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Tchirikov M, Zühlke A, Schlabritz-Lutsevich N, Entezami M, Seliger G, Bergner M, Li W, Köninger A, Wienke A, Yusupbaev R, Ebert AD. Fetoscopic laser coagulation for twin-to-twin transfusion syndrome: a comparison of flexible 1.0/1.2 mm fetoscopes with curved sheaths of 2.7/3.3 mm 2 vs. 2 mm fetoscopic lens technique with sheaths of 6.6/11.3 mm 2. J Perinat Med 2024; 52:530-537. [PMID: 38536953 DOI: 10.1515/jpm-2023-0328] [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: 08/08/2023] [Accepted: 02/19/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVES Fetoscopic laser coagulation of placental anastomoses is usually performed for a treatment of twin-to-twin transfusion syndrome (TTTS). A common complication of fetoscopic laser coagulation for TTTS is preterm preliminary rupture of fetal membranes (PPROM) aggravating the neonatal outcome significantly. However, use of an flexible 1 mm fetoscope with an curved sheath could reduce iatrogenic damage of the amniotic membrane and improve neonatal outcomes after laser treatment. The aim of this study was to compare neonatal outcomes using this flexible fetoscope with curved sheath vs. use of a standard lens technique. METHODS Outcomes were retrospective analyzed after use of a standard lens fetoscope of 2 mm (sheath 6.63 mm2 or 11.27 mm2 for anterior placenta) and a flexible fetoscope of 1 mm or 1.2 mm (sheath 2.65 mm2 or 3.34 mm2) in two German centers of fetal surgery, performed during 2006-2019. RESULTS Neonatal outcome of 247 TTTS patients were analyzed including the rates of double and single fetal survival. The survival of at least one fetus was 97.2 % in the group with the ultrathin technique (n=154) compared to 88.3 % (n=93) in the group with the standard lens fetoscope (p=0.008). Survival of both fetuses was not different between groups (81.0 vs. 75.3 %). The procedure to delivery interval was significantly increased using the ultrathin fetoscope (89.1±35.0 d vs. 71.4±35.4 d, p=0.001) resulting in an increased gestational age at delivery by 11 days on average (231.9±28.1 d vs. 221.1±32.7 d, p=0.012). CONCLUSIONS Fetal survival can be significantly increased following TTTS using flexible fetoscope of 1 mm or 1.2 mm (sheath 2.65 mm2 or 3.34 mm2).
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Affiliation(s)
| | - Anja Zühlke
- Clinic of Anesthesiology, Martha-Maria Clinic, Halle-Dölau, Germany
| | - Natalia Schlabritz-Lutsevich
- School of Medicine at the Permian Basin, Texas Tech University, Health Sciences Center (TTUHSC), Odessa, TX, USA
| | - Michael Entezami
- Center of Prenatal Diagnostic and Human Genetic Kudamm-199, Berlin, Germany
| | - Gregor Seliger
- Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Weijing Li
- EWK, Clinic of Obstetrics and Gynecology, Berlin, Germany
| | - Angela Köninger
- University Clinic of Obstetrics and Gynecology, St. Hedwig, Barmherzige Brüder, Regensburg, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Rustem Yusupbaev
- Republican Scientific and Practical Medical Center for Obstetrics and Gynecology, Tashkent, Uzbekistan
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Cruz-Martínez R, Gil-Pugliese S, Enciso-Meraz JM, Villalobos-Gómez R, López-Briones H, Martínez-Rodríguez M, Bermúdez-Rojas MDLL, Medina-Jiménez V, Coronel-Cruz F, Pineda-Alemán H, García-Espinosa M, Helue-Mena A, Márquez-Dávila A, Gutiérrez-Gómez I, Chávez-González E, Rebolledo-Fernández C. Management of Late Twin-to-Twin Transfusion Syndrome beyond 26 Weeks: Comparison between Fetoscopic Laser Therapy versus Traditional Management. Fetal Diagn Ther 2023; 50:464-471. [PMID: 37517395 DOI: 10.1159/000533202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION A proportion of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS) can present after 26 weeks of gestation. The aim of this study was to compare perinatal outcomes of late TTTS treated by fetoscopic laser coagulation versus traditional management with amniodrainage and/or emergency preterm cesarean delivery (CD). METHODS Retrospective cohort from January 2012 to January 2023 of consecutive MCDA twin pregnancies complicated by TTTS after 26 weeks and evaluated in our referring centers. We analyzed perinatal outcomes of cases treated with fetoscopic laser surgery at our national referral fetal surgery center in Queretaro, Mexico, and compared them with those managed with traditional management (amniodrainage and/or emergency preterm CD). The primary outcome was survival at discharge and the secondary outcome was gestational age (GA) at birth. RESULTS Among the study population, 46 TTTS cases were treated by fetoscopy at 27+6 (26+0-31+0) weeks+days and were compared with a group of 39 cases who underwent emergency preterm CD. In comparison to the group who underwent traditional management, the group treated by laser fetoscopy showed a significantly higher GA at birth (32+3 vs. 29+1 weeks+days, p < 0.001), lower frequency of preterm delivery below 37 weeks (91.3% vs. 100%, p = 0.06), 34 weeks (63.0% vs. 100%, p < 0.001), 32 weeks (50% vs. 74.4%, p = 0.02), or 30 weeks (28.3% vs. 53.8%, p = 0.01), and significantly higher perinatal survival (89.1% vs. 71.8%, p < 0.05 of at least one twin; and 65.2% vs. 38.5%, p = 0.01 of both twins, respectively). CONCLUSION MCDA twins complicated with TTTS can be treated with fetoscopic laser surgery between 26 and 31 weeks of gestation, which is a feasible and safe option, and such cases are associated with a higher GA at birth and better perinatal survival than those managed with amniodrainage and/or emergency preterm CD.
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Affiliation(s)
- Rogelio Cruz-Martínez
- Departament of Maternal-Fetal Medicine, Children's Women's Specialty Hospital "Dr. Felipe Núñez Lara", Queretaro, Mexico
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | - Savino Gil-Pugliese
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | - Juan Manuel Enciso-Meraz
- Department of Maternal-Fetal Medicine, Western National Medical Center, Mexican Institute of Social Security (IMSS), Guadalajara, Mexico
| | - Rosa Villalobos-Gómez
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | - Hugo López-Briones
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | - Miguel Martínez-Rodríguez
- Departament of Maternal-Fetal Medicine, Children's Women's Specialty Hospital "Dr. Felipe Núñez Lara", Queretaro, Mexico
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | | | - Virginia Medina-Jiménez
- State Center for Timely Prenatal Screening, Maternal, and Child Hospital Specialty, Leon, Mexico
| | - Fausto Coronel-Cruz
- Department of Maternal-Fetal Medicine, General Hospital of Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Hugo Pineda-Alemán
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
| | - Maritza García-Espinosa
- Department of Maternal-Fetal Medicine, High Specialty Medical Unit Gineco Obstetrics Hospital No. 4, Mexican Institute of Social Security (IMSS), Mexico City, Mexico
| | - Antonio Helue-Mena
- Department of Maternal-Fetal Medicine, National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, Mexico
| | - Alejandra Márquez-Dávila
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
- Department of Maternal-Fetal Medicine, National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, Mexico
| | - Iván Gutiérrez-Gómez
- Department of Maternal-Fetal Medicine, National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, Mexico
| | - Eréndira Chávez-González
- Fetal Medicine and Surgery Center, Fetal Medicine Mexico Institute, and Fetal Medicine Mexico Foundation, Guadalajara, Mexico
- Division of Health Sciences, Department of Biomedical Sciences, Tonala Center, University of Guadalajara, Guadalajara, Mexico
| | - Carlos Rebolledo-Fernández
- Departament of Maternal-Fetal Medicine, Children's Women's Specialty Hospital "Dr. Felipe Núñez Lara", Queretaro, Mexico
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Knijnenburg PJ, Slaghekke F, Rahmattulla C, Ge Y, Scholl IM, van Klink JM, Haak MC, Middeldorp JM, Sun L, Lopriore E. Intertwin Membrane Perforation and Umbilical Cord Entanglement after Laser Surgery for Twin-Twin Transfusion Syndrome: Prevalence, Risk Factors, and Outcome. Fetal Diagn Ther 2023; 50:289-298. [PMID: 37285826 PMCID: PMC10614233 DOI: 10.1159/000531450] [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: 01/16/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Perforation of the intertwin membrane can occur as a complication of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS). Data on the occurrence and the risk of subsequent cord entanglement are limited. The objective of this study was to assess the prevalence, risk factors and outcome of intertwin membrane perforation, and cord entanglement after laser surgery for TTTS. METHODS In this multicenter retrospective study, we included all TTTS pregnancies treated with laser surgery in two fetal therapy centers, Shanghai (China) and Leiden (the Netherlands) between 2002 and 2020. We evaluated the occurrence of intertwin membrane perforation and cord entanglement after laser, based on routine fortnightly ultrasound examination and investigated the risk factors and the association with adverse short- and long-term outcomes. RESULTS Perforation of the intertwin membrane occurred in 118 (16%) of the 761 TTTS pregnancies treated with laser surgery and was followed by cord entanglement in 21% (25/118). Perforation of the intertwin membrane was associated with higher laser power settings, 45.8 Watt versus 42.2 Watt (p = 0.029) and a second fetal surgery procedure 17% versus 6% (p < 0.001). The group with intertwin membrane perforation had a higher rate of caesarean section (77% vs. 31%, p < 0.001) and a lower gestational age at birth (30.7 vs. 33.3 weeks of gestation, p < 0.001) compared to the group with an intact intertwin membrane. Severe cerebral injury occurred more often in the group with intertwin membrane perforation, 9% (17/185) versus 5% (42/930), respectively (p = 0.019). Neurodevelopmental outcome at 2 years of age was similar between the groups with and without perforation of the intertwin membrane and between the subgroups with and without cord entanglement. CONCLUSION Perforation of the intertwin membrane after laser occurred in 16% of TTTS cases treated with laser and led to cord entanglement in at least 1 in 5 cases. Intertwin membrane perforation was associated with a lower gestational age at birth and a higher rate of severe cerebral injury in surviving neonates.
