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Meuwese RT, Versteeg EM, van Drongelen J, de Hoog D, Bouwhuis D, Vandenbussche FP, van Kuppevelt TH, Daamen WF. A collagen plug with shape memory to seal iatrogenic fetal membrane defects after fetoscopic surgery. Bioact Mater 2023; 20:463-471. [PMID: 35800408 PMCID: PMC9249610 DOI: 10.1016/j.bioactmat.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 05/20/2022] [Accepted: 06/12/2022] [Indexed: 12/04/2022] Open
Abstract
Iatrogenic preterm premature rupture of fetal membranes (iPPROM) after fetal surgery remains a strong trigger for premature birth. As fetal membrane defects do not heal spontaneously and amniotic fluid leakage and chorioamniotic membrane separation may occur, we developed a biocompatible, fetoscopically-applicable collagen plug with shape memory to prevent leakage. This plug expands directly upon employment and seals fetal membranes, hence preventing amniotic fluid leakage and potentially iPPROM. Lyophilized type I collagen plugs were given shape memory and crimped to fit through a fetoscopic cannula (Ø 3 mm). Expansion of the plug was examined in phosphate buffered saline (PBS). Its sealing capacity was studied ex vivo using human fetal membranes, and in situ in a porcine bladder model. The crimped plug with shape memory expanded and tripled in diameter within 1 min when placed into PBS, whereas a crimped plug without shape memory did not. In both human fetal membranes and porcine bladder, the plug expanded in the defect, secured itself and sealed the defect without membrane rupture. In conclusion, collagen plugs with shape memory are promising as medical device for rapid sealing of fetoscopic defects in fetal membranes at the endoscopic entry point. Shape memory can be given to collagen plugs to rapidly expand in aqueous fluids. Within 1 min in aqueous fluid, collagen plugs with shape memory triple in diameter. Collagen plugs with shape memory show potency to seal fetal membrane defects.
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Abstract
The field of fetal medicine has evolved significantly over the past several decades. Our ability to identify and treat the unborn patient has been shaped by advancements in imaging technology, genetic diagnosis, an improved understanding of fetal physiology, and the development and optimization of in utero surgical techniques. The future of the field will be shaped by medical innovators pushing for the continued refinement of minimally invasive surgical technique, the application of pioneering technologies such as robotic surgery and in utero stem cell and gene therapies, and the development of innovative ex utero fetal support systems.
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Affiliation(s)
- Eric Bergh
- Department of Obstetrics and Gynecology, The Fetal Center at Children's Memorial Hermann Hospital, University of Texas Health Science Center, McGovern Medical School, 6410 Fannin Street, Suite 700, Houston, TX 77030, USA.
| | - Cara Buskmiller
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center, McGovern Medical School, 6410 Fannin Street, Suite 700, Houston, TX 77030, USA. https://twitter.com/CaraBuskmiller
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, The Fetal Center at Children's Memorial Hermann Hospital, University of Texas Health Science Center, McGovern Medical School, 6410 Fannin Street, Suite 700, Houston, TX 77030, USA
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Youssefzadeh AC, Glassen GL, Chon AH, Korst LM, Esakoff TF, Afshar Y, Gheorghe CP, Llanes A, Chmait RH. Dual demise following laser surgery for twin-twin transfusion syndrome: Analysis of 52 cases at a single fetal surgery center. Prenat Diagn 2021; 41:1548-1559. [PMID: 34669208 DOI: 10.1002/pd.6058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/06/2021] [Accepted: 10/07/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate all individual cases of dual twin demise following laser surgery for twin-twin transfusion syndrome (TTTS). METHOD This is an analysis of all monochorionic diamniotic twin gestations with TTTS complicated by dual demise following laser surgery from 2006 to 2019. Cases were reviewed by (1) a fetal surgeon researcher and (2) a panel of independent experienced maternal-fetal medicine specialists to code an etiology of demise for the donor and recipient, and to assess for possible preventability. RESULTS Of 753 twins that underwent laser surgery for TTTS, 52 (6.9%) had postoperative dual demise. In this subgroup, gestational age at surgery was 19.5 (16.1-24.9) weeks, and 36 (69.2%) patients were Quintero stage III and IV. The most common etiology was the spectrum of disorders leading to preterm delivery, which included cervical insufficiency, preterm premature rupture of membranes, and preterm labor (44.2% and 48.1%, donor and recipient, respectively). Some degree of preventability was estimated for 23.1% of dual demises. CONCLUSIONS The most common cause of dual demise post laser surgery for TTTS was preterm birth, reinforcing the need for studies regarding the etiology and prevention of post-fetoscopy prematurity. Nearly one-quarter of dual demise cases were deemed potentially preventable.
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Affiliation(s)
- Ariane C Youssefzadeh
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Gabrielle L Glassen
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andrew H Chon
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, LLC, North Hollywood, California, USA
| | - Tania F Esakoff
- Department of Obstetrics and Gynecology, Division of Maternal Fetal-Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yalda Afshar
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Ciprian P Gheorghe
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Loma Linda University, Loma Linda, California, USA
| | - Arlyn Llanes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Amberg BJ, Hodges RJ, Rodgers KA, Crossley KJ, Hooper SB, DeKoninck PLJ. Why Do the Fetal Membranes Rupture Early after Fetoscopy? A Review. Fetal Diagn Ther 2021; 48:493-503. [PMID: 34404043 DOI: 10.1159/000517151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/03/2021] [Indexed: 11/19/2022]
Abstract
Iatrogenic preterm premature rupture of the fetal membranes (iPPROM) remains the Achilles' heel of keyhole fetal surgery (fetoscopy) despite significant efforts in preclinical models to develop new therapies. This limited success is partially due to incomplete understanding why the fetal membranes rupture early after fetoscopy and notable differences in membrane physiology between humans and domestic species. In this review, we summarize aspects of fetoscopy that may contribute to iPPROM, the previous efforts to develop new therapies, and limitations of preclinical models commonly used in fetal membrane research.
