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Ibarra C, Bergh E, Tsao K, Johnson A. Prenatal diagnostic and intervention considerations in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151436. [PMID: 39018717 DOI: 10.1016/j.sempedsurg.2024.151436] [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: 07/19/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a life-threatening birth defect with significant morbidity and mortality. The prenatal management of a pregnancy with a fetus affected with CDH is complex and requires a multi-disciplinary team approach. An improved understanding of prenatal diagnosis and management is essential to developing strategies to optimize outcomes for these patients. In this review, we explore the current knowledge on diagnosis, severity stratification, prognostic prediction, and indications for fetal intervention in the fetus with CDH.
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Affiliation(s)
- Claudia Ibarra
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| | - Eric Bergh
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States.
| | - Kuojen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
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van der Schot AM, van Steenis JL, Sikkel E, Spaanderman MEA, van Drongelen J. Impact of cannula diameter on pregnancy outcomes after minimally invasive fetal laser surgery in the treatment of twin-to-twin transfusion syndrome: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:1242-1253. [PMID: 38400574 PMCID: PMC11168272 DOI: 10.1111/aogs.14761] [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: 08/15/2023] [Revised: 10/27/2023] [Accepted: 11/27/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Preterm prelabor rupture of membranes (PPROM) remains a major complication of fetal laser surgery in the treatment of twin-to-twin transfusion syndrome (TTTS). The aim of the study was to determine the impact of cannula size on pregnancy outcomes, with a particular focus on PPROM. MATERIAL AND METHODS The protocol was developed and registered in the PROSPERO database under registration number CRD42022333630. The PubMed, Web of Science, and EMBASE databases were searched electronically on May 18, 2022, and updated on March 2, 2023, utilizing a combination of the relevant MeSH terms, keywords, and word variants for "TTTS" and "laser". Randomized controlled trials, prospective and retrospective cohorts, case-control studies, and case reports/series with more than five participants were considered eligible for inclusion. Studies reporting the cannula diameter and PPROM rate after laser surgery in the treatment of monochorionic pregnancies affected by TTTS between 16- and 26 weeks' gestation were included. Data was extracted independently, and when appropriate, a random-effects meta-analysis was undertaken to calculate pooled estimates and their confidence intervals. Heterogeneity in the effect estimates of the individual studies was calculated using the I2 statistic. The primary outcome was PPROM rate. Secondary outcomes were survival rate, preterm birth, and incomplete surgery. The quality of the included studies was assessed using a modified quality in prognosis study tool. RESULTS We included a total of 22 studies, consisting of 3426 patients. Only one study was scored as low quality, seven as moderate quality, and the remaining 14 as high quality. The mean PPROM rate after laser surgery treating TTTS was 22.9%, ranging from 11.6% for 9 French (Fr) to 54.0% for 12 Fr. Subsequent meta-regression for the clinically relevant PPROM rate before 34 weeks of gestation, showed increased PPROM rates for increased cannula size (p-value 0.01). CONCLUSIONS This systematic review confirmed PPROM as a frequent complication of fetal laser surgery, with a mean PPROM rate of 22.9%. A larger cannula diameter relates to a significant higher PPROM risk for PPROM before 34 weeks gestation. Hence, the ideal balance between optimal visualization requiring larger port diameters and shorter operation time and more complete procedures that benefit from larger diameters is crucial to reduce iatrogenic PPROM rates.
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Affiliation(s)
- Anouk M. van der Schot
- Department of Obstetrics & GynecologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Josee L. van Steenis
- Department of Obstetrics & GynecologyRadboud University Medical CenterNijmegenThe Netherlands
- Technical Medicine, Science and TechnologyUniversity of TwenteEnschedeThe Netherlands
| | - Esther Sikkel
- Department of Obstetrics & GynecologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Marc E. A. Spaanderman
- Department of Obstetrics & GynecologyRadboud University Medical CenterNijmegenThe Netherlands
- Department of Obstetrics & GynecologyMaastricht University Medical Center+MaastrichtThe Netherlands
- GROW School for Oncology and Reproduction Maastricht UniversityMaastrichtThe Netherlands
| | - Joris van Drongelen
- Department of Obstetrics & GynecologyRadboud University Medical CenterNijmegenThe Netherlands
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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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Provinciatto HG, Barbalho ME, Ferreira LC, Orsini PVB, Provinciatto A, Philip CE, Ruano R, Araujo Júnior E. Prevention of preterm birth in twin-to-twin transfusion syndrome: a systematic review and network meta-analysis. J Perinat Med 2024; 0:jpm-2024-0119. [PMID: 38905455 DOI: 10.1515/jpm-2024-0119] [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: 03/15/2024] [Accepted: 06/07/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVES We aimed to perform a systematic review and network meta-analysis to evaluate the preventive strategies for preterm birth in twin-to-twin transfusion syndrome. METHODS PubMed, Embase and Cochrane Central were searched from inception to December 2023 with no filters. Additionally, the reference lists of the included studies were manually examined to identify any supplementary studies. We selected randomized controlled trials and cohorts comparing interventions to prevent preterm birth in twin pregnancies complicated by twin-to-twin transfusion syndrome. A random-effects frequentist network meta-analysis was performed using RStudio version 4.3.1. Randomized controlled trials and cohorts were assessed respectively using the Risk of Bias in Non-randomized Studies of interventions tool and Cochrane Collaboration's tool for assessing risk of bias in randomized trials. RESULTS In this systematic review and meta-analysis, we included eight studies comprising a total of 719 patients. Compared with expectant management, cerclage stood out as the only intervention associated with an increase in the survival of at least one twin (risk ratio 1.12; 95 % confidence interval 1.01-1.23). Our subgroup analysis based on different thresholds for short cervix demonstrated a significant reduction in the risk of preterm birth before 32 weeks with ultrasound-indicated cerclage using a 15 mm criterion (risk ratio 0.65; 95 % confidence interval 0.47-0.92). CONCLUSIONS Our study suggests the potential benefit of cerclage as a preventive strategy for preterm birth in pregnancies complicated by twin-to-twin transfusion syndrome. These findings highlight the necessity for further investigation to corroborate our results and address the optimal threshold for ultrasound-indicated cerclage.
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Affiliation(s)
| | - Maria E Barbalho
- Department of Medicine, Potiguar University (UnP), Natal, RN, Brazil
| | - Laura C Ferreira
- Department of Medicine, Federal University of Santa Maria (UFSM), Santa Maria, RS, Brazil
| | - Pedro V B Orsini
- Department of Medicine, Federal University of Santa Maria (UFSM), Santa Maria, RS, Brazil
| | | | - Chris E Philip
- Department of Obstetrics and Gynecology, Beaumont Hospital, Dublin, Ireland
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Edward Araujo Júnior
- Department of Obstetrics, 58804 Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP) , São Paulo, SP, Brazil
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Zhang YH, Jiao'e P, Chen L, Zhou WX, Zhan H, Chen LQ, Lin J, Wen H. New radiofrequency ablation procedure for selective reduction in complicated monochorionic twin or triplet pregnancy using multistep, incremental expansion technique. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:522-528. [PMID: 37767731 DOI: 10.1002/uog.27508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/09/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Radiofrequency ablation (RFA) is the preferred approach for selective reduction in complex monochorionic (MC) multiple pregnancies owing to the ease of operation and minimal invasiveness. To optimize the RFA technique and reduce the risk of adverse pregnancy outcome resulting from the heat-sink effect of RFA therapy, we used an innovative RFA method, in which an electrode needle was expanded incrementally and stepwise. This study aimed to assess the efficacy and safety profile of this novel multistep incremental expansion RFA method for selective fetal reduction in MC twin and triplet pregnancies. METHODS This was a single-center retrospective cohort study of all MC multiple pregnancies undergoing RFA between March 2016 and October 2022 at our center. The multistep RFA technique involved the use of an expandable needle, which was gradually expanded during the RFA procedure until cessation of umbilical cord blood flow was achieved. The needle used for the single-step RFA method was fully extended from the start of treatment. RESULTS In total, 132 MC multiple pregnancies underwent selective reduction using RFA, including 50 cases undergoing multistep RFA and 82 cases undergoing single-step RFA. The overall survival rates were not significantly different between the multistep and single-step RFA groups (81.1% vs 72.3%; P = 0.234). Similarly, the rates of preterm prelabor rupture of the membranes within 2 weeks after RFA, procedure-related complications, spontaneous preterm delivery and pathological findings on cranial ultrasound, as well as gestational age at delivery and birth weight, did not differ between the two groups. However, there was a trend towards a prolonged procedure-to-delivery interval following multistep RFA compared with single-step RFA (median, 109 vs 99 days; P = 0.377). Moreover, the fetal loss rate within 2 weeks after RFA in the multistep RFA group was significantly lower than that in the single-step RFA group (10.0% vs 24.4%; P = 0.041). The median ablation time was shorter (5.3 vs 7.8 min; P < 0.001) and the median ablation energy was lower (10.2 vs 18.0 kJ; P < 0.001) in multistep compared with single-step RFA. There were no significant differences in neonatal outcomes following multistep vs single-step RFA. CONCLUSIONS Overall survival rates were similar between the two RFA methods. However, the multistep RFA technique was associated with a lower risk of fetal loss within 2 weeks after RFA. The multistep RFA technique required significantly less ablation energy and a shorter ablation time compared with single-step RFA in selective fetal reduction of MC twin and triplet pregnancies. Additionally, there was a trend towards a prolonged procedure-to-delivery interval with the multistep RFA technique. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Y-H Zhang
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - P Jiao'e
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - L Chen
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - W-X Zhou
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - H Zhan
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - L-Q Chen
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - J Lin
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - H Wen
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
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Cordier AG, Badr DA, Basurto D, Russo F, Deprest J, Orain E, Eixarch E, Otano J, Gratacos E, Moraes De Luna Freire Vargas A, Peralta CFA, Jani JC, Benachi A. Effect of cannula insertion site during fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia on preterm prelabor rupture of membranes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:529-535. [PMID: 38051135 DOI: 10.1002/uog.27548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/02/2023] [Accepted: 11/17/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVE To assess whether the cannula insertion site on the maternal abdomen during fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) was associated with preterm prelabor rupture of membranes (PPROM) before balloon removal. METHODS This was a multicenter retrospective study of consecutive pregnancies with isolated left- or right-sided CDH that underwent FETO in four centers between January 2009 and January 2021. The site for balloon insertion was categorized as above or below the umbilicus. One propensity score was analyzed in both groups to calculate an average treatment effect (ATE) by inverse probability of treatment weighting. Logistic regression and Cox proportional hazard regression including the ATE weights were performed to examine the effect size of entry point on the frequency and timing of PPROM before balloon removal. RESULTS A total of 294 patients were included. The mean ± SD gestational age at PPROM was 33.45 ± 2.01 weeks and the mean rate of PPROM before balloon removal was 25.9% (76/294). Gestational age at FETO was later in the below-umbilicus group (mean ± SD, 29.47 ± 1.29 weeks vs 29.00 ± 1.25 weeks; P = 0.002) and the duration of FETO was longer in the above-umbilicus group (median, 14.49 min (interquartile range (IQR), 8.00-21.00 min) vs 11.00 min (IQR, 7.00-14.49 min); P = 0.002). After balancing for possible confounding factors, trocar entry point below the umbilicus did not increase the risk of PPROM before balloon removal (adjusted odds ratio, 1.56 (95% CI, 0.89-2.74); P = 0.120) and had no effect on the timing of PPROM before balloon removal (adjusted hazard ratio, 1.56 (95% CI, 0.95-2.55); P = 0.080). CONCLUSION There was no evidence that uterine entry site for FETO was correlated with the risk of PPROM before balloon removal. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A-G Cordier
- Department of Obstetrics and Gynecology, Antoine Béclère Hospital, Paris Saclay University, APHP, Clamart, France
- Centre de Référence Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
- Sorbonne Université, APHP, Tenon Hospital, Paris, France
| | - D A Badr
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
| | - D Basurto
- Clinical Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - F Russo
- Clinical Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - J Deprest
- Clinical Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - E Orain
- Department of Obstetrics and Gynecology, Antoine Béclère Hospital, Paris Saclay University, APHP, Clamart, France
| | - E Eixarch
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomediques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - J Otano
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomediques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - E Gratacos
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomediques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - A Moraes De Luna Freire Vargas
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas, Campinas, Brazil
- Fetal Medicine Unit, The Heart Hospital, São Paulo, Brazil
- Gestar Fetal Medicine and Surgery Center, São Paulo, Brazil
| | - C F A Peralta
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas, Campinas, Brazil
- Fetal Medicine Unit, The Heart Hospital, São Paulo, Brazil
- Gestar Fetal Medicine and Surgery Center, São Paulo, Brazil
| | - J C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
| | - A Benachi
- Department of Obstetrics and Gynecology, Antoine Béclère Hospital, Paris Saclay University, APHP, Clamart, France
- Centre de Référence Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
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Vergote S, Robmann S, Van Der Merwe J, Richter J, Deprest J, Mazza E. Preterm membranes are mechanically more resistant than term membranes. Prenat Diagn 2024; 44:317-324. [PMID: 38168862 DOI: 10.1002/pd.6511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/29/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE To compare the biomechanical properties of fetal preterm membranes (20 + 0 weeks to 30 + 0 weeks) to those of the term (37 + 0 to 41 + 0 weeks). METHOD Amnion and chorion were manually separated and samples were cut to the required geometry. Rectangular samples with (mode 1) and without (uniaxial) a notch, were tested for tearing energy, critical elongation, and tangent stiffness. Suture retention and inter-suture distance testing investigated the effect of suture placement. RESULTS From the 15 preterm and 10 term placentas studied, no notable differences were observed in uniaxial testing. Mode 1 fracture testing showed a difference in tearing energy between the preterm and term chorion (0.025 ± 0.005 vs. 0.017 ± 0.005 J/m-1 ; p = 0.027) but not in the amnion (0.030 ± 0.017 vs. 0.029 ± 0.009 J/m-1 ; p = 0.895). Both preterm amnion and chorion showed a higher critical elongation compared with term (1.229 ± 0.057 vs. 1.166 ± 0.046; p = 0.019 and 1.307 ± 0.049 vs. 1.218 ± 0.058; p = 0.012). Preterm amnion had a higher suture retention strength than its term counterpart (0.189 ± 0.065 vs. 0.121 ± 0.031 N; p = 0.023). In inter-suture distance tests, no significant interaction was observed beyond 3 mm, but the preterm chorion showed less interaction at 1-2 mm distances. CONCLUSION Preterm membranes have equivalent or superior tensile properties to term membranes. The chorion appears to contribute to the mechanical integrity of fetal membranes, particularly in preterm stages.
