino , Gravidez , Estudos Retrospectivos , Infecções Urinárias/epidemiologia , Refluxo Vesicoureteral/epidemiologia
5.
Semin Pediatr Surg ; 28(4): 150819, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31451174

RESUMO

The field of maternal-fetal intervention is rapidly progressing and with it comes new and often complex ethical considerations that must be addressed. The purpose of this article is to review the ethical issues that arise in maternal-fetal intervention. We will provide two clinical scenarios and discuss the ethical issues related to each scenario and how they were addressed. We will also provide a list of recommended resources that any institutional offering maternal-fetal intervention should have in place to meet the ethical obligations of such work.


Assuntos
Tomada de Decisões , Feto/cirurgia , Obstetrícia/ética , Feminino , Humanos , Consentimento Livre e Esclarecido , Equipe de Assistência ao Paciente , Gravidez
6.
Semin Pediatr Surg ; 28(4): 150818, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31451175

RESUMO

Congenital diaphragmatic hernia (CDH) is a condition that results from incomplete diaphragm formation during embryogenesis. The diaphragmatic defect allows for herniation of abdominal viscera into the chest, and the resulting pulmonary hypoplasia and pulmonary hypertension can lead to cardiorespiratory failure in the neonatal period. There is a wide spectrum of disease severity in CDH, and while advances in neonatal care and the introduction of extracorporeal membrane oxygenation have improved outcomes in many cases, the most severe defects are still associated with high morbidity and mortality. Improvements in prenatal diagnostic and prognostic capabilities have created an opportunity to select high risk patients for fetal intervention. Three decades of refinements in the fetal surgical therapy for CDH have led to the current technique of Fetoscopic Endoluminal Tracheal Occlusion (FETO). Herein, we review the current considerations for selecting patients for fetal intervention, and the contemporary fetal surgical operation for CDH, FETO, with a focus on early outcomes and ongoing studies.


Assuntos
Fetoscopia , Feto/cirurgia , Hérnias Diafragmáticas Congênitas/cirurgia , Ensaios Clínicos como Assunto , Feminino , Feto/diagnóstico por imagem , Hérnia/diagnóstico por imagem , Hérnias Diafragmáticas Congênitas/complicações , Hérnias Diafragmáticas Congênitas/diagnóstico por imagem , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/etiologia , Fígado/diagnóstico por imagem , Medidas de Volume Pulmonar , Imagem por Ressonância Magnética , Gravidez , Prognóstico , Índice de Gravidade de Doença , Ultrassonografia Pré-Natal
7.
Semin Fetal Neonatal Med ; 24(4): 101001, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31160226

RESUMO

Fetal pain is difficult to assess, because the main feature needed to spot pain, is the subject's capability of declaring it. Nonetheless, much can be affirmed about this issue. In this review we first report the epochs of the development of human nociceptive pathways; then we review since when they are functioning. We also review the latest data about the new topic of analgesia and prenatal surgery and about the scarce effect on fetal pain sentience of the natural sedatives fetuses produce. It appears that pain is a neuroadaptive phenomenon that emerges in the middle of pregnancy, at about 20-22 weeks of gestation, and becomes more and more evident for bystanders and significant for the fetus, throughout the rest of the pregnancy.


Assuntos
Feto/cirurgia , Dor/embriologia , Dor/prevenção & controle , Analgesia , Feminino , Feto/inervação , Humanos , Nociceptividade/fisiologia , Nociceptores/fisiologia , Percepção da Dor/fisiologia , Gravidez
9.
Ginekol Pol ; 90(4): 189-194, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31059111

RESUMO

OBJECTIVES: The aim of the study was to analyze the changes in cardiac function and myocardial contractility of donor and recipient fetuses with twin-to-twin transfusion syndrome (TTTS) subjected to selective laser photocoagulation of the communicating vessels (SLPCV), between and after the procedure. Finally, we verified if fetuses with Quintero's stage I TTTS presented with early impairment of myocardial contractility. MATERIAL AND METHODS: We selected 77 consecutive women with twin pregnancies, whose both fetuses survived at least seven days post-SLPCV. Myocardial contractility of both fetuses was evaluated ultrasonographically, and their myocardial performance indices (Tei-Index values) and shortening fractions (SF) were determined. RESULTS: In donor fetuses, the Tei-Index values for both right and left ventricle remained within the respective reference ranges both before the procedure and during a 7-day follow-up. A significant change in shortening fraction values for the left ventricle in recipient fetuses and the right ventricle of in the donors was observed during a 7-day follow-up. CONCLUSIONS: Comparison of the cardiac parameters of donors and recipients revealed significant differences in Tei-indices during the entire follow-up period. The group with Quintero's I stage TTTS included 74% of recipient fetuses with abnormal Tei-Index values for the right ventricle (mean 0.53).


