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Chmait RH, Monson MA, Chon AH, Masri J, Korst LM, Incerpi MH. Third-trimester fetoscopic ablation therapy for types II and III vasa previa. Am J Obstet Gynecol 2024; 230:87.e1-87.e9. [PMID: 37741533 DOI: 10.1016/j.ajog.2023.09.015] [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: 02/27/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Vasa previa is an obstetrical condition in which fetal vessels located near the cervix traverse the fetal membranes unprotected by underlying placenta. Type I vasa previa arises directly from a velamentous cord root, whereas types II and III arise from an accessory lobe or a distal lobe of the same placenta, respectively. Fetoscopic laser ablation for types II and III vasa previa is a novel therapeutic option with benefits that include surgical resolution of the vasa previa, avoidance of prolonged hospitalization, and opportunity for a term vaginal delivery. The potential risks of fetoscopy can be mitigated by delaying laser surgery until a gestational age of 31 to 33 weeks, immediately before anticipated hospitalized surveillance. OBJECTIVE This study aimed to assess feasibility and outcomes of types II and III vasa previa patients treated via fetoscopic laser ablation in the third trimester. STUDY DESIGN This is a retrospective study of singleton pregnancies with types II and III vasa previa treated with fetoscopic laser ablation at a gestational age ≥31 weeks at a single center between 2006 and 2022. Pregnancy and newborn outcomes were assessed. Continuous variables are expressed as mean±standard deviation. RESULTS Of 84 patients referred for vasa previa, 57 did not undergo laser ablation: 19 either had no or resolved vasa previa, 25 had type I vasa previa (laser-contraindicated), and 13 had type II or III vasa previa but declined laser treatment. Of the remaining 27 patients who underwent laser ablation, 7 were excluded (laser performed at <31 weeks and/or twins), leaving 20 study patients. The mean gestational age at fetoscopic laser ablation was 32.0±0.6 weeks, and total operative time was 62.1±19.6 minutes. There were no perioperative complications. All patients had successful occlusion of the vasa previa vessels (1 required a second procedure). All patients were subsequently managed as outpatients. The mean gestational age at delivery was 37.2±1.8 weeks, the mean birthweight was 2795±465 g, and 70% delivered vaginally. Neonatal intensive care unit admission occurred in 3 cases: 1 for respiratory distress syndrome and 2 for hyperbilirubinemia requiring phototherapy. There were no cases of neonatal transfusion, intraventricular hemorrhage, sepsis, patent ductus arteriosus, or death. CONCLUSION Laser ablation for types II and III vasa previa at 31 to 33 gestational weeks was technically achievable and resulted in favorable outcomes.
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Affiliation(s)
- Ramen H Chmait
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Martha A Monson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Health, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Andrew H Chon
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - Jinnen Masri
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Marc H Incerpi
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Hoagland MA, Fleming J, Foley C, Fernandez P, Wood CL. Avoiding the use of halogenated anesthetic agents for uterine relaxation in open mid-gestation fetal surgery: A case report. Fetal Diagn Ther 2022; 49:190-195. [PMID: 35609531 DOI: 10.1159/000524899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/05/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Profound uterine relaxation is required for open fetal surgery. This is typically achieved by the administration of high-dose halogenated anesthetic agents. However, this anesthetic technique is associated with adverse cardiovascular effects in the fetus and may have long-term neurocognitive effects as well. CASE PRESENTATION We present reports for two patients in whom uterine relaxation was maintained with nitroglycerin and magnesium infusions without any exposures to halogenated anesthetic agents. There were no adverse fetal or maternal effects from this technique. DISCUSSION/CONCLUSION To the best of our knowledge, these are the first reports of open fetal surgery being performed without the use of halogenated anesthetic agents. This has potential short- and long-term benefits for the fetus, particularly as more complex and longer duration minimally invasive procedures are developed.