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Affiliation(s)
- Simen Vergote
- Department of Obstetrics and Gynaecology, UZ Leuven, Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Serjosha Robmann
- Institute for Mechanical Systems, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Johannes Van Der Merwe
- Department of Obstetrics and Gynaecology, UZ Leuven, Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Jute Richter
- Department of Obstetrics and Gynaecology, UZ Leuven, Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Obstetrics and Gynaecology, UZ Leuven, Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
| | - Edoardo Mazza
- Institute for Mechanical Systems, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
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Casella A, Bano S, Vasconcelos F, David AL, Paladini D, Deprest J, De Momi E, Mattos LS, Moccia S, Stoyanov D. Learning-based keypoint registration for fetoscopic mosaicking. Int J Comput Assist Radiol Surg 2024; 19:481-492. [PMID: 38066354 PMCID: PMC10881678 DOI: 10.1007/s11548-023-03025-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 09/20/2023] [Indexed: 02/22/2024]
Abstract
PURPOSE In twin-to-twin transfusion syndrome (TTTS), abnormal vascular anastomoses in the monochorionic placenta can produce uneven blood flow between the two fetuses. In the current practice, TTTS is treated surgically by closing abnormal anastomoses using laser ablation. This surgery is minimally invasive and relies on fetoscopy. Limited field of view makes anastomosis identification a challenging task for the surgeon. METHODS To tackle this challenge, we propose a learning-based framework for in vivo fetoscopy frame registration for field-of-view expansion. The novelties of this framework rely on a learning-based keypoint proposal network and an encoding strategy to filter (i) irrelevant keypoints based on fetoscopic semantic image segmentation and (ii) inconsistent homographies. RESULTS We validate our framework on a dataset of six intraoperative sequences from six TTTS surgeries from six different women against the most recent state-of-the-art algorithm, which relies on the segmentation of placenta vessels. CONCLUSION The proposed framework achieves higher performance compared to the state of the art, paving the way for robust mosaicking to provide surgeons with context awareness during TTTS surgery.
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Affiliation(s)
- Alessandro Casella
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Italy
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
| | - Sophia Bano
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK.
| | - Francisco Vasconcelos
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
| | - Anna L David
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, UK
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
- Department of Development and Regeneration, University Hospital Leuven, Leuven, Belgium
| | - Dario Paladini
- Department of Fetal and Perinatal Medicine, Istituto Giannina Gaslini, Genoa, Italy
| | - Jan Deprest
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
- Department of Development and Regeneration, University Hospital Leuven, Leuven, Belgium
| | - Elena De Momi
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Leonardo S Mattos
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy
| | - Sara Moccia
- The BioRobotics Institute and Department of Excellence in Robotics and AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
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Chimenea A, García-Díaz L, Antiñolo G. Long-Term Neurodevelopmental Outcome After Selective Fetoscopic Laser Therapy for Stage I Twin-Twin Transfusion Syndrome. Clin Pediatr (Phila) 2024:99228241227087. [PMID: 38269530 DOI: 10.1177/00099228241227087] [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] [Indexed: 01/26/2024]
Abstract
Twin-twin transfusion syndrome (TTTS) is a serious complication in monochorionic (MC) pregnancies. Fetoscopic laser surgery (FLS) is the primary treatment for advanced TTTS, but managing Quintero stage I TTTS is still controversial. We conducted an observational study evaluating the 2-year neurodevelopment of fetuses, which underwent FLS for stage I TTTS, compared with advanced TTTS and uncomplicated monochorionic diamniotic twins (MCDTs). The study included 156 children: 14 in stage I TTTS group, 28 in advanced TTTS group, and 114 in uncomplicated twin group. In stage I TTTS, 92.9% showed normal neurodevelopment, with no severe neurological impairments observed. These results were comparable with uncomplicated twins (92.1% normal neurodevelopment, P = .921, adjusted odds ratio [aOR] = 1.56, 95% confidence interval [CI] = 0.42-5.79; 1.8% severe impairment, P = .617). Advanced TTTS had a non-significant lower rate of normal neurodevelopment (89.3%, P = .710, aOR = 1.31, 95% CI = 0.12-14.87). In conclusion, FLS for stage I TTTS shows favorable long-term neurodevelopmental outcomes, similar to uncomplicated MC pregnancies.
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Affiliation(s)
- Angel Chimenea
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville, Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Fetal, IVF and Reproduction Simulation Training Centre, Seville, Spain
| | - Lutgardo García-Díaz
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville, Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Department of Surgery, University of Seville, Seville, Spain
| | - Guillermo Antiñolo
- Department of Materno-Fetal Medicine, Genetics and Reproduction, Institute of Biomedicine of Seville, Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Fetal, IVF and Reproduction Simulation Training Centre, Seville, Spain
- Department of Surgery, University of Seville, Seville, Spain
- Centre for Biomedical Network Research on Rare Diseases, Seville, Spain
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10
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Danciu BM, Oţelea MR, Marincaş MA, Niţescu M, Simionescu AA. Is Spontaneous Preterm Prelabor of Membrane Rupture Irreversible? A Review of Potentially Curative Approaches. Biomedicines 2023; 11:1900. [PMID: 37509539 PMCID: PMC10377155 DOI: 10.3390/biomedicines11071900] [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: 05/25/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
There is still no curative treatment for the spontaneous preterm prelabor rupture of membranes (sPPROM), the main cause of premature birth. Here, we summarize the most recent methods and materials used for sealing membranes after sPPROM. A literature search was conducted between 2013 and 2023 on reported newborns after membranes were sealed or on animal or tissue culture models. Fourteen studies describing the outcomes after using an amniopatch, an immunologic sealant, or a mechanical cervical adapter were included. According to these studies, an increase in the volume of amniotic fluid and the lack of chorioamnionitis demonstrate a favorable neonatal outcome, with a lower incidence of respiratory distress syndrome and early neonatal sepsis, even if sealing is not complete and stable. In vivo and in vitro models demonstrated that amniotic stem cells, in combination with amniocytes, can spontaneously repair small defects; because of the heterogenicity of the data, it is too early to draw a thoughtful conclusion. Future therapies should focus on materials and methods for sealing fetal membranes that are biocompatible, absorbable, available, easy to apply, and easily adherent to the fetal membrane.
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Affiliation(s)
- Bianca Mihaela Danciu
- Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Obstetrics, Gynecology and Neonatology, "Dr. Alfred Rusescu" National Institute for Maternal and Child Health, 127715 Bucharest, Romania
| | - Marina Ruxandra Oţelea
- Clinical Department 5, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Marian Augustin Marincaş
- First Department of Surgery, Bucharest Oncological Institute Prof. Dr. Alexandru Trestioreanu, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania
| | - Maria Niţescu
- Preclinical Department 3, Complementary Sciences, Carol Davila University of Medicine and Pharmacy, 020125 Bucharest, Romania
| | - Anca Angela Simionescu
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
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11
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Jha P, Raghu P, Kennedy AM, Sugi M, Morgan TA, Feldstein V, Pōder L, Penna R. Assessment of Amniotic Fluid Volume in Pregnancy. Radiographics 2023; 43:e220146. [PMID: 37200220 DOI: 10.1148/rg.220146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Amniotic fluid (AF) is an integral part of the fetal environment and is essential for fetal growth and development. Pathways of AF recirculation include the fetal lungs, swallowing, absorption through the fetal gastrointestinal tract, excretion through fetal urine production, and movement. In addition to being a marker for fetal health, adequate AF is necessary for fetal lung development, growth, and movement. The role of diagnostic imaging is to provide a detailed fetal survey, placental evaluation, and clinical correlation with maternal conditions to help identify causes of AF abnormalities and thereby enable specific therapy. Oligohydramnios prompts evaluation for fetal growth restriction as well as genitourinary issues, including renal agenesis, multicystic dysplastic kidneys, ureteropelvic junction obstruction, and bladder outlet obstruction. Premature preterm rupture of membranes should also be clinically excluded as a cause of oligohydramnios. Clinical trials evaluating amnioinfusion are underway as a potential intervention for renal causes of oligohydramnios. Most cases of polyhydramnios are idiopathic, with maternal diabetes being a common cause. Polyhydramnios prompts evaluation for fetal gastrointestinal obstruction and oropharyngeal or thoracic masses, as well as neurologic or musculoskeletal anomalies. Amnioreduction is performed only for maternal indications such as symptomatic polyhydramnios causing maternal respiratory distress. Polyhydramnios with fetal growth restriction is paradoxical and can occur with maternal diabetes and hypertension. When these maternal conditions are absent, this raises concern for aneuploidy. The authors describe the pathways of AF production and circulation, US and MRI assessment of AF, disease-specific disruption of AF pathways, and an algorithmic approach to AF abnormalities. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Priyanka Jha
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Preethi Raghu
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Anne M Kennedy
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Mark Sugi
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Tara A Morgan
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Vickie Feldstein
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Liina Pōder
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
| | - Rubal Penna
- From the University of California San Francisco, 505 Parnassus Ave, San Francisco, Calif (P.J., P.R., M.S., T.A.M., V.F., L.P.); University of Utah Hospital, Salt Lake City, Utah (A.M.K.); and Inland Imaging, Seattle, Wash (R.P.)