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Affiliation(s)
- Patricia J.C. Knijnenburg
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Chinar Rahmattulla
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Yuchun Ge
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - Irene M. Scholl
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M.M. van Klink
- Division of Child and Adolescent Psychology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique C. Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna M. Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Luming Sun
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
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Li Y, Chang Q, Mai Q. Pregnancy and neonatal outcomes of monozygotic twins resulting from assisted reproductive technology: a 10-year retrospective study. Reprod Biol Endocrinol 2023; 21:51. [PMID: 37268975 DOI: 10.1186/s12958-023-01104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 05/18/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Monozygotic twins (MZTs) are associated with high risks of maternal and fetal complications. Even with the widely used elective single embryo transfer (SET), the risk of MZTs following assisted reproductive technology (ART) treatments remains. However, most studies of MZTs focused on the relevant etiology, with few studies describing pregnancy and neonatal outcomes. METHODS This retrospective cohort study included 19,081 SET cycles resulting from in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), preimplantation genetic testing (PGT) and testicular sperm aspiration (TESA) performed between January 2010 and July 2020 in a single university-based center. A total of 187 MZTs were included in this investigation. The main outcome measures were the incidence, pregnancy and neonatal outcomes of MZTs. Multivariate logistic regression analysis was performed to figure out the risk factors for pregnancy loss. RESULTS The overall rate of MZTs from ART treatment in SET cycles was 0.98%. No significant difference was found in the incidence of MZTs among the four groups (p = 0.259). The live birth rate of MZTs in the ICSI group (88.5%) was significantly more favorable than in the IVF, PGT and TESA groups (60.5%, 77.2% and 80%, respectively). IVF resulted in a significantly increased risk of pregnancy loss (39.4%) and early miscarriage (29.5%) in MZT pregnancies compared to ICSI (11.4%, 8.5%), PGT (22.7%, 16.6%) and TESA (20%, 13.3%). The total rate of twin-to-twin transfusion syndrome (TTTS) in MZTs was 2.7% (5/187); however, the TESA group had the highest rate at 20% and was significantly higher than the PGT group (p = 0.005). The four ART groups had no significant effect on the occurrence of congenital abnormalities or other neonatal outcomes in newborns from MZT pregnancies. Multivariate logistic regression analysis revealed that infertility duration, cause of infertility, the total dose of Gn used, history of miscarriages, and the number of miscarriages were not related to the risk of pregnancy loss (p > 0.05). CONCLUSIONS The rate of MZTs was similar among the four ART groups. The pregnancy loss and the early miscarriage rate of MZTs was increased in IVF patients. Neither the cause of infertility nor the history of miscarriage was correlated with the risk of pregnancy loss. MZTs in the TESA group had a higher risk of TTTS, placental effects influenced by sperm and paternally expressed genes may play a role. However, due to the small total number, studies with larger sample sizes are still needed to validate these result. Pregnancy and neonatal outcomes of MZTs after PGT treatment seem to be reassuring but the duration of the study was short, and long-term follow-up of the children is needed.
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Affiliation(s)
- Yubin Li
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qiyuan Chang
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qingyun Mai
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Doğru Ş, Acar A. Fetoscopic surgery for amniotic band syndrome: Case series. Congenit Anom (Kyoto) 2023; 63:4-8. [PMID: 36116114 DOI: 10.1111/cga.12494] [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: 04/14/2022] [Revised: 08/09/2022] [Accepted: 09/03/2022] [Indexed: 01/05/2023]
Abstract
We aimed to evaluate the fetoscopic procedure indications, procedure-related complications, and neonatal outcomes in cases diagnosed with amniotic band syndrome (ABS). Stage II and III cases according to Hüsler classification were included for fetoscopic surgery. Scissors were used to release the amniotic band in six cases, and a diode laser was used in one case. A single entry was made in all cases. The majority of the children acquired a functional limb (71.4%). Fetal morbidity was mainly linked to the consequences of preterm premature rupture of the membranes (57.1%) and preterm birth (28.5%). Excluding complicated cases, fetoscopic band release is encouraging in cases of ABS in the limbs.
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Affiliation(s)
- Şükran Doğru
- Division of Maternal and Fetal Medicine, Necmettin Erbakan University (NEU) Meram Faculty of Medicine, Konya, Turkey
| | - Ali Acar
- Division of Maternal and Fetal Medicine, Necmettin Erbakan University (NEU) Meram Faculty of Medicine, Konya, Turkey
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Cruz-Martínez R, Villalobos-Gómez R, Gil-Pugliese S, Gámez-Varela A, López-Briones H, Martínez-Rodríguez M, Barrios-Prieto E. Management of atypical cases of twin-to-twin transfusion syndrome. Best Pract Res Clin Obstet Gynaecol 2022; 84:155-165. [PMID: 35490103 DOI: 10.1016/j.bpobgyn.2022.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/13/2022] [Indexed: 11/02/2022]
Abstract
Up to 20% of monochorionic diamniotic twin pregnancies can be complicated with twin-to-twin transfusion syndrome (TTTS). This complication is diagnosed by ultrasound demonstrating amniotic fluid discordance between both amniotic sacs, with polyhydramnios in the recipient's sac and oligohydramnios in the donor's, secondary to an imbalance in blood volume exchange between twins. Ultrasound evaluation of the amniotic fluid volume, bladder filling, and assessment of fetal Doppler parameters provide the basis for classification of TTTS, allowing severity assessment. The Quintero's staging system provides a standardized prenatal estimate on the risk of intrauterine fetal demise of one or both twins and the need for fetoscopic laser coagulation of placental vascular anastomoses or delivery depending on the gestational age. However, a proportion of TTTS cases may present without a linear progressive deterioration and no ultrasound signs of preceding staging, in rare situations, they arise even without amniotic fluid discordance. Thus, these unusual clinical presentations of TTTS have long been grouped into the category of atypical TTTS. In this review, we show the clues for diagnosis and management of different atypical cases of TTTS highlighting their underlying mechanism to improve the clinical understanding of such atypical situations, avoid misdiagnosis of TTTS, and allow a timely referral to a fetoscopic center.
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Affiliation(s)
- Rogelio Cruz-Martínez
- Fetal Medicine and Surgery Center, Medicina Fetal México, Guadalajara, Jalisco, Mexico; Department of Maternal-Fetal Medicine, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Jalisco, Mexico; Fetal Medicine Center, Medicina Fetal México, Querétaro, Mexico.
| | - Rosa Villalobos-Gómez
- Fetal Medicine and Surgery Center, Medicina Fetal México, Guadalajara, Jalisco, Mexico; Department of Maternal-Fetal Medicine, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Jalisco, Mexico; Fetal Medicine Center, Medicina Fetal México, Querétaro, Mexico
| | | | - Alma Gámez-Varela
- Fetal Medicine and Surgery Center, Medicina Fetal México, Guadalajara, Jalisco, Mexico
| | | | - Miguel Martínez-Rodríguez
- Fetal Medicine and Surgery Center, Medicina Fetal México, Guadalajara, Jalisco, Mexico; Department of Maternal-Fetal Medicine, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Jalisco, Mexico
| | - Ernesto Barrios-Prieto
- Department of Maternal-Fetal Medicine, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Jalisco, Mexico
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López-Briones H, Villalobos-Gómez R, Chávez-González E, Martínez-Rodríguez M, Helue-Mena A, Gámez-Varela A, Cruz-Martinez R. Twin-to-twin transfusion syndrome and coronavirus disease 2019: Impact on diagnosis, referral, eligibility for fetoscopic laser therapy and outcomes. AJOG GLOBAL REPORTS 2022; 2:100040. [PMID: 35039807 PMCID: PMC8755450 DOI: 10.1016/j.xagr.2021.100040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Because of the progressive nature of twin-to-twin transfusion syndrome, difficulties in healthcare access during the COVID-19 pandemic may lead to delayed diagnosis and referral to fetal surgery centers, which may have repercussions on outcomes. OBJECTIVE This study aimed to assess the clinical impact of the COVID-19 pandemic on pregnancies complicated with twin-to-twin transfusion syndrome. STUDY DESIGN A retrospective cohort study of consecutive monochorionic diamniotic twin pregnancies complicated with twin-to-twin transfusion syndrome evaluated in our national referral fetal surgery center at Queretaro, Mexico, for possible surgical fetoscopy was conducted. Maternal-fetal characteristics and perinatal outcomes of cases evaluated during the first year of the World Health Organization's COVID-19 pandemic declaration (March 11, 2020 to March 10, 2021) were retrospectively compared with outcomes of cases evaluated during the same period in the previous year (March 11, 2019 to March 10, 2020). RESULTS Overall, 109 consecutive twin-to-twin transfusion syndrome cases were evaluated during the 2-year study period, 54 during the COVID-19 pandemic and 55 in the previous year. In the former group, a higher proportion of cases with fetal surveillance interval longer than 2 weeks (70.4% vs 47.3%; P=.01); twin-to-twin transfusion syndrome complications precluding laser therapy, such as intrauterine fetal demise, preterm rupture of membranes, or cervical dilatation with prolapsed amniotic membranes (18.5% vs 1.8%; P<.01); advanced twin-to-twin transfusion syndrome (53.7% vs 36.4%; P=.07); preoperative short cervix (25.9% vs 10.9%; P<.05); and lower overall perinatal survival (56.9% vs 80.0% [P=.01; at least 1 twin] and 39.2% vs 56.4% [P=.08; both twins], respectively) were observed. A significantly lower number of cases were selected for fetoscopic laser therapy during the pandemic (75.9% vs 92.7%; P=.01), with similar postoperative outcomes seen in both study periods. CONCLUSION In pregnancies with twin-to-twin transfusion syndrome, the COVID-19 pandemic has shown an adverse impact involving suboptimal fetal surveillance, advanced stages at diagnosis, poorer survival rates, and higher number of complications that preclude fetoscopic laser therapy.
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Affiliation(s)
- Hugo López-Briones
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico (Drs López-Briones, Rosa Villalobos-Gómez, Chávez-González, Martínez-Rodríguez, Helue-Mena, Gámez-Varela, and Cruz-Martinez)
| | - Rosa Villalobos-Gómez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico (Drs López-Briones, Rosa Villalobos-Gómez, Chávez-González, Martínez-Rodríguez, Helue-Mena, Gámez-Varela, and Cruz-Martinez)
| | - Eréndira Chávez-González
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico (Drs López-Briones, Rosa Villalobos-Gómez, Chávez-González, Martínez-Rodríguez, Helue-Mena, Gámez-Varela, and Cruz-Martinez)
| | - Miguel Martínez-Rodríguez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico (Drs López-Briones, Rosa Villalobos-Gómez, Chávez-González, Martínez-Rodríguez, Helue-Mena, Gámez-Varela, and Cruz-Martinez)
| | - Antonio Helue-Mena
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico (Drs López-Briones, Rosa Villalobos-Gómez, Chávez-González, Martínez-Rodríguez, Helue-Mena, Gámez-Varela, and Cruz-Martinez)
| | - Alma Gámez-Varela
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico (Drs López-Briones, Rosa Villalobos-Gómez, Chávez-González, Martínez-Rodríguez, Helue-Mena, Gámez-Varela, and Cruz-Martinez)
| | - Rogelio Cruz-Martinez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Mexico Foundation, Queretaro, Mexico (Drs López-Briones, Rosa Villalobos-Gómez, Chávez-González, Martínez-Rodríguez, Helue-Mena, Gámez-Varela, and Cruz-Martinez)
- Instituto de Ciencias de Salud, Universidad Autónoma del Estado de Hidalgo, Hidalgo, México (Dr Cruz-Martinez)
- Corresponding author: Rogelio Cruz-Martinez, MD, PhD
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Coelho G, Trigo L, Faig F, Vieira EV, da Silva HPG, Acácio G, Zagatto G, Teles S, Gasparetto TPD, Freitas LF, Zanon N, Lapa DA. The Potential Applications of Augmented Reality in Fetoscopic Surgery for Antenatal Treatment of Myelomeningocele. World Neurosurg 2021; 159:27-32. [PMID: 34922026 DOI: 10.1016/j.wneu.2021.11.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/08/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To develop a preoperative planning method using augmented reality (AR) of a specific surgical procedure: fetoscopy for myelomeningocele repair. METHODS Imaging data were acquired of a pregnant woman at 27 weeks of gestation whose fetus was diagnosed with myelomeningocele. The patient was identified as a candidate for fetoscopic repair of the spine defect, and an AR application for mobile device simulation was developed. The virtual customized model was created by analysis of the presurgical magnetic resonance imaging. A real-time AR interface was developed by using an application that enhanced the anatomical aspects of both mother and fetus. RESULTS A virtual model for planning fetoscopy repair for myelomeningocele was developed. Preoperative and postoperative procedures were successfully carried out, emphasizing the beneficial role of the AR application. The use of the AR model allowed the multidisciplinary team to engage in discussion to determine the appropriate surgical approach. It also allowed a clearer explanation of the procedure to the parents enabling a better understanding of the parents regarding specifics characteristics of their baby's spine defect. CONCLUSIONS This new preoperative platform using a virtual model represents an important tool to improve patient's comprehension, multidisciplinary discussion, and surgical planning. In addition, it can be used worldwide as a teaching tool in the fetal surgery field.