Assuntos
Coração Fetal , Transfusão Feto-Fetal , Feto , Feminino , Coração Fetal/diagnóstico por imagem , Coração Fetal/fisiologia , Transfusão Feto-Fetal/fisiopatologia , Transfusão Feto-Fetal/cirurgia , Feto/irrigação sanguínea , Feto/diagnóstico por imagem , Feto/fisiopatologia , Feto/cirurgia , Seguimentos , Humanos , Fotocoagulação a Laser , Gravidez , Gravidez de Gêmeos , Ultrassonografia Pré-Natal
10.
Biomater Sci ; 7(8): 3092-3109, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31099350

RESUMO

Fetal surgery and fetal therapy involve surgical interventions on the fetus in utero to correct or ameliorate congenital abnormalities and give a developing fetus the best chance at a healthy life. Historical use of biomaterials in fetal surgery has been limited, and most biomaterials used in fetal surgeries today were originally developed for adult or pediatric patients. However, as the field of fetal surgery moves from open surgeries to minimally invasive procedures, many opportunities exist for innovative biomaterials engineers to create materials designed specifically for the unique challenges and opportunities of maternal-fetal surgery. Here, we review biomaterials currently used in clinical fetal surgery as well as promising biomaterials in development for eventual clinical translation. We also highlight unmet challenges in fetal surgery that could particularly benefit from novel biomaterials, including fetal membrane sealing and minimally invasive myelomeningocele defect repair. Finally, we conclude with a discussion of the underdeveloped fetal immune system and opportunities for exploitation with novel immunomodulating biomaterials.


Assuntos
Materiais Biocompatíveis , Terapias Fetais/métodos , Feto/cirurgia , Terapias Fetais/efeitos adversos , Feto/imunologia , Humanos , Imunidade , Risco
11.
BMC Pregnancy Childbirth ; 19(1): 98, 2019 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-30917799

RESUMO

BACKGROUND: Caesarean section with extraction of a deeply impacted fetal head is technically challenging and is associated with serious maternal and neonatal complications. The purpose of the study was to identify risks and evaluate selected outcome parameters associated with difficult fetal head extraction during caesarean section in advanced labour comparing two different extraction techniques (head pushing vs. reverse breech). METHODS: This retrospective cohort study was conducted at the Division of Obstetrics in a tertiary care hospital in Zurich, Switzerland. 629 women at term with a singleton pregnancy in cephalic presentation during advanced intrapartum caesarean section from December 2012 until December 2016 were evaluated. Primary outcome was the incidence of uterine incision extensions. Secondary outcomes were other selected maternal and neonatal outcome parameters. Data analysis was performed using SPSS with Mann-Whitney U independent sampling test and two-tailed Fisher's exact test (p < 0.01). RESULTS: Difficult fetal head extractions are associated with significantly elevated maternal and neonatal risks. When performed by reverse breech technique, significant lower rates of extensions of the uterine incision, shorter operation times and less operative blood loss were identified compared to the head pushing method. No statistically significant differences for the neonatal outcomes were described so far. However, among the group of difficult fetal delivery with the head pushing method two neonates had perinatal skull fractures, with one of those resulting in neonatal death. CONCLUSIONS: The head pushing method is associated with higher maternal morbidity than the reverse breech method for extraction of a deeply engaged fetus during intrapartum caesarean section in advanced stage of labour.