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12
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Devaud YR, Avilla-Royo E, Lionetti L, Tronnier H, Seehusen F, Monné Rodriguez JM, Moehrlen U, Weisskopf M, Vonzun L, Strübing N, Ochsenbein-Kölble N, Ehrbar M. Tissue Glue-Based Sealing Patch for the in vivo Prevention of Iatrogenic Prelabor Preterm Rupture of Fetal Membranes. Fetal Diagn Ther 2023; 50:332-343. [PMID: 37231883 DOI: 10.1159/000530958] [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: 12/22/2022] [Accepted: 04/25/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION One of the main concerns for all fetal surgeries is the risk of preterm delivery due to the preterm prelabor rupture of the fetal membranes (iPPROM). Clinical approaches to seal fetal membrane (FM) defects are missing due to the lack of appropriate strategies to apply sealing biomaterials at the defect site. METHODS Here, we test the performance of a previously developed strategy to seal FM defects with cyanoacrylate-based sealing patches in an ovine model up to 24 days after application. RESULTS Patches sealed tightly the fetoscopy-induced FM defects and remained firmly attached to the defect over 10 days. At 10 days after treatment, 100% (13/13) of the patches were attached to the FMs, and 24 days after treatment 25% (1/4) of the patches placed in CO2 insufflation, and 33% (1/3) in NaCl infusion remained. However, all successfully applied patches (20/24) led to a watertight sealing at 10 or 24 days after treatment. Histological analysis indicated that cyanoacrylates induced a moderate immune response and disrupted the FM epithelium. CONCLUSION Together, these data show the feasibility of minimally invasive sealing of FM defects by locally gathering tissue adhesive. Further development to combine this technology with refined tissue glues or healing-inducing materials holds great promise for future clinical translation.
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Affiliation(s)
- Yannick R Devaud
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- KOVE medical AG, Zurich, Switzerland
| | - Eva Avilla-Royo
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Leonardo Lionetti
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Helena Tronnier
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- KOVE medical AG, Zurich, Switzerland
| | - Frauke Seehusen
- Laboratory for Animal Model Pathology, Institute of Veterinary Pathology, University of Zurich, Zurich, Switzerland
| | - Josep M Monné Rodriguez
- Laboratory for Animal Model Pathology, Institute of Veterinary Pathology, University of Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
- Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Miriam Weisskopf
- Center of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ladina Vonzun
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
| | - Nele Strübing
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
| | - Martin Ehrbar
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Meuwese RT, Versteeg EM, van Drongelen J, de Hoog D, Bouwhuis D, Vandenbussche FP, van Kuppevelt TH, Daamen WF. A collagen plug with shape memory to seal iatrogenic fetal membrane defects after fetoscopic surgery. Bioact Mater 2023; 20:463-471. [PMID: 35800408 PMCID: PMC9249610 DOI: 10.1016/j.bioactmat.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 05/20/2022] [Accepted: 06/12/2022] [Indexed: 12/04/2022] Open
Abstract
Iatrogenic preterm premature rupture of fetal membranes (iPPROM) after fetal surgery remains a strong trigger for premature birth. As fetal membrane defects do not heal spontaneously and amniotic fluid leakage and chorioamniotic membrane separation may occur, we developed a biocompatible, fetoscopically-applicable collagen plug with shape memory to prevent leakage. This plug expands directly upon employment and seals fetal membranes, hence preventing amniotic fluid leakage and potentially iPPROM. Lyophilized type I collagen plugs were given shape memory and crimped to fit through a fetoscopic cannula (Ø 3 mm). Expansion of the plug was examined in phosphate buffered saline (PBS). Its sealing capacity was studied ex vivo using human fetal membranes, and in situ in a porcine bladder model. The crimped plug with shape memory expanded and tripled in diameter within 1 min when placed into PBS, whereas a crimped plug without shape memory did not. In both human fetal membranes and porcine bladder, the plug expanded in the defect, secured itself and sealed the defect without membrane rupture. In conclusion, collagen plugs with shape memory are promising as medical device for rapid sealing of fetoscopic defects in fetal membranes at the endoscopic entry point. Shape memory can be given to collagen plugs to rapidly expand in aqueous fluids. Within 1 min in aqueous fluid, collagen plugs with shape memory triple in diameter. Collagen plugs with shape memory show potency to seal fetal membrane defects.
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14
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Comparison of Pregnancy Outcomes of Previable and Periviable Rupture of Membranes After Laser Photocoagulation for Twin-Twin Transfusion Syndrome. Obstet Gynecol 2022; 140:965-973. [PMID: 36357989 PMCID: PMC9665941 DOI: 10.1097/aog.0000000000004970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To describe the pregnancy outcomes of patients who experienced previable and periviable prelabor rupture of membranes (PROM) after the treatment of twin-twin transfusion syndrome. METHODS We conducted a retrospective cohort study of patients whose pregnancies were complicated by twin-twin transfusion syndrome who were treated with fetoscopic laser photocoagulation at a single fetal center and subsequently experienced PROM from April 2010 to June 2019. Outcomes were infant survival and latency from PROM to delivery. Patients were grouped by gestational age at PROM (before 26 weeks of gestation and 26 weeks or later). The group with PROM before 26 weeks of gestation was stratified by gestational age at PROM for further description of outcomes. RESULTS Two-hundred fifty of 653 patients (38%) developed PROM, 81 before 26 weeks of gestation and 169 after 26 weeks of gestation. In the setting of PROM before 26 weeks of gestation, the rate of survival of both twins to neonatal intensive care unit (NICU) discharge was 46.3%, compared with 76.9% in the setting of PROM at 26 weeks of gestation or later ( P <.001); the survival rate of at least one twin was 61.2% and 98.5%, respectively ( P <.001). Fourteen, 22, and 45 patients experienced PROM at 16-19 6/7, 20-22 6/7, and 23-25 6/7 weeks of gestation, respectively. Survival of both twins and at least one twin to NICU discharge was 25.0%, 47.4%, 52.8% (for two) and 33.3%, 47.4%, and 77.8% (for at least one), respectively, among those groups. Fifty-seven of the 81 patients with PROM before 26 weeks of gestation experienced a latency longer than 48 hours. In the setting of PROM before 26 weeks of gestation, when latency lasted longer than 48 hours, overall survival was improved (69.6% vs 53.7%, respectively, P =.017). With latency longer than 48 hours and PROM at 16-19 6/7, 20-22 6/7, and 23-25 6/7 weeks of gestation, survival of both twins to NICU discharge was 60.0%, 61.5%, and 60.7%, respectively, and survival of at least one twin was 80.0%, 61.5%, and 85.7%, respectively. CONCLUSION Earlier gestational age at PROM after laser photocoagulation is associated with longer latency but lower rates of survival. When PROM occurs before 26 weeks of gestation and latency exceeds 48 hours, rates of neonatal survival are significantly improved.
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Tevaearai F, Sachs MK, El-Hadad S, Vonzun L, Moehrlen U, Mazzone L, Meuli M, Krähenmann F, Ochsenbein-Kölble N. Stage 2: The Vaginal Flora in Women Undergoing Fetal Spina Bifida Repair and Its Potential Association with Preterm Rupture of Membranes and Preterm Birth. J Clin Med 2022; 11:jcm11237038. [PMID: 36498612 PMCID: PMC9735677 DOI: 10.3390/jcm11237038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/19/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Vaginal dysbiosis affects pregnancy outcomes, however, the relevance of abnormal findings on pre/post-surgical vaginal culture in women undergoing fetal spina bifida (fSB) repair is unknown. OBJECTIVES To describe the incidence of normal and abnormal pre- and post-surgical vaginal microorganisms in fSB patients and to investigate potential associations between the type of vaginal flora and the occurrence of preterm prelabour rupture of membranes (PPROM) and preterm birth (PTB). METHODS 99 women undergoing fSB repair were eligible (2010-2019). Pre-surgical vaginal culture was routinely taken before surgery. Post-surgical cultures were taken on indication. Vaginal flora was categorized into four categories: healthy vaginal flora (HVF), bacterial vaginosis (BV), desquamative inflammatory vaginitis (DIV), and yeast infection. RESULTS The incidence of HVF, BV, DIV, or yeast infections was not statistically different between the pre- and postoperative patients. Furthermore, an abnormal pre/post-surgical vaginal flora was not associated with PPROM (OR 1.57 (0.74-3.32), p = 0.213)/OR 1.26 (0.62-2.55), p = 0.515), or with PTB (OR 1.19 (0.82-1.73), p = 0.315)/(OR 0.86 (0.60-1.24), p = 0.425). CONCLUSIONS Abnormal vaginal microbiome was not associated with PPROM and PTB when appropriate treatment was performed.
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Affiliation(s)
- Fanny Tevaearai
- Department of Obstetrics, University Hospital Zurich, 8091 Zurich, Switzerland
- Department of Obstetrics, Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Correspondence: (F.T.); (N.O.-K.); Tel.: +41-79-595-4295 (F.T.); +41-43-253-9712 (N.O.-K.)
| | - Maike Katja Sachs
- Department of Obstetrics, University Hospital Zurich, 8091 Zurich, Switzerland
- Department of Obstetrics, Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
| | - Samia El-Hadad
- Department of Obstetrics, University Hospital Zurich, 8091 Zurich, Switzerland
- Department of Obstetrics, Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
| | - Ladina Vonzun
- Department of Obstetrics, University Hospital Zurich, 8091 Zurich, Switzerland
- Department of Obstetrics, Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, 8091 Zurich, Switzerland
| | - Ueli Moehrlen
- Department of Obstetrics, Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, 8091 Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Luca Mazzone
- Department of Obstetrics, Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, 8091 Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Martin Meuli
- Department of Obstetrics, Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, 8091 Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Franziska Krähenmann
- Department of Obstetrics, University Hospital Zurich, 8091 Zurich, Switzerland
- Department of Obstetrics, Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, 8091 Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zurich, 8091 Zurich, Switzerland
- Department of Obstetrics, Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, 8091 Zurich, Switzerland
- Correspondence: (F.T.); (N.O.-K.); Tel.: +41-79-595-4295 (F.T.); +41-43-253-9712 (N.O.-K.)
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DeFrates KG, Engström J, Sarma NA, Umar A, Shin J, Cheng J, Xie W, Pochan D, Omar AK, Messersmith PB. The influence of molecular design on structure-property relationships of a supramolecular polymer prodrug. Proc Natl Acad Sci U S A 2022; 119:e2208593119. [PMID: 36279462 PMCID: PMC9636931 DOI: 10.1073/pnas.2208593119] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022] Open
Abstract
Supramolecular self-assemblies of hydrophilic macromolecules functionalized with hydrophobic, structure-directing components have long been used for drug delivery. In these systems, loading of poorly soluble compounds is typically achieved through physical encapsulation during or after formation of the supramolecular assembly, resulting in low encapsulation efficiencies and limited control over release kinetics, which are predominately governed by diffusion and carrier degradation. To overcome these limitations, amphiphilic prodrugs that leverage a hydrophobic drug as both the therapeutic and structure-directing component can be used to create supramolecular materials with higher loading and controlled-release kinetics using biodegradable or enzymatically cleavable linkers. Here, we report the design, synthesis, and characterization of a library of supramolecular polymer prodrugs based on poly(ethylene glycol) (PEG) and the proregenerative drug 1,4-dihydrophenonthrolin-4-one-3-carboxylic acid (DPCA). Structure-property relationships were elucidated through experimental characterization of prodrug behavior in both the wet and dry states using scattering techniques and electron microscopy and corroborated by coarse-grained modeling. Molecular architecture and the hydrophobic-to-hydrophilic ratio of PEG-DPCA conjugates strongly influenced their physical state in water, ranging from fully soluble to supramolecular spherical assemblies and nanofibers. Molecular design and supramolecular structure, in turn, were shown to dramatically alter hydrolytic and enzymatic release and cellular transport of DPCA. In addition to potentially expanding therapeutic options for DPCA through control of supramolecular assemblies, the design principles elaborated here may inform the development of other supramolecular prodrugs based on hydrophobic small-molecule compounds.