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Affiliation(s)
- Benjamin J Amberg
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia, .,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia,
| | - Ryan J Hodges
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Karyn A Rodgers
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Kelly J Crossley
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Stuart B Hooper
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Philip L J DeKoninck
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Forde B, Habli M. Unique Considerations: Preterm Prelabor Rupture of Membranes in the Setting of Fetal Surgery and Higher Order Pregnancies. Obstet Gynecol Clin North Am 2021; 47:653-669. [PMID: 33121651 DOI: 10.1016/j.ogc.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Two unique aspects of antenatal care occur in the setting of fetal surgery and multiple gestations. As fetal interventions increase, so do the number of cases of iatrogenic preterm prelabor rupture of membranes (PPROM). Because of the amniotic sac's inability to heal, the risk of PPROM after surgery is directly correlated with the number of interventions, the size of the defect, and the surgery performed. Higher order gestations also carry an increased risk of PPROM. This paper reviews the risks and management of PPROM in the setting of the various prenatal interventions as well as in the setting of multiple gestations.
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Affiliation(s)
- Braxton Forde
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Medical Sciences Building, Room 4555, 231 Albert Sabin Way, Cincinnati, OH 45267-0526, USA.
| | - Mounira Habli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, OH, USA; Fetal Care Center of Cincinnati, Cincinnati Children's Hospital, Cincinnati, OH, USA
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Barrett DW, Okesola BO, Costa E, Thrasivoulou C, Becker DL, Mata A, Deprest JA, David AL, Chowdhury TT. Potential sealing and repair of human FM defects after trauma with peptide amphiphiles and Cx43 antisense. Prenat Diagn 2020; 41:89-99. [PMID: 33045764 DOI: 10.1002/pd.5826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/01/2020] [Accepted: 09/04/2020] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- David W Barrett
- Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary University of London, London, UK
| | - Babatunde O Okesola
- Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary University of London, London, UK
| | - Eleni Costa
- Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary University of London, London, UK
| | | | - David L Becker
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Alvaro Mata
- Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary University of London, London, UK.,Biodiscovery Institute, School of Pharmacy, Department of Chemical and Environmental Engineering, University of Nottingham, Nottingham, UK
| | - Jan A Deprest
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, UK
| | - Anna L David
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, UK.,NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Tina T Chowdhury
- Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary University of London, London, UK
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Bergh EP, Moise KJ, Johnson A, Papanna R. Pregnancy outcomes associated with chorioamnion membrane separation severity following fetoscopic laser surgery for twin-twin transfusion syndrome. Prenat Diagn 2020; 40:1020-1027. [PMID: 32362002 DOI: 10.1002/pd.5725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/23/2020] [Accepted: 04/25/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE We tested the hypothesis that increasing severity of chorioamnion membrane separation (CAS) after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) is associated with worse pregnancy outcomes. METHODS Prospective cohort of patients undergoing FLS for TTTS between 2011 and 2018. CAS was defined as separation of fetal membranes from the uterine wall on post-operative ultrasound. Patient groups were defined: Group 1: No CAS; Group 2: CAS lower than 50th centile; Group 3: CAS upper than 50th centile or complete CAS. Comparative analysis was performed. RESULTS Of 387 patients meeting inclusion criteria, 29 (7.5%) had CAS (median 9.8 mm [4.9-30.8 mm]). Group 1 patients were more likely to undergo FLS at later gestational age, had increased recipient maximum vertical pocket, and higher amnioreduction volume than Group 3. Group 3 had higher rates of preterm premature rupture of membrane, delivered earlier and were more likely to terminate than Group 1. Group 2 had fewer neonatal survivors than Group 1. Survival analysis for gestational age at delivery and Cox proportional hazards model indicated increased risk for early delivery in Groups 2 and 3 compared with Group 1. CONCLUSIONS Patients with CAS ≥9.8 mm or complete CAS after FLS for TTTS had worse obstetric and neonatal outcomes.
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Affiliation(s)
- Eric P Bergh
- Department of Obstetrics, Gynecology and Reproductive Sciences, The Fetal Center, Children's Memorial Hermann Hospital, UTHealth, McGovern School of Medicine, University of Texas, Houston, Texas, USA
| | - Kenneth J Moise
- Department of Obstetrics, Gynecology and Reproductive Sciences, The Fetal Center, Children's Memorial Hermann Hospital, UTHealth, McGovern School of Medicine, University of Texas, Houston, Texas, USA
| | - Anthony Johnson
- Department of Obstetrics, Gynecology and Reproductive Sciences, The Fetal Center, Children's Memorial Hermann Hospital, UTHealth, McGovern School of Medicine, University of Texas, Houston, Texas, USA
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology and Reproductive Sciences, The Fetal Center, Children's Memorial Hermann Hospital, UTHealth, McGovern School of Medicine, University of Texas, Houston, Texas, USA
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8
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Loh M, Bhatia A, Tan KL, Thia E, Yeo GSH. Outcomes following selective fetoscopic laser ablation for twin-to-twin transfusion syndrome: a single-centre experience. Singapore Med J 2019; 61:523-531. [PMID: 31489429 DOI: 10.11622/smedj.2019107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Fetoscopic laser photocoagulation (FLP), a treatment option for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies, is currently the treatment of choice at our centre. We previously reported on our experience of FLP from June 2011 to March 2014. This paper audits our fetal surgery performance since then. METHODS 15 consecutive patients who underwent FLP for Stage II-III TTTS before 26 weeks of gestation from June 2011 to January 2017 were retrospectively reviewed, consisting of five cases from our initial experience and ten subsequent cases. Perioperative, perinatal and neonatal outcomes were analysed. RESULTS Of 15 pregnancies, 10 (66.7%) and 5 (33.3%) were for Stage II and III TTTS respectively, with FLP performed at an earlier Quintero stage in the later cohort. Overall mean gestational ages at presentation, laser and delivery were comparable between the cohorts at 19.7 (15.4-24.3) weeks, 20.3 (16.3-25.0) weeks and 31.2 (27.6-37.0) weeks, respectively. 2 (13.3%) cases had intra-amniotic bleeding and 1 (6.7%) had iatrogenic septostomy. 1 (6.7%) case had persistent TTTS requiring repeat FLP, and another (6.7%) had preterm premature rupture of membranes at seven weeks post procedure. The overall perinatal survival rate was 21 (75.0%) out of 28 infants. One mother underwent termination of pregnancy for social reasons at 1.4 weeks post procedure. Double survival occurred in 8 (57.1%) out of 14 pregnancies, while 13 (92.9%) had at least one survivor. CONCLUSION FLP requires a highly specialised team and tertiary neonatal facility. Continual training improves maternal and perinatal outcomes, ensuring comparable standards with international centres.