Assuntos
Apresentação Pélvica/cirurgia , Cesárea/métodos , Extração Obstétrica/métodos , Adulto , Feminino , Feto/cirurgia , Cabeça/embriologia , Cabeça/cirurgia , Humanos , Recém-Nascido , Terceira Fase do Trabalho de Parto , Gravidez , Estudos Retrospectivos , Resultado do Tratamento
12.
Ultrasound Obstet Gynecol ; 54(6): 786-790, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30868659

RESUMO

OBJECTIVE: To examine the effect of hypoxemia on fetal heart rate (FHR) variability, using an instrumented pregnant sheep model. METHODS: In this prospective study, 19 pregnant sheep were instrumented under general anesthesia, at a mean gestational age of 127 days. After a 5-day recovery period, hypoxemia was induced by attaching the mother to a rebreathing circuit. Hypoxemia was sustained for 120 min, following which it was reversed until maternal and fetal partial pressure of oxygen (pO2 ) returned to baseline. FHR recordings at baseline, after 30 and 120 min of hypoxemia and at recovery were analyzed to calculate short-term variation (STV) in 16 epochs of 3.75 s, every minute. Phase-rectified signal averaging (window length (L) = 10, time (T) = 2 and scale (S) = 2) was used to calculate FHR acceleration (AC) and deceleration (DC) capacities. RESULTS: At baseline, mean ± SD fetal pO2 was 2.90 ± 0.38 kPa. Acute hypoxemia was associated with a significant reduction in mean pO2 at 30 (1.62 ± 0.37 kPa) and 120 (1.51 ± 0.16 kPa) min. Mean ± SD fetal pO2 at recovery was 2.86 ± 0.32 kPa. At baseline, median STV, AC and DC were 1.307 (interquartile range (IQR), 0.515-2.508) ms, 1.295 (IQR, 0.990-2.685) beats per minute (bpm) and 1.197 (IQR, 0.850-1.836) bpm, respectively. At 30 min of hypoxemia, the values were 1.323 (IQR, 0.753-2.744) ms, 1.696 (IQR, 1.310-3.013) bpm and 1.584 (IQR, 1.217-4.132) bpm, respectively. At 120 min of hypoxemia, they were 1.760 (IQR, 0.928-4.656) ms, 3.098 (IQR, 1.530-5.163) bpm and 3.054 (IQR, 1.508-4.522) bpm, respectively. At recovery, they changed to 0.962 (IQR, 0.703-1.154) ms, 1.228 (IQR, 1.071-2.234) bpm and 1.086 (IQR, 0.873-1.568) bpm, respectively. Hypoxemia for 30 and 120 min was associated with a significant increase in DC compared to baseline (P = 0.014 and 0.017, respectively). The changes in STV and AC were not significant. CONCLUSION: Acute hypoxemia is associated with a significant increase in the DC of FHR in a fetal sheep model. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.


Assuntos
Cardiotocografia/métodos , Feto/irrigação sanguínea , Frequência Cardíaca Fetal/fisiologia , Hipóxia/fisiopatologia , Consumo de Oxigênio/fisiologia , Animais , Gasometria/métodos , Desaceleração , Feminino , Feto/fisiopatologia , Feto/cirurgia , Idade Gestacional , Hipóxia/complicações , Modelos Animais , Pressão Parcial , Gravidez , Estudos Prospectivos , Ovinos
13.
Am J Obstet Gynecol ; 220(5): 494.e1-494.e7, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30885769

RESUMO

BACKGROUND: Open maternal-fetal surgery for fetal myelomeningocele results in reduction in neonatal morbidity related to spina bifida but may be associated with fetal, neonatal, and maternal complications in subsequent pregnancies. OBJECTIVE: The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open maternal-fetal surgery for fetal myelomeningocele closure. STUDY DESIGN: An international multicenter prospective observational registry created to track and report maternal, obstetric, fetal/neonatal, and subsequent pregnancy outcomes following open maternal-fetal surgery for fetal myelomeningocele was evaluated for subsequent pregnancy outcome variables. Institutional Review Board approval was obtained for the registry. RESULTS: From 693 cases of open maternal-fetal surgery for fetal myelomeningocele closure entered into the registry, 77 subsequent pregnancies in 60 women were identified. The overall live birth rate was 96.2%, with 52 pregnancies delivering beyond 20 weeks gestational age and median gestational age at delivery of 37 (36.3-37.1) weeks. The uterine rupture rate was 9.6% (n = 5), resulting in 2 fetal deaths. Maternal transfusion was required in 4 patients (7.7%). CONCLUSION: The risk of uterine rupture or dehiscence in subsequent pregnancies with associated fetal morbidity after open maternal-fetal surgery is significant, but is similar to that reported for subsequent pregnancies after classical cesarean deliveries. Future pregnancy considerations should be included in initial counseling for women contemplating open maternal-fetal surgery.