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Affiliation(s)
- Kelsey G. DeFrates
- Department of Bioengineering, University of California, Berkeley, CA 94720
| | - Joakim Engström
- Department of Bioengineering, University of California, Berkeley, CA 94720
- Department of Materials Science and Engineering, University of California, Berkeley, CA 94720
| | - Nivedina A. Sarma
- Department of Materials Science and Engineering, University of California, Berkeley, CA 94720
| | - Athiyya Umar
- Department of Bioengineering, University of California, Berkeley, CA 94720
| | - Jisoo Shin
- Department of Bioengineering, University of California, Berkeley, CA 94720
- Department of Materials Science and Engineering, University of California, Berkeley, CA 94720
| | - Jing Cheng
- Department of Bioengineering, University of California, Berkeley, CA 94720
- Department of Materials Science and Engineering, University of California, Berkeley, CA 94720
| | - Weiran Xie
- Department of Materials Science and Engineering, University of Delaware, Newark, DE 19716
| | - Darrin Pochan
- Department of Materials Science and Engineering, University of Delaware, Newark, DE 19716
| | - Ahmad K. Omar
- Department of Materials Science and Engineering, University of California, Berkeley, CA 94720
- Materials Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720
| | - Phillip B. Messersmith
- Department of Bioengineering, University of California, Berkeley, CA 94720
- Department of Materials Science and Engineering, University of California, Berkeley, CA 94720
- Materials Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720
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17
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Famos F, Avilla-Royo E, Vonzun L, Ochsenbein-Kölble N, Ehrbar M. Miniaturized bioengineered models for preterm fetal membrane healing. Fetal Diagn Ther 2022; 49:235-244. [PMID: 35709687 DOI: 10.1159/000525559] [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: 03/30/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The reason for the absence of fetal membrane (FM) healing after a fetoscopic intervention is not known. We hypothesize that the lack of robust miniaturized models to study preterm FM functions is currently hampering the development of new treatments for FM healing. Specifically, miniaturized models to study preterm FM healing with minimal amounts of tissue are currently lacking. METHODS In this study, we collected FMs from planned cesarean deliveries and developed different ex vivo models with an engineered biomaterial to study FM healing. Then, the effect of PDGF-BB on the migration of cells from preterm and term FMs was evaluated. RESULTS FMs could be viably cultured ex vivo for 14 days. In a model of punctured FMs, migration of cells into FM defects was less pronounced than migration out of the tissue into the biomaterial. In a miniaturized model of preterm cell migration, PDGF-BB promoted migration of preterm amnion cells into the biomaterial. DISCUSSION AND CONCLUSION By using a novel miniaturized model of preterm tissue, we here successfully demonstrate that PDGF-BB can promote preterm FM cell migration of microtissues encapsulated in a three-dimensional environment.
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Affiliation(s)
- Flurina Famos
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Eva Avilla-Royo
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Ladina Vonzun
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
| | - Martin Ehrbar
- Department of Obstetrics, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
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18
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Ortiz JU, Eixarch E, Micheletti T, Lobmaier SM, Bennasar M, Martinez JM, Gratacós E. Impact of Preoperative Cervical Length on Pregnancy Outcome in Twin-Twin Transfusion Syndrome. Z Geburtshilfe Neonatol 2022; 226:245-250. [PMID: 35545124 DOI: 10.1055/a-1812-5608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the impact of preoperative cervical length on pregnancy outcome in monochorionic diamniotic twin pregnancies complicated by twin-twin transfusion syndrome that underwent laser surgery or cord occlusion. MATERIALS AND METHODS Retrospective study of 330 patients stratified by preoperative cervical length (≥25 mm, 16-24 mm,≤15 mm). Maternal characteristics, operative data, and pregnancy outcomes were compared between the cervical length groups as well as between the subgroups of patients with a cervical length≤15 mm according to management (expectant vs. cerclage). RESULTS A preoperative cervical length≥25 mm was observed in 82% (n=271) of cases, 16-24 mm in 9% (n=29), and≤15 mm in 9% (n=30). Patients with a preoperative cervical length≤15 mm showed shorter median procedure-to-delivery interval (5.5 weeks vs. 11.6 (16-24 mm) vs. 13.0 (≥25 mm); p<0.001); lower median gestational age at delivery (29.5 weeks vs. 34.3 (16-24 mm) vs. 33.4 (≥25 mm); p<0.001); higher rate of preterm delivery<32 weeks (78 vs. 20% (16-24 mm) vs. 31% (≥25 mm); p<0.001); and lower neonatal survival rate of at least one twin (70 vs. 88% (16-24 mm) vs. 93% (≥25 mm); p<0.001). Outcome of patients with a preoperative cervical length≤15 mm was similar regardless of management. CONCLUSION Monochorionic diamniotic twin pregnancies complicated by twin-twin transfusion syndrome with a preoperative cervical length≤15 mm showed a higher rate of preterm delivery<32 weeks and lower neonatal survival. The role of a cervical cerclage remains unclear.
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Affiliation(s)
- Javier U Ortiz
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain.,University Hospital rechts der Isar, Technical University of Munich, Division of Obstetrics and Perinatal Medicine, Munich, Germany
| | - Elisenda Eixarch
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain
| | - Talita Micheletti
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain
| | - Silvia M Lobmaier
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain.,University Hospital rechts der Isar, Technical University of Munich, Division of Obstetrics and Perinatal Medicine, Munich, Germany
| | - Mar Bennasar
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain
| | - Josep M Martinez
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain
| | - Eduard Gratacós
- University of Barcelona, Institut d'Investigations Biomèdiques August Pi i Sunyer (IDIBAPS), and Centre for Biomedical Research on Rare Diseases (CIBER-ER), BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain
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19
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Twin-to-twin transfusion syndrome: Controversies in the diagnosis and management. Best Pract Res Clin Obstet Gynaecol 2022; 84:143-154. [PMID: 35589537 DOI: 10.1016/j.bpobgyn.2022.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/12/2022] [Indexed: 11/21/2022]
Abstract
In twin-to-twin transfusion syndrome (TTTS) communicating placental vessels on the chorionic plate between the donor and recipient twins are responsible for the chronic imbalance of blood flow. Evidence demonstrates that fetoscopic laser ablation is superior to serial amnioreductions in terms of survival and neurological outcome for stages II-IV TTTS. However, the optimal management of stage I TTTS remains poorly understood. It is well established that all chorionic plate anastomoses should be closed by laser ablation. Compared to the selective laser method, the Solomon technique yields a significant reduction of recurrent TTTS and post-laser twin anemia polycythemia sequence (TAPS). Over the past 25 years, survival rates after fetoscopic laser surgery have significantly increased. High volume centers report up to 70% double survival and at least one survivor in >90% cases. In this review, we discuss the controversies in the diagnosis and management of TTTS, especially, the optimal management in stage I cases, very early or late diagnosis, and the optimal laser technique. Furthermore, we will discuss a stage-related outcome after laser surgery and examine whether it is necessary at all to distinguish between stages I and II. Finally, the optimal timing as well as mode of delivery after TTTS laser treatment will be discussed.
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20
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MICHELETTI T, EIXARCH E, FEBAS G, BERDUN S, Parra J, Hernansanz A, BORRÓS S, GRATACOS E. Intraamniotic sealing of fetoscopic membrane defects in ex vivo and in vivo sheep models using an integrated semi-rigid bioadhesive patch^. Am J Obstet Gynecol MFM 2022; 4:100593. [DOI: 10.1016/j.ajogmf.2022.100593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 02/02/2022] [Indexed: 11/16/2022]
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21
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Gomez NG, Monson MA, Chon AH, Korst LM, Llanes A, Chmait RH. Outcomes of laser surgery for stage I twin-twin transfusion syndrome. Prenat Diagn 2022; 42:172-179. [PMID: 35032038 DOI: 10.1002/pd.6094] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/29/2021] [Accepted: 01/08/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE A recent randomized controlled trial (RCT) demonstrated no difference in 6 month survival in expectantly managed stage I twin-twin transfusion syndrome (TTTS) patients and those undergoing immediate laser surgery. We aimed to describe outcomes following immediate laser surgery at a single fetal surgery center. METHODS A retrospective study of monochorionic diamniotic twins diagnosed with stage I TTTS who underwent laser surgery between 16 and 26 gestational weeks from 2006 to 2019. The primary outcome was 6 month survivorship. Intact survival was also assessed. Secondarily, outcomes were compared to the RCT expectant management group. RESULTS Of 126 consecutive stage I TTTS patients, 114 (90.5%) met inclusion criteria. Median (range) gestational age at delivery was 34.1 (20.6-39.4) weeks. At 6 months, the proportion of patients with at-least-one survivor in the single-center-laser cohort was 97.4%, with 88.6% dual survivorship. Neurological morbidity outcomes were available in 110 pregnancies (220 fetuses). Severe neurological morbidity occurred in 2.7% (6/220), and 6 month survival without severe neurological morbidity was 90.0%. Outcomes compared favorably with the RCT expectant management group. CONCLUSIONS Given favorable survival and neurological outcomes, laser surgery is a reasonable treatment option for stage I TTTS at experienced fetal surgery centers. Further study is warranted to optimize treatment strategies.
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Affiliation(s)
- Nicole G Gomez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Martha A Monson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, 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, North Hollywood, 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
| | - 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
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22
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Avilla-Royo E, Ochsenbein-Kölble N, Vonzun L, Ehrbar M. Biomaterial-based treatments for the prevention of preterm birth after iatrogenic rupture of the fetal membranes. Biomater Sci 2022; 10:3695-3715. [DOI: 10.1039/d2bm00401a] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Minimally invasive interventions to ameliorate or correct fetal abnormalities are becoming a clinical reality. However, the iatrogenic premature preterm rupture of the fetal membranes (FMs) (iPPROM), which may result in...