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Affiliation(s)
- Monica A Hoagland
- Section of Pediatric Anesthesiology, Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jamie Fleming
- Division of Pediatric Anesthesia, Department of Anesthesiology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Carolyn Foley
- Section of Pediatric Anesthesiology, Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Patrick Fernandez
- Section of Pediatric Anesthesiology, Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cristina L Wood
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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3
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Anesthesia for Fetal Interventions - An Update. Adv Anesth 2021; 39:269-290. [PMID: 34715979 DOI: 10.1016/j.aan.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Wilson RD, Nelson G. Evaluation of the Fetal Therapy Evidence in Lower Urinary Tract Obstruction: Would an ERAS Guideline Improve Outcomes? Fetal Diagn Ther 2021; 48:504-516. [PMID: 34350862 DOI: 10.1159/000517624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/03/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pregnancies that are prenatally identified to have fetal anomalies are complex and require expert multidisciplinary care. As many conditions can impact the fetus prenatally and require intervention, an enhanced recovery after surgery (ERAS) for lower urinary tract obstruction (LUTO) is being evaluated to determine the level of evidenced-based data available. PROBLEM The percutaneous ultrasound-guided fetal surgery procedure for bladder neck obstruction is the focus for elements of preoperative counseling, intraoperative procedure/risk complications, and postoperative management. METHODS A quality improvement review Squire 2.0 (2000-2020) was undertaken for the percutaneous LUTO fetal surgery shunting (lower urinary tract obstruction), process and procedure which require 2 process pathways, one to evaluate the fetal candidate and a second to treat. This structured review is focused on identifying the process elements to allow the determination of the number of evidenced-based elements that would allow for audit and measurement of the clinical element variance for comparative feedback to the individual surgical provider or surgery center. INTERVENTIONS Titles and abstracts were screened to identify potentially relevant articles with priority given to meta-analyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series. RESULTS A series of potential clinical elements for the diagnostic fetal evaluation and for the 3 protocol areas of surgical care for the procedures (pre-, intra-, and postoperative care) are identified using an ERAS-like process. CONCLUSIONS The identified clinical elements have the potential for ERAS-LUTO fetal therapy guideline. Multidisciplinary collaboration (surgeon, anesthesia, nursing, imaging, and laboratory) is required for ERAS quality improvement in the pre-, intra-, and postoperative processes. Process elements in each of the operative areas can be audited, evaluated, compared, and modified/improved.
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Affiliation(s)
- R Douglas Wilson
- Department of Obstetrics and Gynecology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Lin TY, Wataganara T, Shaw SW. From non-invasive to invasive fetal therapy: A comprehensive review and current update. Taiwan J Obstet Gynecol 2021; 60:595-601. [PMID: 34247794 DOI: 10.1016/j.tjog.2021.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/16/2022] Open
Abstract
"Fetus as patient" indicates fundamental concept of fetal therapy. With advance in maternal serum analysis and fetal imaging, prenatal screening has become standard of care. Accurate diagnosis in early gestation allows intervention to reverse pathophysiology and delay progression immediately. Non-invasive, minimally invasive and invasive therapies demonstrate their therapeutic potential in certain diseases. Recently, stem cell and gene therapies have been developed to avoid irreversible impairment. To elevate efficacy of treatment modality, extensive studies should be conducted according to regulatory authority. Striking a balance between scientific and ethical integrity is essential, so long-term follow up should be arranged for protecting mother and fetus.
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Affiliation(s)
- Tzu-Yi Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tuangsit Wataganara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Steven W Shaw
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital, Taipei, Taiwan; Prenatal Cell and Gene Therapy Group, Institute for Women's Health University College London, London, United Kingdom.
