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Gavin NR, Forrest AD, Rosner M, Miller JL, Baschat AA. The role of fetal therapy in the management of mirror syndrome: a narrative review. J Matern Fetal Neonatal Med 2024; 37:2345307. [PMID: 38679585 DOI: 10.1080/14767058.2024.2345307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/15/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVES Mirror syndrome (MS) is a condition characterized by the presence of maternal, fetal, and placental edema and is reversible through delivery or pregnancy termination. As fetal hydrops itself may be amenable to treatment, we sought to determine outcomes for MS primarily managed by fetal therapy through a narrative review of the literature and cases managed at our fetal center. STUDY DESIGN PubMed, Embase, Web of Science, Scopus, and Google Scholar databases were searched through January 2024 using key words: mirror syndrome, Ballantyne's syndrome, fetal hydrops, maternal hydrops, pseudotoxemia, triple edema, maternal recovery, fetal therapy, and resolution. Manuscripts describing primary management by fetal therapy that included maternal and fetal outcomes were identified. Clinical details of MS patients managed with fetal therapy at our center were also included for descriptive analysis. RESULTS 16 of 517 manuscripts (3.1%) described fetal therapy as the primary intended treatment in 17 patients. 3 patients managed at our center were included in the analysis. Among 20 patients undergoing primary fetal therapy for management of mirror syndrome, median gestational age of presentation was 24 weeks and 5 days gestation; predominant clinical findings were maternal edema (15/20), proteinuria (10/20), pulmonary edema (8/20), and hypertension (8/20); the primary laboratory abnormalities were anemia (8/20) and elevated creatinine or transaminases (5/20). Condition-specific fetal therapies led to resolution of hydrops in 17 (85%) cases and MS in 19 (95%) cases. The median time to hydrops resolution was 7.5 days and to resolution of mirror syndrome was 10 days. Fetal therapy prolonged pregnancy by a median of 10 weeks with a median gestational age of 35 weeks and 5 days at delivery. All women delivered for indications other than mirror syndrome and 19/20 fetuses survived. CONCLUSION In appropriately selected cases, MS often resolves after fetal therapy of hydrops allowing for safe pregnancy prolongation with good maternal and infant outcomes.
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Affiliation(s)
- Nicole R Gavin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Connecticut School of Medicine, Storrs, CT, USA
| | - Alexandra D Forrest
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mara Rosner
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jena L Miller
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, The Johns Hopkins Hospital, Baltimore, MD, USA
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2
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Kyvernitakis I, Baschat AA, Malan M, Rath W, Berger R, Henrich W, Schleussner E, Yousefi B, Timmesfeld N, Maul H. Cervical pessary to prevent preterm birth and poor neonatal outcome: An integrity meta-analysis of randomized controlled trials focusing on adherence to the European Medical Device Regulation. Int J Gynaecol Obstet 2024; 165:607-620. [PMID: 37830250 DOI: 10.1002/ijgo.15169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/28/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Findings from randomized trials (RCTs) on cervical pessary treatment to prevent spontaneous preterm birth are inconsistent. OBJECTIVES Our hypothesis suggests that adhering to the European Medical Device Regulation (MDR) and following the instructions for use are essential prerequisites for successful therapy. Conversely, the non-adherence to these guidelines will probably contribute to its failure. SEARCH STRATEGY AND SELECTION CRITERIA Based on validated criteria from integrity assessments we performed a systematic review identifying 14 RCTs evaluating the effect of cervical pessaries. DATA COLLECTION AND ANALYSIS We analyzed the implications of 14 criteria each accounting for 0-2 points of a score reflecting the clinical evaluation plan (CEP) as proposed by the MDR to evaluate the risk-benefit ratio of medical devices. MAIN RESULTS Seven RCTs in each singleton and twin pregnancies (5193 "cases") were included, detecting a high heterogeneity within control groups (I2 = 85% and 87%, respectively, P < 0.01). The CEP score varied from 11 to 26 points for all studies. The most common reasons for low scores and potential data compromise were poor recruitment rates, no (completed) power analysis, and no pre-registration, but mainly non-adherence to technical, biological, and clinical equivalence to the instructions for use as required by the MDR. All trials with score values greater than 20 had applied audit procedures. Within this group we found significantly reduced rates of spontaneous preterm birth at less than 34 weeks within the pessary group in singleton (odds ratio 0.28; 95% confidence interval 0.12-0.65) and twin pregnancies (odds ratio 0.30; 95% confidence interval 0.13-0.67). Similarly, there was a significant reduction in the composite poor neonatal outcome in singleton (odds ratio 0.25; 95% confidence interval 0.10-0.61) and twin pregnancies (odds ratio 0.54; 95% confidence interval 0.35-0.82) after a pessary as compared with controls. CONCLUSION Non-audited RCTs and meta-analyses mixing studies of different clinical quality as pre-defined by a CEP and the MDR pose the risk for erroneous conclusions.
