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Wawrla-Zepf J, Vonzun L, Rüegg L, Strübing N, Krähenmann F, Meuli M, Mazzone L, Moehrlen U, Ochsenbein-Kölble N. Chorioamniotic Membrane Separation after Fetal Spina Bifida Repair: Impact of CMS Size and Patient Management. Fetal Diagn Ther 2024:1-11. [PMID: 39068923 DOI: 10.1159/000540510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Chorioamniotic membrane separation (CMS) is a known complication after fetal spina bifida (fSB) repair. This study's goal was to analyze women's outcomes with open fSB repair and CMS (group A) compared to the ones without (group B) and to assess the influence of CMS size and patient management. METHODS A total of 194 women with open fSB repair at our center were included in this retrospective study. Outcomes of group A were compared to the ones of group B. Regression analysis was performed to assess risk factors for CMS. Two subgroup analyses assessed the impact of CMS size (small [A-small] vs. large [A-large]) as well as patient management (A1 = hospitalization vs. A2 = no hospitalization) on pregnancy outcomes. RESULTS Of 194 women, 23 (11.9%) were in group A and 171 (88.1%) in group B. Preterm premature rupture of membranes (PPROMs) (69.6% vs. 24.1%, p = <0.001), amniotic infection syndrome (AIS) (22.7% vs. 7.1%, p = 0.03), histologically confirmed chorioamnionitis (hCA) (40.0% vs. 14.7%, p = 0.03), length of hospital stay (LOS) after fSB repair (35 [19-65] vs. 17 [14-27] days), and overall LOS (43 [33-71] vs. 35 [27-46] days, p = 0.004) were significantly more often/longer in group A. Gestational age (GA) at delivery was significantly lower in group A compared to group B (35.3 [32.3-36.3] vs. 36.7 [34.9-37.0] weeks, p = 0.006). Regression analysis did not identify risk factors for CMS. Subgroup analysis comparing CMS sized in group A-small versus A-large showed higher AIS rate (42% vs. 0%, p = 0.04), lower LOS (22.0 [15.5-42.5] vs. 59.6 ± 24.1, p = 0.003). Comparison of group A1 versus A2 showed longer LOS (49.3 ± 22.8 vs. 15 [15-17.5] days, p < 0.001), lower planned readmission rate (5.6% vs. 80%, p = 0.003). CONCLUSION CMS significantly increased the risk of PPROM, AIS, hCA, caused longer LOS, and caused lower GA at delivery. Women with small CMS had higher AIS rates but shorter LOS compared to women with large CMS, while apart from LOS pregnancy outcomes did not differ regarding patient management (hospitalization after CMS yes vs. no).
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Affiliation(s)
- Julia Wawrla-Zepf
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Ladina Vonzun
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Ladina Rüegg
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Nele Strübing
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Franziska Krähenmann
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Martin Meuli
- University of Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Luca Mazzone
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
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Banu T, Sharma S, Chowdhury TK, Aziz TT, Martin B, Seyi-Olajide JO, Ameh E, Ozgediz D, Lakhoo K, Bickler SW, Meara JG, Bundy D, Jamison DT, Klazura G, Sykes A, Yap A, Philipo GS. Surgically Correctable Congenital Anomalies: Reducing Morbidity and Mortality in the First 8000 Days of Life. World J Surg 2023; 47:3408-3418. [PMID: 37311874 DOI: 10.1007/s00268-023-07087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Congenital anomalies are a leading cause of morbidity and mortality worldwide. We aimed to review the common surgically correctable congenital anomalies with recent updates on the global disease burden and identify the factors affecting morbidity and mortality. METHOD A literature review was done to assess the burden of surgical congenital anomalies with emphasis on those that present within the first 8000 days of life. The various patterns of diseases were analyzed in both low- and middle-income countries (LMIC) and high-income countries (HIC). RESULTS Surgical problems such as digestive congenital anomalies, congenital heart disease and neural tube defects are now seen more frequently. The burden of disease weighs more heavily on LMIC. Cleft lip and palate has gained attention and appropriate treatment within many countries, and its care has been strengthened by global surgical partnerships. Antenatal scans and timely diagnosis are important factors affecting morbidity and mortality. The frequency of pregnancy termination following prenatal diagnosis of a congenital anomaly is lower in many LMIC than in HIC. CONCLUSION Congenital heart disease and neural tube defects are the most common congenital surgical diseases; however, easily treatable gastrointestinal anomalies are underdiagnosed due to the invisible nature of the condition. Current healthcare systems in most LMICs are still unprepared to tackle the burden of disease caused by congenital anomalies. Increased investment in surgical services is needed.