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23
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Giorgione V, D'antonio F, Manji A, Reed K, Khalil A. Perinatal outcome of pregnancy complicated by twin anemia-polycythemia sequence: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:813-823. [PMID: 33428243 DOI: 10.1002/uog.23585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/18/2020] [Accepted: 12/29/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To report the perinatal outcome of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin anemia-polycythemia sequence (TAPS), according to the type of TAPS (spontaneous or postlaser) and the management option adopted. METHODS MEDLINE, EMBASE and The Cochrane Library databases were searched for studies reporting on the outcome of twin pregnancies complicated by TAPS. Inclusion criteria were non-anomalous MCDA twin pregnancies with a diagnosis of TAPS. The primary outcome was perinatal mortality; secondary outcomes were neonatal morbidity and preterm birth (PTB). The outcomes were stratified according to the type of TAPS (spontaneous or following laser treatment for twin-twin transfusion syndrome) and the management option adopted (expectant, laser surgery, intrauterine transfusion (IUT) or selective reduction (SR)). Random-effects meta-analysis of proportions was used to analyze the data. RESULTS Perinatal outcome was assessed according to whether TAPS occurred spontaneously or after laser treatment in 506 pregnancies (38 studies). Intrauterine death (IUD) occurred in 5.2% (95% CI, 3.6-7.1%) of twins with spontaneous TAPS and in 10.2% (95% CI, 7.4-13.3%) of those with postlaser TAPS, while the corresponding rates of neonatal death were 4.0% (95% CI, 2.6-5.7%) and 9.2% (95% CI, 6.6-12.3%), respectively. Severe neonatal morbidity occurred in 29.3% (95% CI, 25.6-33.1%) of twins after spontaneous TAPS and in 33.3% (95% CI, 17.4-51.8%) after postlaser TAPS, while the corresponding rates of severe neurological morbidity were 4.0% (95% CI, 3.5-5.7%) and 11.1% (95% CI, 6.2-17.2%), respectively. PTB complicated 86.3% (95% CI, 77.2-93.3%) of pregnancies with spontaneous TAPS and all cases with postlaser TAPS (100% (95% CI, 84.3-100%)). Iatrogenic PTB was more frequent than spontaneous PTB in both groups. Perinatal outcome was assessed according to the management option adopted in 417 pregnancies (21 studies). IUD occurred in 9.8% (95% CI, 4.3-17.1%) of twins managed expectantly and in 13.1% (95% CI, 9.2-17.6%), 12.1% (95% CI, 7.7-17.3%) and 7.6% (95% CI, 1.3-18.5%) of those treated with laser surgery, IUT and SR, respectively. Severe neonatal morbidity affected 27.3% (95% CI, 13.6-43.6%) of twins in the expectant-management group, 28.7% (95% CI, 22.7-35.1%) of those in the laser-surgery group, 38.2% (95% CI, 18.3-60.5%) of those in the IUT group and 23.3% (95% CI, 10.5-39.2%) of those in the SR group. PTB complicated 80.4% (95% CI, 59.8-94.8%), 73.4% (95% CI, 48.1-92.3%), 100% (95% CI, 76.5-100%) and 100% (95% CI, 39.8-100%) of pregnancies after expectant management, laser surgery, IUT and SR, respectively. CONCLUSIONS The present meta-analysis provides pooled estimates of the risks of perinatal mortality, neonatal morbidity and PTB in twin pregnancies complicated by TAPS, stratified by the type of TAPS and the management option adopted. Although a direct comparison could not be performed, the results from this systematic review suggest that spontaneous TAPS may have a better prognosis than postlaser TAPS. No differences in terms of mortality and morbidity were observed when comparing different management options for TAPS, although these findings should be interpreted with caution in view of the limitations of the included studies. Individualized prenatal management, taking into account the severity of TAPS and gestational age, is currently the recommended strategy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Giorgione
- Twin Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - F D'antonio
- Center for Fetal Care and High-risk Pregnancy, University of Chieti, Italy
| | - A Manji
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - K Reed
- Twins Trust, Aldershot, UK
| | - A Khalil
- Twin Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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24
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Devaud YR, Stäuble S, Moehrlen U, Weisskopf M, Vonzun L, Zimmermann R, Ehrbar M, Ochsenbein-Kölble N. Minimally Invasive Precise Application of Bioadhesives to Prevent IPPROM on a Pregnant Sheep Model. Fetal Diagn Ther 2021; 48:785-793. [PMID: 34814145 DOI: 10.1159/000519910] [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: 03/28/2021] [Accepted: 09/10/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Iatrogenic preterm premature rupture of the membrane remains the Achille's heel of fetoscopy. The aim of this study was to show in vivo feasibility of fetal membrane (FM) defect sealing by the application of tissue glues with umbrella-shaped receptors. METHODS First, we adapted our previously described ex vivo strategy and evaluated the adhesion strength of different tissue glues, Histoacryl® and Glubran2®, by bonding polytetrafluoroethylene or silicone encapsulated nitinol glue receptor to human FM. Then, we exposed pregnant sheep uterus through a laparotomy and placed a 10-French trocar into the amniotic cavity through which the umbrella-shaped glue receptor (n = 9) was inserted and fixated onto the FM with the tissue glues (n = 8). The tightness of the sealed defects was assessed 4 h post-surgery. RESULTS Both tissue glues tested resulted in adhesion of the glue receptors to the FM ex vivo. In vivo, all glue receptors opened in the amniotic cavity (n = 9) and all successfully placed glue receptors sealed the FM defect (n = 8). Four hours post-surgery, 2 treatment sites showed minimal leakage whereas the negative control without glue (n = 1) showed substantial leakage. DISCUSSION This in vivo study confirms that fetoscopically induced FM defects can be sealed by the application of tissue adhesives.
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Affiliation(s)
- Yannick R Devaud
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Senta Stäuble
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- University of Zurich, Zurich, Switzerland.,Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
| | - Miriam Weisskopf
- University of Zurich, Zurich, Switzerland.,Center of Surgical Research, University Hospital Zurich, Zurich, Switzerland
| | - Ladina Vonzun
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
| | - Roland Zimmermann
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
| | - Martin Ehrbar
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland
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25
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Mustafa HJ, Krispin E, Tadbiri H, Espinoza J, Shamshirsaz AA, Nassr AA, Donepudi R, Belfort MA, Cortes MS, Pederson N, Harman C, Turan OM. Efficacy of long-term indomethacin therapy in prolonging pregnancy after fetoscopic laser surgery for twin-to-twin transfusion syndrome: a collaborative cohort study. BJOG 2021; 129:597-606. [PMID: 34780110 DOI: 10.1111/1471-0528.17017] [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: 09/14/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate the efficacy of long-term indomethacin therapy (LIT) in prolonging pregnancy and reducing spontaneous preterm birth (PTB) in patients undergoing fetoscopic laser surgery (FLS) for the management of twin-to-twin transfusion syndrome (TTTS). DESIGN Retrospective cohort study of prospectively collected data. SETTING Collaborative multicentre study. POPULATION Five hundred and fifty-seven consecutive TTTS cases that underwent FLS. METHODS Long-term indomethacin therapy was defined as indomethacin use for at least 48 hours. Log-binomial regression was used to estimate the relative risk of PTB in the LIT group compared with a non-LIT group. Cox regression was used to evaluate the association between LIT use and FLS-to-delivery survival. MAIN OUTCOME MEASURES Gestational age (GA) at delivery. RESULTS Among the 411 pregnancies included, a total of 180 patients (43.8%) received LIT after FLS and 231 patients (56.2%) did not. Median GA at fetal intervention did not differ between groups (20.4 weeks). Median GA at delivery was significantly higher in the LIT group (33.6 weeks) compared with the non-LIT group (31.1 weeks; P < 0.001). FLS-to-delivery interval was significantly longer in the LIT group (P < 0.001). The risks of PTB before 34, 32, 28 and 26 weeks of gestation were all significantly lower in the LIT group compared with the non-LIT group (relative risks 0.69, 0.51, 0.37 and 0.18, respectively). The number needed to treat with LIT to prevent one PTB before 32 weeks of gestation was four, and to prevent one PTB before 34 weeks was five. CONCLUSION Long-term indomethacin after FLS for TTTS was found to be associated with prolongation of pregnancy and reduced risk for PTB. TWEETABLE ABSTRACT Long-term indomethacin used after fetoscopic laser surgery for twin-to-twin transfusion syndrome is effective in prolonging pregnancy and reducing the risk for preterm birth; especially extreme preterm birth.
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Affiliation(s)
- H J Mustafa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - E Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - H Tadbiri
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M S Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - N Pederson
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - C Harman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - O M Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Avilla-Royo E, Gegenschatz-Schmid K, Grossmann J, Kockmann T, Zimmermann R, Snedeker JG, Ochsenbein-Kölble N, Ehrbar M. Comprehensive quantitative characterization of the human term amnion proteome. Matrix Biol Plus 2021; 12:100084. [PMID: 34765964 PMCID: PMC8572956 DOI: 10.1016/j.mbplus.2021.100084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/03/2021] [Accepted: 09/16/2021] [Indexed: 12/20/2022] Open
Abstract
We report an unprecedented quantitative high coverage of the human amnion proteome. We identified novel proteins that hold great promise for understanding fetal membrane biology. Together, this comprehensive proteome provides a basis for the evaluation of pre-term or diseased fetal membranes.
The loss of fetal membrane (FM) integrity and function at an early time point during pregnancy can have devastating consequences for the fetus and the newborn. However, biomaterials for preventive sealing and healing of FMs are currently non-existing, which can be partly attributed to the current fragmentary knowledge of FM biology. Despite recent advances in proteomics analysis, a robust and comprehensive description of the amnion proteome is currently lacking. Here, by an optimized protein sample preparation and offline fractionation before liquid chromatography coupled to mass spectrometry (LC-MS) analysis, we present a characterization of the healthy human term amnion proteome, which covers more than 40% of the previously reported transcripts in similar RNA sequencing datasets and, with more than 5000 identifications, greatly outnumbers previous reports. Together, beyond providing a basis for the study of compromised and preterm ruptured FMs, this comprehensive human amnion proteome is a stepping-stone for the development of novel healing-inducing biomaterials. The proteomic dataset has been deposited in the ProteomeXchange Consortium with the identifier PXD019410.
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Affiliation(s)
- Eva Avilla-Royo
- Department of Obstetrics, University and University Hospital of Zurich, 8091 Zurich, Switzerland.,Institute for Biomechanics, Swiss Federal Institute of Technology, 8093 Zurich, Switzerland
| | | | - Jonas Grossmann
- Functional Genomics Center, University of Zurich and ETH Zurich, 8057 Zurich, Switzerland.,SIB Swiss Institute of Bioinformatics, 1015 792 Lausanne, Switzerland
| | - Tobias Kockmann
- Functional Genomics Center, University of Zurich and ETH Zurich, 8057 Zurich, Switzerland
| | - Roland Zimmermann
- Department of Obstetrics, University and University Hospital of Zurich, 8091 Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, 8032 Zurich, Switzerland
| | - Jess Gerrit Snedeker
- Institute for Biomechanics, Swiss Federal Institute of Technology, 8093 Zurich, Switzerland.,Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Department of Obstetrics, University and University Hospital of Zurich, 8091 Zurich, Switzerland.,The Zurich Center for Fetal Diagnosis and Therapy, 8032 Zurich, Switzerland
| | - Martin Ehrbar
- Department of Obstetrics, University and University Hospital of Zurich, 8091 Zurich, Switzerland.,University of Zurich, 8006 Zurich, Switzerland
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Amberg B, DeKoninck P, Kashyap A, Rodgers K, Zahra V, Hooper S, Crossley K, Hodges R. The effects of cold, dry and heated, humidified amniotic insufflation on sheep fetal membranes. Placenta 2021; 114:1-7. [PMID: 34418749 DOI: 10.1016/j.placenta.2021.08.003] [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: 01/28/2021] [Revised: 07/16/2021] [Accepted: 08/05/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Uterine distension with pressurised carbon dioxide (CO2) (amniotic insufflation) is used clinically to improve visibility during keyhole fetal surgery. However, there are concerns that amniotic insufflation with unconditioned (cold, dry) CO2 damages the fetal membranes which leads to post-operative preterm prelabour rupture of membranes (iatrogenic PPROM). We assessed whether heating and humidifying the insufflated CO2 could reduce fetal membrane damage in sheep. METHODS Thirteen pregnant ewes at 103-106 days gestation underwent amniotic insufflation with cold, dry (22 °C, 0-5% humidity, n = 6) or heated, humidified (40 °C, 95-100% humidity, n = 7) CO2 at 15 mmHg for 180 min. Twelve non-insufflated amniotic sacs acted as controls. Fetal membrane sections were collected after insufflation and analysed for molecular and histological markers of cell damage (caspase 3 and high mobility group box 1 [HMGB1]), inflammation (interleukin 1-alpha [IL1-alpha], IL8 and vascular cell adhesion molecule [VCAM]) and collagen weakening (matrix metalloprotease 9 [MMP9]). RESULTS Exposure to cold, dry CO2 increased mRNA levels of caspase 3, HMGB1, IL1-alpha, IL8, VCAM and MMP9 and increased amniotic epithelial caspase 3 and HMGB1 cell counts relative to controls. Exposure to heated, humidified CO2 also increased IL8 levels relative to controls however, HMGB1, IL1-alpha and VCAM mRNA levels and amniotic epithelial HMGB1 cell counts were significantly lower than the cold, dry group. DISCUSSION Amniotic insufflation with cold, dry CO2 damaged the amniotic epithelium and induced fetal membrane inflammation. Heated, humidified insufflation partially mitigated this damage and inflammation in sheep and may prove an important step in reducing the risk of iatrogenic PPROM following keyhole fetal surgery.