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Affiliation(s)
- Michelle Loh
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | - Anju Bhatia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Kai Lit Tan
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Edwin Thia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - George Seow Heong Yeo
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
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Abstract
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.
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Affiliation(s)
- Sally M Winkler
- Department of Bioengineering, University of California, Berkeley, CA, USA. and University of California, Berkeley-University of California, San Francisco Graduate Program in Bioengineering, Berkeley, CA, USA
| | - Michael R Harrison
- Division of Pediatric Surgery, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Phillip B Messersmith
- Department of Bioengineering, University of California, Berkeley, CA, USA. and Department of Materials Science and Engineering, University of California, Berkeley, CA, USA and Materials Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
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Stirnemann J, Djaafri F, Kim A, Mediouni I, Bussieres L, Spaggiari E, Veluppillai C, Lapillonne A, Kermorvant E, Magny JF, Colmant C, Ville Y. Preterm premature rupture of membranes is a collateral effect of improvement in perinatal outcomes following fetoscopic coagulation of chorionic vessels for twin-twin transfusion syndrome: a retrospective observational study of 1092 cases. BJOG 2018; 125:1154-1162. [DOI: 10.1111/1471-0528.15147] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2018] [Indexed: 11/29/2022]
Affiliation(s)
- J Stirnemann
- Obstetrics and Fetal Medicine; Hôpital Necker Enfants Malades; AP-HP; Paris France
- EA7328 and PACT; Université Paris Descartes; Paris France
| | - F Djaafri
- Obstetrics and Fetal Medicine; Hôpital Necker Enfants Malades; AP-HP; Paris France
| | - A Kim
- Obstetrics and Fetal Medicine; Hôpital Necker Enfants Malades; AP-HP; Paris France
| | - I Mediouni
- Obstetrics and Fetal Medicine; Hôpital Necker Enfants Malades; AP-HP; Paris France
| | - L Bussieres
- Obstetrics and Fetal Medicine; Hôpital Necker Enfants Malades; AP-HP; Paris France
- EA7328 and PACT; Université Paris Descartes; Paris France
| | - E Spaggiari
- Obstetrics and Fetal Medicine; Hôpital Necker Enfants Malades; AP-HP; Paris France
- EA7328 and PACT; Université Paris Descartes; Paris France
| | - C Veluppillai
- Obstetrics and Fetal Medicine; Hôpital Necker Enfants Malades; AP-HP; Paris France
| | - A Lapillonne
- EA7328 and PACT; Université Paris Descartes; Paris France
- Neonatology and Intensive Care Unit; Hôpital Necker Enfants Malades; AP-HP; Paris France
| | - E Kermorvant
- EA7328 and PACT; Université Paris Descartes; Paris France
- Neonatology and Intensive Care Unit; Hôpital Necker Enfants Malades; AP-HP; Paris France
| | - J-F Magny
- EA7328 and PACT; Université Paris Descartes; Paris France
- Neonatology and Intensive Care Unit; Hôpital Necker Enfants Malades; AP-HP; Paris France
| | - C Colmant
- Obstetrics and Fetal Medicine; Hôpital Necker Enfants Malades; AP-HP; Paris France
| | - Y Ville
- Obstetrics and Fetal Medicine; Hôpital Necker Enfants Malades; AP-HP; Paris France
- EA7328 and PACT; Université Paris Descartes; Paris France
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11
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Snowise S, Mann LK, Moise KJ, Johnson A, Bebbington MW, Papanna R. Preterm prelabor rupture of membranes after fetoscopic laser surgery for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:607-611. [PMID: 27153404 DOI: 10.1002/uog.15958] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/24/2016] [Accepted: 04/29/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To assess the incidence, clinical course, risk factors and outcomes of preterm prelabor rupture of membranes (PPROM) after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). METHODS This was a prospective observational cohort study of 154 consecutive cases of TTTS. PPROM was defined as rupture of membranes before 34 weeks' gestation. Procedure-to-PPROM and PPROM-to-delivery intervals were determined. Relevant preoperative and intraoperative variables were analyzed by univariate and multivariate logistic regression to determine their impact on PPROM after FLS. RESULTS The incidence of PPROM was 39% (n = 60), occurring at a mean gestational age of 27.2 ± 4.6 weeks. Median procedure-to-PPROM interval was 46 (range, 1-105; interquartile range (IQR), 13-66) days and median PPROM-to-delivery interval was 1 (range, 0-93; IQR, 0-13) day. Mean gestational age at delivery in cases with PPROM was 29.0 ± 4.5 weeks compared with 32.6 ± 3.9 weeks in cases without PPROM (P < 0.0001). Insertion of a collagen plug was the only significant factor found on both univariate and multivariate analysis to be associated with an increased rate of PPROM (odds ratio, 3.1 (95% CI, 1.2-8.0); P = 0.006). There was no statistically significant difference in fetal (P = 0.07) or neonatal (P = 0.08) survival between those with and those without PPROM. CONCLUSIONS PPROM after FLS increases prematurity by 3.6 weeks. The latency period after PPROM was 2 weeks; 50% of patients delivered within 24 h. No variable thought to be associated with PPROM after FLS was found to be significantly associated with this complication. Other etiologies and mechanisms for PPROM after FLS should be explored. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S Snowise
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - L K Mann
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - K J Moise
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - A Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - M W Bebbington
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - R Papanna
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
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12
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Rouzaire M, Comptour A, Belville C, Bouvier D, Clairefond G, Ponelle F, Sapin V, Gallot D, Blanchon L. All-trans retinoic acid promotes wound healing of primary amniocytes through the induction of LOXL4, a member of the lysyl oxidase family. Int J Biochem Cell Biol 2016; 81:10-19. [PMID: 27769742 DOI: 10.1016/j.biocel.2016.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 07/23/2016] [Accepted: 10/07/2016] [Indexed: 01/19/2023]
Abstract
Thirty percent of preterm births directly result from preterm premature rupture of fetal membranes (PPROM). Clinical management currently proposes using a collagen plug to mechanically stop loss of amniotic fluid. Vitamin A and its active metabolite (retinoic acid) have well-known pro-healing properties and could thus make good candidates as a proposable adjuvant to this mechanical approach. Here we investigate the molecular mechanisms involved in the pro-healing properties of all-trans retinoic acid (atRA) in fetal membranes via an approach using an in vitro primary amniocyte wound model and transcriptomics. The results demonstrate that atRA promotes migration in primary amniocytes, improving wound healing in vitro by up to 90%. This effect is mediated by the induction of LOXL4, which plays a crucial role in the dynamics of the extracellular matrix by regulating collagen reticulation. This new insight into how atRA exerts its pro-healing properties prompts us to propose using atRA as a candidate strategy to help prevent future PPROM.