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Affiliation(s)
- Tahmina Banu
- Chittagong Research Institute for Children Surgery (CRICS), Panchlaish, Chittagong, 4203, Bangladesh.
| | - Shilpa Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Tanvir Kabir Chowdhury
- Department of Pediatric Surgery, Chittagong Medical College and Hospital (CMCH), Chittagong, Bangladesh
| | - Tasmiah Tahera Aziz
- Chittagong Research Institute for Children Surgery (CRICS), Panchlaish, Chittagong, 4203, Bangladesh
| | - Benjamin Martin
- Department of Paediatric Surgery and Urology, Bristol Children's Hospital, Bristol, UK
| | | | - Emmanuel Ameh
- Division of Pediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria
| | - Doruk Ozgediz
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Kokila Lakhoo
- Department of Paediatric Surgery, University of Oxford and Oxford University Hospitals, Oxford, UK
| | - Stephen W Bickler
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego School of Medicine, 9500 Gilman Drive #0739, La Jolla, San Diego, CA, 92093-0739, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Donald Bundy
- Global Research Consortium for School Health and Nutrition, London School of Hygiene and Tropical Medicine, London, UK
| | - Dean T Jamison
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Greg Klazura
- Loyola University Medical Center, Chicago, IL, USA
| | - Alicia Sykes
- Naval Medical Center San Diego, San Diego, CA, USA
| | - Ava Yap
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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3
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Olutoye OO, Joyeux L, King A, Belfort MA, Lee TC, Keswani SG. Minimally Invasive Fetal Surgery and the Next Frontier. Neoreviews 2023; 24:e67-e83. [PMID: 36720693 DOI: 10.1542/neo.24-2-e67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Luc Joyeux
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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Lee SY, Papanna R, Farmer D, Tsao K. Fetal Repair of Neural Tube Defects. Clin Perinatol 2022; 49:835-848. [PMID: 36328602 DOI: 10.1016/j.clp.2022.06.004] [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: 01/27/2023]
Abstract
Myelomeningocele is the most common congenital neurologic defect, and the only nonlethal disease addressed by fetal surgery. A randomized control trial has established amelioration of the Arnold-Chiari II malformation, reduced ventriculoperitoneal shunt rate, and improvement in distal neurologic function in patients that receive in utero repair. Long-term follow-up of these school-age children demonstrates the persistence of these effects. The use of stem cells in fetal repair is being investigated to further improve distal motor function.
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Affiliation(s)
- Su Yeon Lee
- Department of Surgery, Division of Pediatric, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Boulevard, Room 5107, Sacramento, CA 95817, USA.