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Sirianni J, Abro J, Gutman D. Delivery of an Infant with Airway Compression Due to Cystic Hygroma at 37 Weeks' Gestation Requiring a Multidisciplinary Decision to Use a Combination of Ex Utero Intrapartum Treatment (EXIT) and Airway Palliation at Cesarean Section. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e927803. [PMID: 33388739 PMCID: PMC7791465 DOI: 10.12659/ajcr.927803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Patient: Female, 22-year-old Final Diagnosis: Central line infection • cystic hygroma • pregnancy Symptoms: Cystic hygroma • neck mass • pregnancy Medication: — Clinical Procedure: Cesarean section • ex utero intrapartum treatment • fiberoptic bronchoscopy • general anesthesia • laryngoscopy • rigid bronchoscopy • spinal anesthesia • video laryngoscopy Specialty: Anesthesiology • Obstetrics and Gynecology • Otolaryngology
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Affiliation(s)
- Joel Sirianni
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Joseph Abro
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - David Gutman
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
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Olejek A, Horzelska E, Zamłyński J, Horzelski T, Zamłyński M, Nowak L, Pastuszka A. Alternative Hysterotomy Technique for the Reduction of Prenatal Complications of Intrauterine Myelomeningocele Repair. Fetal Diagn Ther 2020; 47:894-901. [PMID: 33254173 DOI: 10.1159/000510815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 08/11/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The main aim of the fetal surgery of myelomeningocele (MMC) is the improvement in prognosis for children with this defect and at the same time high safety of the procedure for mother and fetus. OBJECTIVE The aim of the study was to determine the effectiveness of alternative hysterotomy technique for fetal surgery of MMC in prevention of essential perinatal complications. METHODS Forty-nine pregnant women diagnosed with fetal MMC (fMMC) who underwent classic hysterotomy without the use of stapler formed the study cohort. Two cases of intrauterine fetal death or neonatal death in the immediate perioperative period in the study group (SG) were excluded from further analyses. In the historical control group (46 patients) from our center hysterotomy was performed according to Management of Myelomeningocele Study (MOMS) protocol. The study cohort's outcomes were compared with the historical controls and with post-MOMS results in Children's Hospital of Philadelphia (CHOP) and Vanderbilt University Medical Center (VUMC). RESULTS In the SG we did not observe delivery before 30 weeks of gestation (0/47; 0%) and the incidence of chorionamniotic membrane separation (CMS, 3/47; 6%) and preterm premature rupture of membranes (PPROM, 7/47; 15%) was lower compared to the other groups. Preterm delivery as a result of uterine contractions occurred significantly less frequently in the SG (8/47; 17%). Fetal surgery with classic hysterotomy resulted in rare use of magnesium sulfate (3/47; 6%). CONCLUSIONS The alternative hysterotomy technique for fetal surgery of MMC results in low occurrences of CMS, PPROM, preterm delivery, and the rare use of tocolytics.
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Affiliation(s)
- Anita Olejek
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia in Katowice, Bytom, Poland
| | - Ewa Horzelska
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia in Katowice, Bytom, Poland,
| | - Jacek Zamłyński
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia in Katowice, Bytom, Poland
| | - Tomasz Horzelski
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia in Katowice, Bytom, Poland
| | - Mateusz Zamłyński
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia in Katowice, Bytom, Poland
| | - Leszek Nowak
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia in Katowice, Bytom, Poland
| | - Agnieszka Pastuszka
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia in Katowice, Bytom, Poland
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Pruthi V, Abbasi N, Ryan G, Drake J, Kulkarni AV, Kwan-Wong T, Phillips J, Thakur V, Church P, Diambomba Y, Kelly E, Vermeersch L, Pollard L, Carvalho JCA, Van Mieghem T. Fetal Surgery for Open Spina Bifida in Canada: Initial Results. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:733-739.e1. [PMID: 33227419 DOI: 10.1016/j.jogc.2020.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/15/2020] [Accepted: 10/15/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Fetal myelomeningocele closure results in better infant outcomes than postnatal closure at the cost of potential prematurity and maternal morbidity. Our aim is to describe the setup of a fetal myelomeningocele closure program in Canada and document its outcomes. METHODS We conducted a retrospective review of all open fetal myelomeningocele closure surgeries performed at the Ontario Fetal Centre in its first 3 years of operation (2017-2020). Maternal and fetal baseline characteristics, surgical details, pregnancy outcomes, and infant follow-up until 1 year of age were recorded. RESULTS Twenty-seven women underwent fetal myelomeningocele closure surgery, 10 of whom (37%) resided outside of Ontario. Mean gestational age at surgery was 25.0 ± 0.7 weeks. All surgeries were technically uncomplicated and no fetal deaths occurred. There was a significant negative correlation between increasing experience and skin-to-skin surgical time (R² = 0.36; P = 0.001). Of the 26 patients who have delivered, 4 (15.4%) experienced preterm prelabour rupture of membranes. Mean gestational age at delivery was 34.9±3.0 weeks. All but 1 patient delivered by cesarean. Maternal complications occurred in 9 women (34.6%). There were no maternal deaths, but 3 (11.5%) infant deaths. Of the 14 surviving infants who have reached at least 1 year of age, 5 (35.7%) underwent ventriculo-peritoneal shunting. Of the 9 infants who have not yet reached 1 year of age, 3 (33.3%) underwent endoscopic third ventriculostomy and none underwent shunting. CONCLUSION Fetal open spina bifida closure can be performed in Canada, with results similar to those reported by other international expert centres. Long-term follow-up is ongoing.