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Affiliation(s)
- Giselle Coelho
- Department of Surgery, Sabará Children's Hospital, São Paulo, São Paulo, Brazil; Scientific Department, EDUCSIM Institute, São Paulo, São Paulo, Brazil; Department of Neurosurgery, University of São Paulo, São Paulo, São Paulo, Brazil.
| | - Lucas Trigo
- Department of Surgery, Sabará Children's Hospital, São Paulo, São Paulo, Brazil
| | - Fernanda Faig
- Department of Surgery, Sabará Children's Hospital, São Paulo, São Paulo, Brazil
| | - Eduardo Varjão Vieira
- Department of Surgery, Sabará Children's Hospital, São Paulo, São Paulo, Brazil; Department of Neurosurgery, University of São Paulo, São Paulo, São Paulo, Brazil; Department of Neurosurgery, Santa Marcelina Hospital, São Paulo, São Paulo, Brazil
| | | | - Gregório Acácio
- Department of Surgery, Sabará Children's Hospital, São Paulo, São Paulo, Brazil
| | - Gustavo Zagatto
- Scientific Department, EDUCSIM Institute, São Paulo, São Paulo, Brazil
| | - Sylker Teles
- Scientific Department, State University of Amazonas, Manaus, Amazonas, Brazil
| | - Taísa Pallú Davaus Gasparetto
- Department of Surgery, Sabará Children's Hospital, São Paulo, São Paulo, Brazil; Department of Radiology, Diagnósticos da América SA, São Paulo, São Paulo, Brazil
| | | | - Nelci Zanon
- Department of Surgery, Sabará Children's Hospital, São Paulo, São Paulo, Brazil; Department of Neurosurgery, CENEPE, Centro de Neurocirurgia Pediátrica, São Paulo, São Paulo, Brazil
| | - Denise Araújo Lapa
- Department of Surgery, Sabará Children's Hospital, São Paulo, São Paulo, Brazil; Department of Fetal Medicine, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
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9
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Liance-Parisot L, Franchinard L, Maurice P, De Carné C, Jouannic JM. [Acute hemoperitoneum following amniodrainage in the third trimester of pregnancy: A case report]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2021; 49:872-873. [PMID: 33771740 DOI: 10.1016/j.gofs.2021.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Indexed: 06/12/2023]
Affiliation(s)
- L Liance-Parisot
- Service de médecine fœtale, Sorbonne Université, Hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - L Franchinard
- Service de médecine fœtale, Sorbonne Université, Hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - P Maurice
- Service de médecine fœtale, Sorbonne Université, Hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - C De Carné
- Service de gynécologie-obstétrique, Sorbonne Université, Hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - J-M Jouannic
- Service de médecine fœtale, Sorbonne Université, Hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France.
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10
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Hochberg A, Silber R, Avnet H, Rosen H, Katorza E, Hoffmann C, Mazkereth R, Lipitz S, Weisz B, Yinon Y. Fetal and neonatal brain lesions following laser ablation for twin-to-twin-transfusion-syndrome as detected by pre- and post-natal brain imaging. Prenat Diagn 2021; 41:1531-1540. [PMID: 34671994 DOI: 10.1002/pd.6061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/25/2021] [Accepted: 10/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the rate of and risk factors for fetal and neonatal brain lesions following laser ablation for twin-to-twin transfusion syndrome (TTTS). METHODS A retrospective cohort study of 83 women with monochorionic twin pregnancies who underwent ablation for TTTS at a single tertiary hospital. Post-laser survivors were followed-up with fetal neurosonogram every 2 weeks and fetal brain MRI at 28-32 weeks of gestation; post-natal brain imaging included neurosonogram. Cases with pre- and post-natal brain lesions were compared to those without. RESULTS 153 fetuses survived the immediate post-laser period and underwent brain imaging. Of these, 17 (11.11%) exhibited brain lesions on prenatal imaging studies, and 36 (32.4%) on post-natal ultrasound. Later gestational age (GA) at the time of ablation (23.0 vs. 21.4 weeks, p = 0.0244), post-laser twin-anemia-polycythemia-sequence (TAPS) (29.41% vs. 9.56%, p = 0.035) and birthweight discordancy (30% vs. 9%, p = 0.0025) were associated with prenatal brain lesions. Earlier GA at delivery (31.0 weeks vs. 32.2, p = 0.0002) and post-laser TAPS (25% vs. 9.33%, p = 0.038) were associated with post-natal brain lesions. CONCLUSIONS Survivors of ablation for TTTS are at risk for brain lesions, which can be detected prenatally. Incorporation of neurosonogram and fetal brain MRI into the routine surveillance of such pregnancies should be considered.
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Affiliation(s)
- Alyssa Hochberg
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Silber
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagai Avnet
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Rosen
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eldad Katorza
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Gertner Institute of Epidemiology & Health Policy Research, Sheba Medical Center, Tel-Hashomer, Israel
| | - Chen Hoffmann
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Radiology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Ram Mazkereth
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Neonatology, Edmond and Lily Safra Children Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Shlomo Lipitz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boaz Weisz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Yinon
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Sileo FG, D'antonio F, Benlioglu C, Bhide A, Khalil A. Perinatal outcomes of twin pregnancies complicated by late twin-twin transfusion syndrome: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2021; 100:832-842. [PMID: 33337543 DOI: 10.1111/aogs.14066] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/09/2020] [Accepted: 12/13/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Untreated twin-to-twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity. Laser surgery is recommended before 26 weeks of gestation. However, the optimal management in case of late TTTS (occurring after 26 weeks of gestation) is yet to be established. MATERIAL AND METHODS We conducted a systematic review and meta-analysis to evaluate the outcomes of monochorionic-diamniotic twin pregnancies complicated by late TTTS according to different management options (expectant, laser therapy, amnioreduction, or delivery). The primary outcome was mortality, including single and double intrauterine, neonatal, and perinatal death. Secondary outcomes were composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (ie, free from neurological complications), and preterm birth before <32 weeks of gestation. Outcomes were reviewed according to the management and reported for the overall population of twins and disease status (ie, donor and recipient separately). Random-effect meta-analyses of proportions were used to analyze the data. RESULTS Nine studies including 796 twin pregnancies affected by TTTS were included. No randomized controlled trials were available for inclusion. TTTS occurred at ≥26 weeks of gestation in 8.7% (95% CI 6.9%-10.9%; 67/769) of cases reporting TTTS at all gestations. Intrauterine death occurred in 17.7% (95% CI 4.9%-36.2%) of pregnancies managed expectantly, 5.3% (95% CI 0.9%-12.9%) of pregnancies treated with laser, and 0% (95% CI 0%-9%) after amnioreduction. Neonatal death occurred in 42.5% (95% CI 17.5%-69.7%) of pregnancies managed expectantly, in 2.8% (95% CI 0.3%-7.7%) of cases treated with laser, and in 20.2% (95% CI 6%-40%) after amnioreduction. Only one study (10 cases) reported data on immediate delivery after diagnosis with no perinatal deaths. Perinatal death incidence was 55.7% (95% CI 31.4%-78.6%) in twin pregnancies managed expectantly, 5.6% (95% CI 0.5%-15.3%) in those treated with laser, and 20.2% (95% CI 6%-40%) in those after amnioreduction. Intact survival was reported in 44.4%, 96.4%, and 78% of fetuses managed expectantly, with laser or amnioreduction, respectively. CONCLUSIONS Evidence regarding perinatal mortality and morbidity in twin pregnancies complicated by late TTTS according to the different managements was of very low quality. Therefore further high-quality research in this field is needed to elucidate the optimal management of these pregnancies.
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Affiliation(s)
- Filomena Giulia Sileo
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK.,Department of Biomedical, Metabolic and Neural Sciences, International Doctorate School in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy.,Unit of Obstetrics and Gynecology, Azienda Unità Sanitaria Locale - IRCCS, Reggio Emilia, Italy
| | - Francesco D'antonio
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, University "G. d'Annunzio" of Chieti, Chieti, Italy
| | - Can Benlioglu
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
| | - Amar Bhide
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Twins Trust Centre for Research and Clinical Excellence, St George's Hospital, London, UK
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12
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Abstract
Periviable deliveries (less than 26 weeks) are a small percentage of deliveries but account for a disproportionately high number of long-term morbidities. Few studies describe interventions and outcomes for periviable preterm premature rupture of membranes (PPROM). The available reports may include only those neonates who received resuscitation, making interpretation and application difficult. Counseling should consider the impact of oligohydramnios on fetal lung development. This article discusses standard and experimental interventions that may offer neonatal benefit. Antenatal corticosteroids, antibiotics, and magnesium sulfate may improve outcomes but data to support an improvement in outcome are limited. Studies specifically evaluating these interventions are needed.