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Affiliation(s)
- Ioannis Kyvernitakis
- Department of Obstetrics and Prenatal Medicine, Asklepios Clinic Barmbek, Asklepios Medical School, Hamburg, Germany
| | - Ahmet A Baschat
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marcel Malan
- Department of Obstetrics and Prenatal Medicine, Asklepios Clinic Barmbek, Asklepios Medical School, Hamburg, Germany
| | - Werner Rath
- Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Richard Berger
- Department of Obstetrics and Gynecology, Marienhaus Klinikum St. Elisabeth, Neuwied, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ekkehard Schleussner
- Department of Obstetrics and Prenatal Medicine, University of Jena, Jena, Germany
| | - Bahareh Yousefi
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University Bochum, Bochum, Germany
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University Bochum, Bochum, Germany
| | - Holger Maul
- Department of Obstetrics and Prenatal Medicine, Asklepios Clinic Barmbek, Asklepios Medical School, Hamburg, Germany
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Sferra SR, Penikis AB, Guo M, Baschat AA, Mogayzel PJ, Burton VJ, Kunisaki SM. Neurodevelopmental Outcomes in Children After Fetoscopic Endoluminal Tracheal Occlusion for Severe Congenital Diaphragmatic Hernia: Results From a Multidisciplinary Clinic. J Pediatr Surg 2024:S0022-3468(24)00195-7. [PMID: 38599907 DOI: 10.1016/j.jpedsurg.2024.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND We compared early neurodevelopmental morbidity in young children with severe CDH who underwent FETO to those without fetal therapy. METHODS We conducted a prospective study of severe CDH patients undergoing FETO (n = 18) at a single North American center from 2015 to 2021 (NCT02710968). Outpatient survivors (n = 12) were evaluated by a multidisciplinary team and compared to expectantly managed CDH patients. Neurodevelopmental outcomes were assessed using the Capute Scales [Clinical Linguistic and Auditory Milestone Scales (CLAMS) and Cognitive Adaptive Test (CAT)], with a developmental quotient (DQ) < 85 indicative of at-risk for delay. RESULTS At one year, 58% (n = 7) of FETO patients underwent evaluation, with notable concern for language delay (CLAMS median DQ, 80.1 [interquartile range, 67.6-86.7]). FETO scores improved by 24-months, whereas high severity/non-FETO scores declined [CLAMS median DQ (Difference in DQ), 92.3 (+12.2) vs. 77.1 (-13.4), respectively; p = 0.049]. On the initial CAT, FETO patients had concern for visual motor and problem-solving delays, with a median DQ of 81.3 (62.1-89.4). At 24-months, FETO patients had improving scores [Median CAT DQ, 90.8 (+9.5)], whereas high severity/non-FETO [87.5 (-3.0), p = 0.28] had declining scores. CONCLUSION These initial data suggest that FETO is associated with favorable neurodevelopmental outcomes at 24-months compared to severe CDH under expectant management. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Shelby R Sferra
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Annalise B Penikis
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Matthew Guo
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA
| | - Peter J Mogayzel
- Eudowood Division of Pediatric Pulmonary, Department of Pediatrics, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Baltimore, MD 21287, USA
| | - Vera Joanna Burton
- Neurology and Developmental Medicine, Department of Neurology, Johns Hopkins University School of Medicine, 801 N. Broadway Baltimore, MD 21205, USA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA.