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health Science Center at Houston, 6410 Fannin Street, Suite 210, Houston, TX 77030, USA
| | - Diana Farmer
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Boulevard, Sacramento, CA 95817, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery, UT Health Science Center at Houston, 6410 Fannin Street, Suite 950, Houston, TX 77030, USA
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Burgos CM, Frenckner B, Broman LM. Premature and Extracorporeal Life Support: Is it Time? A Systematic Review. ASAIO J 2022; 68:633-645. [PMID: 34593681 DOI: 10.1097/mat.0000000000001555] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Early preterm birth < 34 gestational weeks (GA) and birth weight (BW) <2 kg are relative contraindications for extracorporeal membrane oxygenation (ECMO). However, with improved technology, ECMO is presently managed more safely and with decreasing complications. Thus, these relative contraindications may no longer apply. We performed a systematic review to evaluate the existing literature on ECMO in early and late (34-37 GA) prematurity focusing on survival to hospital discharge and the complication intracranial hemorrhage (ICH). Data sources: MEDLINE, PubMed, Web of Science, Embase, and the Cochrane Database. Only publications in the English language were evaluated. Of the 36 included studies, 23 were related to ECMO support for respiratory failure, 10 for cardiac causes, and four for congenital diaphragmatic hernia (CDH). Over the past decades, the frequency of ICH has declined (89-21%); survival has increased in both early prematurity (25-76%), and in CDH (33-75%), with outcome similar to late prematurity (48%). The study was limited by an inherent risk of bias from overlapping single-center and registry data. Both the risk of ICH and death have decreased in prematurely born treated with ECMO. We challenge the 34 week GA time limit for ECMO and propose an international task force to revise current guidelines. At present, gestational age < 34 weeks might no longer be considered a contraindication for ECMO in premature neonates.
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Affiliation(s)
- Carmen Mesas Burgos
- From the Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Björn Frenckner
- From the Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Marquart JP, Foy AB, Wagner AJ. Controversies in Fetal Surgery: Prenatal Repair of Myelomeningocele in the Modern Era. Clin Perinatol 2022; 49:267-277. [PMID: 35210005 DOI: 10.1016/j.clp.2021.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Fetal surgery is a constantly evolving field that showed noticeable progress with the treatment of myelomeningocele (MMC) using prenatal repair. Despite this success, there are ongoing questions regarding the optimal approach for fetal myelomeningocele repair, as well as which patients are eligible. Expansion of the inclusion and exclusion criteria is an important ongoing area of study for myelomeningocele including the recent Management of Myelomeningocele Plus trial. The significant personal and financial burden required of families seeking treatment has likely limited its accessibility to the general population.
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Affiliation(s)
- John P Marquart
- Children's Wisconsin, 999 North 92nd Street, Suite C320, Milwaukee, WI 53226, USA
| | - Andrew B Foy
- Department of Pediatric Neurosurgery, Children's Wisconsin, 8915 W. Connell Court, Milwaukee, WI 53226, USA
| | - Amy J Wagner
- Division of Pediatric Surgery, Children's Wisconsin, 999 North 92nd Street, Suite C320, Milwaukee, WI 53226, USA.
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Lillegard JB, Eyerly-Webb SA, Watson DA, Bahtiyar MO, Bennett KA, Emery SP, Fisher AJ, Goldstein RB, Goodnight WH, Lim FY, McCullough LB, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Treadwell MC, Tsao K, Wagner AJ, Zaretsky MV. Placental Location in Maternal-Fetal Surgery for Myelomeningocele. Fetal Diagn Ther 2021; 49:117-124. [PMID: 34915495 DOI: 10.1159/000521379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Uterine incision based on placental location in open maternal-fetal surgery (OMFS) has never been evaluated in regards to maternal or fetal outcomes. OBJECTIVE To investigate whether an anterior placenta was associated with increased rates of intraoperative, perioperative, antepartum, obstetric, or neonatal complications in mothers and babies who underwent OMFS for myelomeningocele (fMMC) closure. METHODS Data from the international multi-center prospective registry of patients who underwent OMFS for fMMC closure (fMMC Consortium Registry, 12/15/2010-7/31/2019) was used to compare fetal and maternal outcomes between anterior and posterior placental locations. RESULTS Placental location for 623 patients was evenly distributed between anterior (51%) or posterior (49%). Intraoperative fetal bradycardia (8.3% vs 3.0%, p=0.005) and performance of fetal resuscitation (3.6% vs 1.0%, p=0.034) occurred more frequently in cases with an anterior placenta when compared to those with a posterior placenta. Obstetric outcomes including membrane separation, placental abruption, and spontaneous rupture of membranes were not different among the two groups. However, thinning of the hysterotomy site (27.7% vs 17.7%, p=0.008) occurred more frequently in cases of anterior placenta. Gestational age at delivery (p=0.583) and length of stay in the neonatal intensive care unit (p=0.655) were similar between the two groups. Fetal incision dehiscence and wound revision were not significantly different between groups. Critical clinical outcomes including fetal demise, perinatal death, and neonatal death were all infrequent occurrences and not associated with placental location. CONCLUSIONS Anterior placental location is associated with increased risk of intraoperative fetal resuscitation and increased thinning at the hysterotomy closure site. Individual institutional experiences may have varied but the aggregate data from the fMMC Consortium did not show a significant impact on the gestational age at delivery or maternal or fetal clinical outcomes.