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Affiliation(s)
- Kelly S Gibson
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Case Western Reserve University, The MetroHealth System, Suite G240, 2500 MetroHealth Drive, Cleveland, Ohio 44109, USA.
| | - Kerri Brackney
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Case Western Reserve University, The MetroHealth System, Suite G240, 2500 MetroHealth Drive, Cleveland, Ohio 44109, USA
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13
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Bertrang Warncke A, Zbären S, Bolla D, Baumann M, Mosimann B, Surbek D, Baud D, Raio L. Is computerized cardiotocography useful in monochorionic twins with selective intrauterine growth restriction? J Matern Fetal Neonatal Med 2020; 35:116-121. [PMID: 31928265 DOI: 10.1080/14767058.2020.1712708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To assess the value of using computerized cardiotocography (cCTG) short-term variation (STV) for intrapartum monitoring in monochorionic twins (MC) complicated by selective intrauterine growth restriction (sIUGR).Material and methods: All available cCTGs retrieved from computerized medical records of MC with sIUGR were retrospectively studied regarding the behavior of the STV. sIUGR was defined as intertwin estimated fetal weight (EFW) discordance of ≥20% with the abdominal circumference (AC) below the fifth percentile and/or the EFW of the smaller twin below the 10th percentile. The sIUGR classification system proposed by Gratacos et al. was used using types I-III on the basis of umbilical artery Doppler characteristics of the IUGR twin. The admission (entry) STV and final pre-delivery (last) STV values were analyzed. Cases with intrauterine demise, with structural or chromosomal abnormalities, with twin anemia polycythemia sequence (TAPS) and/or twin-to-twin transfusion syndrome (TTTS) were excluded.Results: During the study period, 64 consecutive cases were managed within our department. Thirty-two cases fulfilled the inclusion criteria for analysis. Mean gestational age at assessment and at delivery was 28.4 ± 2.7 and 31.5 ± 2.2 weeks, respectively. The entry STV and last STV before delivery were not statistically different (mean IUGR STV entry: 9.3 ± 3.4 ms versus last 8 ± 2.2 ms; p = .051; mean co-twin STV entry: 9.1 ± 2.8 ms versus last 9.2 ± 3 ms; p = .87). Neither was the sIUGR-type adjusted STV.Conclusions: In MC pregnancies complicated by sIUGR, the cCTG STV does not distinguish between fetuses, nor does it show differences in cases of fetal deterioration monitored by conventional CTG.
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Affiliation(s)
- Anouk Bertrang Warncke
- Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sibylle Zbären
- Department of Obstetrics and Gynaecology, Spitalzentrum Biel, Biel, Switzerland
| | - Daniele Bolla
- Department of Obstetrics and Gynaecology, SRO AG, Spital Langenthal, Langenthal, Switzerland
| | - Marc Baumann
- Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beatrice Mosimann
- Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Baud
- Department of Obstetrics and Gynaecology, University Hospital, Center Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Luigi Raio
- Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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14
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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: 84] [Impact Index Per Article: 16.8] [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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15
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[Antenatal management in case of preterm premature rupture of membranes before fetal viability: CNGOF Preterm Premature Rupture of Membranes Guidelines]. ACTA ACUST UNITED AC 2018; 46:1076-1088. [PMID: 30409732 DOI: 10.1016/j.gofs.2018.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To evaluate the maternal, perinatal and long-term prognosis in the event of previable premature rupture of the membranes (PROM) and to specify the interventions likely to reduce the risks and improve the prognosis. METHODS The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS Previable PROM is a rare event whose frequency varies from 0.3 to 1% according to estimates (NP4). When occurring as a complication of amniocentesis, the prognosis is generally better than when spontaneous (NP3). Between 23 and 39% of women will deliver in the week following PROM and nearly 40% of women will not have given birth 2 weeks after (NP3). The frequency of medical termination of pregnancy varies greatly according to the studies (NP4), as does that of fetal death (NP4). Hospital survival and survival rates without major morbidity as a proportion of conservatively treated patients range from 17-55% and 26-63%, respectively (NP4). Neonatal prognosis is largely dominated by prematurity and its complications (NP3). The frequency of maternal sepsis varies from 0.8 to 4.8% in the most recent studies (NP4). Only one case of maternal death is reported, although 3 cases were identified in France between 2007 and 2012 (NP3). Information is a major component of the care to be provided to women and their partners (Professional consensus). An initial period of hospitalization may be proposed after previable PROM (Professional consensus). Thereafter, there is no argument to recommend hospital management rather than extra-hospital management when there is no argument in favour of intrauterine infection (Professional consensus). An evaluation of the amount of amniotic fluid by ultrasound may be proposed at the initial consultation and after a period of 7 to 14 days if pregnancy continues (Professional consensus). Prophylactic antibiotic treatment is recommended as soon as PROM is diagnosed (Professional consensus). The gestational age at which corticosteroid therapy may be proposed will depend on the thresholds selected for neonatal resuscitation care. In particular, it will take into account parental positioning (Professional consensus). From the time of the decision to perform neonatal resuscitation until the gestational age of 32 weeks, it is recommended to administer MgSO4 to the woman whose delivery is imminent (Grade A). Tocolysis is not recommended in this context (Professional consensus). In certain situations, meeting strictly the conditions mentioned by the CSP article L. 2213-1, a maternal request for medical interruption of pregnancy may be discussed. CONCLUSION The levels of evidence of scientific work on the management of previable PROM are low, therefore, most of the recommendations proposed here are based on professional agreement by "reasonable" extension of recommendations valid for later gestational ages.
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16
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Elbanna WSS, Oun IA, Ellatif EMA, Hablas WR, El Shaikh WI, Wafa YA. Evaluation of Fetoscopy Role in Fetal Surgery and Fetal Medicine. OPEN JOURNAL OF OBSTETRICS AND GYNECOLOGY 2018; 08:946-957. [DOI: 10.4236/ojog.2018.811096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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17
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Barrett DW, Kethees A, Thrasivoulou C, Mata A, Virasami A, Sebire NJ, Engels AC, Deprest JA, Becker DL, David AL, Chowdhury TT. Trauma induces overexpression of Cx43 in human fetal membrane defects. Prenat Diagn 2017; 37:899-906. [PMID: 28664994 PMCID: PMC5638101 DOI: 10.1002/pd.5104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/22/2017] [Accepted: 06/26/2017] [Indexed: 11/11/2022]
Abstract
Objective We developed an in vitro model to examine whether trauma induces connexin 43 (Cx43) expression and collagen organisation in the amniotic membrane (AM) of fetal membrane (FM) defects. Method Term human FM was traumatised in vitro. Cell morphology and Cx43 were examined in the wound edge AM by immunofluorescence (IMF) confocal microscopy and compared to control AM. Collagen microstructure was examined by second harmonic generation (SHG) imaging. Cell viability was assessed with calcein and ethidium staining. Results After trauma, the AM showed a dense region of cells, which had migrated towards the wound edge. In wound edge AM, Cx43 puncta was preferentially distributed in mesenchymal cells compared to epithelial cells with significant expression in the fibroblast layer than epithelial layer (p < 0.001). In the fibroblast layer, the collagen fibres were highly polarised and aligned in parallel to the axis of the wound edge AM. There was an absence of cell migration across the defect with no healing after 168 h. Cell viability of the FM after trauma was maintained during culture. Conclusion Cx43 overexpression in wounded AM drives structural changes in collagen that slows down efficacy of cell migration across the FM defect. © 2017 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd. What's already known about this topic?
After fetal surgery, the human fetal membrane shows limited healing and overexpression of Cx43 at the wound edge. Cx43 knockdown leads to accelerated wound healing by influencing cell migration and tissue dynamics.
What does this study add?
We developed an artificial fetal membrane model to examine Cx43 expression after trauma and changes in collagen dynamics. We observed Cx43 overexpression and polarised collagen at the wound edge. These changes were found to be similar to human fetoscopic wounds after fetal surgery.
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Affiliation(s)
- David W Barrett
- Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary University of London, London, UK
| | - Aumie Kethees
- Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary University of London, London, UK
| | | | - Alvaro Mata
- Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary University of London, London, UK
| | - Alex Virasami
- Histopathology Department, Camelia Botnar Laboratories, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Neil J Sebire
- Histopathology Department, Camelia Botnar Laboratories, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Alex C Engels
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Jan A Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - David L Becker
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Anna L David
- Institute for Women's Health, University College London, London, UK
| | - Tina T Chowdhury
- Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary University of London, London, UK
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18
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Nakata M, Ishii K, Sumie M, Takano M, Hirata H, Murata S, Takahashi Y, Murakoshi T, Sago H. A prospective pilot study of fetoscopic laser surgery for twin-to-twin transfusion syndrome between 26 and 27 weeks of gestation. Taiwan J Obstet Gynecol 2017; 55:512-4. [PMID: 27590373 DOI: 10.1016/j.tjog.2016.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The aim of this study is to clarify the feasibility and efficacy of fetoscopic laser photocoagulation of placental vascular communicating vessels (FLP) on twin-twin transfusion syndrome (TTTS) after 26 weeks of gestation. MATERIALS AND METHODS This is a prospective pilot study investigating all cases of TTTS between 26 weeks and 27 weeks during 2012 and 2013 in Japan. The primary endpoints in this study were the feasibility of FLP and rate of harmful complications for the mother's health. Also, perinatal prognosis was investigated. RESULTS Six cases were enrolled and underwent FLP. Two of the six cases were classified preoperatively as Quintero Stage II and four cases were Stage III. FLP was completely achieved in all six cases. No severe maternal complications were noted during and immediately after the surgery. All but one case continued the pregnancies > 14 days after FLP. The median gestational age at delivery was 33.4 weeks (28.0-36.6 weeks). All 12 fetuses survived at the 28(th) day in the neonatal period. No case was diagnosed with cerebral lesion at the neonatal period. CONCLUSION This prospective pilot study shows that FLP could be a therapeutic option for TTTS between 26 weeks and 27 weeks of gestation.
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Affiliation(s)
- Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan; Perinatal Care Center, Tokuyama Central Hospital, Shunan, Japan.
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Masahiro Sumie
- Fetal Medicine, National Center of Child Health and Development, Tokyo, Japan
| | - Mayumi Takano
- Perinatal Care Center, Tokuyama Central Hospital, Shunan, Japan
| | - Hiroko Hirata
- Perinatal Care Center, Tokuyama Central Hospital, Shunan, Japan
| | - Susumu Murata
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan
| | | | - Takeshi Murakoshi
- Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Haruhiko Sago
- Fetal Medicine, National Center of Child Health and Development, Tokyo, Japan
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19
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Lecointre L, Sananès N, Weingertner AS, Gaudineau A, Akladios C, Cavillon V, Langer B, Favre R. [Fetoscopic laser coagulation in 200 consecutive monochorionic pregnancies with twin-twin transfusion syndrome]. J Gynecol Obstet Hum Reprod 2017; 46:175-181. [PMID: 28403975 DOI: 10.1016/j.jogoh.2016.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 10/09/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To report preoperative data, surgical characteristics, complications and perinatal outcome of twin-twin transfusion syndrome (TTTS) managed with laser ablation surgery, to analyze predictors of neonatal survival and to compare the 100 most recent cases with the older 100. MATERIALS AND METHODS Observational cohort moncentric study of 200 cases of TTTS consecutively treated with fetoscopic laser coagulation between January 2004 and December 2014. RESULTS There were 49 stage I, 88 stage II, 55 stage III and eight stage IV. Median gestation at time of laser was 20.1±3.0 weeks' gestation (WG) whereas median gestation at delivery was 31.6±5.4 WG. Overall perinatal survival rate was 68.0% and 84.0% have one or more surviving twins. Preterm premature rupture of membranes occurred in 39 cases with and the median gestational age for this complication was 28.8±4.6 SA. Predictive factors to have at least one living birth were Quintero stage and gestational age at delivery. In the most recent period, there were significantly more TTTS Quintero stage I treated with laser, more coagulation by the Solomon technique and a larger number of coagulated vessels. CONCLUSION The neonatal survival of TTTS is improved by fetoscopic laser coagulation, preferely by using Solomon tecnhique. The use of active management of stage I is currently on research.