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4
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Bergh E, Baschat AA, Cortes MS, Hedrick HL, Ryan G, Lim FY, Zaretsky MV, Schenone MH, Crombleholme TM, Ruano R, Gosnell KA, Johnson A. Fetoscopic Endoluminal Tracheal Occlusion for Severe, Left-Sided Congenital Diaphragmatic Hernia: The North American Fetal Therapy Network Fetoscopic Endoluminal Tracheal Occlusion Consortium Experience. Obstet Gynecol 2024; 143:440-448. [PMID: 38128107 PMCID: PMC10863657 DOI: 10.1097/aog.0000000000005491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/01/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To report the outcomes of fetoscopic endoluminal tracheal occlusion in a multicenter North American cohort of patients with isolated, left-sided congenital diaphragmatic hernia (CDH) and to compare neonatal mortality and morbidity in patients with severe left-sided congenital diaphragmatic hernia who underwent fetoscopic endoluminal tracheal occlusion with those expectantly managed. METHODS We analyzed data from 10 centers in the NAFTNet (North American Fetal Therapy Network) FETO (Fetoscopic Endoluminal Tracheal Occlusion) Consortium registry, collected between November 1, 2008, and December 31, 2020. In addition to reporting procedure-related surgical outcomes of fetoscopic endoluminal tracheal occlusion, we performed a comparative analysis of fetoscopic endoluminal tracheal occlusion compared with contemporaneous expectantly managed patients. RESULTS Fetoscopic endoluminal tracheal occlusion was successfully performed in 87 of 89 patients (97.8%). Six-month survival in patients with severe left-sided congenital diaphragmatic hernia did not differ significantly between patients who underwent fetoscopic endoluminal tracheal occlusion and those managed expectantly (69.8% vs 58.1%, P =.30). Patients who underwent fetoscopic endoluminal tracheal occlusion had higher rates of preterm prelabor rupture of membranes (54.0% vs 14.3%, P <.001), earlier gestational age at delivery (median 35.0 weeks vs 38.3 weeks, P <.001), and lower birth weights (mean 2,487 g vs 2,857 g, P =.001). On subanalysis, in patients for whom all recorded observed-to-expected lung/head ratio measurements were below 25%, patients with fetoscopic endoluminal tracheal occlusion required fewer days of extracorporeal membrane oxygenation (ECMO) (median 9.0 days vs 17.0 days, P =.014). CONCLUSION In this cohort, fetoscopic endoluminal tracheal occlusion was successfully implemented across several North American fetal therapy centers. Although survival was similar among patients undergoing fetoscopic endoluminal tracheal occlusion and those expectantly managed, fetoscopic endoluminal tracheal occlusion in North American centers may reduce morbidity, as suggested by fewer days of ECMO in those patients with persistently reduced lung volumes (observed-to-expected lung/head ratio below 25%).
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Affiliation(s)
- Eric Bergh
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth Houston, the University of Texas McGovern Medical School, and the Fetal Center at Children's Memorial Hermann Hospital, and the Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Texas Children's Hospital Fetal Center, Baylor College of Medicine, Houston, Texas; the Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland; The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; the Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; the Center for Fetal, Cellular & Molecular Therapy, Cincinnati Fetal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; the Fetal Care Center, Children's Hospital Colorado, Aurora, Colorado; the Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, Minnesota; the Fetal Care Center Dallas, Dallas, Texas; and the Fetal Treatment Center, University of California, San Francisco, San Francisco, California
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5
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Forbes L, Miller JL, Baschat AA, Kanaan C, Gevaerd Martins J. MoMo pregnancies Mo problems: notoriously complicated monochorionic monoamniotic multiple gestation. Ultrasound Obstet Gynecol 2024. [PMID: 38419262 DOI: 10.1002/uog.27628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024]
Affiliation(s)
- L Forbes
- Eastern Virginia Medical School, Department of Obstetrics and Gynecology, Norfolk, VA, USA
| | - J L Miller
- Johns Hopkins University, Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - A A Baschat
- Johns Hopkins University, Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - C Kanaan
- Eastern Virginia Medical School, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Norfolk, VA, USA
| | - J Gevaerd Martins
- Eastern Virginia Medical School, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Norfolk, VA, USA
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6
