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Montaguti E, Gesuete V, Perolo A, Balducci A, Fiorentini M, Donti A, Pilu G. A case of massive fetal cardiac rhabdomyoma: ultrasound features and management. J Matern Fetal Neonatal Med 2023; 36:2197099. [PMID: 37031967 DOI: 10.1080/14767058.2023.2197099] [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: 04/11/2023]
Abstract
We report the case of a massive fetal cardiac rhabdomyoma recently occurred at our clinic. A woman at 23 weeks of gestational age was referred to our center for a fetal cardiac echogenic mass of 26 mm detected at the second-trimester screening ultrasound. During pregnancy, though, the mass progressively increased its dimensions until reaching 48 mm in diameter at 37 weeks of gestation. Fetal echoencephalography and brain magnetic resonance did not show any further fetal anomalies, but molecular genetic testing at amniocentesis revealed a heterozygotic missense variant of gene TSC2 associated with Tuberous Sclerosis. The mass was therefore most likely preferable to a single large rhabdomyoma of gradually increasing dimensions. The baby was delivered at term with a cesarean section. Because of the rhabdomyoma remarkable size and newborn ECG electrical alterations, postnatal therapies with Flecainide and Everolimus were started. Everolimus treatment led to a significant and progressive reduction in the cardiac mass volume. This case, therefore, shows the efficacy of what seems to be a promising treatment in pediatric patients with large rhabdomyomas.Learning points:Rhabdomyomas may present with different features: most often they appear as multiple masses along the interventricular sept, but they may also appear as a single large thoracic mass.When a rhabdomyoma is suspected, genetic counseling is recommended.Both before and after birth, a multidisciplinary approach is useful to choose the appropriate therapy for the newborn.mTOR inhibitors therapies look like promising therapeutic approaches to stimulate the involution of rhabdomyomas.
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Affiliation(s)
- Elisa Montaguti
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna Italy
| | - Valentina Gesuete
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna Italy
| | - Antonella Perolo
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna Italy
| | - Anna Balducci
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna Italy
| | - Marta Fiorentini
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna Italy
| | - Andrea Donti
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna Italy
| | - Gianluigi Pilu
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna Italy
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Eticha TG, Ararso R, Sultan S, Terefe K, Berhe SW, Tsega T, Abebe Y, Baye C. Isolated Asymptomatic Fetal Intracardiac Mass: A Case of Rhabdomyoma. Int Med Case Rep J 2023; 16:97-102. [PMID: 36880053 PMCID: PMC9985386 DOI: 10.2147/imcrj.s402663] [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: 01/11/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Introduction Fetal cardiac rhabdomyoma is one of the rare benign cardiac masses which is commonly associated with the tuberous sclerosis complex (TSC). Though mostly fetal cardiac rhabdomyoma is asymptomatic it may lead to life-threatening conditions like outflow obstruction, arrhythmias, hydrops fetalis, or sudden fetal death. Case Report We are reporting an isolated, asymptomatic fetal intra-cardiac mass (rhabdomyoma) that was discovered at 32 weeks of gestation and was followed as an outpatient until 39 weeks plus one day, at which point a cesarean section was performed. After delivery, the child underwent evaluations at the 1st day, 7th day, 30th day, 7th month, and 12th month of age. Following a checkup, the child's anthropometric and neurobehavioral growth were both healthy. Except for the tumor, which was neither growing nor shrinking in size, none of the clinical diagnostic criteria for tuberous sclerosis complex were met for this child up to the age of one year. Conclusion The most common primary benign fetal cardiac tumor is cardiac rhabdomyoma, which is usually associated with tuberous sclerosis. In developing nations where it is challenging to obtain MRIs and genetic studies, and in a similar patient like ours with no other features of tuberous sclerosis, the child needs to be followed in the future, bearing in mind that tuberous sclerosis manifestations will continue to develop over a patient's lifetime.