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Affiliation(s)
- L Lecointre
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France.
| | - N Sananès
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Inserm, UMR-S 1121, « Biomatériaux et Bioingénierie », 11, rue Humann, 67085 Strasbourg cedex, France
| | - A S Weingertner
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
| | - A Gaudineau
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - C Akladios
- Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - V Cavillon
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
| | - B Langer
- Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - R Favre
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
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Sananès N, Gabriele V, Weingertner AS, Ruano R, Sanz-Cortes M, Gaudineau A, Langer B, Nisand I, Akladios CY, Favre R. Evaluation of long-term neurodevelopment in twin-twin transfusion syndrome after laser therapy. Prenat Diagn 2016; 36:1139-1145. [DOI: 10.1002/pd.4950] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/10/2016] [Accepted: 10/18/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Nicolas Sananès
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
- INSERM, UMR-S 1121, ‘Biomatériaux et Bioingénierie’; Strasbourg France
| | - Victor Gabriele
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
| | | | - Rodrigo Ruano
- Texas Children's Fetal Center and Baylor College of Medicine; Houston TX USA
| | | | - Adrien Gaudineau
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
| | - Bruno Langer
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
| | - Israël Nisand
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
| | | | - Romain Favre
- Department of Obstetrics and Gynecology; Strasbourg University Hospital; Strasbourg France
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21
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Peeters SHP, Stolk TT, Slaghekke F, Middeldorp JM, Klumper FJ, Lopriore E, Oepkes D. Iatrogenic perforation of intertwin membrane after laser surgery for twin-to-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:550-556. [PMID: 24961923 DOI: 10.1002/uog.13445] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 06/02/2014] [Accepted: 06/09/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate management and outcome of iatrogenic monoamniotic twins (iMAT) compared with twins with intact intertwin dividing membranes after laser surgery for twin-to-twin transfusion syndrome (TTTS). METHODS This was a retrospective analysis of twins with and without iatrogenic rupture of the intertwin membranes that had been treated for TTTS with laser surgery at our center between 2004 and 2012. Primary outcomes were perinatal survival and severe neonatal morbidity. Secondary outcomes were mode of delivery, gestational age at birth and cord entanglement. RESULTS In total, 338 pregnancies were included. In 67/338 (20%) pregnancies, iMAT was suspected antenatally. In 47 of these 67 (70%), a preterm Cesarean section was performed for monoamnionicity. Perinatal survival was 108/134 (81%) vs 396/542 (73%) in twins with intact intertwin membranes (P = 0.13). Mean gestational age at birth in iMAT was 31 completed weeks, compared to 33 weeks in twins with intact membranes (P < 0.01). At birth, cord entanglement was present in 8/67 (12%) iMAT pregnancies. Severe neonatal morbidity was assessed in 106/110 (96%) in iMAT cases and 392/416 (94%) in controls. The incidence of severe neonatal morbidity was 28/106 (26%) in iMAT vs 72/392 (18%) in controls (P = 0.25). Severe cerebral injury was significantly increased in the iMAT group as compared with controls, at 16/106 (15%) vs 18/392 (5%) (P < 0.01). CONCLUSIONS Iatrogenic rupture of intertwin membranes was suspected in 20% of pregnancies treated with laser therapy for TTTS and was associated with a lower gestational age at birth and increased neonatal morbidity.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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22
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Lecointre L, Sananes N, Weingertner AS, Kohler M, Guerra F, Fritz G, Viville B, Langer B, Nisand I, Favre R. Fetoscopic laser coagulation for twin-twin transfusion syndrome before 17 weeks' gestation: laser data, complications and neonatal outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:299-303. [PMID: 24677292 DOI: 10.1002/uog.13375] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 01/22/2014] [Accepted: 03/14/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To compare laser data, complications and neonatal outcome in pregnancies that undergo 'early' (≤ 17 weeks' gestation) fetoscopic laser ablation of placental vascular anastomoses for twin-twin transfusion syndrome (TTTS) with those from 'conventional' cases treated after 17 weeks. METHODS This was a cohort study of data collected prospectively between January 2004 and December 2012. We included monochorionic diamniotic twin pregnancies complicated by TTTS and treated by fetoscopic laser coagulation. Pregnancies were grouped according to laser treatment ≤ 17 gestational weeks or > 17 weeks and obstetric and neonatal outcomes were compared between groups. RESULTS A total of 178 pregnancies with TTTS underwent laser therapy: 40 at or before 17 weeks and 138 after 17 weeks. There was no statistically significant difference between these two groups with respect to the rate of preterm prelabor rupture of membranes (PPROM), gestational age at PPROM and rate of PPROM occurring in the 7 days following fetoscopic laser coagulation. In the early group, the interval between performing fetoscopic laser coagulation and the time of delivery was significantly longer (104 days vs 74 days, P=0.0002) and the delivery rate within 7 days of laser treatment was significantly lower (2.5% vs 15.9%, P=0.026). There was no significant difference between the two groups with regard to the rates of pregnancy without live birth (15.4% vs 15.4%, P=0.993), with one live birth (84.6% vs 84.6%, P=0.993) and with two live births (64.1% vs 58.1%, P=0.500). CONCLUSION In the event of early TTTS, fetoscopic laser coagulation is technically feasible before 17 gestational weeks and obstetric and neonatal outcomes are comparable with those in cases of laser treatment performed after 17 weeks.
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Affiliation(s)
- L Lecointre
- Fetal Medicine, CMCO-HUS, Schiltigheim/Strasbourg, France
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23
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Baud D, Windrim R, Keunen J, Kelly EN, Shah P, van Mieghem T, Seaward PGR, Ryan G. Fetoscopic laser therapy for twin-twin transfusion syndrome before 17 and after 26 weeks' gestation. Am J Obstet Gynecol 2013. [PMID: 23178244 DOI: 10.1016/j.ajog.2012.11.027] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The purpose of this study was to compare perinatal outcomes of pregnancies that undergo "early" (<17 weeks' gestation) or "late" (>26 weeks' gestation) fetoscopic laser ablation of placental vascular anastomoses for twin-twin transfusion syndrome (TTTS) with "conventional" cases that were treated at 17-26 weeks' gestation. STUDY DESIGN We conducted a single center, retrospective analysis of 325 consecutive pregnancies that underwent fetoscopic laser therapy for severe TTTS. RESULTS Twenty-four "early," 18 "late," and 283 "conventional" pregnancies with severe TTTS underwent laser therapy. Fetoscopy duration, gestation at delivery, survival rate, and complications were comparable among groups, except for preterm premature rupture of membranes at <7 days after laser therapy, which was more common in the "early" group than in either of the other 2 groups. CONCLUSION Laser therapy for TTTS at <17 or >26 weeks' gestation has similar outcomes to procedures done at 17-26 weeks' gestation. We suggest that conventional gestational age guidelines of 16-26 weeks for laser therapy for TTTS should be reevaluated.
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Affiliation(s)
- David Baud
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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24
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Deka D, Dadhwal V, Gajatheepan SB, Singh A, Sharma KA, Malhotra N. The art of fetoscopy: a step toward minimally invasive fetal therapy. J Obstet Gynaecol India 2012; 62:655-9. [PMID: 24293843 DOI: 10.1007/s13224-012-0232-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 06/14/2012] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To study the feasibility, learning curve, and safety of fetoscopy, so that fetal surgery can be confidently performed in ongoing pregnancies. METHODS Fetoscopy was performed at 12-20 weeks of gestation, in 12 women with fetal congenital malformations and/or for termination of pregnancy, under local anesthesia using fine fetoscopes ranging from 1 to 2-mm diameter. The fetal parts and placenta were examined for clarity of vision, identification, and anomalies. RESULTS Fetoscopy required great skill, patience, and extensive use of ultrasound for correct orientation. Visualization was better with endoscope of 2-mm diameter. Laser coagulation of placental vessels using diode laser system was possible in the last two cases. There were no major complications. CONCLUSIONS Fetal endoscopy is a feasible procedure, safe in experienced hands but has an appreciable learning curve.
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Affiliation(s)
- Dipika Deka
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029 India
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25
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Valsky DV, Eixarch E, Martinez-Crespo JM, Acosta ER, Lewi L, Deprest J, Gratacós E. Fetoscopic Laser Surgery for Twin-to-Twin Transfusion Syndrome after 26 Weeks of Gestation. Fetal Diagn Ther 2012; 31:30-4. [DOI: 10.1159/000330369] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 06/24/2011] [Indexed: 11/19/2022]
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26
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Tchirikov M, Oshovskyy V, Steetskamp J, Falkert A, Huber G, Entezami M. Neonatal outcome using ultrathin fetoscope for laser coagulation in twin-to-twin-transfusion syndrome. J Perinat Med 2011; 39:725-30. [PMID: 21867454 DOI: 10.1515/jpm.2011.091] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To improve neonatal outcome using ultrathin fetoscope for laser treatment of twin-to-twin transfusion syndrome. METHODS Retrospective cohort study of a series of 80 cases of twin-to-twin-transfusion syndrome prior to 26-weeks' gestation subjected to laser coagulation by means of a 1.0/1.2 mm fiber fetoscope with a sheath sectional area 2.65 mm(2)/3.34 mm(2) (n=27) and a 2.0 mm classic lens fetoscope with a sheath sectional area: 6.63 mm(2)/11.27 mm(2) (n=53). RESULTS The survival rates of at least one twin in the compared groups were 94.4% (classic optic) and 100% (ultrathin optic), for both twins: 75.5% and 83.3%, respectively. By decreasing sheath diameter a pregnancy was prolonged by an average of 21.3 days (P=0.0045), with a resulting increase in the recipient's weight of 389 g (P=0.0049) and an increase in the donor's Apgar score. However, the intervention with ultrathin optic took 11 min longer (P=0.031). CONCLUSION The reduction of the iatrogenic damage of the amniotic membrane using ultrathin fetoscope with a small sheath, significantly improves the neonatal outcome after laser treatment of twin-to-twin-transfusion syndrome. The operator should only commence working with the 1 mm fetoscope after the learning curve has been accomplished.
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Affiliation(s)
- Michael Tchirikov
- University Clinic of Obstetrics and Fetal Medicine, University Medical Center Halle (Saale) of Martin Luther University of Halle-Wittenberg, Germany.
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27
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Valsky DV, Martinez-Serrano MJ, Sanz M, Eixarch E, Acosta ER, Martinez JM, Puerto B, Gratacós E. Cord occlusion followed by laser cord transection in monochorionic monoamniotic discordant twins. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:684-688. [PMID: 21500298 DOI: 10.1002/uog.8924] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To compare the outcomes of a consecutive case series of monochorionic (MC) monoamniotic (MA) discordant twins treated with umbilical cord occlusion and transection, with those of a cohort of MC diamniotic (DA) twins treated with conventional cord occlusion. METHODS This study included 17 MCMA twins (12 true MA and five iatrogenic) treated with cord occlusion and transection and a control group of 72 MCDA discordant twins treated during the same period with cord occlusion in a single center. Duration of surgery, rates of preterm delivery (PTD) or preterm premature rupture of membranes (PPROM) < 32 weeks and intrauterine fetal demise (IUFD), perinatal outcome and neonatal survival were prospectively recorded in both groups. RESULTS Median durations of surgery were 28.5 (range, 14.0-74.0) min and 24.0 (3.0-60.0) min in the cord transection and control groups, respectively (P = 0.24). There were no significant differences between cord transection and control groups in the rates of PPROM (35.3% vs. 20.8%, P = 0.22), PTD (41.2% vs. 28.2%, P = 0.29), IUFD (0% vs. 2.8%, P = 1.0) and neonatal survival (76.5% vs. 80.6%, P = 1.0). Gestational age at delivery (median 35.0 (24.5-39.0) vs. 37.1 (26.2-41.0) weeks, P = 0.21) and fetal birth weight (2215 (800-3200) g vs. 2605 (588-3830) g, P = 0.51) were similar between study groups. CONCLUSION Cord occlusion and transection in MCMA discordant twins resulted in similar perinatal outcomes to those of MCDA discordant twins treated with cord occlusion.