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Kyvernitakis I, Rosner M, Birk A, Goodman L, Herlands L, Wohlmuth P, Laurie M, Millard S, Kush M, Miller J, Baschat AA. Stage based recipient and donor outcome in twin-to-twin transfusion syndrome treated by fetoscopic laser surgery using Solomon technique. Ultrasound Obstet Gynecol 2024. [PMID: 38379440 DOI: 10.1002/uog.27620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/03/2024] [Accepted: 02/04/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVE To evaluate twin survival stratified by Quintero stage in patients with twin-to-twin transfusion syndrome (TTTS) after Solomon laser treatment. METHODS Single center cohort of consecutive twin pregnancies treated with Solomon laser for TTTS. Preoperative Quintero stage, perioperative characteristics and obstetric factors were related to neonatal survival of the recipient and donor at discharge. Determinants of twin survival were evaluated using univariate, logistic regression and cumulative survival probability analyses. RESULTS Of 402 twins with TTTS, 80 (19.9%) had stage I, 126 (31.3%) stage II, 169 (42%) stage III and 27 (6.7%) stage IV. Post laser TAPS or recurrent TTTS occurred in 19 (4.7%) patients and 11 (2.7%) required repeat laser. Preterm premature rupture of membranes occurred in 150 (37.3%) patients and median gestational age of delivery 32+1 weeks. In 303 (75.4%) both twins were alive at discharge; [66 (82.5%) in stage I, 101 (80.2%) in stage II, 114 (67.5%) in stage III and 22 (81.5%) in stage IV, p=0.062]. Compared to recipients, donor survival was only lower in stage III (155 (91.7%) recipients vs 118 (69.8%) donors, Chi square 24.685, p<0.0001). Larger intertwin size discordance and umbilical artery (UA) end-diastolic velocity (EDV) determined donor demise (Nagelkerke R2 0.38, P<0.001). Overall, spontaneous post laser donor demise accounted for the majority (39.5%) of all losses. Cumulative donor survival decreased from 92% to 65% with size discordance >30% and 48% when UA EDV was absent (p<0.001). CONCLUSION Solomon laser achieves TTTS resolution and double survival in a high proportion of cases. Recipient and donor survival is comparable unless there is significant size discordance and placental dysfunction. This degree of unequal placental sharing, typically found in stage III, is the primary factor preventing double survival due to a higher rate of donor demise. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- I Kyvernitakis
- Section for Prenatal Diagnosis and Fetal therapy, Asklepios Klinik Barmbek, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
| | - M Rosner
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Birk
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - L Goodman
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - L Herlands
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P Wohlmuth
- Section for Prenatal Diagnosis and Fetal therapy, Asklepios Klinik Barmbek, Asklepios Medical School, University of Semmelweis, Hamburg, Germany
| | - M Laurie
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S Millard
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M Kush
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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7
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Hendriks S, Althaus J, Atkinson MA, Baschat AA, Berkman BE, Grady C, Wasserman D, Wendler D, Miller JL. Precarious hope: Ethical considerations for offering experimental fetal therapies outside of research after initial studies in humans. Prenat Diagn 2024; 44:180-186. [PMID: 38069681 DOI: 10.1002/pd.6474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/24/2023] [Accepted: 11/20/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE Risks and benefits of experimental fetal therapies can remain uncertain after initial clinical studies, especially long-term effects. Nevertheless, pregnant individuals may request them, hoping to benefit their future child. Guidance about offering experimental fetal therapies outside research (as "innovative therapy") is limited, despite their ethical complexity. We propose points for clinicians and reviewers to consider when deciding whether and how to offer experimental fetal therapies as innovative therapies after initial clinical studies. METHOD We used conceptual analysis and a current case to develop points for consideration, grounded in broader debates on innovative therapy and the unique challenges associated with experimental fetal therapies. RESULTS Clinicians should evaluate whether offering experimental fetal therapies as innovative therapy is appropriate for a pregnant individual and their fetus. The anticipated risk-benefit ratio for the fetus should be favorable. For the pregnant individual, risks may outweigh benefits, within reasonable limits. Medical resources should be sufficient to ensure appropriate care. Clinicians should support pregnant individuals in making informed choices. Clinicians offering innovative therapies with more than minimal risk should collect and report data on outcomes. Independent review should take place. CONCLUSION Considering these points may advance the interests of fetuses, future children, and their families.