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Affiliation(s)
- Vagisha Pruthi
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON
| | - Nimrah Abbasi
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON
| | - Greg Ryan
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON
| | - James Drake
- Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON; Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, ON
| | - Abhaya V Kulkarni
- Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON; Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, ON
| | - Terence Kwan-Wong
- Division of Plastic Surgery, Hospital for Sick Children, Toronto, ON
| | - John Phillips
- Division of Plastic Surgery, Hospital for Sick Children, Toronto, ON
| | - Varsha Thakur
- Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON; Department of Cardiology, Hospital for Sick Children and University of Toronto, Toronto, ON
| | - Paige Church
- Department of Paediatrics, Holland-Bloorview, Sunnybrook Health Centre and University of Toronto, Toronto, ON
| | - Yenge Diambomba
- Department of Neonatology, Mount Sinai Hospital and University of Toronto, Toronto, ON
| | - Edmond Kelly
- Department of Neonatology, Mount Sinai Hospital and University of Toronto, Toronto, ON
| | - Leslie Vermeersch
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON
| | - Lindsay Pollard
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON
| | - Jose C A Carvalho
- Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON; Department of Anesthesia and Pain Management, Mount Sinai Hospital and University of Toronto, Toronto, ON; Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON
| | - Tim Van Mieghem
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON; Ontario Fetal Centre, Mount Sinai Hospital, Toronto, ON.
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Sharma D, Tsibizova VI. Current perspective and scope of fetal therapy: part 1. J Matern Fetal Neonatal Med 2020; 35:3783-3811. [PMID: 33135508 DOI: 10.1080/14767058.2020.1839880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical Science, Jaipur, India
| | - Valentina I Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, Saint Petersburg, Russia
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Gotha L, Pruthi V, Abbasi N, Kulkarni AV, Church P, Drake JM, Carvalho JCA, Diambomba Y, Thakur V, Ryan G, Van Mieghem T. Fetal spina bifida: What we tell the parents. Prenat Diagn 2020; 40:1499-1507. [PMID: 32692418 DOI: 10.1002/pd.5802] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 06/08/2020] [Accepted: 07/19/2020] [Indexed: 12/20/2022]
Abstract
Worldwide, about 150 000 infants are born with spina bifida yearly, making this condition one of the most common fetal central nervous system anomalies compatible with life. Over the last decade, major changes have been introduced in the prenatal diagnosis and management of spina bifida. In this review, we provide a brief summary of the current management of fetal spina bifida and present essential information that should be provided to expecting parents when their fetus has been diagnosed with spina bifida. This information is focused around common parental questions, as encountered in our typical clinical practice, to facilitate knowledge translation.
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Affiliation(s)
- Lara Gotha
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Vagisha Pruthi
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada.,Ontario Fetal Centre, Toronto, Canada
| | - Nimrah Abbasi
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada.,Ontario Fetal Centre, Toronto, Canada
| | - Abhaya V Kulkarni
- Ontario Fetal Centre, Toronto, Canada.,Division of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Paige Church
- Department of Pediatrics, Sunnybrook Health Sciences Centre, Holland-Bloorview Kids Rehabilitation Hospital and University of Toronto, Toronto, Canada
| | - James M Drake
- Ontario Fetal Centre, Toronto, Canada.,Division of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Jose C A Carvalho
- Ontario Fetal Centre, Toronto, Canada.,Department of Anesthesia, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Yenge Diambomba
- Ontario Fetal Centre, Toronto, Canada.,Department of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Varsha Thakur
- Ontario Fetal Centre, Toronto, Canada.,Department of Cardiology, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Greg Ryan
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada.,Ontario Fetal Centre, Toronto, Canada
| | - Tim Van Mieghem
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada.,Ontario Fetal Centre, Toronto, Canada
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Abstract
Fetal anesthesia teams must understand the pathophysiology and rationale for the treatment of each disease process. Treatment can range from minimally invasive procedures to maternal laparotomy, hysterotomy, and major fetal surgery. Timing may be in early, mid-, or late gestation. Techniques continue to be refined, and the anesthetic plans must evolve to meet the needs of the procedures. Anesthetic plans range from moderate sedation to general anesthesia that includes monitoring of 2 patients simultaneously, fluid restriction, invasive blood pressure monitoring, vasopressor administration, and advanced medication choices to optimize fetal cardiac function.