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Affiliation(s)
- Marion Rouzaire
- Clermont Université, Auvergne University, EA7281- Retinoids, Reproduction, Developmental Diseases, Medicine School, 63000 Clermont-Ferrand, France
| | - Aurélie Comptour
- Clermont Université, Auvergne University, EA7281- Retinoids, Reproduction, Developmental Diseases, Medicine School, 63000 Clermont-Ferrand, France
| | - Corinne Belville
- Clermont Université, Auvergne University, EA7281- Retinoids, Reproduction, Developmental Diseases, Medicine School, 63000 Clermont-Ferrand, France; Clermont Université, Auvergne University, GReD, 63000 Clermont-Ferrand, France
| | - Damien Bouvier
- Clermont Université, Auvergne University, EA7281- Retinoids, Reproduction, Developmental Diseases, Medicine School, 63000 Clermont-Ferrand, France; CHU Clermont-Ferrand, Biochemistry and Molecular Biology Department, 63000 Clermont-Ferrand, France
| | - Gaël Clairefond
- Clermont Université, Auvergne University, EA7281- Retinoids, Reproduction, Developmental Diseases, Medicine School, 63000 Clermont-Ferrand, France
| | - Flora Ponelle
- Clermont Université, Auvergne University, EA7281- Retinoids, Reproduction, Developmental Diseases, Medicine School, 63000 Clermont-Ferrand, France
| | - Vincent Sapin
- Clermont Université, Auvergne University, EA7281- Retinoids, Reproduction, Developmental Diseases, Medicine School, 63000 Clermont-Ferrand, France; CHU Clermont-Ferrand, Biochemistry and Molecular Biology Department, 63000 Clermont-Ferrand, France.
| | - Denis Gallot
- Clermont Université, Auvergne University, EA7281- Retinoids, Reproduction, Developmental Diseases, Medicine School, 63000 Clermont-Ferrand, France; CHU Clermont-Ferrand, Obstetrics and Gynecology Department, 63000 Clermont-Ferrand, France
| | - Loïc Blanchon
- Clermont Université, Auvergne University, EA7281- Retinoids, Reproduction, Developmental Diseases, Medicine School, 63000 Clermont-Ferrand, France
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Kim SH, Jung E, Lee MY, Lee BS, Won HS, Kim EAR, Kim KS. The Impact of Introduction of Fetoscopic Laser Surgery on Twin-to-Twin Transfusion Syndrome. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.4.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Soo Hyun Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Euiseok Jung
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Sop Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ellen Ai-Rhan Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Soo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Histologic changes of the fetal membranes after fetoscopic laser surgery for twin-twin transfusion syndrome. Pediatr Res 2015; 78:247-55. [PMID: 26020146 DOI: 10.1038/pr.2015.105] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/27/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Preterm premature rupture of membranes remains a major complication after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). We studied the histologic changes of fetal membranes post-FLS and investigated a possible impact of amniotic fluid (AF) dilution. METHODS Fetal membranes of 31 pregnancies that underwent FLS for TTTS were investigated histologically at delivery at different sites: trocar site of recipient sac and at distance, donor sac, and inter-twin membrane. RESULTS The trocar insertion site on the recipient sac showed no signs of histologic hallmarks of healing. Wide-spread alteration in collagen organization and higher apoptotic index in the amnion of the recipient sac which were absent in donor's and reference membranes. To explain the mechanisms, we analyzed the AF composition of recipient sacs from TTTS pregnancies vs. GA-matched healthy singleton controls and found glucose, protein and lactate dehydrogenase activity were all significantly lower in TTTS sacs consistent with over-dilution of recipient's AF (~2-fold). In-vitro exposure of healthy amniochorion to analogous dilutional stress conditions recapitulated the histologic changes and induced apoptosis and autophagy. CONCLUSION Alteration in structural integrity of the recipient's amniochorion, possibly in response to dilution stress, along with ineffective repair mechanisms may explain the increased incidence of preterm birth post-FLS.