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Affiliation(s)
- Saskia Hendriks
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
| | - Janyne Althaus
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, Baltimore, Maryland, USA
| | - Meredith A Atkinson
- Department of Pediatrics, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Benjamin E Berkman
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
- National Human Genome Research Institute, Bethesda, Maryland, USA
| | - Christine Grady
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
| | - David Wasserman
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
| | - Jena L Miller
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, Johns Hopkins University, Baltimore, Maryland, USA
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8
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Dibbon KC, Mercer GV, Maekawa AS, Hanrahan J, Steeves KL, Ringer LCM, Simpson AJ, Simpson MJ, Baschat AA, Kingdom JC, Macgowan CK, Sled JG, Jobst KJ, Cahill LS. Polystyrene micro- and nanoplastics cause placental dysfunction in mice†. Biol Reprod 2024; 110:211-218. [PMID: 37724921 DOI: 10.1093/biolre/ioad126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/22/2023] [Accepted: 09/13/2023] [Indexed: 09/21/2023] Open
Abstract
Maternal exposure to microplastics and nanoplastics has been shown to result in fetal growth restriction in mice. In this study, we investigated the placental and fetal hemodynamic responses to plastics exposure in mice using high-frequency ultrasound. Healthy, pregnant CD-1 dams were given either 106 ng/L of 5 μm polystyrene microplastics or 106 ng/L of 50 nm polystyrene nanoplastics in drinking water throughout gestation and were compared with controls. Maternal exposure to both microplastics and nanoplastics resulted in evidence of placental dysfunction that was highly dependent on the particle size. The umbilical artery blood flow increased by 48% in the microplastic-exposed group and decreased by 25% in the nanoplastic-exposed group compared to controls (p < 0.05). The microplastic- and nanoplastic-exposed fetuses showed a significant decrease in the middle cerebral artery pulsatility index of 10% and 13%, respectively, compared to controls (p < 0.05), indicating vasodilation of the cerebral circulation, a fetal adaptation that is part of the brain sparing response to preserve oxygen delivery. Hemodynamic markers of placental dysfunction and fetal hypoxia were more pronounced in the group exposed to polystyrene nanoplastics, suggesting nanoplastic exposure during human pregnancy has the potential to disrupt fetal brain development, which in turn may cause suboptimal neurodevelopmental outcomes.
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Affiliation(s)
- Katherine C Dibbon
- Department of Chemistry, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Grace V Mercer
- Department of Chemistry, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Alexandre S Maekawa
- Department of Chemistry, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Jenna Hanrahan
- Department of Chemistry, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Katherine L Steeves
- Department of Chemistry, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Lauren C M Ringer
- Department of Chemistry, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - André J Simpson
- Environmental NMR Centre and Department of Physical and Environmental Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Myrna J Simpson
- Environmental NMR Centre and Department of Physical and Environmental Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Ahmet A Baschat
- Department of Gynecology & Obstetrics, Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD, USA
| | - John C Kingdom
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Christopher K Macgowan
- Translational Medicine, Hospital for Sick Children , Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - John G Sled
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine, Hospital for Sick Children , Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Mouse Imaging Centre, Hospital for Sick Children , Toronto, Ontario, Canada
| | - Karl J Jobst
- Department of Chemistry, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Lindsay S Cahill
- Department of Chemistry, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
- Discipline of Radiology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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9
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Hanrahan J, Steeves KL, Locke DP, O'Brien TM, Maekawa AS, Amiri R, Macgowan CK, Baschat AA, Kingdom JC, Simpson AJ, Simpson MJ, Sled JG, Jobst KJ, Cahill LS. Maternal exposure to polyethylene micro- and nanoplastics impairs umbilical blood flow but not fetal growth in pregnant mice. Sci Rep 2024; 14:399. [PMID: 38172192 PMCID: PMC10764924 DOI: 10.1038/s41598-023-50781-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/25/2023] [Indexed: 01/05/2024] Open
Abstract
While microplastics have been recently detected in human blood and the placenta, their impact on human health is not well understood. Using a mouse model of environmental exposure during pregnancy, our group has previously reported that exposure to polystyrene micro- and nanoplastics throughout gestation results in fetal growth restriction. While polystyrene is environmentally relevant, polyethylene is the most widely produced plastic and amongst the most commonly detected microplastic in drinking water and human blood. In this study, we investigated the effect of maternal exposure to polyethylene micro- and nanoplastics on fetal growth and placental function. Healthy, pregnant CD-1 dams were divided into three groups: 106 ng/L of 740-4990 nm polyethylene with surfactant in drinking water (n = 12), surfactant alone in drinking water (n = 12) or regular filtered drinking water (n = 11). At embryonic day 17.5, high-frequency ultrasound was used to investigate the placental and fetal hemodynamic responses following exposure. While maternal exposure to polyethylene did not impact fetal growth, there was a significant effect on placental function with a 43% increase in umbilical artery blood flow in the polyethylene group compared to controls (p < 0.01). These results suggest polyethylene has the potential to cause adverse pregnancy outcomes through abnormal placental function.