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Affiliation(s)
- D V Valsky
- Department of Maternal-Fetal Medicine (Institut Clínic de Ginecologia, Obstetrícia i Neonatologia), Hospital Clinic-IDIBAPS, University of Barcelona, and Centro de Investigación Biomédica en Red en Enfermedades Raras, Spain
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28
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Cruz-Martinez R, Van Mieghem T, Lewi L, Eixarch E, Cobo T, Martinez JM, Deprest J, Gratacos E. Incidence and clinical implications of early inadvertent septostomy after laser therapy for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:458-462. [PMID: 21433166 DOI: 10.1002/uog.8922] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To evaluate the incidence and clinical outcome of inadvertent septostomy after fetoscopic laser therapy for twin-twin transfusion syndrome (TTTS) and, particularly, to explore its association with the risk of developing pseudoamniotic band syndrome (PABS). METHODS In a cohort of 414 consecutive monochorionic twin pregnancies with confirmed TTTS treated with laser, the incidence of postoperative septostomy within 1 week of the procedure was recorded prospectively. Rates of preterm delivery, preterm premature rupture of membranes (PPROM), intrauterine fetal demise (IUFD) and PABS were compared among cases with and without septostomy. RESULTS The mean gestational age at laser therapy was 20.4 (range, 15.3-27.6) weeks. Postoperative septostomy occurred in 30 (7.2%) cases. Pregnancies complicated with septostomy had a significantly higher proportion of preterm delivery before 32 weeks (76.7% vs. 30.2%, P < 0.001), PPROM before 32 weeks (46.7% vs. 19.0%, P < 0.001), IUFD (43.3% vs. 25.8%, P < 0.05) and PABS (13.3% vs. 1.0%, P < 0.001), compared with pregnancies without septostomy. CONCLUSIONS Inadvertent septostomy occurred in 7% of cases after fetoscopic laser therapy and was associated with a substantially increased risk of adverse perinatal outcome and PABS.
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Affiliation(s)
- R Cruz-Martinez
- Department of Maternal-Fetal Medicine, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
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29
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Hernandez-Andrade E, Benavides-Serralde JA, Guzmán Huerta ME, Moreno-Alvarez O, Mancilla-Ramírez J. Social and economic factors influencing a fetal surgery program for complicated monochorionic twin pregnancies in a developing country. Fetal Diagn Ther 2011; 29:224-8. [PMID: 21358168 DOI: 10.1159/000322111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Accepted: 10/10/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To analyze social and economic factors affecting the implementation of a fetal surgery program in a developing country. MATERIALS AND METHODS During an 18-month period, 30 women with complicated monochorionic diamniotic twin pregnancies were evaluated. 27 women had twin-to-twin transfusion syndrome (TTTS), 2 women had a selective intrauterine growth restriction, and 1 a discordant twin pregnancy with 1 fetus with a severe open neural tube defect. The TTTS cases were treated with fetoscopic laser ablation of the interplacental vascular communications and the remaining 3 cases with bipolar cord occlusion of the affected twin. The patients were evaluated using family income levels (very low, low, median, and high income). Demographic characteristics, gestational age at referral, the prevalence of infections, tocolysis care with hospital readmission, prolonged hospital stay until delivery, and gestational age at delivery were evaluated. RESULTS The overall survival rate of fetuses treated with laser ablation was 60% (32/54). Survival of at least 1 twin was achieved in 21/27 pregnancies (77%), and survival of both twins in 12/27 pregnancies (44%). The 3 pregnancies treated with cord occlusion had survival of the normal twin. Patients with low and very low family income showed a significantly higher prevalence of vaginal infections, increased periods of tocolysis requiring hospitalization, prolonged hospital stay until the end of pregnancy, and lower gestational age at delivery. CONCLUSION When a fetal surgery program is implemented in a developing country, social and economic factors will influence the overall healthcare costs and treatment outcomes.
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Affiliation(s)
- E Hernandez-Andrade
- National Institute of Perinatal Medicine (INPer), Mexico City, Mexico. ehernandez @ servidor.inper.edu.mx
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30
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Clinical and biochemical predictors of very preterm birth in twin-to-twin transfusion syndrome treated by fetoscopy. Am J Obstet Gynecol 2011; 204:58.e1-5. [PMID: 20950791 DOI: 10.1016/j.ajog.2010.08.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 05/31/2010] [Accepted: 08/17/2010] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate pre- and postoperative predictors of preterm birth in twin-to-twin transfusion syndrome treated with fetoscopic placental laser coagulation. STUDY DESIGN Prospective cohort study (n = 166) assessing cervical length (pre and postoperatively), amniotic fluid interleukin-6, serum C-reactive protein and duration of surgery. Logistic regression was used to investigate associations with preterm delivery. RESULTS Preterm delivery within 7 days, before 28.0 and 32.0 weeks occurred in 4.8%, 16.8%, and 28.9%, respectively. The only significant predictor of delivery within 7 days was postoperative cervical length (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.3-0.9). Concerning delivery before 32.0 weeks, preoperative cervical length (OR, 0.9; 95% CI, 0.8-1.0), and gestational age (OR, 0.8; 95% CI, 0.4-0.9) were independent risk factors but the association was weak. The presence of a single survivor after surgery was associated with a clear reduction of risk (OR, 0.3; 95% CI, 0.1-0.6). Inflammatory biomarkers and duration of surgery did not discriminate risk of prematurity. CONCLUSION No strong preoperative predictive factor of preterm birth could be identified. A single survivor was a strong protective factor of very preterm birth.
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Stamilio DM, Fraser WD, Moore TR. Twin-twin transfusion syndrome: an ethics-based and evidence-based argument for clinical research. Am J Obstet Gynecol 2010; 203:3-16. [PMID: 20171601 DOI: 10.1016/j.ajog.2009.12.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 11/29/2009] [Accepted: 12/07/2009] [Indexed: 11/17/2022]
Abstract
Aspects of twin-twin transfusion syndrome (TTTS) diagnosis, treatment alternatives, and research opportunities were considered during a consensus conference that was held by the North American Fetal Therapy Network in 2009. A 3-member scientific consensus panel gathered data from expert conference presentations, postconference communications, and comprehensive scientific literature database searches to develop recommendations for TTTS diagnosis, therapy, and research. The panel recommends retaining the Quintero staging system until a superior system has been validated appropriately. It concludes that there is normative equipoise to justify the performance of randomized clinical trials to identify the optimal treatment strategy for mild TTTS. Recommendations for the design and conduct of clinical trials and observational studies are also provided.
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Affiliation(s)
- David M Stamilio
- Department of Obstetrics & Gynecology, Maternal Fetal Medicine Division, Washington University School of Medicine, St. Louis, MO, USA
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32
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Tchirikov M, Steetskamp J, Hohmann M, Koelbl H. Long-term amnioinfusion through a subcutaneously implanted amniotic fluid replacement port system for treatment of PPROM in humans. Eur J Obstet Gynecol Reprod Biol 2010; 152:30-3. [PMID: 20488612 DOI: 10.1016/j.ejogrb.2010.04.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 04/01/2010] [Accepted: 04/25/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To introduce a novel method for the treatment of PPROM (preterm premature rupture of membranes) using continuous amnioinfusion via a subcutaneously implanted port system. STUDY DESIGN After development and testing since 2001 in a fetal sheep model, the port system has been successfully implanted in two humans with PPROM. In the first case, the subcutaneous port system was implanted during the 23rd week of gestation in a 39-year-old 5th-gravida with PPROM since the 18th week of gestation; in the second case, the port system was implanted during the 24th week of gestation in a 27-year-old 3rd gravida with PPROM since the 21st week of gestation. After port implantation, 100ml/h saline solution was infused intermittently into the amniotic cavity. The whole course of treatment was supported by tocolysis. RESULTS In the cases presented, gestation was terminated by cesarean section, in one case in the 29th week of gestation, and in the other case in the 30th week. The newborns showed no signs of lung hypoplasia and were successfully extubated on the 1st or 2nd day after delivery. Six months later the children did not exhibit any deviation from the normal development. CONCLUSION Long-term amnioinfusion via a subcutaneously implanted port system could be used in humans with PPROM for prolongation of pregnancy and to avoid lung hypoplasia. Prospective randomized studies are ongoing.
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Affiliation(s)
- Michael Tchirikov
- University Medical Center Mainz, Department of Obstetrics and Gynecology, International Teaching Center of Prenatal Diagnostic and Intrauterine Microinvasive Fetal Surgery, Mainz,
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Tchirikov M, Gatopoulos G, Strohner M, Puhl A, Steetskamp J. Two new approaches in intrauterine tracheal occlusion using an ultrathin fetoscope. Laryngoscope 2010; 120:394-8. [PMID: 19950374 DOI: 10.1002/lary.20687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To introduce and establish a new approach in minimal invasive fetoscopic surgery in order to reduce access trauma and the iatrogenic preterm premature rupture of the membranes (PPROM) as a major complication of intrauterine treatment of congenital diaphragmatic hernia. METHODS In total, 27 pregnant sheep were operated on using fetoscopes with 1.2 and 1.0 mm optics. We used an elliptic sheath alone with a maximum diameter of 2.6/1.3 mm; in these cases the balloon was placed under ultrasound control. In comparison, we placed the balloon under fetoscopic control using the fetoscopic sheath and a 7F (2.3 mm) introducer. Therefore, the maximum access trauma was not bigger than the diameter of sheath of introducer. RESULTS With this technique we successfully operated on 22 sheep. The use of real time three-dimensional ultrasound control distinctly facilitates the operation procedure. CONCLUSIONS Our preliminary findings show that fetoscopic tracheal occlusion using ultrathin fetoscopes and reducing the access trauma on the level of 4.2 or even 2.65 mm(2) could be seen as a method of reducing the rate of PPROM.
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Affiliation(s)
- Michael Tchirikov
- Department of Obstetrics and Gynecology, University Medical Center, Mainz, Germany.
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Ahmed S, Luks FI, O'Brien BM, Muratore CS, Carr SR. Influence of experience, case load, and stage distribution on outcome of endoscopic laser surgery for TTTS-a review. Prenat Diagn 2010; 30:314-9. [DOI: 10.1002/pd.2454] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
The term fetal surgery is used widely for fetal intervention during pregnancy; maternal-fetal surgery may be more appropriate, because all these invasive procedures also affect the mother. Although there is no direct benefit to the mother from these procedures, the risk to her is for a purely altruistic purpose. It is therefore important to understand the potential complications of maternal-fetal surgery, so the physician can provide accurate counseling to the patient.