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Papanna R, Mann LK, Tseng SCG, Stewart RJ, Kaur SS, Swindle MM, Kyriakides TR, Tatevian N, Moise KJ. Cryopreserved human amniotic membrane and a bioinspired underwater adhesive to seal and promote healing of iatrogenic fetal membrane defect sites. Placenta 2015; 36:888-94. [PMID: 26059341 DOI: 10.1016/j.placenta.2015.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 03/27/2015] [Accepted: 05/21/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION We investigated the ability of cryopreserved human amniotic membrane (hAM) scaffold sealed with an underwater adhesive, bio-inspired by marine sandcastle worms to promote healing of iatrogenic fetal membrane defects in a pregnant swine model. METHODS Twelve Yucatan miniature pigs underwent laparotomy under general anesthesia at 70 days gestation (term = 114 days). The gestational sacs were assigned to uninstrumented (n = 24) and instrumented with 12 Fr trocar, which was further randomized into four different arms-no hAM patch, (n = 22), hAM patch secured with suture (n = 16), hAM patch with no suture (n = 14), and hAM patch secured with adhesive (n = 9). The animals were euthanized 20 days after the procedure. Gross and histological examination of the entry site was performed for fetal membrane healing. RESULTS There were no differences in fetal survival, amniotic fluid levels, or dye-leakage from the amniotic cavity between the groups. The fetal membranes spontaneously healed in instrumented sacs without hAM patches. In sacs with hAM patches secured with sutures, the patch was incorporated into the swine fetal membranes. In sacs with hAM patches without sutures, 100% of the patches were displaced from the defect site, whereas in sacs with hAM patches secured with adhesive 55% of the patches remained in place and showed complete healing (p = 0.04). DISCUSSION In contrast to humans, swine fetal membranes heal spontaneously after an iatrogenic injury and thus not an adequate model. hAM patches became incorporated into the defect site by cellular ingrowth from the fetal membranes. The bioinspired adhesive adhered the hAM patches within the defect site.
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Affiliation(s)
- R Papanna
- The Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Medical School, Houston, TX, USA.
| | - L K Mann
- The Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Medical School, Houston, TX, USA
| | - S C G Tseng
- Research & Development of Tissue Tech, Ocular Surface Center, P.A., Miami, FL, USA
| | - R J Stewart
- Department of Engineering, College of Engineering, The University of Utah, Salt Lake City, UT, USA
| | - S S Kaur
- Department of Engineering, College of Engineering, The University of Utah, Salt Lake City, UT, USA
| | - M M Swindle
- Comparative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - T R Kyriakides
- Department of Pathology, Yale University, New Haven, CT, USA
| | - N Tatevian
- Department of Pathology, The University of Texas Medical School, Houston, TX, USA
| | - K J Moise
- The Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Medical School, Houston, TX, USA
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Papanna R, Mann LK, Baschat AA, Bebbington MW, Khalek N, Johnson A, Snowise S, Moise KJ. Cervical length in prediction of preterm birth after laser surgery for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:175-182. [PMID: 25319967 DOI: 10.1002/uog.14696] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/21/2014] [Accepted: 10/04/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To determine the risk factors for spontaneous preterm delivery (PTD) or preterm prelabor rupture of membranes (PPROM) at < 34 weeks' gestation after fetoscopic laser surgery for twin-twin transfusion syndrome and to identify the optimal threshold for preoperative cervical length (CL) that indicates a high risk for spontaneous PTD. METHODS This was a secondary analysis of data prospectively collected from 449 patients at three fetal centers. CL measurements were obtained by preoperative transvaginal ultrasound, at a gestational age of 16-26 weeks. The risk factors associated with spontaneous PTD before 34 weeks' gestation were determined using multivariable logistic regression analysis. We excluded patients with dual fetal demise and those with maternal or fetal indications for delivery without PPROM (n = 63). The optimal threshold for cervical length to predict spontaneous PTD before 34 weeks was determined using a receiver-operating characteristics (ROC) curve and Youden index. Additionally, the CL threshold for spontaneous PTD at 2-week intervals between 24 and 34 weeks was determined. RESULTS Spontaneous PTD before 34 weeks occurred in 206 (53.4%) of the included patients. Only the preoperative CL was significantly associated with spontaneous PTD. The preoperative CL was normally distributed with a mean of 37.6 ± 10.3 mm (range, 5-66 mm). Maternal age and parity were positively associated, and gestational age at procedure and anterior placenta were negatively associated, with CL on multivariable linear regression analysis. The area under the ROC curve for predicting spontaneous PTD with CL measurements was 0.61 (P = 0.02) and the optimal threshold was 28 mm with a Youden index of 0.19 (sensitivity and specificity of 92% and 27%, respectively). A CL measurement of < 28 mm increased the risk of spontaneous PTD for all gestational age thresholds. CONCLUSIONS Spontaneous PTD at < 34 weeks' gestation is associated with a preoperative CL of < 28 mm. Preventive strategies should focus on this high-risk group.
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Affiliation(s)
- R Papanna
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, The Fetal Center at Children's Memorial Hermann Hospital, UT Health - The University of Texas Medical School at Houston, TX, USA
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Maggio L, Carr SR, Watson-Smith D, OʼBrien BM, Lopes V, Muratore CS, Luks FI. Iatrogenic Preterm Premature Rupture of Membranes after Fetoscopic Laser Ablative Surgery. Fetal Diagn Ther 2014; 38:29-34. [DOI: 10.1159/000369250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/20/2014] [Indexed: 11/19/2022]
Abstract
Introduction: To describe the incidence and risk factors for iatrogenic premature preterm rupture of membranes (iPPROM) after fetoscopic laser surgery for the twin-to-twin-transfusion syndrome. Materials and Methods: This is a retrospective review of all patients who have undergone fetoscopic laser surgery at a single fetal treatment center since 2000. We defined iPPROM as spontaneous rupture of membranes before the onset of labor prior to 34 weeks of gestation. The iPPROM cohort was compared to the cohort without iPPROM for several preoperative, operative, and delivery characteristics. Results: Ninety-two consecutive patients were reviewed. The overall rate of iPPROM was 18.5% (n = 17). The rates of iPPROM within 1 and 4 weeks were 5.4 and 10.9%, respectively. The median interval from surgery to delivery was significantly shorter in the iPPROM group (21 vs. 62 days, p = 0.01). The mean gestational age at delivery (27.0 vs. 31.1 weeks, p = 0.02) was lower in the iPPROM group. No other characteristics studied differed significantly between the groups. Discussion: The incidence of iPPROM was substantially lower than in recent multicenter reports; however, no risk factors of iPPROM could be identified. Whether this is related to variations in surgical or anesthetic management will require further investigation.