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Affiliation(s)
- Joseph B Lillegard
- Midwest Fetal Care Center, Children's Minnesota, Minneapolis, Minnesota, USA
- Division of General Surgery Research, Mayo Clinic, Rochester, Minnesota, USA
- Pediatric Surgical Associates, Minneapolis, Minnesota, USA
| | | | - David A Watson
- Research Design and Analytics, Children's Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | | | - Ruth B Goldstein
- University of California San Francisco, San Francisco, California, USA
| | - William H Goodnight
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Foong-Yen Lim
- Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | | | | | | | - Rodrigo Ruano
- University of Texas Health Science Center, Houston, Texas, USA
| | | | | | - KuoJen Tsao
- University of Texas Health Science Center, Houston, Texas, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin Fetal Concerns Center, Milwaukee, Wisconsin, USA
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Two-port, exteriorized uterus, fetoscopic meningomyelocele closure has fewer adverse neonatal outcomes than open hysterotomy closure. Am J Obstet Gynecol 2021; 225:327.e1-327.e9. [PMID: 33957114 DOI: 10.1016/j.ajog.2021.04.252] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND In utero closure of meningomyelocele using an open hysterotomy approach is associated with preterm delivery and adverse neonatal outcomes. OBJECTIVE This study compared the neonatal outcomes in in utero meningomyelocele closure using a 2-port, exteriorized uterus, fetoscopic approach vs the conventional open hysterotomy approach. STUDY DESIGN This retrospective cohort study included all consecutive patients who underwent in utero meningomyelocele closure using open hysterotomy (n=44) or a 2-port, exteriorized uterus, fetoscopic approach (n=46) at a single institution between 2012 and 2020. The 2-port, exteriorized uterus, fetoscopic closure was composed of the following 3 layers: a bovine collagen patch, a myofascial layer, and a skin. The frequency of respiratory distress syndrome and a composite of other adverse neonatal outcomes, including retinopathy of prematurity, periventricular leukomalacia, and perinatal death, were compared between the study groups. Regression analyses were performed to determine any association between the fetoscopic closure and adverse neonatal outcomes, adjusted for several confounders, including gestational age of <37 weeks at delivery. RESULTS The fetoscopic closure was associated with a lower rate of respiratory distress syndrome than the open hysterotomy closure (11.5% [5 of 45] vs 29.5% [13 of 44]; P=.037). The proportion of neonates with a composite of other adverse neonatal outcomes in the fetoscopic group was half of that observed patients in the open hysterotomy group; however, this difference did not reach statistical significance (4.3% [2 of 46] vs 9.1% [4 of 44]; P=.429). Here, regression analysis has demonstrated that fetoscopic meningomyelocele closure was associated with a lower risk of respiratory distress syndrome (adjusted odds ratio, 0.23; 95% confidence interval, 0.06-0.84; P=.026) than open hysterotomy closure. CONCLUSION In utero meningomyelocele closure using a 2-port, exteriorized uterus, fetoscopic approach was associated with a lower risk of respiratory distress syndrome than the conventional open hysterotomy meningomyelocele closure.