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Affiliation(s)
- Tadesse Gure Eticha
- Department of Obstetrics and Gynecology, Haramaya University, Harar, Ethiopia
| | - Roba Ararso
- Department of Obstetrics and Gynecology, Haramaya University, Harar, Ethiopia
| | - Semir Sultan
- Department of Obstetrics and Gynecology, Haramaya University, Harar, Ethiopia
| | - Kiros Terefe
- Department of Obstetrics and Gynecology, University of Gondar, Gondar, Ethiopia
| | | | - Temesgen Tsega
- Department of Pediatrics and Child Health, Saint Paul Millennium Medical College, Addis Ababa, Ethiopia
| | - Yeshiwas Abebe
- Department of Obstetrics and Gynecology, University of Gondar, Gondar, Ethiopia
| | - Chernet Baye
- Department of Obstetrics and Gynecology, University of Gondar, Gondar, Ethiopia
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Hurtado-Sierra D, Ramos Garzón JX, Rojas LZ, Fernández-Gómez O, Manrique-Rincón F. Case report: Accelerated regression of giant cardiac rhabdomyomas in neonates with low dose everolimus. Front Pediatr 2023; 11:1109646. [PMID: 36873633 PMCID: PMC9975344 DOI: 10.3389/fped.2023.1109646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/23/2023] [Indexed: 02/17/2023] Open
Abstract
Cardiac rhabdomyoma (CRHM) is the principal cardiac tumor in children and is most often associated with tuberous sclerosis complex (TSC). Mutations in the TSC1 and TSC2 genes cause the overactivation of the mammalian Target of Rapamycin (mTOR). This protein family is responsible for abnormal cell proliferation leading to the formation of CRHMs and hamartomas in other organs. Despite the tendency for spontaneous regression, some CRHMs can cause heart failure and intractable arrhythmias, requiring surgical resection. In recent years, the use of everolimus and sirolimus (mTOR inhibitors) in the treatment of CRHMs has been reported. We report two cases of neonates with giant rhabdomyomas, with hemodynamic repercussions treated with low-dose everolimus (4.5 mg/m2/week). In both cases, we obtained an approximate decrease of 50% in the total area of the mass after three weeks of treatment. Despite rebound growth after stopping the drug, we were able to evidence that the use of low doses of everolimus immediately after birth is effective and safe in the treatment of giant CRHMs, avoiding surgical resection of the tumor and associated morbidity and mortality.
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Affiliation(s)
- Daniel Hurtado-Sierra
- Pediatric Cardiology Unit, Instituto del Corazón de Bucaramanga, Bucaramanga, Colombia
| | | | - Lyda Z Rojas
- Research Center, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Oscar Fernández-Gómez
- Pediatric Cardiology Unit, Instituto del Corazón de Bucaramanga, Bucaramanga, Colombia
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Grgat D, Dilber D, Hrabak Paar M. Common benign primary pediatric cardiac tumors: a primer for radiologists. Jpn J Radiol 2022; 41:477-487. [PMID: 36495370 DOI: 10.1007/s11604-022-01371-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
Cardiac tumors are neoplasms arising from or located in the heart or the pericardium. Although rare, primary cardiac tumors in children require an accurate and timely diagnosis. Most pediatric primary cardiac tumors are benign (around 90%). Echocardiography is the first imaging modality used due to its availability, noninvasiveness, inexpensiveness, and absence of ionizing radiation. Computed tomography (CT) and magnetic resonance imaging (MRI) offer better soft tissue visualization as well as better visualization of extracardiac structures. A great advantage of MRI is the possibility of measuring cardiac function and blood flow, which can be important for obstructing cardiac tumors. In this article, we will offer a brief review of clinical, echocardiographic, CT, and MRI features of cardiac rhabdomyomas, fibromas, teratomas, and lipomas providing their differential diagnosis.
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Affiliation(s)
- Dora Grgat
- Institute for Emergency Medicine of Zagreb County, Velika Gorica, Croatia
| | - Daniel Dilber
- School of Medicine, Department of Pediatrics, University of Zagreb, University Hospital Center Zagreb, Zagreb, Croatia
| | - Maja Hrabak Paar
- School of Medicine, Department of Diagnostic and Interventional Radiology, University of Zagreb, University Hospital Center Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia.