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Affiliation(s)
- Benjamin Amberg
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia; The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Philip DeKoninck
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia; The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia; Department of Obstetrics and Gynaecology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Aidan Kashyap
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia; The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Karyn Rodgers
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia; The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Valarie Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia; The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia; The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Kelly Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia; The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Ryan Hodges
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia; The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.
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Amberg BJ, Hodges RJ, Rodgers KA, Crossley KJ, Hooper SB, DeKoninck PLJ. Why Do the Fetal Membranes Rupture Early after Fetoscopy? A Review. Fetal Diagn Ther 2021; 48:493-503. [PMID: 34404043 DOI: 10.1159/000517151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/03/2021] [Indexed: 11/19/2022]
Abstract
Iatrogenic preterm premature rupture of the fetal membranes (iPPROM) remains the Achilles' heel of keyhole fetal surgery (fetoscopy) despite significant efforts in preclinical models to develop new therapies. This limited success is partially due to incomplete understanding why the fetal membranes rupture early after fetoscopy and notable differences in membrane physiology between humans and domestic species. In this review, we summarize aspects of fetoscopy that may contribute to iPPROM, the previous efforts to develop new therapies, and limitations of preclinical models commonly used in fetal membrane research.
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Affiliation(s)
- Benjamin J Amberg
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia, .,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia,
| | - Ryan J Hodges
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Karyn A Rodgers
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Kelly J Crossley
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Stuart B Hooper
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Philip L J DeKoninck
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Ibirogba ER, Shazly SA, Narang K, Wahood W, Trad ATA, Tsimis ME, Ruano R. Interventional resealing of preterm premature rupture of the membranes: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2021; 35:5978-5992. [PMID: 34392785 DOI: 10.1080/14767058.2021.1903858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To compare the effectiveness and outcomes of interventional resealing of membranes, "amniopatch" for spontaneous vs. iatrogenic preterm premature rupture of the membranes (sPPROM and iPPROM). METHODS We performed a systematic review of literature involving an electronic search of the following databases: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Scopus. An indirect meta-analysis was then performed to compare the obstetric, maternal, fetal, and neonatal outcomes of amniopatch between the sPPROM and iPPROM groups. RESULTS The mean gestational age (GA) at the time rupture was 17.8 ± 1.8 and 25.2 ± 3.8 weeks for iPPROM and sPPROM, respectively, p = .005. Mean GA at the time of amniopatch procedure was 19.2 ± 2.07 weeks for iPPROM and 23 ± 3.1 weeks of gestation for sPPROM, p = .023. The rates of fluid re-accumulation (sPPROM 26% and iPPROM 53%, p = .09) were comparable between the sPPROM and iPPROM groups. Neonatal outcomes except for the rate of IUFD were also comparable between the groups. The incidence of IUFD was significantly higher in the iPPROM group (ES: 24%; 95% CI: 8.00-44.0%; p < .001), compared to sPPROM (ES: 0%; 95% CI: 0.00-4.00%). Obstetric and maternal outcomes were comparable between the two groups. CONCLUSIONS Amniopatch appears to be a feasible and safe procedure for PPROM treatment. Further research is warranted to investigate the effectiveness of this procedure and establish a standardized criterion for the appropriate selection of patients that could benefit from this intervention.
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Affiliation(s)
- Eniola R Ibirogba
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Division, Mayo Clinic, Rochester, MN, USA.,Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Division, Spectrum Health/Michigan State University, Grand Rapids, MI, USA
| | - Sherif A Shazly
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Division, Mayo Clinic, Rochester, MN, USA
| | - Kavita Narang
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Division, Mayo Clinic, Rochester, MN, USA
| | - Waseem Wahood
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Ayssa Teles Abrao Trad
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Division, Mayo Clinic, Rochester, MN, USA
| | - Michael E Tsimis
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Division, Spectrum Health/Michigan State University, Grand Rapids, MI, USA
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Division, Mayo Clinic, Rochester, MN, USA
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30
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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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31
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Narang K, Ibirogba ER, Sangi-Haghpeykar H, Ruano R. Obstetric outcomes after fetal intervention – a single-center descriptive review. J Matern Fetal Neonatal Med 2021; 35:7102-7108. [DOI: 10.1080/14767058.2021.1943658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Kavita Narang
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Eniola R. Ibirogba
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Rodrigo Ruano
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
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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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Micheletti T, Eixarch E, Bennasar M, Torres X, Martinez-Crespo JM, Deprest J, Gratacos E. Risk Factors Associated with Preterm Prelabor Rupture of Membranes after Cord Occlusion in Monochorionic Diamniotic Twins. Fetal Diagn Ther 2021; 48:457-463. [PMID: 34130298 DOI: 10.1159/000516513] [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: 03/07/2021] [Accepted: 04/13/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Preterm prelabor rupture of membranes (PPROM) is a common complication after fetal surgeries. The aim of this study was to assess risk factors for and outcomes after PPROM following cord occlusion (CO) in monochorionic diamniotic (MCDA) pregnancies. METHODS This was a retrospective cohort study of 188 consecutive MCDA pregnancies treated by bipolar or laser CO, either primarily because of discordant malformation (dMF) or severe selective fetal growth restriction (sFGR), or secondarily when complete bichorionization was not possible in case of twin-to-twin transfusion syndrome (TTTS) or sFGR. Intentional septostomy was performed when needed. The procedure-related PPROM was defined as rupture of membranes <32 weeks' gestation (PROM <32 weeks). Selected pre-, intra-, and early postoperative variables were analyzed by univariate and binomial logistic regression to determine they are correlated to PROM <32 weeks after CO. RESULTS Between 2006 and 2017, 188 cases underwent CO. Diagnosis was TTTS in 28.2% (n = 53), severe sFGR in 49.5% (n = 93), and dMF in 22.3% (n = 42). PROM <32 weeks occurred in 21.3% (n = 40), resulting in worse perinatal outcomes, as preterm birth <32 weeks occurred in 80.7% (vs. 8.3%, p = 0.000), procedure-to-delivery interval was 47.5 days (vs. 125, p = 0.000), gestational age (GA) at birth 30.0 weeks (vs. 37.7 weeks, p = 0.000), and survival 65.0% (vs. 91.1%, p = 0.000). In univariate analysis, indication, anterior placenta, cervical length, GA at surgery, operation time, amniodistention and drainage fluid volumes, chorioamniotic membrane separation, and septostomy were selected as relevant factors to be included in the regression model. In a multivariate analysis, TTTS was the only factor associated to PROM <32 weeks (OR 3.5 CI 95% 1.5-7.9). CONCLUSIONS PROM <32 weeks after CO increases the risk of preterm delivery. In this cohort, the membrane rupture was more likely when CO was done in the context of TTTS.
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Affiliation(s)
- Talita Micheletti
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Elisenda Eixarch
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - Mar Bennasar
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ximena Torres
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Josep Maria Martinez-Crespo
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - Jan Deprest
- Department of Obstetrics & Gynaecology, Fetal Medicine Unit, UZ Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Eduard Gratacos
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain.,Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
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Jha P, Feldstein VA, Revzin MV, Katz DS, Moshiri M. Role of Imaging in Obstetric Interventions: Criteria, Considerations, and Complications. Radiographics 2021; 41:1243-1264. [PMID: 34115536 DOI: 10.1148/rg.2021200163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
US has an established role in the prenatal detection of congenital and developmental disorders. Many pregnant women undergo US at 18-20 weeks of gestation for assessment of fetal anatomy and detection of structural anomalies. With advances in fetoscopy and minimally invasive procedures, in utero fetal interventions can be offered to address some of the detected structural and physiologic fetal abnormalities. Most interventions are reserved for conditions that, if left untreated, often cause in utero death or a substantially compromised neonatal outcome. US is crucial for preprocedural evaluation and planning, real-time procedural guidance, and monitoring and assessment of postprocedural complications. Percutaneous needle-based interventions include in utero transfusion, thoracentesis and placement of a thoracoamniotic shunt, vesicocentesis and placement of a vesicoamniotic shunt, and aortic valvuloplasty. Fetoscopic interventions include myelomeningocele repair and tracheal balloon occlusion for congenital diaphragmatic hernia. In rare cases, open hysterotomy may be required for repair of a myelomeningocele or resection of a sacrococcygeal teratoma. Monochorionic twin pregnancies involve specific complications such as twin-twin transfusion syndrome, which is treated with fetoscopic laser ablation of vascular connections, and twin reversed arterial perfusion sequence, which is treated with radiofrequency ablation. Finally, when extended placental support is necessary at delivery for repair of congenital high airway obstruction or resection of lung masses, ex utero intrapartum treatment can be planned. Radiologists should be aware of the congenital anomalies that are amenable to in utero interventions and, when necessary, consider referral to centers where such treatments are offered. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ©RSNA, 2021.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Vickie A Feldstein
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Margarita V Revzin
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Douglas S Katz
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Mariam Moshiri
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
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35
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Kim R, Lee MY, Won HS, Kim JM, Lee YJ, Jeong BD, Kim HJ. Perinatal outcomes and factors affecting the survival rate of fetuses with twin-to-twin transfusion syndrome treated with fetoscopic laser coagulation: a single-center seven-year experience. J Matern Fetal Neonatal Med 2021; 35:5595-5606. [PMID: 33879028 DOI: 10.1080/14767058.2021.1888286] [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: 10/21/2022]
Abstract
OBJECTIVES This single-center study aimed to assess the perinatal outcomes and its associated factors in fetuses with twin-to-twin transfusion syndrome (TTTS) treated by fetoscopic laser coagulation (FLC). METHODS In this retrospective study, we included fetuses prenatally diagnosed with TTTS at Asan Medical Center, Seoul, Korea, between October 2011 and December 2018. All patients with TTTS stage II or higher and those with stage I TTTS coupled with symptomatic polyhydramnios or cardiac dysfunction were eligible for FLC. RESULTS A total of 172 cases of monochorionic diamniotic twins and one case of dichorionic triamniotic triplets were prenatally diagnosed with TTTS and treated with FLC. The median gestational ages (GAs) at diagnosis and FLC were 20.3 and 20.5 weeks, respectively. The median GA of survivors at delivery was 32.5 weeks. The overall at least one twin- and double-survival rates within 28 days after birth were 82.1% and 55.5%, respectively. The GAs at diagnosis and FLC, Quintero stage, inter-twin weight discordance, associated selective intrauterine growth restriction (sIUGR), procedure time, volume of amnioreduction, preterm prelabor rupture of membranes (PPROM) within one week after FLC, intraoperative intrauterine bleeding, and chorioamnionitis were significant predictive factors of perinatal death. Associated sIUGR, absent end-diastolic flow of umbilical artery, and abnormal cord insertion were significantly associated with donor demise in utero, whereas lower GA at diagnosis and FLC, smaller twins at FLC, pulsatile umbilical vein, and presence of mitral regurgitation were significantly associated with recipient demise in utero. Since the application of the Solomon technique, the survival rate has improved from 75.4% to 88.8%. The FLC before 17 weeks was associated with PPROM within one week after FLC and lower survival rate, whereas that after 24 weeks was associated with twin anemia-polycythemia sequence and higher survival rate. We reached a survival rate of 82% for at least one survival with only 12 procedures. CONCLUSIONS FLC is an effective treatment for TTTS. The learning curve reached the acceptable target faster than in previous studies. Several prenatal parameters are identified as predictive factors of fetal survival in TTTS treated with FLC.