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Engels AC, Van Calster B, Richter J, DeKoninck P, Lewi L, De Catte L, Devlieger R, Deprest JA. Collagen plug sealing of iatrogenic fetal membrane defects after fetoscopic surgery for congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:54-59. [PMID: 23801588 DOI: 10.1002/uog.12547] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/11/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To investigate the efficacy of collagen plugs at reducing the risk of preterm premature rupture of membranes (PPROM) after fetoscopic surgery for congenital diaphragmatic hernia (CDH). METHODS This was a single-center cohort study on all consecutive cases undergoing fetoscopic endoluminal tracheal occlusion (FETO) for severe or moderate CDH, between April 2002 and May 2011 (n = 141). Cases either received a collagen plug for sealing the fetal membrane defect after FETO or did not, depending on the operating surgeon. The principal outcome measure was the time from fetal surgery to PPROM, further referred to as 'latency'. A multivariable Cox regression model was used to investigate the association between collagen plug and latency while adjusting for risk factors for PPROM. RESULTS Of the 141 cases, 54 (38%) received a collagen plug and 87 (62%) did not. Sixty cases experienced PPROM, 26 among cases with and 34 among cases without a plug (48 vs 39%). The hazard ratio of plug use was 1.29 (95% CI, 0.76-2.19), which does not exclude a potentially increased risk for PPROM when a collagen plug is used. For cases with a plug, 24% had PPROM before balloon removal and 24% had PPROM after elective balloon removal. For cases without a plug, these rates were 30 and 9%, respectively. Perinatal outcomes were similar in both groups. CONCLUSIONS No evidence was found that collagen plugs reduce the risk of PPROM after FETO for CDH.
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Affiliation(s)
- A C Engels
- KU Leuven, Centre for Surgical Technologies, Leuven, Belgium
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Papanna R, Block-Abraham D, Mann LK, Buhimschi IA, Bebbington M, Garcia E, Kahlek N, Harman C, Johnson A, Baschat A, Moise KJ. Risk factors associated with preterm delivery after fetoscopic laser ablation for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:48-53. [PMID: 24013922 PMCID: PMC4142227 DOI: 10.1002/uog.13206] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/02/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Despite improved perinatal survival following fetoscopic laser ablation (FLA) for twin-twin transfusion syndrome (TTTS), prematurity remains an important contributor to perinatal mortality and morbidity. The objective of the study was to identify risk factors for complicated preterm delivery after FLA. METHODS Retrospective cohort study of prospectively collected data on maternal/fetal demographics and pre-operative, operative and postoperative variables of 459 patients treated with FLA in three USA fetal centers. Multivariate linear regression was performed to identify significant risk factors associated with preterm delivery, which were cross-validated using the k-fold method. Multivariate logistic regression was performed to identify risk factors for early compared with late preterm delivery based on median gestational age at delivery of 32 weeks. RESULTS There were significant differences in case selection and outcomes between the centers. After controlling for the center of surgery, multivariate analysis indicated that a lower maternal age at procedure, a history of previous prematurity, shortened cervical length, use of amnioinfusion, a cannula diameter of 12 French (Fr), lack of a collagen plug placement and iatrogenic preterm premature rupture of membranes (iPPROM) were significantly associated with a lower gestational age at delivery. CONCLUSIONS Specific fetal/maternal and operative variables are associated with preterm delivery after FLA for the treatment of TTTS. Further studies to modify some of these variables may decrease the perinatal morbidity after laser therapy.
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Affiliation(s)
- R Papanna
- Section of Maternal-Fetal Medicine, Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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Oepkes D. Re: Risk factors associated with preterm delivery after fetoscopic laser ablation for twin-twin transfusion syndrome. R. Papanna, D. Block-Abraham, L. K. Mann, I. A. Buhimschi, M. Bebbington, E. Garcia, N. Kahlek, C. Harman, A. Johnson, A. Baschat and K. J. Moise Jr. Ultrasound Obstet Gynecol 2014; 43: 48-53. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:11-12. [PMID: 24395686 DOI: 10.1002/uog.13265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- D Oepkes
- Department of Obstetrics, Leiden University Medical Center, K-06-35, P.O.Box 9600, 2300, RC, Leiden, The Netherlands.
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Papanna R, Mann LK, Moise KY, Johnson A, Moise KJ. Absorbable gelatin plug does not prevent iatrogenic preterm premature rupture of membranes after fetoscopic laser surgery for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:456-460. [PMID: 23606579 DOI: 10.1002/uog.12487] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 04/07/2013] [Accepted: 04/10/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Despite fetoscopic laser ablation (FLA) having emerged as an effective treatment for twin-twin transfusion syndrome (TTTS), major postintervention challenges, such as iatrogenic preterm premature rupture of membranes (iPPROM), remain. A chorioamniotic plug (CAP) made of absorbable gelatin sponge has been used to seal the trocar entry site in the chorioamniotic layers to promote healing and prevent iPPROM, yet the results have been equivocal. Our objective was to test the hypothesis that, following FLA for TTTS, iPPROM may be prevented by placement of an absorbable gelatin CAP. METHODS A retrospective cohort study was performed on prospectively collected data from 134 consecutive patients who underwent FLA for TTTS. The decision for CAP placement was at the discretion of the physician. Preoperative, operative and postoperative variables were collected and analyzed. The primary outcome was the incidence of iPPROM, and the secondary outcomes were procedure-to-delivery interval and gestational age at delivery. Comparative statistical analysis was performed as appropriate. RESULTS A CAP was placed in 72 (54%) of 134 patients. Factors significantly associated with CAP placement were higher gravidity (P = 0.03), anterior placentation (P = 0.04), general endotracheal intubation (P = 0.02) and a cannula diameter of 12-Fr (P = 0.003). There were no differences between CAP and no-CAP groups in the rate of iPPROM (39% vs 34%, respectively; P = 0.42) or in the procedure-to-delivery interval (65.3 ± 34.7 days vs 58.2 ± 30.8 days, respectively; P = 0.21). The gestational age at delivery was later in the CAP group compared with the no-CAP group (30.7 ± 4.5 weeks vs 28.9 ± 3.9 weeks, respectively; P = 0.02). CONCLUSIONS CAP did not reduce the overall risk for iPPROM and did not increase the procedure-to-delivery interval. Further research is needed to identify other methods to prevent iPPROM and prolong pregnancy after laser therapy.