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The Genetics and Diagnosis of Pediatric Neurocutaneous Disorders: Neurofibromatosis and Tuberous Sclerosis Complex. Clin Dermatol 2022; 40:374-382. [PMID: 35248688 DOI: 10.1016/j.clindermatol.2022.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Neurofibromatosis (NF) and tuberous sclerosis complex (TSC) are the two most common neurocutaneous disorders, both transmitted as autosomal dominant or, in the case of NF, also as a mosaic condition. The causative genetic mutations in these neurocutaneous disorders can lead to benign skin changes or uninhibited growth and proliferation in multiple organ systems due to the loss of tumor suppression in mitogen-activated protein kinase and mammalian target of rapamycin signaling pathways. Common clinical features in NF include pigmented lesions, known as café au lait patches, neurofibromas, intertriginous freckles (Crowe's sign), and benign fibrous growths, such as hamartomas in multiple organ systems. Common clinical features in TSC include hypopigmented macules, known as ash leaf spots, in addition to neurologic sequelae, such as autism, seizures, and developmental delays. Advances in genetic sequencing technologies have allowed an exponential expansion in the understanding of NF and TSC. Consensus criteria have been established for both diagnoses that can be confirmed in most cases through gene testing. Once diagnosed, the clinical and diagnostic value of disease-specific surveillance include early identification of benign and malignant tumors. Genetic counseling is important for informed reproductive decision-making for patients and at-risk family members. The improvement in understanding of pathways of pathogenic disease development and oncogenesis in both conditions have produced a new series of therapeutic options that can be used to control seizures and tumor growth. Tremendous advances in life expectancy and quality of life are now a reality due to early introduction of seizure control and novel medications. While we lack cures, early institution of interventions, such as seizure control in tuberous sclerosis, appears to be disease-modifying and holds immense promise to offer patients better lives.
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Sugalska M, Tomik A, Jóźwiak S, Werner B. Treatment of Cardiac Rhabdomyomas with mTOR Inhibitors in Children with Tuberous Sclerosis Complex-A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4907. [PMID: 34062963 PMCID: PMC8124908 DOI: 10.3390/ijerph18094907] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cardiac rhabdomyomas (CRs) are the earliest sign of tuberous sclerosis complex (TSC). Most of them spontaneously regress after birth. However, multiple and/or large tumors may result in heart failure or cardiac arrhythmia. Recently, the attempts to treat CRs with mTOR inhibitors (mTORi) have been undertaken. We reviewed the current data regarding the effectiveness and safety of mTORi in the treatment of CRs in children with TSC. METHODS The review was conducted according to the PRISMA guidelines. Medline, Embase, Cochrane library, and ClinicalTrial.gov databases were searched for original, full-text articles reporting the use of mTORi (everolimus or sirolimus) in the treatment of CRs in children with TSC. RESULTS Thirty articles describing 41 patients were identified (mostly case reports, no randomized or large cohort studies). Thirty-three children (80.5%) had symptomatic CRs and mTORi therapy resulted in clinical improvement in 30 of them (90.9%). CRs size reduction was reported in 95.1%. Some CRs regrew after mTORi withdrawal but usually without clinical symptoms recurrence. The observed side effects were mostly mild. CONCLUSIONS mTORi may be considered as a temporary and safe treatment for symptomatic CRs in children with TSC, especially in high-risk or inoperable tumors. However, high-quality, randomized trials are still lacking.
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Affiliation(s)
- Monika Sugalska
- Department of Pediatric Neurology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Anna Tomik
- Department of Pediatric Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.T.); (B.W.)
| | - Sergiusz Jóźwiak
- Department of Pediatric Neurology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Bożena Werner
- Department of Pediatric Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.T.); (B.W.)