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Affiliation(s)
- Rina Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jung-Min Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yoo-Jin Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ba-Da Jeong
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hwa-Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Republic of Korea
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Pajno C, D'Ambrosio V, D'Alisa R, DI Mascio D, Vena F, Corno S, Spiniello L, Martinino A, Manicone F, Muzii L, Brunelli R, Giancotti A. Fetoscopic laser ablation in twin-to-twin transfusion syndrome: tips for counselling. Minerva Obstet Gynecol 2021; 73:247-252. [PMID: 33851804 DOI: 10.23736/s2724-606x.20.04714-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Twin-to-twin transfusion syndrome (TTTS) is a serious complication that affects approximately 10-15% of monochorionic twin pregnancies. The most important role for the development of this condition is the presence of an unbalanced flow through the inter-twin vascular anastomoses. Depending on the number, type and direction of the connecting vessels, blood can be transfused disproportionately from one twin (the donor) to the other twin (the recipient). The diagnosis is defined prenatally by ultrasound and involves of two main criteria: the presence of a monochorionic diamniotic (MCDA) pregnancy; and the presence of oligohydramnios in the donor's sac- deep vertical pocket (DVP) 2 cm - and polyhydramnios in the recipient's sac- DVP>8 cm. Once diagnosed, TTTS is usually graded by using the Quintero staging system, that is composed by five stages, from oligohydramnios in the donor and polyhydramnios in the recipient twin to fetal demise in one or both twins. Photocoagulation of the anastomotic vessels, usually followed by equatorial dichorionization, it has currently become the most common fetoscopic operation today and is considered as the gold standard for stage II-IV TTTS. pPROM, chorioamniotic separation and iatrogenic preterm birth are among the most common complications of fetoscopic laser ablation, and the mean gestational age at delivery after laser procedure is about 31 weeks.
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Affiliation(s)
- Cristina Pajno
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Valentina D'Ambrosio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy -
| | - Rossella D'Alisa
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniele DI Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Flaminia Vena
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Sara Corno
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Spiniello
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Alessandro Martinino
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesca Manicone
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Brunelli
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
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Casella A, Moccia S, Paladini D, Frontoni E, De Momi E, Mattos LS. A shape-constraint adversarial framework with instance-normalized spatio-temporal features for inter-fetal membrane segmentation. Med Image Anal 2021; 70:102008. [PMID: 33647785 DOI: 10.1016/j.media.2021.102008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 12/17/2020] [Accepted: 02/16/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES During Twin-to-Twin Transfusion Syndrome (TTTS), abnormal vascular anastomoses in the monochorionic placenta can produce uneven blood flow between the fetuses. In the current practice, this syndrome is surgically treated by closing the abnormal connections using laser ablation. Surgeons commonly use the inter-fetal membrane as a reference. Limited field of view, low fetoscopic image quality and high inter-subject variability make the membrane identification a challenging task. However, currently available tools are not optimal for automatic membrane segmentation in fetoscopic videos, due to membrane texture homogeneity and high illumination variability. METHODS To tackle these challenges, we present a new deep-learning framework for inter-fetal membrane segmentation on in-vivo fetoscopic videos. The framework enhances existing architectures by (i) encoding a novel (instance-normalized) dense block, invariant to illumination changes, that extracts spatio-temporal features to enforce pixel connectivity in time, and (ii) relying on an adversarial training, which constrains macro appearance. RESULTS We performed a comprehensive validation using 20 different videos (2000 frames) from 20 different surgeries, achieving a mean Dice Similarity Coefficient of 0.8780±0.1383. CONCLUSIONS The proposed framework has great potential to positively impact the actual surgical practice for TTTS treatment, allowing the implementation of surgical guidance systems that can enhance context awareness and potentially lower the duration of the surgeries.
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Affiliation(s)
- Alessandro Casella
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy; Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy.
| | - Sara Moccia
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy; Department of Excellence in Robotics and AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Dario Paladini
- Department of Fetal and Perinatal Medicine, Istituto "Giannina Gaslini", Genoa, Italy
| | - Emanuele Frontoni
- Department of Information Engineering, Universitá Politecnica delle Marche, Ancona, Italy
| | - Elena De Momi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Leonard S Mattos
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy
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Forde B, Habli M. Unique Considerations: Preterm Prelabor Rupture of Membranes in the Setting of Fetal Surgery and Higher Order Pregnancies. Obstet Gynecol Clin North Am 2021; 47:653-669. [PMID: 33121651 DOI: 10.1016/j.ogc.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Two unique aspects of antenatal care occur in the setting of fetal surgery and multiple gestations. As fetal interventions increase, so do the number of cases of iatrogenic preterm prelabor rupture of membranes (PPROM). Because of the amniotic sac's inability to heal, the risk of PPROM after surgery is directly correlated with the number of interventions, the size of the defect, and the surgery performed. Higher order gestations also carry an increased risk of PPROM. This paper reviews the risks and management of PPROM in the setting of the various prenatal interventions as well as in the setting of multiple gestations.
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Affiliation(s)
- Braxton Forde
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Medical Sciences Building, Room 4555, 231 Albert Sabin Way, Cincinnati, OH 45267-0526, USA.
| | - Mounira Habli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, OH, USA; Fetal Care Center of Cincinnati, Cincinnati Children's Hospital, Cincinnati, OH, USA
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Micheletti T, Eixarch E, Berdun S, Febas G, Mazza E, Borrós S, Gratacos E. Ex-vivo mechanical sealing properties and toxicity of a bioadhesive patch as sealing system for fetal membrane iatrogenic defects. Sci Rep 2020; 10:18608. [PMID: 33122661 PMCID: PMC7596722 DOI: 10.1038/s41598-020-75242-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/28/2020] [Indexed: 12/25/2022] Open
Abstract
Preterm prelabor rupture of membranes (PPROM) is the most frequent complication of fetal surgery. Strategies to seal the membrane defect created by fetoscopy aiming to reduce the occurrence of PPROM have been attempted with little success. The objective of this study was to evaluate the ex-vivo mechanical sealing properties and toxicity of four different bioadhesives integrated in semi-rigid patches for fetal membranes. We performed and ex-vivo study using term human fetal membranes to compare the four integrated patches composed of silicone or silicone-polyurethane combined with dopaminated-hyaluronic acid or hydroxypropyl methylcellulose (HPMC). For mechanical sealing properties, membranes were mounted in a multiaxial inflation device with saline, perforated and sealed with the 4 combinations. We measured bursting pressure and maximum pressure free of leakage (n = 8). For toxicity, an organ culture of membranes sealed with the patches was used to measure pyknotic index (PI) and lactate dehydrogenase (LDH) concentration (n = 5). All bioadhesives achieved appropriate bursting pressures, but only HPMC forms achieved high maximum pressures free of leakage. Concerning toxicity, bioadhesives showed low PI and LDH levels, suggesting no cell toxicity. We conclude that a semi-rigid patch coated with HPMC achieved ex-vivo sealing of iatrogenic defects in fetal membranes with no signs of cell toxicity. These results warrant further research addressing long-term adhesiveness and feasibility as a sealing system for fetoscopy.
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Affiliation(s)
- Talita Micheletti
- BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Building Helios 2, Sabino Arana Street, 1, 08028, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Elisenda Eixarch
- BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Building Helios 2, Sabino Arana Street, 1, 08028, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. .,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain.
| | - Sergio Berdun
- BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Building Helios 2, Sabino Arana Street, 1, 08028, Barcelona, Spain
| | - Germán Febas
- Grup d'Enginyeria de Materials (GEMAT), Institut Químic de Sarrià, Universitat Ramon Llull, Barcelona, Spain
| | - Edoardo Mazza
- Swiss Federal Institute of Technology, Zurich, Switzerland.,Empa, Materials Science and Technology, Dübendorf, Switzerland
| | - Salvador Borrós
- Grup d'Enginyeria de Materials (GEMAT), Institut Químic de Sarrià, Universitat Ramon Llull, Barcelona, Spain
| | - Eduard Gratacos
- BCNatal
- Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Building Helios 2, Sabino Arana Street, 1, 08028, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain.,Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
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Valenzuela I, van der Merwe J, De Catte L, Devlieger R, Deprest J, Lewi L. Foetal therapies and their influence on preterm birth. Semin Immunopathol 2020; 42:501-514. [PMID: 32785752 DOI: 10.1007/s00281-020-00811-2] [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: 06/29/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
Foetal therapy aims to improve perinatal survival or to prevent severe long-term handicap. Foetal medicine opens a new territory by treating the foetus as a patient. The mother has nothing to gain in terms of health benefits, yet she is inherently also undergoing treatment. In utero foetal interventions can be divided into ultrasound-guided minimally invasive procedures, fetoscopic procedures and open hysterotomy procedures, which carry an inherent risk of ruptured membranes and preterm birth. In this review, we summarise the conditions that may benefit from foetal therapy and review the current therapies on offer, each with their associated risk of ruptured membrane and preterm birth. We also look into some risk limiting and preventative strategies to mitigate these complications.
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Affiliation(s)
- Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Liesbeth Lewi
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium. .,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.
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Roche ET. Minimally Invasive Delivery of Tissue Engineered Heart Valves to the Pulmonary Annulus. JACC Basic Transl Sci 2020; 5:829-830. [PMID: 32876644 PMCID: PMC7452324 DOI: 10.1016/j.jacbts.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Ellen T. Roche
- Institute for Medical Engineering and Science and Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts
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Fetal surgery and neonatal ICU admissions. Curr Opin Pediatr 2020; 32:619-624. [PMID: 32692057 DOI: 10.1097/mop.0000000000000900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Fetal intervention is a dynamic field with wide-reaching implications on neonatal ICU admissions and the care of neonates with congenital anomalies. The aim of this review is to summarize recent advancements in fetal surgery and provide a broad understanding of how these topics interrelate. RECENT FINDINGS Advancements in prenatal imaging and diagnosis have dramatically expanded the indications for fetal intervention. Most recently, there has been a large focus on evaluating minimally invasive strategies of fetal intervention, notably fetoscopic surgery, and the use of stem cells for fetal treatment of myelomeningocele. With the advances in fetal intervention, neonatal care has adapted to the needs of these various patients to help improve the outcomes of this unique population. SUMMARY Fetal intevention relies on a multidisciplinary team from prenatal imaging and maternal fetal medicine to fetal surgery and postnatal subspecialty care, particuarly neonatology. Fetal intervention uniquely involves two patients, both mother and fetus, and therefore, has unique risks and considerations, particularly in the advancement of the field. As the number of conditions suited to fetal intervention grows, awareness and advancement of the postnatal intensive care necessary for these patients are essential.
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Jha P, Morgan TA, Kennedy A. US Evaluation of Twin Pregnancies: Importance of Chorionicity and Amnionicity. Radiographics 2020; 39:2146-2166. [PMID: 31697621 DOI: 10.1148/rg.2019190042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The twin birth rate is increasing in the United States. Twin pregnancies can be dichorionic or monochorionic (MC). MC twins account for 20% of twin pregnancies but 30% of all-cause pregnancy-related complications. This article describes the imaging findings that establish chorionicity and amnionicity. Ideally, these are established in the first trimester when accuracy is high, but they can also be determined later in pregnancy. Complications unique to MC twin pregnancy include twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, and selective fetal growth restriction. The US features, staging systems, and management of these complications are reviewed, and the consequences of MC twin demise are illustrated. Ongoing surveillance for these conditions starts at 16 weeks gestation. Monoamniotic (MA) twins are a small subset of MC twins. In addition to all of the MC complications, specific MA complications include cord entanglement and conjoined twinning. Radiologists must be able to determine chorionicity and amnionicity and should be aware of potential complications so that patients may be referred to appropriate regional specialized centers. A proposed algorithm for referral to specialized fetal treatment centers is outlined. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Tara A Morgan
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
| | - Anne Kennedy
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., T.A.M.); and Department of Radiology and Imaging Sciences, University of Utah Medical Center, Salt Lake City, Utah (A.K.)