Assuntos
Feto/cirurgia , Meningomielocele/cirurgia , Resultado da Gravidez , Aborto Espontâneo/epidemiologia , Adulto , Transfusão de Sangue/estatística & dados numéricos , Cesárea , Feminino , Morte Fetal , Idade Gestacional , Humanos , Nascimento Vivo , Gravidez , Estudos Prospectivos , Sistema de Registros , Ruptura Uterina/epidemiologia
14.
Pediatr Clin North Am ; 66(2): 295-308, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30819337

RESUMO

Fetal surgery is an established but still rapidly evolving specialty, born from the rationale that destructive embryologic processes, recognized early in gestation, can be curtailed by prenatal correction. As more and more centers begin offering fetal interventions, quality of care must be verified through transparency about clinical capabilities and resources. Level designations should be assigned based on capability, as in trauma and neonatal ICU centers for excellence, and volume requirements must be set for fetal surgery certification. Regionalization of this specialty care may be required to optimize outcomes.


Assuntos
Doenças Fetais/cirurgia , Terapias Fetais/métodos , Feto/cirurgia , Feminino , Humanos , Gravidez
15.
J Obstet Gynaecol Res ; 45(3): 719-723, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30656800

RESUMO

Severe congenital diaphragmatic hernia (CDH) remains a significant challenge for neonatal specialists. In order to reduce complications during extraction of the surgical balloon after fetoscopic tracheal occlusion (FETO) CDH, we have developed a FETO with a 'long tail balloon' of 2.5 mL volume. Here we describe two successful uses of the device with observed/expected total fetal lung volume (o/e TFLV) of 15% and with o/e TFLV of 24% and 'liver up'. The o/e TFLV increased to 134% in first case and to 47% in second fetus. The balloon was successfully extracted at 34 weeks' gestation by pulling the long tail suture during second fetoscopy. In the second case the fetus pulled out the balloon from trachea itself by traction onto the balloon's long tail. Both neonates were operated on for their CDH with a good outcome. This work showed the feasibility of this long tail balloon for FETO to reduce the technical difficulty of the balloon extraction and the possibility that fetuses are able to extract the balloon by itself by pulling the balloons' long tail. Further development of long tail balloon for FETO could facilitate its extraction thereby reducing neonatal complications.


Assuntos
Oclusão com Balão/instrumentação , Fetoscopia/instrumentação , Feto/cirurgia , Hérnias Diafragmáticas Congênitas/cirurgia , Traqueia/cirurgia , Adulto , Oclusão com Balão/métodos , Feminino , Fetoscopia/métodos , Humanos , Resultado do Tratamento
16.
Surg Innov ; 26(1): 27-36, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30484382

RESUMO

This article presents a multi-modality tracking and navigation system achieved by merging optical tracking and ultrasound imaging into a novel navigation software to help in surgical pre-planning and real-time target setting and guidance. Fetal surgeries require extensive experience in coordination of hand-eye-ultrasound-surgical equipment, knowledge, and precise assessment of relative anatomy. While there are navigation systems available for similar constrained working spaces in arthroscopic and cardiovascular procedures, fetal minimally invasive surgery does not yet have a dedicated navigation platform capable of supporting robotic instruments that can be adapted to the set of unique procedures. This article discusses the testing of the novel multi-modality navigation system in a phantom environment developed for this purpose. The outcomes suggest that the subjects demonstrated an increase in average reaching accuracy by about 60% and an overall reduction in time taken by 33.6%. They also showed higher levels of confidence in reaching the targets, which was visualised from the pattern of trajectory of movements during the procedure. To evaluate the navigation system, a phantom surgical environment was found necessary. Therefore, the article also discusses the details of the development of a fetal phantom environment for congenital diaphragmatic hernia for surgical testing, evaluation, and training. A surgical procedure was conducted on the phantom using the proposed tracking navigation system and using only ultrasound.