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Affiliation(s)
- Kha M Tran
- University of Pennsylvania Perelman School of Medicine, Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Debnath Chatterjee
- Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Aurora, CO 80045, USA
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12
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Chmait RH, Catanzarite V, Chon AH, Korst LM, Llanes A, Ouzounian JG. Fetoscopic Laser Ablation Therapy for Type II Vasa Previa. Fetal Diagn Ther 2020; 47:682-688. [PMID: 32629451 DOI: 10.1159/000508044] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In type II vasa previa, fetoscopic laser ablation has the potential to avoid prolonged hospitalization, elective prematurity, and cesarean delivery associated with traditional conservative management. OBJECTIVE To assess the feasibility and to report perinatal outcomes of type II vasa previa patients treated via fetoscopic laser ablation. STUDY DESIGN This is a retrospective descriptive study of all women with vasa previa treated with laser at our center between 2006 and 2019. After 2010, laser ablation of vasa previa was only offered after 31 gestational weeks. Continuous variables are expressed as means ± SD. RESULTS 33 patients were evaluated for laser ablation of suspected vasa previa. Fifteen were not candidates (7 had type I vasa previa and 8 had no vasa previa), and the 18 remaining had type II vasa previa. Ten (56%) elected to undergo in utero laser ablation of the vasa previa vessel(s), which was successful in all patients. The mean gestational age (GA) at the time of the procedure was 28.8 ± 5.4 weeks, and the total operative time was 48.1 ± 21.3 min; there were no perioperative complications. The number of vessels lasered were distributed as follows: 1 (2 cases), 2 (5 cases), and 3 (3 cases). All patients except for 1 were subsequently managed as outpatients. The mean GA at delivery was 35.5 ± 3.2 weeks, and vaginal delivery occurred in 5 cases. The 5 patients with singletons who underwent laser ablation for primary diagnosis of type II vasa previa after the protocol change in 2010 had the following outcomes: mean GA of surgery was 32.5 ± 0.8 weeks, mean GA at delivery was 38.1 ± 1.4 weeks, vaginal delivery occurred in all cases, mean birth weight was 2,965 ± 596 g, and none were admitted to the neonatal intensive care unit. CONCLUSION This cohort represents the largest number of vasa previa cases treated via in utero laser reported to date. Laser occlusion of type II vasa previa was technically achievable in all cases and resulted in favorable outcomes.
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Affiliation(s)
- Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,
| | - Valerian Catanzarite
- San Diego Perinatal Center, Rady Children's Specialists of San Diego, San Diego, California, USA
| | - Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, Los Angeles, California, USA
| | - Arlyn Llanes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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13
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Abbasi N, Morency AM, Langer JC, Chiu PPL, Chami R, Windrim R, Keunen J, Seaward G, Ryan G. Fetal Sclerotherapy for Hydropic Congenital Cystic Adenomatoid Malformations of the Lung Refractory to Steroids: A Case Report and Review of the Literature. Fetal Diagn Ther 2019; 47:24-33. [PMID: 31112955 DOI: 10.1159/000497143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/21/2019] [Indexed: 11/19/2022]
Abstract
Microcystic congenital cystic adenomatoid malformations (CCAM), when associated with hydrops, carry a dismal prognosis. Options for treatment are limited and experimental, including antenatal corticosteroids, open fetal surgery, laser ablation and, more recently, sclerotherapy. We describe a case of a large, predominantly microcystic CCAM in a hydropic fetus treated successfully with direct interstitial injection of a sclerosant agent (3% sodium tetradecyl sulfate) at 23+3 weeks gestation, after multiple failed courses of steroids. Elective thoracoscopic right lower lobectomy was performed at 1 year of life and there have been no respiratory or other medical morbidities since. A literature review of fetal lung masses treated with sclerosants antenatally reveals that sclerotherapy may represent a novel treatment option for large hydropic microcystic CCAMs, which are unresponsive to corticosteroids. Further studies are required to evaluate the utility and safety of fetal sclerotherapy, as this may represent an alternative minimally invasive treatment option to fetal lobectomy.