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Affiliation(s)
- Danny Wu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA 94143-0132, USA.
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Hüsler MR, Wilson RD, Horii SC, Bebbington MW, Adzick NS, Johnson MP. When is fetoscopic release of amniotic bands indicated? Review of outcome of cases treatedin uteroand selection criteria for fetal surgery. Prenat Diagn 2009; 29:457-63. [DOI: 10.1002/pd.2222] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Klaritsch P, Albert K, Van Mieghem T, Gucciardo L, Done’ E, Bynens B, Deprest J. Instrumental requirements for minimal invasive fetal surgery. BJOG 2008; 116:188-97. [DOI: 10.1111/j.1471-0528.2008.02021.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Robinson MB, Crombleholme TM, Kurth CD. Maternal Pulmonary Edema During Fetoscopic Surgery. Anesth Analg 2008; 107:1978-80. [DOI: 10.1213/ane.0b013e3181891201] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gratacós E, Antolin E, Lewi L, Martínez JM, Hernandez-Andrade E, Acosta-Rojas R, Enríquez G, Cabero L, Deprest J. Monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic flow (Type III): feasibility and perinatal outcome of fetoscopic placental laser coagulation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:669-675. [PMID: 18504780 DOI: 10.1002/uog.5362] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To assess the feasibility and impact on perinatal outcome of fetoscopic laser coagulation of placental anastomoses in monochorionic twins with selective intrauterine growth restriction (sIUGR) and intermittent absent or reversed end-diastolic flow (iAREDF) in the umbilical artery (Type III), in comparison with expectant management. METHODS This is a descriptive study of the outcome of 18 cases of monochorionic twins with Type III sIUGR treated with laser, and 31 pregnancies managed expectantly over the same period. All newborns underwent neonatal brain ultrasound scans. Perinatal outcome and the incidence of neurological damage were compared between the two groups. RESULTS Laser coagulation could be performed in only 88.9% (16/18) of cases owing to technical difficulties, and in 12.5% (2/16) a second procedure was required to achieve complete coagulation of the large artery-to-artery anastomosis. Mean gestational age at delivery was 31.0 (range, 26-33) weeks in the expectant management group and 32.6 (range, 23-38) weeks in the laser group (P = 0.32). Overall perinatal survival was 85.5% (53/62) and 63.9% (23/36), respectively (P = 0.02). Intrauterine demise of the smaller twin occurred in 19.4% (6/31) and 66.7% (12/18), respectively (P = 0.001), and was associated with death of the cotwin in 50% (3/6) and 0% (0/12) of these cases, respectively (P = 0.02). The prevalence of periventricular leukomalacia in the larger fetus was 4/28 (14.3%) in the expectant management group and 1/17 (5.9%) in the laser group (P = 0.63). CONCLUSIONS Laser coagulation in sIUGR-iAREDF pregnancies is technically difficult and not always feasible. Placental dichorionization significantly increases the proportion of fetuses with intrauterine death of the growth-restricted twin, but it protects the normal twin from its cotwin's death in the event of demise of the growth-restricted twin.
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Affiliation(s)
- E Gratacós
- Department of Maternal-Fetal Medicine (ICGON) and Fetal and Perinatal Research Group (IDIBAPS), Hospital Clinic, University of Barcelona, Spain.
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Morel O, Tran N, Barranger E, Foliguet B, Marchal F, Chastant-Maillard S, Judlin P, Villemot JP, Thiebaugeorges O. Radiofrequency driven cord occlusion for selective termination of pregnancy: evaluation in the fetal sheep. Am J Obstet Gynecol 2008; 198:227.e1-5. [PMID: 18068143 DOI: 10.1016/j.ajog.2007.07.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 07/02/2007] [Accepted: 07/24/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This study was designed to assess the ability of an ultrasound-guided radiofrequency (RF)-driven procedure to induce complete and irreversible cord occlusion using a 90 days fetal sheep model. STUDY DESIGN Twenty 90 days gestation sheep underwent general anesthesia. The first ten fetuses were exposed under hysterotomy, and RF electrode was inserted visually in the middle of the umbilical cord and deployed. Fetuses were then replaced into the amniotic fluid and RF procedure (average target temperature of 100 degrees C during 10 minutes) was applied. For the next ten fetuses, RF electrode was inserted into the cords under trans-parietal ultrasound guidance and the same RF procedure was applied. Cord occlusion was assessed by Doppler examination (absence of cordonal flows at the end of the procedure and until fetal heart failure occurred) and by subsequent histopathological analysis. RESULTS Cord occlusion was always complete at Doppler examination at the end of RF procedure for the ten experiments realized under hysterotomy. No cordonal reperfusion was observed until fetal heart failure. Histopathological analysis confirmed cordonal occlusion at the site of impact. Neither cordonal rupture nor cordonal bleeding was observed for any of the ten experiments. When RF electrode was inserted under ultrasound guidance, complete occlusion could be obtained only for 6 of the ten experiments. CONCLUSION Our results suggest that RF might be an appropriate method for selective termination of pregnancy. Yet, optimal insertion of the electrode is required to engender a complete and irreversible cord occlusion, and ultrasound-guidance training seems necessary before current human application.
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Twin chorionicity and the risk of adverse perinatal outcome. Int J Gynaecol Obstet 2007; 96:98-102. [DOI: 10.1016/j.ijgo.2006.11.002] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2006] [Revised: 10/29/2006] [Accepted: 11/01/2006] [Indexed: 11/21/2022]
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Deprest J, Jani J, Lewi L, Ochsenbein-Kölble N, Cannie M, Doné E, Roubliova X, Van Mieghem T, Debeer A, Debuck F, Sbragia L, Toelen J, Devlieger R, Lewi P, Van de Velde M. Fetoscopic surgery: encouraged by clinical experience and boosted by instrument innovation. Semin Fetal Neonatal Med 2006; 11:398-412. [PMID: 17056307 DOI: 10.1016/j.siny.2006.09.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Today, modern ultrasound equipment and the wide implementation of screening programmes allow the timely diagnosis of many congenital anomalies. For some of these, fetal surgery may be a life-saving option. In Europe, open fetal surgery became poorly accepted because of its invasiveness and the high incidence of postoperative premature labour and rupture of the fetal membranes. In the 1990s, the merger of fetoscopy and advanced video-endoscopic surgery formed the basis for endoscopic fetal surgery. We review the current applications of fetal surgery via both methods of access. The first clinical fetoscopic surgeries were interventions on the umbilical cord and the placenta, often referred to as obstetrical endoscopy. The outcome of a randomized clinical trial demonstrating that fetoscopic laser coagulation of chorionic plate vessels is the most effective treatment for twin-twin transfusion syndrome (TTTS) has revived interest in endoscopic fetal therapy. Operating on the fetus is another more challenging enterprise. Clinical fetal surgery programmes were virtually non-existent in Europe until minimally invasive fetoscopic surgery made such operations clinically possible as well as maternally acceptable. At present, most experience has been gathered with fetal tracheal occlusion as a therapy for severe congenital diaphragmatic hernia. As in other fields, minimally invasive surgery has pushed back boundaries and now allows safe operations to be performed on the fetal patient. Whereas minimal access seems to solve the problem of preterm labour, all procedures remain invasive, and carry a risk to the mother and a substantial risk of preterm prelabour rupture of the membranes (PPROM). The latter problem may prove to be a bottleneck for further developments, although treatment modalities are currently being evaluated.
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Affiliation(s)
- Jan Deprest
- Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospital Leuven, 3000 Leuven, Belgium.
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Becker J, Hernandez-Andrade E, Muñoz-Abellana B, Acosta R, Cabero L, Gratacós E. Stage-dependent fetal umbilical blood flow changes induced by laser therapy and amniodrainage in twin-to-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 28:674-80. [PMID: 16823767 DOI: 10.1002/uog.2734] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
OBJECTIVE To estimate changes in umbilical blood flow (UBF) and Doppler indices in pregnancies complicated by twin-to-twin transfusion syndrome (TTS) treated with either laser therapy or amniodrainage, and to evaluate the influence of the presence of hemodynamic deterioration prior to therapy, as determined by the Quintero stages of severity. METHODS Forty-eight cases of TTS were included, and further classified into severity Stages I or II (absence of critically abnormal Dopplers (CAD), n = 22) and Stages III or IV (presence of CAD or hydrops fetalis, n = 26). In Stages I-II, 14 cases were treated with laser and eight with amniodrainage, and in Stages III-IV, 17 were treated with laser and nine with amniodrainage. Differences in the UBF, umbilical artery pulstility index (UA-PI) and ductus venosus pulsatility index (DV-PI) were estimated for both groups of severity before and after both treatments. Eleven normal monochorionic pregnancies were evaluated as controls. RESULTS In recipients, UBF was significantly higher with respect to controls regardless of the stage, while donors had a significant decrease in UBF, but only in Stages III-IV. After laser treatment no changes were observed in fetuses in Stages I-II. In Stages III-IV, recipients showed a significant reduction in the DV-PI (mean DV-PI 1.31 +/- 0.18 vs. 1.05 +/- 0.22; P = 0.005) whereas donors showed a significant increase in the UBF (mean UBF 134 +/- 36 mL/min vs. 195 +/- 25 mL/min; P < 0.001) and in the DV-PI (mean DV-PI 0.99 +/- 0.26 vs. 1.36 +/- 0.42; P = 0.002), and a reduction in the UA-PI (mean UA-PI 1.86 +/- 0.41 vs. 1.58 +/- 0.30; P = 0.01). After amniodrainage only donor fetuses in Stages III-IV showed an increase in UA-PI (mean UA-PI 1.54 +/- 0.35 vs. 1.72 +/- 0.40; P = 0.015). No other changes were observed in any of the parameters studied. CONCLUSION Laser therapy induces consistent hemodynamic variations in TTS mainly manifested in Stages III-IV.
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Affiliation(s)
- J Becker
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
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Morel O, Tran N, Marchal F, Hennequin V, Foliguet B, Villemot JP, Thiebaugeorges O. Ultrasound-guided radiofrequency-driven umbilical cord occlusion: an in-vitro study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 28:187-92. [PMID: 16628610 DOI: 10.1002/uog.2691] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
OBJECTIVES To assess the ability and safety of radiofrequency (RF) to induce cord thermal lesions using in-vitro perfused umbilical cords. METHODS Nineteen human term umbilical cords were cannulated at both ends and perfused continuously with saline serum in a saline serum bath (37 degrees C). The RF electrode was then inserted into the cord close to the umbilical vein. Different RF power and temperature controls were applied to determine the optimal RF procedure in terms of cord tissue injury and safety in nine experiments. The safety of RF procedures was investigated in ten cords by measuring temperature changes at different sites close to the RF electrode insertion and the impact of RF on cord narrowing was evaluated by continuous monitoring of intraluminal pressure. Subsequent histopathological analysis was carried out in all cases. RESULTS The optimal RF procedure reached a temperature of 100 degrees C in 10 min. RF produced a significant increase in intraluminal pressure (from 54.2 +/- 16.4 mmHg at baseline to 118.3 +/- 42.7 mmHg after 10 min, P < 0.05). There was no significant increase in temperature next to the site of insertion during the RF procedure. Histopathological analysis confirmed a > 30% decrease in cord and vein diameter. Cord tissue lesions were characterized by damage in the vessel walls and in the surrounding Wharton's jelly. CONCLUSION Our results suggest that RF might be a feasible and safe technique to induce occlusion of umbilical vessels. Further in-vivo experiments are needed to assess its ability to induce a complete occlusion of the umbilical cord.