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Nespoli LF, Albani E, Corti C, Spaccini L, Alfei E, Daniele I, Zuccotti GV, Lista G, Calcaterra V, Mannarino S. Efficacy of Everolimus Low-Dose Treatment for Cardiac Rhabdomyomas in Neonatal Tuberous Sclerosis: Case Report and Literature Review. Pediatr Rep 2021; 13:104-112. [PMID: 33804320 PMCID: PMC7931111 DOI: 10.3390/pediatric13010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 01/27/2021] [Accepted: 02/25/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Cardiac rhabdomyomas (CRs) are the most common cardiac tumors in newborns. Approximately 80-90% of cases are associated with tuberous sclerosis complex (TSC). In selective cases, Everolimus has resulted in a remarkable tumoral regression effect in children with TS. The optimal dosage for neonates is still unknown. Case presentation: We describe the use of Everolimus in a neonate with multiple biventricular CRs, causing subaortic obstruction, in which a low-dose treatment (0.1 mg/die), in an effort to maintain serum trough levels of 3-7 ng/mL, was successfully used off-label, without adverse effects. Conclusions: We showed that a low-dose Everolimus regimen may be an effective and safe treatment for CR regression in TS neonates, when the minimum therapeutic range was maintained.
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Affiliation(s)
- Luisa Federica Nespoli
- Pediatric Cardiology Unit, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy; (L.F.N.); (C.C.)
| | - Elena Albani
- Department of Pediatrics, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy; (E.A.); (G.V.Z.); (V.C.)
| | - Carla Corti
- Pediatric Cardiology Unit, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy; (L.F.N.); (C.C.)
| | - Luigina Spaccini
- Clinical Genetics Unit, Department of Obstetrics and Gynecology, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy;
| | - Enrico Alfei
- Pediatric Neurology Unit, “V. Buzzi” Children’s Hospital, Milano, 20154 Milano, Italy;
| | - Irene Daniele
- Neonatal Pathology and Neonatal Intensive Care Unit, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy; (I.D.); (G.L.)
| | - Gian Vincenzo Zuccotti
- Department of Pediatrics, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy; (E.A.); (G.V.Z.); (V.C.)
- Department of Biomedical and Clinical Science “L. Sacco”, University of Milano, 20157 Milano, Italy
| | - Gianluca Lista
- Neonatal Pathology and Neonatal Intensive Care Unit, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy; (I.D.); (G.L.)
| | - Valeria Calcaterra
- Department of Pediatrics, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy; (E.A.); (G.V.Z.); (V.C.)
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Savina Mannarino
- Pediatric Cardiology Unit, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy; (L.F.N.); (C.C.)
- Correspondence:
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8
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Silva-Sánchez MP, Alvarado-Socarras JL, Castro-Monsalve J, Meneses KM, Santiago J, Prada CE. Everolimus for severe arrhythmias in tuberous sclerosis complex related cardiac rhabdomyomas. Am J Med Genet A 2021; 185:1525-1531. [PMID: 33590972 DOI: 10.1002/ajmg.a.62120] [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: 11/21/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 01/19/2023]
Abstract
Intracardiac rhabdomyoma is the most common primary cardiac tumor in children. Most cases are associated with tuberous sclerosis complex (TSC). Most of them are asymptomatic in the neonate and do not require treatment. However, some develop cardiovascular symptoms such as arrhythmias, heart failure, and ventricular inflow/outflow tract obstruction in the neonatal period with early death. Many of these tumors are not candidates for surgical resection and medical management is limited. Treatment with mammalian target of rapamycin (mTOR) inhibitor is currently approved for the management of central nervous tumors and angiomyolipoma in TSC. Two patients with malignant arrhythmias related to nonsurgical multiple rhabdomyomas associated with TSC who were successfully treated with an mTOR inhibitor were described. Everolimus therapy showed significant regression of rhabdomyomas with rapid improvement of arrhythmias and heart failure prior to tumor shrinkage.