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Schmitz D, Henn W. The fetus in the age of the genome. Hum Genet 2021; 141:1017-1026. [PMID: 34426855 PMCID: PMC9160108 DOI: 10.1007/s00439-021-02348-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 08/16/2021] [Indexed: 12/15/2022]
Abstract
Due to a number of recent achievements, the field of prenatal medicine is now on the verge of a profound transformation into prenatal genomic medicine. This transformation is expected to not only substantially expand the spectrum of prenatal diagnostic and screening possibilities, but finally also to advance fetal care and the prenatal management of certain fetal diseases and malformations. It will come along with new and profound challenges for the normative framework and clinical care pathways in prenatal (and reproductive) medicine. To adequately address the potential ethically challenging aspects without discarding the obvious benefits, several agents are required to engage in different debates. The permissibility of the sequencing of the whole fetal exome or genome will have to be examined from a philosophical and legal point of view, in particular with regard to conflicts with potential rights of future children. A second requirement is a societal debate on the question of priority setting and justice in relation to prenatal genomic testing. Third, a professional-ethical debate and positioning on the goal of prenatal genomic testing and a consequential re-structuring of clinical care pathways seems to be important. In all these efforts, it might be helpful to envisage the unborn rather not as a fetus, not as a separate moral subject and a second "patient", but in its unique physical connection with the pregnant woman, and to accept the moral quandaries implicitly given in this situation.
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Affiliation(s)
- Dagmar Schmitz
- Institute for History, Theory and Ethics in Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany.
| | - Wolfram Henn
- Institute of Human Genetics, Saarland University, Homburg/Saar, Germany
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Abstract
ZusammenfassungDas Gendiagnostikgesetz (GenDG) verbietet seit 2010 die pränatale Diagnostik spätmanifestierender Erkrankungen (§ 15(2) GenDG). In seiner Begründung bezog sich der Gesetzgeber in Analogie zu internationalen Empfehlungen für den pädiatrischen Bereich vor allem auf das Recht des heranwachsenden Kindes bzw. des späteren Erwachsenen auf Nichtwissen. Mit diesem gesetzlichen Verbot hat Deutschland einen viel diskutierten Sonderweg in der Regulierung genetischer Pränataldiagnostik eingeschlagen. Seither jedoch hat sich nicht nur die Perspektive auf prädiktive Testungen im Kindesalter verändert. In zunehmendem Maße generieren auf das gesamte Genom abzielende Diagnostikangebote auch andere vorgeburtlich genetische Informationen, die – in ähnlicher Weise wie diejenigen zu spätmanifestierenden Erkrankungen eine potenzielle Gefahr für das Recht auf Nichtwissen der späteren Person darstellen. Es soll daher im Rahmen dieses Beitrages überprüft werden, inwiefern das deutsche Diagnostikverbot und dessen Bezug auf das Recht auf Nichtwissen des späteren Kindes eine tragfähige Basis zur Regulierung gendiagnostischer Untersuchungen in der Pränatalmedizin insgesamt darstellt bzw. zukünftig darstellen kann.Untersucht wird der Argumentationsgang des Diagnostikverbotes im Hinblick auf spätmanifestierende Erkrankungen vor dem Hintergrund der Entwicklungen in der prädiktiven (genomischen) Diagnostik. Eine Analyse des normativen Begründungsrahmens zeigt, dass nach wie vor deutlicher Klärungsbedarf hinsichtlich der philosophisch-ethischen Fundierung wie auch hinsichtlich der Interpretation eines Rechts auf Nichtwissen eines (zukünftigen) Kindes im Kontext von genetischer Diagnostik besteht. Darüber hinaus müssen auch Interessen des (zukünftigen) Kindes an eventuell möglich werdender pränataler Behandlung oder Prävention von Erkrankungen in die Abwägung miteinbezogen werden.Um zukünftigen Herausforderungen genomischer Pränataldiagnostik und -therapie begegnen zu können, müsste dringend geklärt werden, inwiefern Rechte zukünftiger Personen tatsächlich in der speziellen Situation der Schwangerschaft relevant sein können und mit welchen Pflichten diese für den Gesetzgeber, aber insbesondere auch für zukünftige Eltern und Ärzte einhergehen. Der Menschenrechtsdiskurs könnte hierfür eine tragfähige Basis und hilfreiche Strategien liefern.
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Abstract
Congenital malformations occur in about 3% of all live births and are a leading cause of perinatal morbidity and mortality. An evolving understanding of the developing human fetus, advances in imaging, availability of cutting-edge instrumentation, and enhanced understanding of fetal pathophysiology, have allowed for prenatal surgical interventions to improve fetal diseases and neonatal outcomes. Fetal surgical therapy is no longer restricted to life-threatening prenatal diagnoses and can be categorized into either open surgical techniques or minimally invasive endoscopic/ultrasound-guided techniques. Patient selection requires a thorough multidisciplinary evaluation and shared decision-making process.
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Abstract
PURPOSE OF REVIEW To review the advance of maternal--fetal surgery, the research of stem cell transplantation and tissue engineering in prenatal management of fetal meningomyelocele (fMMC). RECENT FINDINGS Advance in the imaging study provides more accurate assessment of fMMC in utero. Prenatal maternal--fetal surgery in fMMC demonstrates favourable postnatal outcome. Minimally invasive fetal surgery minimizes uterine wall disruption. Endoscopic fetal surgery is performed via laparotomy-assisted or entirely percutaneous approach. The postnatal outcome for open and endoscopic fetal surgery shares no difference. Single layer closure during repair of fMMC is preferred to reduce postnatal surgical intervention. All maternal--fetal surgeries impose anesthetic and obstetric risk to pregnant woman. Ruptured of membrane and preterm delivery are common complications. Trans-amniotic stem cell therapy (TRASCET) showed potential tissue regeneration in animal models. Fetal tissue engineering with growth factors and dura substitutes with biosynthetic materials promote spinal cord regeneration. This will overcome the challenge of closure in large fMMC. Planning of the maternal--fetal surgery should adhere to ethical framework to minimize morbidity to both fetus and mother. SUMMARY Combination of endoscopic fetal surgery with TRASCET or tissue engineering will be a new vision to achieve to improve the outcome of prenatal intervention in fMMC.
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Verweij EJ, de Vries MC, Oldekamp EJ, Eggink AJ, Oepkes D, Slaghekke F, Spoor JKH, Deprest JA, Miller JL, Baschat AA, DeKoninck PLJ. Fetoscopic myelomeningocoele closure: Is the scientific evidence enough to challenge the gold standard for prenatal surgery? Prenat Diagn 2021; 41:949-956. [PMID: 33778976 PMCID: PMC8360048 DOI: 10.1002/pd.5940] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022]
Abstract
Since the completion of the Management of Myelomeningocoele Study, maternal-fetal surgery for spina bifida has become a valid option for expecting parents. More recently, multiple groups are exploring a minimally invasive approach and recent outcomes have addressed many of the initial concerns with this approach. Based on a previously published framework, we attempt to delineate the developmental stage of the surgical techniques. Furthermore, we discuss the barriers of performing randomized controlled trials comparing two surgical interventions and suggest that data collection through registries is an alternative method to gather high-grade evidence.
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Affiliation(s)
- E Joanne Verweij
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther J Oldekamp
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem K H Spoor
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan A Deprest
- Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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14
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Soltani Khaboushan A, Shakibaei M, Kajbafzadeh AM, Majidi Zolbin M. Prenatal Neural Tube Anomalies: A Decade of Intrauterine Stem Cell Transplantation Using Advanced Tissue Engineering Methods. Stem Cell Rev Rep 2021; 18:752-767. [PMID: 33742349 DOI: 10.1007/s12015-021-10150-w] [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] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
Neural tube defects (NTDs) are among the most common congenital defects during neurulation. Spina bifida is a type of NTD that can occur in different forms. Since myelomeningocele (MMC) is the most severe form of spina bifida, finding a satisfactory treatment for MMC is a gold standard for the treatment of spina bifida. The Management of Myelomeningocele Study (MOMS) demonstrated that intrauterine treatment of spina bifida could ameliorate the complications associated with spina bifida and would also reduce the placement of ventriculoperitoneal (VP) shunt by 50%. Recently developed tissue engineering (TE) approaches using scaffolds, stem cells, and growth factors allow treatment of the fetus with minimally invasive methods and promising outcomes. The application of novel patches with appropriate stem cells and growth factors leads to better coverage of the defect with fewer complications. These approaches with less invasive surgical procedures, even in animal models with similar characteristics as the human MMC defect, paves the way for the modern application of less invasive surgical methods. Significantly, the early detection of these problems and applying these approaches can increase the potential efficacy of MMC treatment with fewer complications. However, further studies should be conducted to find the most suitable scaffolds and stem cells, and their application should be evaluated in animal models. This review intends to discuss advanced TE methods for treating MMC and recent successes in increasing the efficacy of the treatment.
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Affiliation(s)
- Alireza Soltani Khaboushan
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, Keshavarz Boulevard, Tehran, 1419433151, Iran.,Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Shakibaei
- Musculoskeletal Research Group and Tumor Biology, Chair of Vegetative Anatomy, Institute of Anatomy, Faculty of Medicine, Ludwig-Maximilian-University Munich, Pettenkoferstrasse 11, D-80336, Munich, Germany
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, Keshavarz Boulevard, Tehran, 1419433151, Iran.
| | - Masoumeh Majidi Zolbin
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, Keshavarz Boulevard, Tehran, 1419433151, Iran.
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15
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Glinianaia SV, Morris JK, Best KE, Santoro M, Coi A, Armaroli A, Rankin J. Long-term survival of children born with congenital anomalies: A systematic review and meta-analysis of population-based studies. PLoS Med 2020; 17:e1003356. [PMID: 32986711 PMCID: PMC7521740 DOI: 10.1371/journal.pmed.1003356] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/26/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Following a reduction in global child mortality due to communicable diseases, the relative contribution of congenital anomalies to child mortality is increasing. Although infant survival of children born with congenital anomalies has improved for many anomaly types in recent decades, there is less evidence on survival beyond infancy. We aimed to systematically review, summarise, and quantify the existing population-based data on long-term survival of individuals born with specific major congenital anomalies and examine the factors associated with survival. METHODS AND FINDINGS Seven electronic databases (Medline, Embase, Scopus, PsycINFO, CINAHL, ProQuest Natural, and Biological Science Collections), reference lists, and citations of the included articles for studies published 1 January 1995 to 30 April 2020 were searched. Screening for eligibility, data extraction, and quality appraisal were performed in duplicate. We included original population-based studies that reported long-term survival (beyond 1 year of life) of children born with a major congenital anomaly with the follow-up starting from birth that were published in the English language as peer-reviewed papers. Studies on congenital heart defects (CHDs) were excluded because of a recent systematic review of population-based studies of CHD survival. Meta-analysis was performed to pool survival estimates, accounting for trends over time. Of 10,888 identified articles, 55 (n = 367,801 live births) met the inclusion criteria and were summarised narratively, 41 studies (n = 54,676) investigating eight congenital anomaly types (spina bifida [n = 7,422], encephalocele [n = 1,562], oesophageal atresia [n = 6,303], biliary atresia [n = 3,877], diaphragmatic hernia [n = 6,176], gastroschisis [n = 4,845], Down syndrome by presence of CHD [n = 22,317], and trisomy 18 [n = 2,174]) were included in the meta-analysis. These studies covered birth years from 1970 to 2015. Survival for children with spina bifida, oesophageal atresia, biliary atresia, diaphragmatic hernia, gastroschisis, and Down syndrome with an associated CHD has significantly improved over time, with the pooled odds ratios (ORs) of surviving per 10-year increase in birth year being OR = 1.34 (95% confidence interval [95% CI] 1.24-1.46), OR = 1.50 (95% CI 1.38-1.62), OR = 1.62 (95% CI 1.28-2.05), OR = 1.57 (95% CI 1.37-1.81), OR = 1.24 (95% CI 1.02-1.5), and OR = 1.99 (95% CI 1.67-2.37), respectively (p < 0.001 for all, except for gastroschisis [p = 0.029]). There was no observed improvement for children with encephalocele (OR = 0.98, 95% CI 0.95-1.01, p = 0.19) and children with biliary atresia surviving with native liver (OR = 0.96, 95% CI 0.88-1.03, p = 0.26). The presence of additional structural anomalies, low birth weight, and earlier year of birth were the most commonly reported predictors of reduced survival for any congenital anomaly type. The main limitation of the meta-analysis was the small number of studies and the small size of the cohorts, which limited the predictive capabilities of the models resulting in wide confidence intervals. CONCLUSIONS This systematic review and meta-analysis summarises estimates of long-term survival associated with major congenital anomalies. We report a significant improvement in survival of children with specific congenital anomalies over the last few decades and predict survival estimates up to 20 years of age for those born in 2020. This information is important for the planning and delivery of specialised medical, social, and education services and for counselling affected families. This trial was registered on the PROSPERO database (CRD42017074675).
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Affiliation(s)
- Svetlana V. Glinianaia
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- * E-mail:
| | - Joan K. Morris
- Population Health Research Institute, St George’s, University of London, London, United Kingdom
| | - Kate E. Best
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Michele Santoro
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Alessio Coi
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Annarita Armaroli
- Center for Clinical and Epidemiological Research, University of Ferrara, Ferrara, Italy
| | - Judith Rankin
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
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16
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Abstract
Fetal intervention has progressed in the past two decades from experimental proof-of-concept to practice-adopted, life saving interventions in human fetuses with congenital anomalies. This progress is informed by advances in innovative research, prenatal diagnosis, and fetal surgical techniques. Invasive open hysterotomy, associated with notable maternal-fetal risks, is steadily replaced by less invasive fetoscopic alternatives. A better understanding of the natural history and pathophysiology of congenital diseases has advanced the prenatal regenerative paradigm. By altering the natural course of disease through regrowth or redevelopment of malformed fetal organs, prenatal regenerative medicine has transformed maternal-fetal care. This review discusses the uses of regenerative medicine in the prenatal diagnosis and management of three congenital diseases: congenital diaphragmatic hernia, lower urinary tract obstruction, and spina bifida.
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Affiliation(s)
- Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Center for Regenerative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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17
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Janik K, Manire MA, Smith GM, Krynska B. Spinal Cord Injury in Myelomeningocele: Prospects for Therapy. Front Cell Neurosci 2020; 14:201. [PMID: 32714152 PMCID: PMC7340150 DOI: 10.3389/fncel.2020.00201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/09/2020] [Indexed: 01/10/2023] Open
Abstract
Myelomeningocele (MMC) is the most common congenital defect of the central nervous system and results in devastating and lifelong disability. In MMC, the initial failure of neural tube closure early in gestation is followed by a progressive prenatal injury to the exposed spinal cord, which contributes to the deterioration of neurological function in fetuses. Prenatal strategies to control the spinal cord injury offer an appealing therapeutic approach to improve neurological function, although the definitive pathophysiological mechanisms of injury remain to be fully elucidated. A better understanding of these mechanisms at the cellular and molecular level is of paramount importance for the development of targeted prenatal MMC therapies to minimize or eliminate the effects of the injury and improve neurological function. In this review article, we discuss the pathological development of MMC with a focus on in utero injury to the exposed spinal cord. We emphasize the need for a better understanding of the causative factors in MMC spinal cord injury, pathophysiological alterations associated with the injury, and cellular and molecular mechanisms by which these alterations are induced.
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Affiliation(s)
- Karolina Janik
- Shriners Hospitals Pediatric Research Center, Center for Neural Repair and Rehabilitation, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Meredith A Manire
- Department of Obstetrics and Gynecology, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA, United States
| | - George M Smith
- Shriners Hospitals Pediatric Research Center, Center for Neural Repair and Rehabilitation, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Barbara Krynska
- Shriners Hospitals Pediatric Research Center, Center for Neural Repair and Rehabilitation, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
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