Assuntos
Endoscopia/métodos , Hérnias Diafragmáticas Congênitas/diagnóstico por imagem , Hérnias Diafragmáticas Congênitas/cirurgia , Imagens de Fantasmas , Procedimentos Cirúrgicos Robóticos/métodos , Cirurgia Assistida por Computador , Feto/cirurgia , Humanos , Imagem Multimodal/métodos , Sensibilidade e Especificidade , Ultrassonografia de Intervenção
17.
Fetal Diagn Ther ; 46(1): 38-44, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30199879

RESUMO

INTRODUCTION: Fetal spina bifida repair (fSBR) has proven effective in the reversibility of hindbrain herniation, lower rate of shunt-dependent hydrocephalus, and independent ambulation. Besides distinct advantages, there are also concerns related to fSBR. One of these is the postnatal occurrence of inclusion cysts (IC). METHODS: In a prospective study, 48 children who underwent fSBR were followed up. Postnatal assessment included clinical examination, cystometry, and spinal MRI. Indication for IC resection was the evidence of a spinal mass on MRI in the presence of deteriorating motor or bladder function, pain, or considerable growth of the IC. RESULTS: Fourteen children (30%) developed IC, all within the first 2 years of life. Six children underwent IC resection; 4 children due to deteriorating function, 2 children due to doubling of the mass on MRI within 1 year. Following IC resection, 4/6 children (67%) demonstrated altered motor function and 6 children (100%) were diagnosed with neurogenic bladder dysfunction. CONCLUSIONS: Systematic follow-up of patients with a history of fSBR revealed a high incidence of IC. Whether these are of dysembryogenic or iatrogenic origin, remains unclear. Since both IC per se and IC resection may lead to loss of neurologic function, IC can be considered a "third hit".


Assuntos
Cistos do Sistema Nervoso Central/complicações , Disrafismo Espinal/complicações , Cistos do Sistema Nervoso Central/diagnóstico por imagem , Cistos do Sistema Nervoso Central/epidemiologia , Cistos do Sistema Nervoso Central/cirurgia , Feminino , Feto/cirurgia , Humanos , Incidência , Lactente , Imagem por Ressonância Magnética , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Gravidez , Estudos Prospectivos , Disrafismo Espinal/cirurgia
18.
Fetal Diagn Ther ; 45(3): 192-196, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29672287

RESUMO

INTRODUCTION: Optimal uterine relaxation is achieved through higher minimum alveolar concentration (MAC) of inhalational anesthetics, increasing risks to mother and fetus. Our objective was to determine if earlier administration of magnesium sulfate would reduce the requirement of inhalational anesthetics in fetal myelomeningocele repair. MATERIALS AND METHODS: Prospective observational study of fetal myelomeningocele repair was performed from September 2011 to August 2017. Groups compared were: (1) magnesium sulfate at uterine closure; (2) magnesium sulfate at maternal skin incision. Maternal demographics, anesthetic agents, intraoperative complications, and pregnancy outcomes were reviewed. A Student t test was used for analysis. RESULTS: There were 30 cases in group 1 and 21 cases in group 2. There was no difference in gestational age at intervention (24.92 ± 0.62 vs. 25.22 ± 0.47 weeks, p = 0.07) or at delivery (34.83 ± 2.77 vs. 33.98 ± 3.83 weeks, p = 0.38) between groups 1 and 2, respectively. The maximum MAC of sevoflurane was significantly lower in group 2 (1.84 ± 0.25 vs. 1.05 ± 0.28, p < 0.0001). There was no difference in the average dose of phenylephrine used. DISCUSSION: Magnesium sulfate infusion initiated earlier in open fetal surgery reduces the total anesthetic exposure to the fetus.


Assuntos
Anestésicos Inalatórios/administração & dosagem , Terapias Fetais , Feto/cirurgia , Sulfato de Magnésio/administração & dosagem , Meningomielocele/cirurgia , Adulto , Feminino , Humanos , Masculino , Gravidez , Resultado da Gravidez , Estudos Prospectivos , Resultado do Tratamento
19.
J Pediatr Surg ; 54(1): 75-79, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30529115