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Affiliation(s)
- R Papanna
- Section of Maternal-Fetal Medicine, Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and the Texas Children's Fetal Center, Houston, TX, USA
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Papanna R, Bebbington MW, Moise K. Novel findings of iatrogenic fetal membrane defect after previous fetoscopy for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:118-119. [PMID: 23335008 DOI: 10.1002/uog.12405] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Engels AC, Hoylaerts MF, Endo M, Loyen S, Verbist G, Manodoro S, DeKoninck P, Richter J, Deprest JA. In vitro sealing of iatrogenic fetal membrane defects by a collagen plug imbued with fibrinogen and plasma. Prenat Diagn 2013; 33:162-7. [PMID: 23296773 DOI: 10.1002/pd.4032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We aimed to demonstrate local thrombin generation by fetal membranes, as well as its ability to generate fibrin from fibrinogen concentrate. Furthermore, we aimed to investigate the efficacy of collagen plugs, soaked with plasma and fibrinogen, to seal iatrogenic fetal membrane defects. METHODS Thrombin generation by homogenized fetal membranes was measured by calibrated automated thrombography. To identify the coagulation caused by an iatrogenic membrane defect, we analyzed fibrin formation by optical densitometry, upon various concentrations of fibrinogen. The ability of a collagen plug soaked with fibrinogen and plasma was tested in an ex vivo model for its ability to seal an iatrogenic fetal membrane defect. RESULTS Fetal membrane homogenates potently induced thrombin generation in amniotic fluid and diluted plasma. Upon the addition of fibrinogen concentrate, potent fibrin formation was triggered. Measured by densiometry, fibrin formation was optimal at 1250 µg/mL fibrinogen in combination with 4% plasma. A collagen plug soaked with fibrinogen and plasma sealed an iatrogenic membrane defect about 35% better than collagen plugs without these additives (P = 0.037). CONCLUSIONS These in vitro experiments suggest that the addition of fibrinogen and plasma may enhance the sealing efficacy of collagen plugs in closing iatrogenic fetal membrane defects.
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Affiliation(s)
- A C Engels
- Centre for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
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Mann LK, Papanna R, Moise KJ, Byrd RH, Popek EJ, Kaur S, Tseng SC, Stewart RJ. Fetal membrane patch and biomimetic adhesive coacervates as a sealant for fetoscopic defects. Acta Biomater 2012; 8:2160-5. [PMID: 22373817 DOI: 10.1016/j.actbio.2012.02.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Revised: 01/29/2012] [Accepted: 02/16/2012] [Indexed: 01/12/2023]
Abstract
Iatrogenic preterm premature rupture of membranes after fetoscopic procedures affects 10-47% of patients, secondary to the non-healing nature of membranes and the separation of layers during the entry. In this study we developed an in vitro model to mimic the uterine wall-fetal membrane interface using a water column with one end sealed with human fetal membranes and poultry breast, and a defect was created with an 11 French trocar. Further, a fetal membrane patch in conjunction with multiphase adhesive coacervates modeled after the sandcastle worm bioadhesive was tested for sealing of an iatrogenic defect. The sealant withstood an additional traction of 12 g for 30-60 min and turbulence of the water column without leakage of fluid or slippage. The adhesive is non-toxic when in direct contact with human fetal membranes in an organ culture setting. A fetal membrane patch with multiphase adhesive complex coacervates may help to seal the defect and prevent iatrogenic preterm premature rupture of the membranes.
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Beck V, Lewi P, Gucciardo L, Devlieger R. Preterm Prelabor Rupture of Membranes and Fetal Survival after Minimally Invasive Fetal Surgery: A Systematic Review of the Literature. Fetal Diagn Ther 2012; 31:1-9. [DOI: 10.1159/000331165] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 07/26/2011] [Indexed: 11/19/2022]
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Chalouhi GE, Essaoui M, Stirnemann J, Quibel T, Deloison B, Salomon L, Ville Y. Laser therapy for twin-to-twin transfusion syndrome (TTTS). Prenat Diagn 2011; 31:637-46. [PMID: 21660997 DOI: 10.1002/pd.2803] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 05/10/2011] [Accepted: 05/10/2011] [Indexed: 11/06/2022]
Abstract
Monochorionic twins are subjected to specific complications which originate in either imbalance or abnormality of the single placenta serving two twins including twin-to-twin transfusion syndrome. The diagnosis is well established in overt clinical forms with the association of polyuric polyhydramnios and oliguric oligohydramnios. The best treatment of cases presenting before 26 weeks of gestion is fetoscopic laser ablation of the intertwin anastomoses on the chorionic plate. Although subjected to subtle variations, the core technique follows robust guidelines which could help understanding and acquiring the required skills and experience to perform this procedure. However appropriate and tailored hands-on training and appropriate perinatal set-up are critical not only for surgical management but also for the follow-up and management of related complications.