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Affiliation(s)
- Nimrah Abbasi
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada, .,University of Toronto, Toronto, Ontario, Canada,
| | - Anne-Maude Morency
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Priscilla P L Chiu
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Rose Chami
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Rory Windrim
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Johannes Keunen
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Gareth Seaward
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
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14
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Masmejan S, Baud D, Ryan G, Van Mieghem T. Management of fetal tumors. Best Pract Res Clin Obstet Gynaecol 2019; 58:107-120. [PMID: 30770283 DOI: 10.1016/j.bpobgyn.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 12/28/2022]
Abstract
In this review article, we discuss the most common fetal tumors, their prenatal management, and outcomes. Overall, the most important outcome predictors are tumor histology, size, vascularity, and location. Very large lesions, lesions causing cardiac failure, and hydrops and lesions obstructing the fetal airway have the poorest outcome, as they may cause fetal death or complications at the time of delivery. Fetal therapy has been developed to improve outcomes for the most severe cases and can consist of transplacental therapy (sirolimus for rhabdomyomas or steroids for hemangiomas and microcystic lung lesions) or surgical intervention (shunting of cystic masses, tumor ablation, occlusion of blood flow or airway exploration, and protection). Given the rarity of fetal tumors, patients should be referred to expert centers where care can be optimized and individualized to allow the best possible outcomes.
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Affiliation(s)
- Sophie Masmejan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada; Obstetrics Unit, Mother-Child Department, University Hospital Lausanne, Switzerland
| | - David Baud
- Obstetrics Unit, Mother-Child Department, University Hospital Lausanne, Switzerland
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Tim Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada.
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15
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AlRefai A, Drake J, Kulkarni AV, Connor KL, Shannon P, Toi A, Chitayat D, Blaser S, Church PT, Abbasi N, Ryan G, Van Mieghem T. Fetal myelomeningocele surgery: Only treating the tip of the iceberg. Prenat Diagn 2018; 39:10-15. [PMID: 30536580 DOI: 10.1002/pd.5390] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/03/2018] [Accepted: 11/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fetal myelomeningocele (fMMC) surgery improves infant outcomes when compared with postnatal surgery. Surgical selection criteria and the option of pregnancy termination, however, limit the number of cases that are eligible for prenatal surgery. We aimed to quantify what proportion of cases could ultimately benefit from fetal therapy. METHODS We retrospectively reviewed all cases of fMMC referred to a large tertiary care center over a 10-year period and assessed their eligibility for fetal surgery, pregnancy termination rates, and actual uptake of the surgery. RESULTS Of 158 cases, 67 (42%) were ineligible for fetal surgery based on surgical exclusion criteria. Eleven fetuses (7%) had chromosomal anomalies, 10 of which (91%) had other anomalies on ultrasound. Thirty-four patients had a combination of maternal and fetal contraindications. Of the remaining 91 eligible cases (58%), 45 (49%) pregnancies were terminated, leaving only 46 (29% of initial 158 cases) as potential candidates for fetal repair. Actual uptake of fetal surgery was 15% (n = 14 of 91), but this increased after a national program was started. CONCLUSION Only a minority of fMMC cases will ultimately undergo fetal surgery. These numbers support the centralization of care in expert centers.
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Affiliation(s)
- Alyaa AlRefai
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - James Drake
- Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Abhaya V Kulkarni
- Department of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Kristin L Connor
- Department of Health Sciences, Carleton University, Ottawa, Canada
| | - Patrick Shannon
- Department of Pathology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Ants Toi
- Department of Radiology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - David Chitayat
- Department of Medical Genetics, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Susan Blaser
- Department of Radiology, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Paige T Church
- Department of Paediatrics, Holland Bloorview Kids Rehabilitation Hospital and University of Toronto, Toronto, Canada
| | - Nimrah Abbasi
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Tim Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
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16
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Chon AH, Korst LM, Abdel-Sattar M, Llanes A, Ouzounian JG, Chmait RH. Types II and III congenital pulmonary airway malformation with hydrops treated in utero with percutaneous sclerotherapy. Prenat Diagn 2018; 38:493-498. [PMID: 29665020 DOI: 10.1002/pd.5266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To present outcomes of fetuses with congenital pulmonary airway malformation (CPAM) treated with sclerotherapy. METHODS Retrospective study of 8 patients with a prenatal diagnosis of CPAM type II or III with secondary hydrops treated with percutaneous sclerotherapy using 5% ethanolamine oleate (EO). All patients underwent ultrasonic measurement of the CPAM volume ratio. Results are expressed as median (range). RESULTS Gestational age at initial sclerotherapy was 22.0 weeks (19.6-31.4); 3 patients underwent 2 procedures. Intrauterine fetal demise (IUFD) occurred in 4 cases; 2 died on postoperative day #1 (one from inadvertent intravascular EO injection); 2 died >6 weeks after the procedure. Preoperative CPAM volume ratio was 3.6 (1.6-7.8) in survivors and 2.7 (1.7-4.7) in those with IUFD. The volume of EO at the initial sclerotherapy procedure was 3 mL (2-5) in survivors and 7 mL (6-10) in IUFD cases. The gestational age at delivery of the 4 survivors was 38.4 weeks (37.4-39.3); all underwent postnatal resection. CONCLUSION The efficacy of percutaneous sclerotherapy for CPAM types II and III remains in question. Further studies are needed to determine the optimal dose of sclerotherapy agent and the safety and efficacy of this procedure.
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Affiliation(s)
- Andrew H Chon
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lisa M Korst
- Childbirth Research Associates LLC, Los Angeles, CA, USA
| | - Mira Abdel-Sattar
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Arlyn Llanes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Joseph G Ouzounian
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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17
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Fry JT, Frader JE. "We want to do everything": how parents represent their experiences with maternal-fetal surgery online. J Perinatol 2018; 38:226-232. [PMID: 29317765 DOI: 10.1038/s41372-017-0040-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/04/2017] [Accepted: 12/12/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE There is little available evidence on how patients make decisions regarding maternal-fetal surgery. We studied online patient narratives for insight on how pregnant women and their partners consider such decisions. STUDY DESIGN We used Google search strings and a purposive snowball method to locate patient blogs. We analyzed blog entries using qualitative methods to identify author details, medical information, and common themes. RESULTS We located 32 blogs of patients who describe maternal-fetal surgery consultation. Twenty-eight (88%) underwent fetal interventions. Most (91%) explicitly described consultation with maternal-fetal surgery teams; 83% of those depicted making decisions prior to formal consultation. Few expressed regret for decisions made (6%). CONCLUSIONS AND RELEVANCE Patients openly share experiences with maternal-fetal surgery online. Women portray their decisions as made outside of formal medical processes and overwhelmingly feel these decisions were "right". As the field of maternal-fetal surgery expands, prospective evaluation of patient decision-making is needed.
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Affiliation(s)
- Jessica T Fry
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Joel E Frader
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Palliative Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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18
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Abdel-Sattar M, Chon AH, Llanes A, Korst LM, Ouzounian JG, Chmait RH. Comparison of umbilical cord occlusion methods: Radiofrequency ablation versus laser photocoagulation. Prenat Diagn 2018; 38:110-116. [DOI: 10.1002/pd.5196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/04/2017] [Accepted: 12/10/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Mira Abdel-Sattar
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
| | - Andrew H. Chon
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
| | - Arlyn Llanes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
| | - Lisa M. Korst
- Childbirth Research Associates; North Hollywood CA USA
| | - Joseph G. Ouzounian
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
| | - Ramen H. Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
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19
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H Chon A, Takeda MR, Felix JC, Chmait RH. A Complication of Percutaneous Sclerotherapy for Congenital Pulmonary Airway Malformation: Intravascular Injection and Cardiac Necrosis. Fetal Pediatr Pathol 2017; 36:437-444. [PMID: 29206544 DOI: 10.1080/15513815.2017.1346017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION A congenital pulmonary airway malformation (CPAM) type III may become large enough to cause hydrops fetalis. In such circumstances, the fetus can be treated with open fetal resection, maternal betamethasone administration, or percutaneous sclerotherapy. CASE REPORT A 24 week gestation fetus with a CPAM type III was treated by percutaneous sclerotherapy using ethanolamine oleate (EO). The EO inadvertently entered the left atrium and ventricle with subsequent fetal bradycardia and demise. Autopsy revealed myocardial necrosis. CONCLUSION Percutaneous sclerotherapy has been previously described in the literature for the treatment of microcystic CPAMs with secondary hydrops. This is the first reported case of an adverse event after fetal sclerotherapy.
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Affiliation(s)
- Andrew H Chon
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Southern California , Los Angeles , CA , USA
| | - Moe R Takeda
- b Department of Pathology , University of Southern California , Los Angeles , CA , USA
| | - Juan C Felix
- b Department of Pathology , University of Southern California , Los Angeles , CA , USA
| | - Ramen H Chmait
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Southern California , Los Angeles , CA , USA
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