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Affiliation(s)
| | | | | | | | - Justo Santiago
- Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Carlos E Prada
- Fundación Cardiovascular de Colombia, Floridablanca, Colombia.,Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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9
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Moavero R, Curatolo P. Long-term use of mTORC1 inhibitors in tuberous sclerosis complex associated neurological aspects. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1789862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Rome, Italy
- Child Neurology Unit, Neuroscience and Neurorehabilitation Department, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Rome, Italy
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10
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Literature review of international mammalian target of rapamycin inhibitor use in the non-surgical management of haemodynamically significant cardiac rhabdomyomas. Cardiol Young 2020; 30:923-933. [PMID: 32524929 DOI: 10.1017/s104795112000147x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Cardiac rhabdomyomas represent the most common primary paediatric cardiac tumour and typically regresses over time in the majority of patients. Among those who are symptomatic, surgical resection or catheterisation procedures have traditionally proven effective. More recently, those invasive or challenging tumours have been successfully treated with mammalian target of rapamycin inhibitors, typically everolimus and sirolimus. This review outlines the current medical literature of the state-of-the-art medical treatment of these tumours. We specifically focus on dosing regimens, duration of therapy, and side-effect profiles of mammalian target of rapamycin inhibitors among this population. Although the majority of cases responded to mammalian target of rapamycin inhibition, standardised guidelines for dosing and duration of treatment remain to be defined.
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Pluym ID, Sklansky M, Wu JY, Afshar Y, Holliman K, Devore GR, Walden A, Platt LD, Krakow D. Fetal cardiac rhabdomyomas treated with maternal sirolimus. Prenat Diagn 2020; 40:358-364. [PMID: 31742705 DOI: 10.1002/pd.5613] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/25/2019] [Accepted: 10/30/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To review the pathophysiology of rhabdomyomas and the emerging option of prenatal treatment of fetal cardiac rhabdomyomas. METHODS We present a case of fetal rhabdomyomas causing significant hemodynamic compromise that received in utero treatment of maternal sirolimus. Genetic amniocentesis confirmed a TSC2 mutation. A treatment program was initiated with a 10-mg loading dose titrated to a goal maternal trough of 10 to 15 ng/dL. In order to follow fetal cardiac function, a sophisticated method of speckle tracking echocardiography was used before and after treatment. Obstetric ultrasound was used to monitor fetal growth, and clinical surveillance, echocardiography, and brain MRI were used to monitor postnatal growth and development through 6 months of neonatal life. RESULTS Sirolimus was initiated from 28 to 36 weeks of gestation with improvement of cardiac status. During this period, intrauterine growth restriction developed. Postnatally, the infant has had stable rhabdomyomas and cardiac function without reinitiating sirolimus. Brain MRI demonstrated scattered cortical tubers and subependymal nodules, and the infant has not had seizure-like activity. At 6 months of age, the infant has achieved appropriate developmental milestones. CONCLUSION In counseling cases of prenatal onset large obstructing rhabdomyomas and cardiac compromise, in utero sirolimus treatment can be considered.
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Affiliation(s)
- Ilina D Pluym
- Department of Obstetrics and Gynecology, University of California at Los Angeles, Los Angeles, CA
| | - Mark Sklansky
- Department of Pediatrics, UCLA, Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joyce Y Wu
- Division of Pediatric Neurology, Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA
| | - Yalda Afshar
- Department of Obstetrics and Gynecology, University of California at Los Angeles, Los Angeles, CA
| | - Kerry Holliman
- Department of Obstetrics and Gynecology, University of California at Los Angeles, Los Angeles, CA
| | - Greggory R Devore
- Department of Obstetrics and Gynecology, University of California at Los Angeles, Los Angeles, CA.,Fetal Diagnostic Centers, Pasadena, CA
| | | | - Lawrence D Platt
- Department of Obstetrics and Gynecology, University of California at Los Angeles, Los Angeles, CA.,Center for Fetal Medicine and Women's Ultrasound, Los Angeles, CA
| | - Deborah Krakow
- Department of Obstetrics and Gynecology, University of California at Los Angeles, Los Angeles, CA.,Department of Pediatrics, UCLA, Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Human Genetics, University of California at Los Angeles, Los Angeles, CA.,Department of Orthopaedic Surgery, University of California at Los Angeles, Los Angeles, CA
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