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Affiliation(s)
- G E Chalouhi
- National Referral Centre for the Management of Complicated Monochorionic Pregnancies, Department of Obstetrics and Fetal Medicine, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants-Malades, 75015 Paris, France
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Deprest J, Emonds MP, Richter J, DeKoninck P, Van Mieghem T, Van Schoubroeck D, Devlieger R, De Catte L, Lewi L. Amniopatch for iatrogenic rupture of the fetal membranes. Prenat Diagn 2011; 31:661-6. [PMID: 21656529 DOI: 10.1002/pd.2780] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/14/2011] [Accepted: 04/17/2011] [Indexed: 11/10/2022]
Abstract
With the increased use of invasive fetal procedures, the number of women facing post-procedure membrane rupture is increasing. Here we review the use of platelets and fresh frozen plasma for sealing iatrogenic fetal membrane defects by describing the mechanisms of action of the amniopatch procedure as well as published experience. In cases of iatrogenic preterm pre-labour rupture of the membranes, amniopatch effectively seals the fetal membranes in over two-thirds of cases. There is a risk of 16% of in utero fetal death, which may occur at varying intervals from the procedure and often for unknown reasons. Amniopatch has also been used as a treatment of chorionic membrane separation. In summary, current experience suggests that in cases of early onset but persistent amniotic fluid leakage following an invasive fetal procedure, amniopatch is an option.
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Affiliation(s)
- Jan Deprest
- Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospital Gasthuisberg, Leuven, Belgium.
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Deprest J, Van Mieghem T, Emonds MP, Richter J, De Koninck P, Zia S, Van Keirsbilck J, Sandaite I, Olde Damink L, Lewi L. [Amniopatch to treat iatrogenic rupture of the fetal membranes]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2011; 39:378-382. [PMID: 21596607 DOI: 10.1016/j.gyobfe.2011.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 03/23/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE With the increased use of invasive fetal procedures, the number of patients facing postprocedure membrane rupture is increasing. We aimed to describe the use of platelets and fresh frozen plasma for sealing iatrogenic fetal membrane defects. PATIENTS AND METHODS We describe the mechanisms of action of the amniopatch procedure as well as published experience. RESULTS Amniopatch effectively sealed the fetal membranes in over two thirds of published cases (n=44). There is a risk of 17% of in utero fetal death, which may occur remotely from the procedure and is often unexplained. DISCUSSION AND CONCLUSION In case of early onset but persistent amniotic fluid leakage following an invasive fetal procedure, amniopatch may be offered.
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Affiliation(s)
- J Deprest
- Département d'obstétrique et de gynécologie, division femme et enfant, hôpital universitaire Gasthuisberg, Leuven, Belgique.
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29
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Use of the Learning Curve-Cumulative Summation test for quantitative and individualized assessment of competency of a surgical procedure in obstetrics and gynecology: fetoscopic laser ablation as a model. Am J Obstet Gynecol 2011; 204:218.e1-9. [PMID: 21111398 DOI: 10.1016/j.ajog.2010.10.910] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 10/08/2010] [Accepted: 10/13/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to determine the learning curve (LC) for fetoscopic laser photocoagulation (FLP) as a model for the evaluation of training in surgical procedures. STUDY DESIGN A retrospective review of consecutive case series of FLP from 2 centers with 3 operators (operator I [O-I], observer trained; operator II [O-II], hands-on trained; and operator III [O-III], clinical fellow) was performed and the LC-cumulative summation (CUSUM) test was plotted. RESULTS The acceptable and unacceptable success rates for at least 1 fetus survival after FLP were set at 82% and 70%, respectively, from a systematic review. A total of 171 consecutive cases were performed by the 3 operators (O-I, 91; O-II, 49; and O-III, 31). From LC-CUSUM test O-I needed 60 procedures, O-II needed 20 procedures, and O-III needed 20 procedures to reach an acceptable performance rate for at least 1 survivor. CONCLUSION The LC-CUSUM test can be used to accurately assess the LC in a surgical procedure in obstetrics and gynecology. Hands-on trained operators exhibit a shorter LC.
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30
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Haller CM, Buerzle W, Brubaker CE, Messersmith PB, Mazza E, Ochsenbein-Koelble N, Zimmermann R, Ehrbar M. Mussel-mimetic tissue adhesive for fetal membrane repair: a standardized ex vivo evaluation using elastomeric membranes. Prenat Diagn 2011; 31:654-60. [PMID: 21351279 DOI: 10.1002/pd.2712] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 12/29/2010] [Accepted: 12/29/2010] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Iatrogenic preterm premature rupture of membranes (iPPROM), the main complication of invasive interventions in the prenatal period, seriously limits the benefit of diagnostic or surgical prenatal procedures. This study aimed to evaluate preventive plugging of punctured fetal membranes in an ex vivo situation using a new mussel-mimetic tissue adhesive (mussel glue) to inhibit leakage. METHODS A novel biomechanical test device that tests the closure of injured membranes under near-physiological conditions was used. Mussel glue, a poly(ethylene glycol)-based hydrogel, was used to seal membrane defects of up to 3 mm in mechanically well-defined elastomeric membranes with three different degrees of stiffness. RESULTS Elastomeric test membranes were successfully employed for testing mussel glue under well-defined conditions. Mussel glue plugs were distended by up to 94%, which translated to an improved sealing efficiency on elastomeric membranes with high stiffness. For the stiffest membrane tested, a critical burst pressure of 48 mbar (36 mmHg) was accomplished in this ex vivo setting. CONCLUSIONS Mussel glue appears to efficiently seal membrane defects under well-standardized ex vivo conditions. As repaired membranes resist pressures measured in amniotic cavities, mussel glue might represent a novel sealing method for iatrogenic membrane defects.
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Affiliation(s)
- C M Haller
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
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31
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Papanna R, Mann LK, Molina S, Johnson A, Moise KJ. Changes in the recipient fetal Tei index in the peri-operative period after laser photocoagulation of placental anastomoses for twin-twin transfusion syndrome. Prenat Diagn 2011; 31:176-80. [DOI: 10.1002/pd.2673] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Revised: 09/19/2010] [Accepted: 10/24/2010] [Indexed: 11/09/2022]
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