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Affiliation(s)
- O Morel
- Laboratory of Surgery School, Faculty of Medicine, Comprehensive Cancer Center, Nancy, France.
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Moreno R, Rosal M, Cabero L, Gratacós E, Aran JM. Feasibility of retroviral vector-mediated in utero gene transfer to the fetal rabbit. Fetal Diagn Ther 2006; 20:485-93. [PMID: 16260880 DOI: 10.1159/000088036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2004] [Accepted: 08/23/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Successful treatment or prevention of severe hereditary diseases could conceivably be achieved by genetic intervention early in development. Viral vector-mediated fetal gene transfer is proving a valuable tool to test the above concept in relevant animal models. Although the pregnant rabbit is a well-recognized model for fetal therapy, few preclinical assays have used it to validate fetal gene transfer approaches. In this preliminary study we assessed for the first time the feasibility of retroviral vector-mediated in utero gene transfer in the fetal rabbit. METHODS Different amounts of the vesicular stomatitis virus G pseudotyped MFG(nls)LacZ retroviral vector, expressing a nuclear-localized beta-galactosidase reporter protein were injected intraperitoneally and -hepatically into 20- to 22-day-old fetuses. At 8-9 days post-treatment, the pups were sacrificed and the tissues harvested for analysis. Evidence of gene transfer was obtained by PCR amplification of proviral sequences within genomic DNA isolated from the treated samples. Transgenic beta-galactosidase expression was assessed by X-gal histochemical staining. RESULTS By intraperitoneal injection 43% of the viable fetuses treated (3/7) showed evidence of successful LacZ gene transfer and low-level beta-galactosidase expression into liver and heart, whereas by intrahepatic injection roughly 38% (3/8) of the livers were positive for LacZ gene transfer and expression. The success rate for the viable fetuses rose to 67% positive livers (4/6) when a near double amount of recombinant virus was injected using a 10-fold concentrated virus stock. In terms of short-term safety, fetal and maternal survival rates approached 80% of treated fetuses, and 100% of treated does. CONCLUSIONS The pregnant rabbit is a useful and reliable model allowing the design of further studies to optimize the conditions for effective, safer, and persistent retroviral vector-mediated fetal gene transfer.
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Affiliation(s)
- Rafael Moreno
- Medical and Molecular Genetics Center, Institut de Recerca Oncològica, Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
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Papadopulos NA, Papadopoulos MA, Kovacs L, Zeilhofer HF, Henke J, Boettcher P, Biemer E. Foetal surgery and cleft lip and palate: current status and new perspectives. ACTA ACUST UNITED AC 2005; 58:593-607. [PMID: 15992528 DOI: 10.1016/j.bjps.2005.01.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Accepted: 01/14/2005] [Indexed: 10/25/2022]
Abstract
Now-a-days, high-resolution ultrasound allows an accurate and relatively early diagnosis of congenital malformations. In a limited number of such conditions foetal surgery may be lifesaving. However, premature labour has been the major drawback for open foetal surgery. Recently, improvement of video-endoscopic technology has boosted the development of operative techniques for feto-endoscopic surgery, which has been demonstrated to be less invasive than the open approach. Main clinical application of fetoscopic procedures today is the treatment of feto-foetal transfusion syndrome. Although still in development, feto-endoscopic surgery seems to offer new hope for surgical foetal therapy not only in cases of life threatening conditions. Experimental intrauterine correction of cleft lip and palate (CLP) has been lately performed using the feto-endoscopic approach. This procedure offers two major advantages: first, scarless foetal wound healing and bone healing without callus formation, which would also allow a better/normal maxillary growth, and second, significant decrease of foetal and maternal morbidity. Herein, we report the current status of experimental and clinical foetal surgery and propose possible directions for continuing research to make intrauterine procedures safer. Furthermore, we discuss current knowledge and new perspectives of experimental foetal cleft lip and palate repair, which in the future may lead to such excellent results in the operative treatment of clefts, that less or no secondary corrections and therapies, such as orthodontic, dental, logopedic, etc. would be needed. Only if these conditions can be fulfilled, will we be able to improve substantially our therapy for the human foetus with a cleft lip and palate. In spite of all efforts, however, it must be considered that it may not ever be possible to find the optimal treatment method for this or other craniofacial malformations.
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Affiliation(s)
- N A Papadopulos
- Department of Plastic and Reconstructive Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaningerstrasse 22, D-81675 Munich, Germany.
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Gratacós E, Sanin-Blair J, Lewi L, Toran N, Verbist G, Cabero L, Deprest J. A histological study of fetoscopic membrane defects to document membrane healing. Placenta 2005; 27:452-6. [PMID: 15953634 DOI: 10.1016/j.placenta.2005.03.008] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2004] [Revised: 03/04/2005] [Accepted: 03/15/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the rate of spontaneous healing in human fetal membranes after fetoscopy. STUDY DESIGN Membranes from patients that had undergone fetoscopic interventions and delivered in one of the two treatment centers were included in the study. The membranes were examined macroscopically for any remaining defects and if present, the size of the defect in chorion and amnion was measured. Subsequently, the defect was excised and stained with HE for histological evaluation. Additional immunohistochemical staining was performed with Ki-67, cytokeratin and vimentin. The proliferation index (percentage of proliferating cells) was calculated in amnion and chorion. RESULTS Nineteen membrane defects were included in the study. The median time interval between invasive procedures and delivery was 60 days (range 3-112). All fetoscopic defects (n=19) could be identified in the gestational sac and in none spontaneous closure had occurred. Proliferation indices as measured by inmunohistochemistry were very low (median 2.8%, range 0-7%) in the chorion and 0% in the amnion. CONCLUSION No evidence of spontaneous membrane healing was found after fetoscopic procedures, suggesting that the membrane defect normally persists until delivery. Absence of amniotic fluid leakage after invasive procedures may be based on mechanisms other than histologic membrane repair.
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Affiliation(s)
- E Gratacós
- Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d' Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Adama van Scheltema PN, In't Anker PS, Vereecken A, Vandenbussche FPHA, Kanhai HHH, Devlieger R. Biochemical composition of amniotic fluid in pregnancies complicated with twin-twin transfusion syndrome. Fetal Diagn Ther 2005; 20:186-9. [PMID: 15824495 DOI: 10.1159/000083902] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2003] [Accepted: 03/12/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare the electrolyte composition of pregnancies complicated with twin-twin transfusion syndrome (TTTS) with that of physiologic pregnancies. MATERIALS AND METHODS Amniotic fluid samples from 16 pregnancies were studied. Specimens were obtained from recipient sacs in 10 pregnancies undergoing fetoscopy for severe midtrimester TTTS. Additionally, 6 amniotic fluid samples were obtained transcervically from legal second-trimester pregnancy terminations. The concentrations of sodium, potassium, chloride, bicarbonate, calcium, glucose, osmolality, pH, total protein content and albumin were determined in each sample. RESULTS The mean gestational age at sampling was 20.2 weeks (range 17.2-27.1) in the TTTS group and 18.4 (range 16.0-22.0) in the control group (p = NS). We found significant lower levels of albumin (0.22 +/- 0.04 vs. 0.39 +/- 0.11, p = 0.01) and total protein (0.19 +/- 0.08 vs. 0.51 +/- 0.17, p < 0.001) and higher levels of bicarbonate (16.90 +/- 1.45 vs. 14.50 +/- 2.17, p = 0.02) in amniotic fluid samples taken from recipient sacs of TTTS pregnancies. CONCLUSION Amniotic fluid from the receptor in severe midtrimester TTTS differs significantly from control amniotic fluid samples in bicarbonate concentration, total protein content and albumin concentration. These findings may help to understand the pathophysiology of TTTS and to optimise therapeutic modalities.
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Affiliation(s)
- P N Adama van Scheltema
- Fetal Diagnosis and Therapy Unit, Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
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Lewi L, Jani J, Deprest J. Invasive Antenatal Interventions in Complicated Multiple Pregnancies. Obstet Gynecol Clin North Am 2005; 32:105-26, x. [PMID: 15644293 DOI: 10.1016/j.ogc.2004.10.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Multiple pregnancies still pose challenging problems for modern medicine. Complications in monochorionic multiple pregnancies have sparked a revival of fetoscopy as a means surgery on the placenta and umbilical cord. As such, fetoscopic laser coagulation is currently the best first-line treatment for severe twin-to-twin transfusion syndrome. Also, fetoscopic or ultrasound-guided cord coagulation seems to be an effective technique for selective feticide in monochorionic twins, albeit with still considerably higher fetal loss rates compared with selective feticide by potassium chloride injection in dichorionic twins.
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Affiliation(s)
- Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.
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Wataganara T, Gratacos E, Jani J, Becker J, Lewi L, Sullivan LM, Bianchi DW, Deprest JA. Persistent elevation of cell-free fetal DNA levels in maternal plasma after selective laser coagulation of chorionic plate anastomoses in severe midgestational twin-twin transfusion syndrome. Am J Obstet Gynecol 2005; 192:604-9. [PMID: 15696010 DOI: 10.1016/j.ajog.2004.07.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study was undertaken to determine whether laser thermocoagulation for twin-twin transfusion syndrome (TTTS) causes increased cell-free fetal DNA levels in maternal plasma, potentially as a result of placental injury. STUDY DESIGN We enrolled 34 patients with twin pregnancies complicated by severe TTTS who underwent fetoscopic selective laser ablation of placental vascular anastomoses. Blood samples were drawn before and sequentially after the procedure. Fetal DNA in maternal plasma was quantified by polymerase chain reaction amplification of a Y-chromosome sequence. RESULTS Compared with baseline, median elevations of fetal DNA levels were 0.8% at 30 minutes ( P = .32), 15.8% at 60 minutes ( P = .1), 179.5% at 24 hours ( P = .003), and 172.9% at 48 hours ( P = .003). Factors associated with increased fetal DNA levels at 24 hours after procedure included longer operation time, higher number of vessels ablated, and subsequent in utero fetal death ( P = .01, .04, and .04, respectively). CONCLUSIONS Persistent elevation of fetal DNA levels in maternal plasma after laser ablation suggests that circulating fetal DNA could derive from placental injury. Plasma fetal DNA analysis may be an additional prognostic marker for fetal outcome after laser therapy.
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Affiliation(s)
- Tuangsit Wataganara
- Division of Genetics, Department of Pediatrics, Obstetrics and Gynecology, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, Mass, USA
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