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Shiro M, Yamamoto R, Ichikawa C, Nakanishi K, Kawaguchi H, Hayashi S, Takeuchi M, Ishii K. Placental histopathological features of fetoscopic laser photocoagulation for monoaminotic diamniotic twin pregnancies. Placenta 2020; 100:159-163. [PMID: 32980047 DOI: 10.1016/j.placenta.2020.07.002] [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: 03/16/2020] [Revised: 06/08/2020] [Accepted: 07/06/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION This study aimed to compare the histopathological placental features of monochorionic diamniotic (MCDA) twins who did and did not undergo fetoscopic laser photocoagulation (FLP). METHODS This was a retrospective single-institution cohort study on MCDA twins who underwent FLP between October 2010 and December 2018. The control group included MCDA twins who did not undergo FLP and were delivered during the same period in the institute. The incidence of chorioamnionitis (CAM), funisitis, and other pathological findings was compared between the FLP and control groups after matching by gestational age at delivery. RESULTS In total, 292 MCDA pregnant women who underwent FLP and 356 controls gave birth during the study period. After matching the two groups in the ratio 1:1 by gestational age at delivery, each group comprised 194 subjects. The incidence of histological CAM with Blanc association (stage I, 6.2% vs. 3.1%, crude odds ratio (cOR) = 3.1, P = 0.052; stage II, 7.2% vs. 5.7%, cOR = 1.6, P = 0.30; stage III, 2.1% vs. 2.6%, cOR = 0.66, P = 0.52) and funisitis (artery, 5.2% vs. 3.6%, cOR = 1.3, P = 0.63; vein 7.2% vs. 4.1%, cOR = 1.6, P = 0.29) was not statistically significant difference between the FLP and control groups. The FLP group demonstrated a higher incidence of partial placental infarction than the control group (10.3% vs. 3.1%, cOR = 4.3, P = 0.004, adjusted OR = 2.8, P = 0.031). DISCUSSION FLP did not appear to increase the incidence of histological CAM or funisitis in subjects matched by gestational age at delivery. The FLP group demonstrated a higher incidence of partial placental infarction than the control group.
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Affiliation(s)
- Michihisa Shiro
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Chihiro Ichikawa
- Department of Pathology, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Kentaro Nakanishi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Haruna Kawaguchi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Makoto Takeuchi
- Department of Pathology, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, 840, Murodo, Izumi, Osaka, 594-1101, Japan.
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Abstract
Congenital diaphragmatic hernia (CDH) remains one of the most elusive birth defects to treat. Despite greater knowledge of disease and advances in technology, approximately one-third of CDH children born today still die. Consequently, clinicians and researchers have struggled to find the optimal treatment strategies for CDH. Without further innovations in postnatal treatment, many have focused an antenatal approach to improve pulmonary function. Fetoscopic Endoluminal Tracheal Occlusion (FETO) for CDH has evolved to the bedside after decades of research. While still under clinical investigation, FETO remains a promising adjunct to the treatment of CDH.
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Affiliation(s)
- KuoJen Tsao
- Departments of Pediatric Surgery and Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States.
| | - Anthony Johnson
- Departments Obstetrics, Gynecology & Reproductive Sciences and Pediatric Surgery, Division of Maternal-Fetal Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX, United States
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46
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Spruijt MS, Lopriore E, J Steggerda S, Slaghekke F, Van Klink JMM. Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond. Expert Rev Hematol 2020; 13:259-267. [PMID: 31971028 DOI: 10.1080/17474086.2020.1720643] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Twin-twin transfusion syndrome (TTTS) is a devastating complication of monochorionic twin pregnancy and remains a major challenge for worldwide fetal medicine specialists. In TTTS, intertwin transfusion through vascular anastomoses in the shared placenta leads to severe hemodynamic imbalance. This review summarizes the current knowledge of TTTS.Areas covered: The most recent insights concerning the management of TTTS, as well as fetal and neonatal complications are described. Relevant articles were selected based on a Pubmed search using the keywords below. Understanding of the underlying pathophysiology has improved greatly as a result of placental injection studies. Advancements in antenatal management have led to increased perinatal survival and a decreased incidence of neonatal complications, including brain injury and neurodevelopmental impairment.Expert opinion: Further opportunities for improvement comprise technological innovations in laser procedures and the prevention of preterm rupture of membranes with subsequent prematurity. A noninvasive treatment such as high-intensity focused ultrasound (HIFU) seems to hold promise for the future treatment of TTTS. Fetal MRI studies are important to improve our understanding of fetal brain injury and should relate their findings to long-term neurodevelopment. International collaboration and centralization of care are of paramount importance to ensure the best care for our patients.
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Affiliation(s)
- Marjolijn S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J Steggerda
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanine M M Van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Bergh EP, Mann LK, Jain RR, Donepudi R, Moise KJ, Johnson A, Papanna R. Effect of intra-amniotic fluid pressure from polyhydramnios on cervical length in patients with twin-twin transfusion syndrome undergoing fetoscopic laser surgery. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:774-779. [PMID: 30693576 DOI: 10.1002/uog.20228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To determine the relationship between intra-amniotic pressure and cervical length (CL) in patients with twin-twin transfusion syndrome (TTTS) undergoing fetoscopic laser photocoagulation (FLP), and to identify pre- or intraoperative factors associated with increased intra-amniotic pressure in this population. METHODS This was a prospective cohort study of patients undergoing FLP for TTTS. Exclusion criteria were triplet or higher-order gestation and prior cervical cerclage, amnioreduction or FLP procedure. CL was assessed using preprocedure transvaginal ultrasound. Intra-amniotic pressure measurements were obtained on initial placement of the trocar into the amniotic cavity, using a direct hydrostatic pressure gauge. The relationship between intra-amniotic pressure and CL was assessed using multivariate linear regression analysis, including relevant preoperative and intraoperative variables. RESULTS In total, 283 pregnancies met the inclusion criteria. Quintero stage of TTTS was I in 33 pregnancies, II in 88, III in 150 and IV in 12. Mean gestational age (GA) at FLP was 20.7 ± 3 weeks. Mean intra-amniotic pressure was 23.1 ± 9 mmHg. On unadjusted linear regression analysis, there was no significant association between intra-amniotic pressure and preoperative CL (P = 0.24) or GA at delivery (P = 0.22). On multivariate analysis, the factors associated significantly with intra-amniotic pressure were: number of prior term deliveries (P = 0.03), recipient maximum vertical pocket (P < 0.0001), Quintero stage IV (P = 0.01) and type of anesthesia (sedation vs general anesthesia; P = 0.01). CONCLUSION In pregnancies with TTTS, intra-amniotic pressure is not associated with CL or GA at delivery. This novel finding suggests that cervical shortening in this population is not mechanically driven. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E P Bergh
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - L K Mann
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - R R Jain
- Department of Anesthesiology, McGovern Medical School, Houston, TX, USA
| | - R Donepudi
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - K J Moise
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - A Johnson
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
| | - R Papanna
- The Texas Fetal Center, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Medical School, Houston, TX, USA
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Legrand J, Javaux A, Ourak M, Wenmakers D, Vercauteren T, Deprest J, Ourselin S, Denis K, Vander Poorten E. Handheld Active Add-On Control Unit for a Cable-Driven Flexible Endoscope. Front Robot AI 2019; 6:87. [PMID: 33501102 PMCID: PMC7805766 DOI: 10.3389/frobt.2019.00087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/29/2019] [Indexed: 11/13/2022] Open
Abstract
The instruments currently used by surgeons for in utero treatment of the twin-to-twin transfusion syndrome (TTTS) are rigid or semi-rigid. Their poor dexterity makes this surgical intervention risky and the surgeon's work very complex. This paper proposes the design, assembly and quantitative evaluation of an add-on system intended to be placed on a commercialized cable-driven flexible endoscope. The add-on system is lightweight and easily exchangeable thanks to the McKibben muscle actuators embedded in its system. The combination of the flexible endoscope and the new add-on unit results in an easy controllable flexible instrument with great potential use in TTTS treatment, and especially for regions that are hard to reach with conventional instruments. The fetoscope has a precision of 7.4% over its entire bending range and allows to decrease the maximum planar force on the body wall of 6.15% compared to the original endoscope. The add-on control system also allows a more stable and precise actuation of the endoscope flexible tip.
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Affiliation(s)
- Julie Legrand
- Laboratory of Robot-Assisted Surgery, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Allan Javaux
- Laboratory of Robot-Assisted Surgery, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Mouloud Ourak
- Laboratory of Robot-Assisted Surgery, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Dirk Wenmakers
- Laboratory of Robot-Assisted Surgery, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Tom Vercauteren
- Department of Imaging and Biomedical Engineering, King's College London, London, United Kingdom
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Sebastien Ourselin
- Department of Imaging and Biomedical Engineering, King's College London, London, United Kingdom
| | - Kathleen Denis
- Laboratory of Robot-Assisted Surgery, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Emmanuel Vander Poorten
- Laboratory of Robot-Assisted Surgery, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
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Loh M, Bhatia A, Tan KL, Thia E, Yeo GSH. Outcomes following selective fetoscopic laser ablation for twin-to-twin transfusion syndrome: a single-centre experience. Singapore Med J 2019; 61:523-531. [PMID: 31489429 DOI: 10.11622/smedj.2019107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Fetoscopic laser photocoagulation (FLP), a treatment option for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies, is currently the treatment of choice at our centre. We previously reported on our experience of FLP from June 2011 to March 2014. This paper audits our fetal surgery performance since then. METHODS 15 consecutive patients who underwent FLP for Stage II-III TTTS before 26 weeks of gestation from June 2011 to January 2017 were retrospectively reviewed, consisting of five cases from our initial experience and ten subsequent cases. Perioperative, perinatal and neonatal outcomes were analysed. RESULTS Of 15 pregnancies, 10 (66.7%) and 5 (33.3%) were for Stage II and III TTTS respectively, with FLP performed at an earlier Quintero stage in the later cohort. Overall mean gestational ages at presentation, laser and delivery were comparable between the cohorts at 19.7 (15.4-24.3) weeks, 20.3 (16.3-25.0) weeks and 31.2 (27.6-37.0) weeks, respectively. 2 (13.3%) cases had intra-amniotic bleeding and 1 (6.7%) had iatrogenic septostomy. 1 (6.7%) case had persistent TTTS requiring repeat FLP, and another (6.7%) had preterm premature rupture of membranes at seven weeks post procedure. The overall perinatal survival rate was 21 (75.0%) out of 28 infants. One mother underwent termination of pregnancy for social reasons at 1.4 weeks post procedure. Double survival occurred in 8 (57.1%) out of 14 pregnancies, while 13 (92.9%) had at least one survivor. CONCLUSION FLP requires a highly specialised team and tertiary neonatal facility. Continual training improves maternal and perinatal outcomes, ensuring comparable standards with international centres.
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Affiliation(s)
- Michelle Loh
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | - Anju Bhatia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Kai Lit Tan
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Edwin Thia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - George Seow Heong Yeo
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
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50
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Abstract
Fetal surgery and fetal therapy involve surgical interventions on the fetus in utero to correct or ameliorate congenital abnormalities and give a developing fetus the best chance at a healthy life. Historical use of biomaterials in fetal surgery has been limited, and most biomaterials used in fetal surgeries today were originally developed for adult or pediatric patients. However, as the field of fetal surgery moves from open surgeries to minimally invasive procedures, many opportunities exist for innovative biomaterials engineers to create materials designed specifically for the unique challenges and opportunities of maternal-fetal surgery. Here, we review biomaterials currently used in clinical fetal surgery as well as promising biomaterials in development for eventual clinical translation. We also highlight unmet challenges in fetal surgery that could particularly benefit from novel biomaterials, including fetal membrane sealing and minimally invasive myelomeningocele defect repair. Finally, we conclude with a discussion of the underdeveloped fetal immune system and opportunities for exploitation with novel immunomodulating biomaterials.
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Affiliation(s)
- Sally M Winkler
- Department of Bioengineering, University of California, Berkeley, CA, USA. and University of California, Berkeley-University of California, San Francisco Graduate Program in Bioengineering, Berkeley, CA, USA
| | - Michael R Harrison
- Division of Pediatric Surgery, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Phillip B Messersmith
- Department of Bioengineering, University of California, Berkeley, CA, USA. and Department of Materials Science and Engineering, University of California, Berkeley, CA, USA and Materials Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
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