RESUMO

PURPOSE: The purpose of this study was to determine whether seeding density of placental mesenchymal stromal cells (PMSCs) on extracellular matrix (ECM) during in utero repair of myelomeningocele (MMC) affects motor function and neuronal preservation in the ovine model. METHODS: MMC defects were surgically created in 33 fetuses and repaired following randomization into four treatment groups: ECM only (n = 10), PMSC-ECM (42 K cells/cm2) (n = 8), PMSC-ECM (167 K cells/cm2) (n = 7), or PMSC-ECM (250-300 K cells/cm2) (n = 8). Motor function was evaluated using the Sheep Locomotor Rating Scale (SLR). Serial sections of the lumbar spinal cord were analyzed by measuring their cross-sectional areas which were then normalized to normal lambs. Large neurons (LN, diameter 30-70 µm) were counted manually and density calculated per mm2 gray matter. RESULTS: Lambs treated with PMSCs at any density had a higher median SLR score (15 [IQR 13.5-15]) than ECM alone (6.5 [IQR 4-12.75], p = 0.036). Cross-sectional areas of spinal cord and gray matter were highest in the PMSC-ECM (167 K/cm2) group (p = 0.002 and 0.006, respectively). LN density was highest in the greatest density PMSC-ECM (250-300 K/cm2) group (p = 0.045) which positively correlated with SLR score (r = 0.807, p < 0.0001). CONCLUSIONS: Fetal repair of myelomeningocele with high density PMSC-ECM resulted in increased large neuron density, which strongly correlated with improved motor function. TYPE OF STUDY: Basic science. LEVEL OF EVIDENCE: N/A.


Assuntos
Matriz Extracelular/transplante , Terapias Fetais/métodos , Meningomielocele/cirurgia , Transplante de Células-Tronco Mesenquimais/métodos , Animais , Feminino , Feto/cirurgia , Células-Tronco Mesenquimais , Atividade Motora/fisiologia , Neurônios/citologia , Placenta/citologia , Gravidez , Ovinos , Medula Espinal/citologia
20.
AJNR Am J Neuroradiol ; 40(1): 191-198, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30591508

RESUMO

BACKGROUND AND PURPOSE: Fetal MR imaging is part of the comprehensive prenatal assessment of fetuses with open spinal dysraphism. We aimed to assess the reliability of brain stem and posterior fossa measurements; use the reliable measurements to characterize fetuses with open spinal dysraphism versus what can be observed in healthy age-matched controls; and document changes in those within 1 week after prenatal repair. MATERIALS AND METHODS: Retrospective evaluation of 349 MR imaging examinations took place, including 274 in controls and 52 in fetuses with open spinal dysraphism, of whom 23 underwent prenatal repair and had additional early postoperative MR images. We evaluated measurements of the brain stem and the posterior fossa and the ventricular width in all populations for their reliability and differences between the groups. RESULTS: The transverse cerebellar diameter, cerebellar herniation level, clivus-supraocciput angle, transverse diameter of the posterior fossa, posterior fossa area, and ventricular width showed an acceptable intra- and interobserver reliability (intraclass correlation coefficient > 0.5). In fetuses with open spinal dysraphism, these measurements were significantly different from those of healthy fetuses (all with P < .0001). Furthermore, they also changed significantly (P value range = .01 to < .0001) within 1 week after the fetal operation with an evolution toward normal, most evident for the clivus-supraocciput angle (65.9 ± 12.5°; 76.6 ± 10.9; P < .0001) and cerebellar herniation level (-9.9 ± 4.2 mm; -0.7 ± 5.2; P < .0001). CONCLUSIONS: In fetuses with open spinal dysraphism, brain stem measurements varied substantially between observers. However, measurements characterizing the posterior fossa could be reliably assessed and were significantly different from normal. Following a fetal operation, these deviations from normal values changed significantly within 1 week.


Assuntos
Tronco Encefálico/diagnóstico por imagem , Tronco Encefálico/cirurgia , Fossa Craniana Posterior/diagnóstico por imagem , Fossa Craniana Posterior/cirurgia , Feto/diagnóstico por imagem , Feto/cirurgia , Imagem por Ressonância Magnética/métodos , Procedimentos Neurocirúrgicos/métodos , Disrafismo Espinal/diagnóstico por imagem , Disrafismo Espinal/cirurgia , Adulto , Cerebelo/diagnóstico por imagem , Feminino , Humanos , Variações Dependentes do Observador , Gravidez , Diagnóstico Pré-Natal , Reprodutibilidade dos Testes , Estudos Retrospectivos , Resultado do Tratamento
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA