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Puricelli MD, Barr SJ, Ellefson JL, Matabele MN, Nuttall EC, Garcia G, Huang SX, Venkatesh M, Lobeck IN. Perinatal Airway Management Mandibular Anomalies: A National Inpatient Cohort Analysis. Laryngoscope 2024. [PMID: 39140255 DOI: 10.1002/lary.31699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 07/25/2024] [Accepted: 07/29/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVE To characterize incidence of mandibular anomalies (MAs) and compare gestational age, airway interventions, and complications among individuals with MA phenotypes (isolated retrognathia, isolated micrognathia, syndromic micrognathia, micrognathia plus cleft palate/cleft lip and palate, agnathia/micrognathia plus cervical auricle/otocephaly, and agnathia/micrognathia plus microstomia) and unaffected individuals. METHODS The Healthcare Cost and Utilization Project Kids' Inpatient Database was used to collect data over a 20-year period beginning in 2000. Interventions were classified as perinatal when performed on day of life (DOL) 0 or 1 and subsequent when performed during the birth hospitalization after DOL 1. Hypoxic complications included cardiac arrest, birth asphyxia, hypoxic-ischemic encephalopathy, anoxic brain damage, intraventricular hemorrhage or cerebral infarction. Descriptive statistics are reported, and the Rao-Scott chi-square test compared groups. RESULTS MAs affected 119 per 100,000 birth visits. Preterm delivery was more frequent for all MA phenotypes. Individuals with MA phenotypes are more likely to require medical attention (airway intervention on DOL 0 or 1 OR no airway intervention received but patient sustained hypoxic complication/mortality): 16.2%-70.7% vs. 3.8%, p < 0.01. Despite receipt of airway interventions at a higher rate, collectively individuals with MAs who received an airway intervention on DOL 0 or 1 have a mildly elevated risk of hypoxic complication or mortality (32.4% vs. 26.4%, p < 0.01). CONCLUSIONS Preterm birth is more common, however, does not account for the elevated rate of airway intervention. Individuals with MAs require higher rates of medical attention, and current airway management paradigms are insufficient to prevent complications and mortality. LEVEL OF EVIDENCE III Laryngoscope, 2024.
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Affiliation(s)
- Michael D Puricelli
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Samantha J Barr
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Johanna L Ellefson
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Maya N Matabele
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Elle C Nuttall
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Gisselle Garcia
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Sabrina X Huang
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Manasa Venkatesh
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Inna N Lobeck
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
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Nallani R, Francis CL, Wagner AF, Brown JR. Management of Neonatal Airway Obstruction: A Point-Counterpoint Ethical Discussion. Otolaryngol Head Neck Surg 2024; 171:599-602. [PMID: 38482947 DOI: 10.1002/ohn.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/26/2024] [Accepted: 02/11/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Rohit Nallani
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Carrie L Francis
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
- Division of Pediatric Otolaryngology, Kansas City, Missouri, USA
| | | | - Jason R Brown
- Division of Pediatric Otolaryngology, Kansas City, Missouri, USA
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Berger JA, Nelson O, Staben J, Javia LR, Simpao AF, Khalek N, Oliver ER, Adzick NS, Lin EE. Immediate postdelivery airway management of neonates with prenatally diagnosed micrognathia: A retrospective observational study. Paediatr Anaesth 2024; 34:267-273. [PMID: 38069629 DOI: 10.1111/pan.14806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/23/2023] [Accepted: 11/21/2023] [Indexed: 02/08/2024]
Abstract
INTRODUCTION Micrognathic neonates are at risk for upper airway obstruction, and many require intubation in the delivery room. Ex-utero intrapartum treatment is one technique for managing airway obstruction but poses substantial maternal risks. Procedure requiring a second team in the operating room is an alternative approach to secure the obstructed airway while minimizing maternal risk. The aim of this study was to describe the patient characteristics, airway management, and outcomes for micrognathic neonates and their mothers undergoing a procedure requiring a second team in the operating room at a single quaternary care children's hospital. METHODS This was a retrospective descriptive study. Subjects had prenatally diagnosed micrognathia and underwent procedure requiring a second team in the operating room between 2009 and 2021. Collected data included infant characteristics, delivery room airway management, critical events, and medications. Follow-up data included genetic testing and subsequent procedures within 90 days. Maternal data included type of anesthetic, blood loss, and incidence of transfusion. RESULTS Fourteen deliveries were performed via procedure requiring a second team in the operating room during the study period. 85.7% were male, and 50% had a genetic syndrome. Spontaneous respiratory efforts were observed in 93%. Twelve patients (85.7%) required an endotracheal tube or tracheostomy. Management approaches varied. Medications were primarily a combination of atropine, ketamine, and dexmedetomidine. Oxygen desaturation was common, and three patients experienced bradycardia. There were no periprocedural deaths. Follow-up at 90 days revealed that 78% of patients underwent at least one additional procedure, and one patient died due to an unrelated cause. All mothers underwent cesarean deliveries under neuraxial anesthesia. Median blood loss was 700 mL [IQR 700 mL, 800 mL]. Only one mother required a blood transfusion for pre-procedural placental abruption. DISCUSSION Procedure requiring a second team in the operating room is a safe and effective approach to manage airway obstruction in micrognathic neonates while minimizing maternal morbidity. CONCLUSIONS Though shown to be safe and effective, more data are needed to support the use of procedure requiring a second team in the operating room as an alternative to ex-utero intrapartum treatment for micrognathia outside of highly specialized maternal-fetal centers.
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Affiliation(s)
- Jessica A Berger
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James Staben
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Luv R Javia
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Clinical Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Allan F Simpao
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward R Oliver
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elaina E Lin
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Liseth O, Weng J, Schenone M, Moore K, Betcher H, Branda M, Rivera-Chiauzzi E, Larish A. The impact of fetal surgical procedures on perinatal anxiety and depression. Am J Obstet Gynecol MFM 2024; 6:101244. [PMID: 38061550 DOI: 10.1016/j.ajogmf.2023.101244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/19/2023] [Accepted: 11/27/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Perinatal mental illness presents a significant health burden to both patients and families. Many factors are hypothesized to increase the incidence of perinatal depression and anxiety in the fetal surgical population, including uncertain fetal prognosis and inherent risks of surgery and preterm delivery. OBJECTIVE This study aimed to determine the incidence and disease course of postpartum depression and anxiety in the fetal surgery population. STUDY DESIGN A retrospective medical record review study was conducted of fetal surgery patients delivering between November 2016 and November 2021 at an academic level IV perinatal healthcare center. Demographics and surgical, obstetrical, and psychiatric diagnoses were abstracted. Standard descriptive analyses were performed. RESULTS Eligible patients were identified (N=119). Fetal surgery was performed at a mean gestational age of 22.8 weeks (standard deviation, 4.11). Laser ablation of placental anastomoses (n=51) and in utero myelomeningocele repair (n=22) were the most common procedures. Of 119 patients, 34 (28.6%) were diagnosed with preexisting depression or anxiety, with 19 (55.9%) and 17 (50.0%) on baseline medication for depression or anxiety, respectively, before surgery. Of 85 patients, 23 (27.1%) without a history of anxiety or depression had new identification of one or both after delivery. Of note, 2 patients experienced suicidal ideation after delivery. Of the 119 patients, 8 (6.7%) and 12 (10.1%) initiated a new psychiatric medication during or after pregnancy, respectively, and 19 (16.0%) received a therapy referral. Among patients with baseline anxiety or depression, 20 of 34 patients (58.8%) experienced an exacerbation after delivery, 9 of 34 patients (26.5%) were referred for therapy, 9 of 34 patients (26.5%) were changing dose or medication for anxiety, and 11 of 34 patients (32.4%) were changing dose or medication for depression. Of the 119 patients, 24 (20.2%) experienced new or worsening depression or anxiety after the standard 6-week postpartum visit. CONCLUSION Among patients undergoing fetal surgery, a high incidence of postpartum depression and anxiety was identified, with most patients with prepregnancy anxiety or depression experiencing exacerbation after delivery. The timeframe to clinical presentation with depression or anxiety symptoms may be delayed beyond the traditional 6-week postpartum period and into the first postpartum year. This observation could be attributed to de novo postpartum exacerbation or a lack of standardized treatment approaches earlier in the disease course or antepartum period. Understanding effective longitudinal supportive interventions is an essential next step.
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Affiliation(s)
- Olivia Liseth
- Alix School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (Mses Liseth and Weng)
| | - Jessica Weng
- Alix School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (Mses Liseth and Weng)
| | - Mauro Schenone
- Departments of Obstetrics and Gynecology (Drs Schenone, Rivera-Chiauzzi, and Larish)
| | | | | | - Megan Branda
- and Biostatistics (Ms Branda), Mayo Clinic, Rochester, MN
| | - Enid Rivera-Chiauzzi
- Departments of Obstetrics and Gynecology (Drs Schenone, Rivera-Chiauzzi, and Larish)
| | - Alyssa Larish
- Departments of Obstetrics and Gynecology (Drs Schenone, Rivera-Chiauzzi, and Larish).
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Domínguez-Moreno M, Chimenea Á, García-Díaz L, Antiñolo G. Maternal and obstetric outcomes after Ex-Utero Intrapartum Treatment (EXIT): a single center experience. BMC Pregnancy Childbirth 2023; 23:831. [PMID: 38042795 PMCID: PMC10693058 DOI: 10.1186/s12884-023-06129-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/14/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND The Ex-utero Intrapartum Treatment (EXIT) is a procedure developed to manage a range of fetal conditions, aiming to ensure the maintenance of neonatal airway and preserving the feto-placental circulation. Its goal is to enhance the neonatal ability to successfully transition and adapt to postnatal life, thereby reducing perinatal morbidity and mortality. However, EXIT has been associated with a high risk of maternal complications. This paper provides an overview of the indications and characteristics of the EXIT procedure, as well as the obstetric outcomes and maternal complications. METHODS A retrospective analysis was conducted on a cohort of patients undergoing EXIT at our center between January 2007 and December 2022. Maternal outcomes, including demographic information, data related to the surgical procedure, surgical complications, and postoperative complications were analyzed. To assess the severity of the surgical complications, a modified Clavien-Dindo classification was used. Comparative analysis was performed by randomly selecting a sample from elective cesarean deliveries performed at our center. RESULTS A total of 34 EXIT procedures were performed. According to the modified Clavien-Dindo classification, we observed no major complications, while minor maternal complications were present in 2.94% of cases. Compared to elective cesarean deliveries (n = 350), there were no significant differences in terms of maternal complications, highlighting the similarity observed in the mean decrease in postoperative hemoglobin (1.15 g/dL in EXIT vs. 1.2 g/dL in elective cesarean deliveries, p = 0.94). In EXIT group, there was a higher rate of polyhydramnios (26.47% vs 6.59%, p < 0.001), as well as the need for amnioreduction (14.71% vs 0%, p = 0.001) and preterm delivery (32.35% vs 6.02%, p = 0.001). There were no cases of endometritis, post-procedural fever, or abruptio placentae following EXIT. CONCLUSIONS EXIT can be considered a safe procedure when performed under adequate conditions, including appropriate uterine access and proper anesthetic management. In our series, EXIT procedure was not associated with a higher incidence of maternal complications when compared to elective cesarean delivery. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Marta Domínguez-Moreno
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
| | - Ángel Chimenea
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Fetal, IVF and Reproduction Simulation Training Centre (FIRST), Seville, Spain
| | - Lutgardo García-Díaz
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain.
- Department of Surgery, University of Seville, Seville, Spain.
| | - Guillermo Antiñolo
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain.
- Fetal, IVF and Reproduction Simulation Training Centre (FIRST), Seville, Spain.
- Department of Surgery, University of Seville, Seville, Spain.
- Centre for Biomedical Network Research On Rare Diseases (CIBERER), Seville, Spain.
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Matabele MN, Cheng C, Venkatesh M, Barr S, Ellefson J, Beninati M, Lobeck IN, Puricelli MD. Perinatal airway management in neonatal goiter: A healthcare cost and utilization project (HCUP) kids' inpatient database analysis. Int J Pediatr Otorhinolaryngol 2023; 175:111767. [PMID: 37931498 PMCID: PMC10841841 DOI: 10.1016/j.ijporl.2023.111767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/14/2023] [Accepted: 10/20/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Fetal goiter is a rare congenital disorder that can present with life-threatening neonatal airway obstruction. Lifesaving and function-preserving airway management strategies are available, but routine delivery affords a limited window for intervention. Accordingly, fetal goiter is reported among the most common indications for ex-utero intrapartum treatment (EXIT). While EXIT prolongs the window for airway intervention to benefit the neonate, it elevates the risk to the pregnant person and requires extensive resources; therefore, data to guide ideal treatment selection are essential. This study aims to compare perinatal airway interventions between individuals with a birth hospitalization discharge diagnosis (BHDD) of goiter and the general population. MATERIALS AND METHODS Individuals with and without BHDD of goiter were identified in the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database from 2000 to 2019. The frequency of airway interventions on day of life (DOL) 0 or 1 were compared using the Rao-Scott chi-square test. Additionally, gestational age, type of intervention, complications, mortality, birth weight, and length of stay were examined for the goiter cohort. RESULTS Two-hundred eighty-seven weighted cases of goiter were identified in the study period. The population was 61 % male, 55 % White, and median birthweight was 3.3 kg. The median length of stay was 4.3 days, and average total charges were $42,332. Airway intervention on DOL 0 or 1 was performed in 16.9 % of individuals with goiter compared to 1.6 % in neonates without goiter (p < 0.001). Interventions in the goiter cohort included endotracheal intubation in 16 % of cases, laryngoscopy/bronchoscopy in 1-5% of cases, and tracheostomy in <1 % of cases. Fewer than 1 % of individuals undergoing intubation additionally had mass decompression/resection on DOL 0 or 1. No neonates received extracorporeal membrane oxygenation cannulation or cardiopulmonary resuscitation. Hypoxic encephalopathy occurred in <1 % of cases, among which endotracheal intubation was the only airway intervention performed. There were no mortalities among neonates with goiter. CONCLUSION Individuals with BHDD of goiter receive significantly higher rates of perinatal airway intervention. In most cases, endoscopic interventions alone were sufficient to avoid hypoxic neurological complications. These findings contribute to data to aid in clinical counseling and empower patients to make informed decisions according to their values and treatment goals.
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Affiliation(s)
- Maya N Matabele
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christie Cheng
- Department of Otolaryngology, University of Michigan, Ann Arbor, MI, USA
| | - Manasa Venkatesh
- Department of Surgery Statistical Analysis and Research Programming Core, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Samantha Barr
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Johanna Ellefson
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael Beninati
- Division of Maternal-Fetal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Inna N Lobeck
- Division of Pediatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael D Puricelli
- Division of Otolaryngology Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Bose SK, Stratigis JD, Ahn N, Pogoriler J, Hedrick HL, Rintoul NE, Partridge EA, Flake AW, Khalek N, Gebb J, Teefey CP, Soni S, Hamaguchi R, Moldenhauer J, Adzick NS, Peranteau WH. Prenatally Diagnosed Large Lung Lesions: Timing of Resection and Perinatal Outcomes. J Pediatr Surg 2023; 58:2384-2390. [PMID: 37813715 DOI: 10.1016/j.jpedsurg.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Fetuses with large lung lesions including congenital cystic adenomatoid malformations (CCAMs) are at risk for cardiopulmonary compromise. Prenatal maternal betamethasone and cyst drainage for micro- and macrocystic lesions respectively have improved outcomes yet some lesions remain large and require resection before birth (open fetal surgery, OFS), at delivery via an Ex Utero Intrapartum Treatment (EXIT), or immediately post cesarean section (section-to-resection, STR). We sought to compare prenatal characteristics and outcomes in fetuses undergoing OFS, EXIT, or STR to inform decision-making and prenatal counseling. METHODS A single institution retrospective review was conducted evaluating patients undergoing OFS, EXIT, or STR for prenatally diagnosed lung lesions from 2000 to 2021. Specimens were reviewed by an anatomic pathologist. Lesions were divided into "CCAMs" (the largest pathology group) and "all lung lesions" since pathologic diagnosis is not possible during prenatal evaluation when care decisions are made. Prenatal variables included initial, greatest, and final CCAM volume-ratio (CVR), betamethasone use/frequency, cyst drainage, and the presence of hydrops. Outcomes included survival, ECMO utilization, NICU length of stay (LOS), postnatal nitric oxide use, and ventilator days. RESULTS Sixty-nine percent (59 of 85 patients) of lung lesions undergoing resection were CCAMs. Among patients with pathologic diagnosis of CCAM, the initial, largest, and final CVRs were greatest in OFS followed by EXIT and STR patients. Similarly, the incidence of hydrops was significantly greater and the rate of hydrops resolution was lower in the OFS group. Although the rate of cyst drainage did not differ between groups, maternal betamethasone use varied significantly (OFS 60.0%, EXIT 100.0%, STR 74.3%; p = 0.0378). Notably, all OFS took place prior to 2014. There was no difference in survival, ventilator days, nitric oxide, NICU LOS, or ECMO between groups. In multiple variable logistic modeling, determinants of survival to NICU discharge among patients undergoing resection with a pathologic diagnosis of CCAM included initial CVR <3.5 and need for <3 maternal betamethasone doses. CONCLUSION For CCAMs that remain large despite maternal betamethasone or cyst drainage, surgical resection via OFS, EXIT, or STR are viable options with favorable and comparable survival between groups. In the modern era there has been a shift from OFS and EXIT procedures to STR for fetuses with persistently large lung lesions. This shift has been fueled by the increased use of maternal betamethasone and introduction of a Special Delivery Unit during the study period and the appreciation of similar fetal and neonatal outcomes for STR vs. EXIT and OFS with reduced maternal morbidity associated with a STR. Accordingly, efforts to optimize multidisciplinary perinatal care for fetuses with large lung lesions are important to inform patient selection criteria and promote STR as the preferred surgical approach in the modern era. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sourav K Bose
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John D Stratigis
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicholas Ahn
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Pogoriler
- Department of Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily A Partridge
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nahla Khalek
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julianna Gebb
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina Paidas Teefey
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shelly Soni
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryoko Hamaguchi
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie Moldenhauer
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William H Peranteau
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Mikulski MF, Well A, Beckerman Z, Fraser CD, Bebbington MW, Moise KJ. Open and endoscopic fetal myelomeningocele surgeries display similar in-hospital safety profiles in a large, multi-institutional database. Am J Obstet Gynecol MFM 2023; 5:100854. [PMID: 36587805 DOI: 10.1016/j.ajogmf.2022.100854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Open intrauterine fetal myelomeningocele repair has demonstrated decreased ventriculoperitoneal shunting and improved motor outcomes despite maternal and fetal risks. Few data directly compare the safety of open vs endoscopic approaches. OBJECTIVE This study aimed to analyze in-hospital maternal and fetal outcomes of pregnant patients undergoing open vs endoscopic fetal myelomeningocele repair using a large, multi-center database. STUDY DESIGN This was a review of the Pediatric Health Information System database from October 1, 2015, to December 31, 2021. All patients who underwent open or endoscopic fetal myelomeningocele repair according to the International Classification of Diseases, Tenth Revision, were identified. Demographics, gestational age, and outcomes were analyzed. Descriptive and univariate statistics were used. RESULTS A total of 378 pregnant patients underwent fetal myelomeningocele repair. The approach was endoscopic in 143 cases (37.8%) and open in 235 cases (62.2%). Overall postprocedural outcomes included no maternal in-hospital mortalities or intensive care unit admissions, a median length of stay of 4 days (interquartile range, 4-5), 14 cases (3.7%) of surgical and postoperative complications, 6 cases (1.6%) of intrauterine infections, 12 cases (3.2%) of obstetrical complications (including preterm premature rupture of membranes), 3 cases (0.8%) of intrauterine fetal demise, and 16 cases (4.2%) of preterm delivery. Compared with an open approach, the endoscopic approach occurred at a later gestational age (25 weeks [interquartile range, 24-25] vs 24 weeks [interquartile range, 24-25]; P<.001) and had an increased rate of intrauterine infection (6 [4.2%] cases vs 0 [0%] case; P=.002). There was no difference between approaches in the rates of surgical complications, obstetrical complications, intrauterine fetal demise, or preterm deliveries. CONCLUSION Compared with an open approach, endoscopic fetal myelomeningocele repair displays a comparable rate of fetal complications, including intrauterine fetal demise and preterm delivery, and a similar in-hospital maternal safety profile despite an association with increased intrauterine infection.
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Affiliation(s)
- Matthew F Mikulski
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser).
| | - Andrew Well
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser)
| | - Ziv Beckerman
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser); Department of Surgery, Duke University School of Medicine, Durham NC (Dr Beckerman)
| | - Charles D Fraser
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser)
| | - Michael W Bebbington
- Women's Health (Drs Bebbington and Moise), The University of Texas at Austin Dell Medical School, Austin, TX
| | - Kenneth J Moise
- Women's Health (Drs Bebbington and Moise), The University of Texas at Austin Dell Medical School, Austin, TX
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Puricelli MD, Danielsen BM, Van Beek-King J, Wraight CL, Stewart KS, Beninati M, Lobeck IN, Iruretagoyena JI. Taking the Natural Exit: Opportunities for Treatment Rightsizing in Fetal Head and Neck Mass. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2022. [DOI: 10.1177/87564793221100275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fetal head and neck masses, when present, may cause neonatal airway obstruction at birth and associated morbidity and mortality. Escalated maternal treatment intensity such as surgical laryngoscopist/airway surgeon attended delivery and ex utero intrapartum treatment can mitigate the neonatal risk, however, increase maternal risk for complications. Accordingly, accurate prediction of the potential neonatal benefit and maternal risk is essential. Serial third-trimester sonographic features suggestive of more severe airway obstruction may justify more aggressive intervention in the right patient. This case study presents a 23-year-old G1P0 with a fetus predicted to have reduced perinatal airway risk based upon serial third-trimester ultrasound findings. Treatment was de-escalated, and the patient was successfully managed. Collaborative data collection aimed at treatment rightsizing across neonatal, maternal, and systematic domains will support ideal allocation.
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Affiliation(s)
- Michael D. Puricelli
- Division of Otolaryngology, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Brodey Matthew Danielsen
- University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Jessica Van Beek-King
- Division of Otolaryngology, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - C. Lydia Wraight
- Division of Neonatology, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Katharina S. Stewart
- Division of Maternal-Fetal Medicine, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Michael Beninati
- Division of Maternal-Fetal Medicine, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
- Division of Acute Care and Regional General Surgery, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Inna N. Lobeck
- Division of Pediatric Surgery, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - J. Igor Iruretagoyena
- Division of Maternal-Fetal Medicine, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
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10
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Varela MF, Peiro JL. EX-UTERO INTRAPARTUM TREATMENT (EXIT). REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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11
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Ex utero intrapartum technique (EXIT): Indications, procedure methods and materno-fetal complications - A literature review. J Gynecol Obstet Hum Reprod 2021; 51:102252. [PMID: 34638008 DOI: 10.1016/j.jogoh.2021.102252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/24/2021] [Accepted: 10/06/2021] [Indexed: 12/23/2022]
Abstract
A congenital malformation of the head, neck or thorax can lead to upper airway compression with a risk of asphyxia or neonatal death. To secure and protect the upper airway, the Ex Utero Intrapartum Therapy (EXIT) procedure has been developed. The procedure allows delivery of the fetus via a hysterotomy while relying on the placenta as the organ of respiration for the fetus prior to clamping of the umbilical cord. A high level of expertise is necessary for successful completion of the EXIT procedure, which is not void of maternal and fetal risks. In this literature review, we present the indications, procedure methods and materno-fetal complications associated with the EXIT procedure.
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12
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Varela MF, Pinzon-Guzman C, Riddle S, Parikh R, McKinney D, Rutter M, Lim FY, Peiro JL. EXIT-to-airway: Fundamentals, prenatal work-up, and technical aspects. Semin Pediatr Surg 2021; 30:151066. [PMID: 34172204 DOI: 10.1016/j.sempedsurg.2021.151066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Ex-utero intrapartum treatment (EXIT) is a delivery strategy developed to manage a variety of prenatally diagnosed conditions in the transition to newborn life. This procedure allows control and provides time for intervention in otherwise life-threatening malformations, such as congenital upper airway obstructions. EXIT-to-airway has changed the outcome of fetuses with these anomalies. The main purpose of this intervention is to improve the safety of establishing a reliable airway at birth. Maximal but controlled uterine relaxation to maintain feto-maternal perfusion and thus gas exchange, while keeping the fetal and maternal well-being are the paradigms of any type of EXIT. The most important aspect of fetal airway management is to consolidate a highly trained, well-coordinated, multidisciplinary team that is prepared for every contingency. A comprehensive prenatal assessment, including ultrasound, fetal echocardiogram, fetal MRI, and genetic testing is imperative for patient selection. Extensive preoperative planning, ad-hoc team meetings, and surgical simulations for challenging cases are critical strategies to achieve the best outcomes. This article outlines the prenatal work-up, decision making, technical aspects, and principles for a successful EXIT-to-airway procedure.
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Affiliation(s)
- Maria Florencia Varela
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA
| | - Carolina Pinzon-Guzman
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
| | - Stefanie Riddle
- Division of Neonatology, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA.; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rupi Parikh
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David McKinney
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael Rutter
- Division of Pediatric Otolaryngology, Head and Neck Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jose L Peiro
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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13
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Dick JR, Wimalasundera R, Nandi R. Maternal and fetal anaesthesia for fetal surgery. Anaesthesia 2021; 76 Suppl 4:63-68. [PMID: 33682103 DOI: 10.1111/anae.15423] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2021] [Indexed: 11/28/2022]
Abstract
Over the last three decades, advances in early diagnosis of fetal anomalies, imaging and surgical techniques have led to a huge expansion in fetal surgery. A small number of specialist centres perform fetal surgery, which involves high-risk anaesthesia for the mother and fetus. The anaesthetist plays an integral role within the large multispecialty and multidisciplinary team, involved in planning and delivering care for complex surgical procedures. This article reviews three fetal surgical procedures, congenital diaphragmatic hernia, myelomeningocele repair and ex-utero intrapartum treatment for airway obstruction. The underlying fetal pathology, surgical management, anaesthetic considerations and risks for both the mother and fetus are described for each. Fundamental to this is the understanding that clear communication and collaboration between all team members is vital to ensure successful outcomes of patients, the mother and the fetus.
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Affiliation(s)
- J R Dick
- Department of Obstetric Anaesthesia, University College Hospital, London, UK
| | - R Wimalasundera
- Department of Obstetrics and Fetal Medicine, University College Hospital, London, UK
| | - R Nandi
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
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14
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Stanek J. CD34 immunostain increases sensitivity of the diagnosis of fetal vascular malperfusion in placentas from ex-utero intrapartum treatment. J Perinat Med 2021; 49:203-208. [PMID: 32903209 DOI: 10.1515/jpm-2020-0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/20/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES EXIT (ex-utero intrapartum treatment) procedure is a fetal survival-increasing modification of cesarean section. Previously we found an increase incidence of fetal vascular malperfusion (FVM) in placentas from EXIT procedures which indicates the underlying stasis of fetal blood flow in such cases. This retrospective analysis analyzes the impact of the recently introduced CD34 immunostain for the FVM diagnosis in placentas from EXIT procedures. METHODS A total of 105 placentas from EXIT procedures (48 to airway, 43 to ECMO and 14 to resection) were studied. In 73 older cases, the placental histological diagnosis of segmental FVM was made on H&E stained placental sections only (segmental villous avascularity) (Group 1), while in 32 most recent cases, the CD34 component of a double E-cadherin/CD34 immunostain slides was also routinely used to detect the early FVM (endothelial fragmentation, villous hypovascularity) (Group 2). Twenty-three clinical and 47 independent placental phenotypes were compared by χ2 or ANOVA, where appropriate. RESULTS There was no statistical significance between the groups in rates of segmental villous avascularity (29 vs. 34%), but performing CD34 immunostain resulted in adding and/or upgrading 12 more cases of segmental FVM in Group 2, thus increasing the sensitivity of placental examination for FVM by 37%. There were no other statistically significantly differences in clinical (except for congenital diaphragmatic hernias statistically significantly more common in Group 2, 34 vs. 56%, p=0.03) and placental phenotypes, proving the otherwise comparability of the groups. CONCLUSIONS The use of CD34 immunostain increases the sensitivity of placental examination for FVM by 1/3, which may improve the neonatal management by revealing the increased likelihood of the potentially life-threatening neonatal complications.
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Affiliation(s)
- Jerzy Stanek
- Division of Pathology, Cincinnati Children's Hospital Medical Center3333 Burnet Avenue, Cincinnati, OH 45229, USA
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15
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Zaretsky M, Brockel M, Derderian SC, Francom C, Wood C. A Graceful EXIT impeded by obstetrical complications. BMJ Case Rep 2021; 14:14/2/e237911. [PMID: 33547119 PMCID: PMC7871254 DOI: 10.1136/bcr-2020-237911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report an ex utero intrapartum therapy-to-airway procedure in which obstetric factors dramatically influenced the sequence of events necessary to complete the procedure.
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Affiliation(s)
- Michael Zaretsky
- Department of Obstetrics and Gynecology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Megan Brockel
- Department of Anesthesia, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | | | - Christian Francom
- Department of Otolaryngology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Cristina Wood
- Department of Anesthesia, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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16
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Puricelli MD, Rahbar R, Allen GC, Balakrishnan K, Brigger MT, Daniel SJ, Fayoux P, Goudy S, Hewitt R, Hsu WC, Ida JB, Johnson R, Leboulanger N, Rickert SM, Roy S, Russell J, Rutter M, Sidell D, Soma M, Thierry B, Trozzi M, Zalzal G, Zdanski CJ, Smith RJH. International Pediatric Otolaryngology Group (IPOG): Consensus recommendations on the prenatal and perinatal management of anticipated airway obstruction. Int J Pediatr Otorhinolaryngol 2020; 138:110281. [PMID: 32891939 DOI: 10.1016/j.ijporl.2020.110281] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/25/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery. METHODS Recommendations are based on expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was distributed to all members of the IPOG and responses recorded. The respondents were given the opportunity to comment on the content and format of the survey, which was modified for the second round. "Consensus" was defined by >80% respondent affirmative responses, "agreement" by 51-80% affirmative responses, and "no agreement" by 50% or less affirmative responses. RESULTS Recommendations are provided regarding etiologies of perinatal airway obstruction, imaging evaluation, adjunct evaluation, multidisciplinary team and decision factors, micrognathia management, congenital high airway obstruction syndrome management, head and neck mass management, attended delivery procedure, and delivery on placental support procedure. CONCLUSIONS Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits.
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Affiliation(s)
- Michael D Puricelli
- Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Reza Rahbar
- Department of Otolaryngology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory C Allen
- Department of Otolaryngology - Head & Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Karthik Balakrishnan
- Department of Otolaryngology, Head and Neck Surgery, Division of Pediatric Otolaryngology, Stanford University, Stanford, CA, USA
| | - Matthew T Brigger
- Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA, USA
| | - Sam J Daniel
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Canada
| | - Pierre Fayoux
- Department of Pediatric Otolaryngology Head-Neck Surgery, University Hospital of Lille, Lille, France
| | - Steven Goudy
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Richard Hewitt
- Department of Ear, Nose and Throat Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Wei-Chung Hsu
- Department of Otolaryngology, College of Medicine, National Taiwan University and National Taiwan University Hospital, Taipei, Taiwan
| | - Jonathan B Ida
- Division of Pediatric Otolaryngology, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Romaine Johnson
- Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nicolas Leboulanger
- Pediatric Otolaryngology - Head and Neck Surgery, Necker Enfants Malades Hospital, Paris University, Paris, France
| | - Scott M Rickert
- Department of Otolaryngology, NYU Langone, New York, NY, USA
| | - Soham Roy
- Department of Otorhinolaryngology, University of Texas - Houston, Houston, TX, USA
| | - John Russell
- Department of Paediatric Otolaryngology, Childrens Health Ireland, Crumlin, Ireland
| | - Michael Rutter
- FRACS, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Douglas Sidell
- Department of Otolaryngology, Head and Neck Surgery, Division of Pediatric Otolaryngology, Stanford University, Stanford, CA, USA
| | - Marlene Soma
- Department of Otolaryngology, Sydney Children's Hospital, Randwick, Australia
| | - Briac Thierry
- Pediatric Otolaryngology - Head and Neck Surgery, Necker Enfants Malades Hospital, Paris University, Paris, France
| | - Marilena Trozzi
- Airway Surgery Unit, Pediatric Surgery Department, Bambino Gesù Children's Hospital, Rome (IT), Italy
| | - George Zalzal
- Department of Otolaryngology, Children's National Health System, Washington, DC, USA
| | - Carlton J Zdanski
- Division of Pediatric Otolaryngology/Head and Neck Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Richard J H Smith
- Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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17
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Cash H, Bly R, Masco V, Dighe M, Cheng E, Delaney S, Ma K, Perkins JA. Prenatal Imaging Findings Predict Obstructive Fetal Airways Requiring EXIT. Laryngoscope 2020; 131:E1357-E1362. [PMID: 32770766 DOI: 10.1002/lary.28959] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/02/2020] [Accepted: 06/30/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Detection of fetal airway compromise through imaging raises the possible need for ex utero intrapartum treatment (EXIT) procedures. Despite EXIT procedures involving massive resource utilization and posing increased risk to the mother, decisions for EXIT are usually based on anecdotal experience. Our objectives were to analyze prenatal consultations with potential fetal airway obstruction for imaging and obstetric findings used to determine management strategy. METHODS Retrospective chart review was performed for prenatal abnormal fetal airway consults between 2004-2019 at a quaternary pediatric facility. Data collected included demographics, imaging characteristics, delivery information, and airway management. Our primary outcome was EXIT performance and the secondary outcome was postnatal airway management. Fisher's exact test was used to compare management decisions, outcomes, and imaging findings. RESULTS Thirty-seven patients met inclusion criteria. The most common diagnoses observed were lymphatic malformation, teratoma, and micrognathia. Of the imaging findings collected, only midline neck mass location was associated with EXIT procedure performance. Factors associated with invasive airway support at birth were mass-induced in-utero neck extension and neck vessel compression, polyhydramnios, and micrognathia. CONCLUSIONS Multidisciplinary input and interpretation of prenatal imaging can guide management of fetal airway-related pathology. EXIT is an overall safe procedure and can decrease risk due to airway obstruction at birth. We identified in-utero neck extension, neck vessel compression, micrognathia, and polyhydramnios as better indicators of a need for invasive airways measures at birth and suggest use of these criteria in combination with clinical judgement when recommending EXIT. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1357-E1362, 2021.
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Affiliation(s)
- Harrison Cash
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Randall Bly
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Vanessa Masco
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Manjiri Dighe
- Department of Radiology, Prenatal Imaging, University of Washington, Seattle, Washington, U.S.A
| | - Edith Cheng
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Shani Delaney
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Kimberly Ma
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Jonathan A Perkins
- Department of Otolaryngology - Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A.,Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
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18
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Abstract
Ex Utero Intrapartum Treatment (EXIT) is a technique developed to safely and efficiently establish cardiopulmonary support at delivery while maintaining placental bypass. Indications for the EXIT approach are expanding and currently include EXIT-to-airway, EXIT-to-resection, EXIT-to-extracorporeal membrane oxygenation (ECMO), and EXIT-to-separation of conjoined twins. The EXIT technique involves planned partial delivery of the fetus via hysterotomy while maintaining uterine relaxation and placental support, allowing for the establishment of neonatal cardiopulmonary stability in a controlled manner. Fetal interventions performed during EXIT can include endotracheal intubation, tracheostomy, mass excision, removal of a temporary tracheal occlusive device, ECMO cannulation, and others. The most important aspect of an EXIT procedure is the formation of a multi-disciplinary team with broad expertise in fetal intervention to collaborate throughout the pre, intra, and post-partum periods. This chapter reviews the prenatal workup, decision making, surgical indications, and operative considerations associated with EXIT procedures.
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Affiliation(s)
- Christina M Bence
- Children's Hospital of Wisconsin, Medical College of Wisconsin, 999 N. 92nd Street, Suite 320, Milwaukee, WI 53226, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin, Medical College of Wisconsin, 999 N. 92nd Street, Suite 320, Milwaukee, WI 53226, USA.
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Kahr MK, Winder F, Vonzun L, Meuli M, Mazzone L, Moehrlen U, Krähenmann F, Hüsler M, Zimmermann R, Ochsenbein-Kölble N. Risk Factors for Preterm Birth following Open Fetal Myelomeningocele Repair: Results from a Prospective Cohort. Fetal Diagn Ther 2019; 47:15-23. [PMID: 31104051 DOI: 10.1159/000500048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 04/01/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fetal myelomeningocele (fMMC) repair is a therapeutic option in selected cases. This study aimed to identify risk factors for preterm birth (PTB) following open fMMC repair. METHODS Sixty-seven women underwent fMMC repair and delivered a baby between 2010 and 2018 at our center. Demographic, surgical, and pregnancy complications, including potential risk factors for PTB such as preterm premature rupture of membranes (PPROM), chorioamniotic membrane separation (CMS), and placental abruption were evaluated. RESULTS Maternal body mass index, maternal age, parity, previous uterine surgery, gestational age at fetal surgery, total surgery duration, surgical subcutaneous hematoma, oligohydramnios, and amniotic fluid leakage were not identified as risk factors for PTB. CMS (p = 0.028, 92 vs. 52%) and PPROM (p = 0.001, 95 vs. 52%) were highly associated with PTB. Placental abruption was found more often in women after fMMC repair than in a general obstetrical population (12 vs. 1%) and ended in premature birth in all cases (p = 0.024, 100 vs. 60%). However, the majority of women delivered at a gestational age >35 weeks. CONCLUSIONS In our study cohort, risk factors for PTB were PPROM, CMS, and placental abruption, whereas surgery duration did not influence outcome. We conclude that the surgery technique should aim to minimize CMS and amniotic fluid leakage.
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Affiliation(s)
- Maike Katja Kahr
- Division of Obstetrics, University Hospital of Zürich, Zurich, Switzerland, .,Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland,
| | - Franziska Winder
- Division of Obstetrics, University Hospital of Zürich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Ladina Vonzun
- Division of Obstetrics, University Hospital of Zürich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Martin Meuli
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Luca Mazzone
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Franziska Krähenmann
- Division of Obstetrics, University Hospital of Zürich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Margaret Hüsler
- Division of Obstetrics, University Hospital of Zürich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Roland Zimmermann
- Division of Obstetrics, University Hospital of Zürich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Division of Obstetrics, University Hospital of Zürich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
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20
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Goodnight WH, Bahtiyar O, Bennett KA, Emery SP, Lillegard JB, Fisher A, Goldstein R, Jatres J, Lim FY, McCullough L, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Thom E, Treadwell MC, Tsao K, Wagner AJ, Waqar LN, Zaretsky M. Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele. Am J Obstet Gynecol 2019; 220:494.e1-494.e7. [PMID: 30885769 PMCID: PMC6511319 DOI: 10.1016/j.ajog.2019.03.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Open maternal-fetal surgery for fetal myelomeningocele results in reduction in neonatal morbidity related to spina bifida but may be associated with fetal, neonatal, and maternal complications in subsequent pregnancies. OBJECTIVE The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open maternal-fetal surgery for fetal myelomeningocele closure. STUDY DESIGN An international multicenter prospective observational registry created to track and report maternal, obstetric, fetal/neonatal, and subsequent pregnancy outcomes following open maternal-fetal surgery for fetal myelomeningocele was evaluated for subsequent pregnancy outcome variables. Institutional Review Board approval was obtained for the registry. RESULTS From 693 cases of open maternal-fetal surgery for fetal myelomeningocele closure entered into the registry, 77 subsequent pregnancies in 60 women were identified. The overall live birth rate was 96.2%, with 52 pregnancies delivering beyond 20 weeks gestational age and median gestational age at delivery of 37 (36.3-37.1) weeks. The uterine rupture rate was 9.6% (n = 5), resulting in 2 fetal deaths. Maternal transfusion was required in 4 patients (7.7%). CONCLUSION The risk of uterine rupture or dehiscence in subsequent pregnancies with associated fetal morbidity after open maternal-fetal surgery is significant, but is similar to that reported for subsequent pregnancies after classical cesarean deliveries. Future pregnancy considerations should be included in initial counseling for women contemplating open maternal-fetal surgery.
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Affiliation(s)
| | | | | | | | - J B Lillegard
- Midwest Fetal Care Center, Children's Hospital of Minnesota, Minneapolis, MN
| | | | - Ruth Goldstein
- University of California San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | | | | | - KuoJen Tsao
- University of Texas Health Center, Houston, TX
| | - Amy J Wagner
- Children's Hospital of Wisconsin Fetal Concerns Center, Milwaukee, WI
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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Abstract
Congenital causes of airway obstruction once noted at birth are now diagnosed prenatally. The adoption of ex utero intrapartum treatment has allowed for planned airway stabilization on placental support, dramatically decreasing the incidence of hypoxic injury or peripartum demise related to neonatal airway obstruction. Airway access is gained either through laryngoscopy, bronchoscopy, or a surgical airway. In complete airway obstruction, primary resection of the obstructing lesion may be performed before completion of delivery. This article reviews the current and emerging methods of fetal evaluation, indications for ex utero intrapartum treatment, and provides a detailed description of the procedure and necessary personnel.
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Affiliation(s)
- Kara Prickett
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, 1400 Tullie Road, NE, Atlanta, GA 30329, USA.
| | - Luv Javia
- Cochlear Implant Program, Center for Pediatric Airway Disorders, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Ex utero intrapartum treatment procedure in two fetuses with airway obstruction. Obstet Gynecol Sci 2018; 61:417-420. [PMID: 29780786 PMCID: PMC5956127 DOI: 10.5468/ogs.2018.61.3.417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 07/27/2017] [Accepted: 08/07/2017] [Indexed: 11/08/2022] Open
Abstract
The ex utero intrapartum treatment (EXIT) procedure was introduced to reduce fetal hypoxic damage while establishing an airway in fetuses with upper and lower airway obstruction. Delivery of the fetal head and shoulders while maintaining the uteroplacental circulation offers time to secure the fetal airway. Here, we report two cases of EXIT procedure for fetal airway obstruction, which were successfully managed with extensive preoperative planning by a professional multidisciplinary team.
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Beuriat PA, Szathmari A, Rousselle C, Sabatier I, Di Rocco F, Mottolese C. Complete Reversibility of the Chiari Type II Malformation After Postnatal Repair of Myelomeningocele. World Neurosurg 2017; 108:62-68. [DOI: 10.1016/j.wneu.2017.08.152] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 11/15/2022]
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Moaddab A, Nassr AA, Belfort MA, Shamshirsaz AA. Ethical issues in fetal therapy. Best Pract Res Clin Obstet Gynaecol 2017; 43:58-67. [PMID: 28268059 DOI: 10.1016/j.bpobgyn.2017.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 02/03/2023]
Abstract
The introduction of routine fetal ultrasound and the technical improvements in ultrasound equipment have greatly increased our ability to diagnose fetal anomalies. As a consequence, congenital anomalies are diagnosed today earlier and in a greater number of patients than ever before. The development of fetal intervention and fetal surgery techniques, improved anesthesia methodology, and sophisticated perinatal care at the limits of viability, have now made prenatal management of some birth defects or fetal malformations a reality. The increasing number of indications for fetal therapy and the apparent desire of parents to seek out these procedures have raised concern regarding the ethical issues related to the therapy. While fetal therapy may have a huge impact on the prenatal management of some congenital birth defects and/or fetal malformations, because of the invasive nature of these procedures, the lack of sufficient data regarding long-term outcomes, and the medical/ethical uncertainties associated with some of these interventions there is cause for concern. This chapter aims to highlight some of the most important ethical considerations pertaining to fetal therapy, and to provide a conceptual ethical framework for a decision-making process to help in the choice of management options.
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Affiliation(s)
- Amirhossein Moaddab
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States; Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States.
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27
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Leduc L, Monet B, Sansregret A, Gauthier R, Bourque J, Rypens F. Immediate closure of uterine wall following spontaneous rupture at 23 weeks' gestation, allowing prolongation of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:534-535. [PMID: 26823145 DOI: 10.1002/uog.15872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/19/2016] [Accepted: 01/22/2016] [Indexed: 06/05/2023]
Affiliation(s)
- L Leduc
- Department of Obstetrics & Gynecology, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada.
| | - B Monet
- Department of Obstetrics & Gynecology, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - A Sansregret
- Department of Obstetrics & Gynecology, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - R Gauthier
- Department of Obstetrics & Gynecology, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - J Bourque
- Department of Obstetrics & Gynecology, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - F Rypens
- Department of Radiology, CHU Sainte-Justine, Montreal, Quebec, Canada
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28
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Abstract
Historically, the gold standard for the treatment of congenital malformations has been planned delivery at tertiary care center with attempted post-natal repair or amelioration of the lesion. Over the last few decades however, rapid advances in imaging and instrumentation technology combined with superior knowledge of fetal pathophysiology has led to the development of novel intrauterine interventions for most common fetal anomalies. Great success has already been seen the treatment of previous devastating anomalies such as myelomeningocele (MMC), congenital cystic malformations of the lung, twin-twin transfusion, and sacrococcygeal teratomas. Although still limited, these innovative techniques have unique potential to improve outcomes in the most devastating fetal anomalies.
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Affiliation(s)
- Kathryn M Maselli
- Department of Surgery, Medstar Georgetown University Hospital, Washington DC 20007, USA
| | - Andrea Badillo
- Division of Pediatric Surgery, Children's National Medical Center, Washington DC 20010, USA
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29
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Laje P, Tharakan SJ, Hedrick HL. Immediate operative management of the fetus with airway anomalies resulting from congenital malformations. Semin Fetal Neonatal Med 2016; 21:240-5. [PMID: 27132111 DOI: 10.1016/j.siny.2016.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Prenatal diagnosis has transformed the outcome of fetuses with airway obstruction. The thorough evaluation of prenatal imaging allows for categorizing fetuses with airway compromise into those who will require a special mode of delivery and those who can be delivered without any special resources. The ex-utero intrapartum treatment (EXIT) approach allows accessing the airway while the fetus is under placental support, converting a potentially catastrophic situation into a controlled one. An expert multidisciplinary team is the key to success.
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Affiliation(s)
- Pablo Laje
- The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sasha J Tharakan
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Holly L Hedrick
- The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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30
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Sananes N, Javadian P, Schwach Werneck Britto I, Meyer N, Koch A, Gaudineau A, Favre R, Ruano R. Technical aspects and effectiveness of percutaneous fetal therapies for large sacrococcygeal teratomas: cohort study and literature review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:712-719. [PMID: 26138446 DOI: 10.1002/uog.14935] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 04/29/2015] [Accepted: 06/24/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The objectives of this study were to evaluate the efficacy of minimally invasive ablation of high-risk large sacrococcygeal teratomas (SCT) and to compare the efficacy of vascular and interstitial tumor ablation. METHODS This was a retrospective multicenter study including a cohort of fetuses with high-risk large SCTs between 2004 and 2010. In addition, we performed a systematic literature review of all cases that underwent tumor ablation in order to compare the survival rates after 'vascular' and 'interstitial' ablation. Statistical analysis was conducted using Bayesian methods. RESULTS In our cohort, a total of 13 fetuses had high-risk large SCT and five of them underwent tumor ablation. The estimated difference in hydrops resolution rate between the fetal intervention and the no fetal intervention groups was 44.6% (95% credibility interval, 1.5 to 81.0%; Pdiff> 0 = 97.9%). The estimated difference in survival rate between the fetal intervention and the no fetal intervention groups was 31.0% (13.9 to 48.1%; Pdiff> 0 = 99.9%). We analyzed our five cases together with 28 cases from the literature and estimated the difference in survival rate between the vascular and interstitial ablation groups as 19.8% (-13.1 to 50.1%; Pdiff> 0 = 88.3%). The estimated difference in hydrops resolution rate between the vascular and the interstitial ablation groups was 36.7% (-5.7 to 72.7%; Pdiff> 0 = 95.5%). CONCLUSION Minimally invasive surgery seems to improve perinatal outcome in cases of high-risk large fetal SCT. Our findings suggest that 'vascular' ablation may improve outcome and may be more effective than 'interstitial' tumor ablation, but this hypothesis needs further investigation in a larger multicenter prospective study. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- N Sananes
- Texas Children's Fetal Center and Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France
- INSERM, UMR-S 1121, 'Biomatériaux et Bioingénierie', Strasbourg, France
| | - P Javadian
- Texas Children's Fetal Center and Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - I Schwach Werneck Britto
- Texas Children's Fetal Center and Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - N Meyer
- Department of Public Health, Strasbourg University Hospital, Strasbourg, France
| | - A Koch
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France
| | - A Gaudineau
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France
| | - R Favre
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France
| | - R Ruano
- Texas Children's Fetal Center and Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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32
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Sheikh F, Akinkuotu A, Olutoye OO, Pimpalwar S, Cassady CI, Fernandes CJ, Ruano R, Lee TC, Cass DL. Prenatally diagnosed neck masses: long-term outcomes and quality of life. J Pediatr Surg 2015; 50:1210-3. [PMID: 25863543 DOI: 10.1016/j.jpedsurg.2015.02.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 02/13/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine long-term outcomes of fetuses with neck masses (NM), including functional and cosmetic results. METHODS A retrospective review was performed of all fetuses evaluated for NM from November 2001 to March 2014. Quality of life (QOL) was evaluated using the validated PedsQL™ questionnaire. RESULTS Of 35 fetuses evaluated, 9 died perinatally and 1 died late from tracheostomy complications. NM ranged from 4 to 20cm (mean, 9.1cm); 18 were delivered by EXIT. Of 25 surviving patients, 22 had mass resection, 7 requiring more than one procedure. Surviving patients with lymphatic malformations (LM) had the highest incidence of moderate and severe disfigurement and a higher rate of persistent/recurrent disease (100% vs. 31%, p=0.002) and cranial nerve dysfunction (50% vs. 0%, p=0.005) compared to those with non-LM diagnoses. Of 9 children attending school, 78% achieve grades of A/B's. QOL for 13 patients revealed a mean score of 83/100 for physical and 78/100 for psychosocial functioning. Median follow-up was 6 years (7 months-17 years). CONCLUSION Unlike those with teratoma or other lesions, children with congenital cervicofacial LM are at high-risk for persistent disease, nerve dysfunction and moderate-severe disfigurement. There is substantial perinatal morbidity for fetuses with neck masses, but for those surviving, the long-term functional and cognitive outcomes are good.
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Affiliation(s)
- Fariha Sheikh
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Adesola Akinkuotu
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Oluyinka O Olutoye
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Sheena Pimpalwar
- Department of Radiology, Baylor College of Medicine, Houston, TX
| | - Christopher I Cassady
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Radiology, Baylor College of Medicine, Houston, TX
| | | | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Timothy C Lee
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Darrell L Cass
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX.
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33
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Abstract
In utero fetal surgery interventions are currently considered in selected cases of congenital diaphragmatic hernia, cystic pulmonary abnormalities, amniotic band sequence, selected congenital heart abnormalities, myelomeningocele, sacrococcygeal teratoma, obstructive uropathy, and complications of twin pregnancy. Randomized controlled trials have demonstrated an advantage for open fetal surgery of myelomeningocele and for fetoscopic selective laser coagulation of placental vessels in twin-to-twin transfusion syndrome. The evidence for other fetal surgery interventions, such as tracheal occlusion in congenital diaphragmatic hernia, excision of lung lesions, fetal balloon cardiac valvuloplasty, and vesicoamniotic shunting for obstructive uropathy, is more limited. Conditions amenable to intrauterine surgical treatment are rare; the mother may consider termination of pregnancy as an option for many of them; treatment can be lifesaving but in itself carries risks to both the infant (preterm premature rupture of the membranes, preterm delivery) and the mother. This makes conducting prospective or randomized trials difficult and explains the relative lack of good-quality evidence in this field. Moreover, there is scanty information on long-term outcomes. It is recommended that fetal surgery procedures be performed in centers with extensive facilities and expertise. The aims of this review were to describe the main fetal surgery procedures and their evidence-based results and to provide generalist obstetricians with an overview of current indications for fetal surgery.
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Laje P, Peranteau WH, Hedrick HL, Flake AW, Johnson MP, Moldenhauer JS, Adzick NS. Ex utero intrapartum treatment (EXIT) in the management of cervical lymphatic malformation. J Pediatr Surg 2015; 50:311-4. [PMID: 25638626 DOI: 10.1016/j.jpedsurg.2014.11.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 11/02/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to review the outcomes and technical details of EXIT procedures performed in fetuses with large cervical lymphatic malformations. METHODS A retrospective chart review of fetuses with a prenatal diagnosis of cervical lymphatic malformation evaluated at our center between 1995 and 2013 was performed. RESULTS We evaluated a total of 112 fetuses with a prenatal diagnosis of cervical lymphatic malformation. Thirteen of the 112 fetuses (11%) were delivered by an EXIT procedure. Criteria to deliver by EXIT were: 1) deviation/compression/obstruction of the airway, and 2) involvement of the floor of the mouth. Two fetuses developed hydrops. Five fetuses developed polyhydramnios. Eleven EXITs were performed electively at term (n=7; 37-38 weeks) or late pre-term (n=4; 34-36/6 weeks), whereas two patients underwent emergency EXIT at 33 and 38 weeks, respectively. The airway was accessed successfully in 12 of 13 cases. Laryngoscopy only was sufficient in 7, rigid bronchoscopy was required in 4, and 1 required a tracheostomy. In one case with a massive lymphatic malformation of the face, neck, and airway, a tracheostomy was not attempted, and the fetus expired. Four patients had invasion of the larynx by the lymphatic malformation. Five patients required a tracheostomy later. Median time from fetal exposure to intubation was 8 (2-29) min. Median total EXIT time was 105.5 (67-142) min. Median maternal blood loss was 800 (300-1000) ml. Median maternal hospital stay was 4 (3-6) days. CONCLUSION The EXIT procedure allows controlled airway access in fetuses with cervical lymphatic malformations and evidence of airway impairment on prenatal images.
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Affiliation(s)
- Pablo Laje
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - William H Peranteau
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - Alan W Flake
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - Mark P Johnson
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - Julie S Moldenhauer
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia Philadelphia, PA, USA.
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35
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Walz PC, Schroeder JW. Prenatal diagnosis of obstructive head and neck masses and perinatal airway management: the ex utero intrapartum treatment procedure. Otolaryngol Clin North Am 2014; 48:191-207. [PMID: 25442130 DOI: 10.1016/j.otc.2014.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Advances in prenatal imaging in the last 20 years have enabled prenatal diagnosis of obstructive head and neck masses. These advances, coupled with improvements in maternal-fetal anesthesia, have made possible the development of the ex utero intrapartum treatment (EXIT) procedure for management of obstructive head and neck masses, during which the airway is managed in a controlled fashion while maintaining fetal circulation for oxygenation. This review addresses the preoperative and perioperative assessment and management of patients with prenatally diagnosed airway obstruction, indications and contraindications for the EXIT procedure, technical details of the procedure, and outcomes.
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Affiliation(s)
- Patrick C Walz
- Department of Pediatric Otolaryngology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611-2991, USA
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36
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Van Mieghem T, Al-Ibrahim A, Deprest J, Lewi L, Langer JC, Baud D, O'Brien K, Beecroft R, Chaturvedi R, Jaeggi E, Fish J, Ryan G. Minimally invasive therapy for fetal sacrococcygeal teratoma: case series and systematic review of the literature. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:611-619. [PMID: 24488859 DOI: 10.1002/uog.13315] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 01/07/2014] [Accepted: 01/16/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Large solid sacrococcygeal teratomas (SCT) can cause high-output cardiac failure and fetal or neonatal death. The aim of this study was to describe the outcomes of minimally invasive antenatal procedures for the treatment of fetal SCT. METHODS A case review was performed of five fetuses with a large SCT treated antenatally using minimally invasive techniques, and a systematic literature review on fetal therapy for solid SCTs was carried out. RESULTS Five women were referred between 17 + 5 and 26 + 4 weeks' gestation for a large fetal SCT with evidence of fetal cardiac failure. Vascular flow to the tumors was interrupted by fetoscopic laser ablation (n = 1), radiofrequency ablation (RFA; n = 2) or interstitial laser ablation ± vascular coiling (n = 2). There were two intrauterine fetal deaths. The other three cases resulted in preterm labor within 10 days of surgery. One neonate died. Two survived without procedure-related complications but had long-term morbidity related to prematurity. The systematic literature review revealed 16 SCTs treated minimally invasively for (early) hydrops. Including our cases, six of 20 hydropic fetuses survived after minimally invasive therapy (30%). Survival after RFA or interstitial laser ablation was 45% (5/11). Of 12 fetuses treated for SCT without obvious hydrops and for which perinatal survival data were available, eight (67%) survived. Mean gestational age at delivery after minimally invasive therapy was 29.7 ± 4.0 weeks. Survival after open fetal surgery in hydropic fetuses was 6/11 (55%), with a mean gestational age at delivery of 29.8 ± 2.9 weeks. CONCLUSIONS Fetal therapy can potentially improve perinatal outcomes for hydropic fetuses with a solid SCT, but is often complicated by intrauterine death and preterm birth.
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Affiliation(s)
- T Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada; Fetal Medicine Unit, Department of Obstetrics & Gynaecology, University Hospitals Leuven, Leuven, Belgium; University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
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