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Affiliation(s)
- Jenna Hanrahan
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue, St. John's, NL, A1C 5S7, Canada
| | - Katherine L Steeves
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue, St. John's, NL, A1C 5S7, Canada
| | - Drew P Locke
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue, St. John's, NL, A1C 5S7, Canada
| | - Thomas M O'Brien
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue, St. John's, NL, A1C 5S7, Canada
| | - Alexandre S Maekawa
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue, St. John's, NL, A1C 5S7, Canada
| | - Roshanak Amiri
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue, St. John's, NL, A1C 5S7, Canada
| | - Christopher K Macgowan
- Translational Medicine, Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, M5G 1L7, Canada
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - John C Kingdom
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, M5G 1E2, Canada
- Mount Sinai Hospital, Toronto, ON, M5G 1X5, Canada
| | - André J Simpson
- Environmental NMR Centre and Department of Physical and Environmental Sciences, University of Toronto, Toronto, ON, M1C 1A4, Canada
| | - Myrna J Simpson
- Environmental NMR Centre and Department of Physical and Environmental Sciences, University of Toronto, Toronto, ON, M1C 1A4, Canada
| | - John G Sled
- Translational Medicine, Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, M5G 1L7, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, M5G 1E2, Canada
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, M5T 3H7, Canada
| | - Karl J Jobst
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue, St. John's, NL, A1C 5S7, Canada
| | - Lindsay S Cahill
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue, St. John's, NL, A1C 5S7, Canada.
- Discipline of Radiology, Memorial University of Newfoundland, St. John's, NL, A1C 5S7, Canada.
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10
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Miller JL, Baschat AA, Rosner M, Blumenfeld YJ, Moldenhauer JS, Johnson A, Schenone MH, Zaretsky MV, Chmait RH, Gonzalez JM, Miller RS, Moon-Grady AJ, Bendel-Stenzel E, Keiser AM, Avadhani R, Jelin AC, Davis JM, Warren DS, Hanley DF, Watkins JA, Samuels J, Sugarman J, Atkinson MA. Neonatal Survival After Serial Amnioinfusions for Bilateral Renal Agenesis: The Renal Anhydramnios Fetal Therapy Trial. JAMA 2023; 330:2096-2105. [PMID: 38051327 PMCID: PMC10698620 DOI: 10.1001/jama.2023.21153] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/28/2023] [Indexed: 12/07/2023]
Abstract
Importance Early anhydramnios during pregnancy, resulting from fetal bilateral renal agenesis, causes lethal pulmonary hypoplasia in neonates. Restoring amniotic fluid via serial amnioinfusions may promote lung development, enabling survival. Objective To assess neonatal outcomes of serial amnioinfusions initiated before 26 weeks' gestation to mitigate lethal pulmonary hypoplasia. Design, Setting, and Participants Prospective, nonrandomized clinical trial conducted at 9 US fetal therapy centers between December 2018 and July 2022. Outcomes are reported for 21 maternal-fetal pairs with confirmed anhydramnios due to isolated fetal bilateral renal agenesis without other identified congenital anomalies. Exposure Enrolled participants initiated ultrasound-guided percutaneous amnioinfusions of isotonic fluid before 26 weeks' gestation, with frequency of infusions individualized to maintain normal amniotic fluid levels for gestational age. Main Outcomes and Measures The primary end point was postnatal infant survival to 14 days of life or longer with dialysis access placement. Results The trial was stopped early based on an interim analysis of 18 maternal-fetal pairs given concern about neonatal morbidity and mortality beyond the primary end point despite demonstration of the efficacy of the intervention. There were 17 live births (94%), with a median gestational age at delivery of 32 weeks, 4 days (IQR, 32-34 weeks). All participants delivered prior to 37 weeks' gestation. The primary outcome was achieved in 14 (82%) of 17 live-born infants (95% CI, 44%-99%). Factors associated with survival to the primary outcome included a higher number of amnioinfusions (P = .01), gestational age greater than 32 weeks (P = .005), and higher birth weight (P = .03). Only 6 (35%) of the 17 neonates born alive survived to hospital discharge while receiving peritoneal dialysis at a median age of 24 weeks of life (range, 12-32 weeks). Conclusions and Relevance Serial amnioinfusions mitigated lethal pulmonary hypoplasia but were associated with preterm delivery. The lower rate of survival to discharge highlights the additional mortality burden independent of lung function. Additional long-term data are needed to fully characterize the outcomes in surviving neonates and assess the morbidity and mortality burden. Trial Registration ClinicalTrials.gov Identifier: NCT03101891.
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Affiliation(s)
- Jena L. Miller
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Ahmet A. Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Mara Rosner
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Yair J. Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anthony Johnson
- The Fetal Center, Department of Obstetrics and Gynecology, University of Texas Health Center, Houston
| | - Mauro H. Schenone
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | | | - Ramen H. Chmait
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles
| | - Juan M. Gonzalez
- Department of Obstetrics and Gynecology, University of California, San Francisco
| | - Russell S. Miller
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Anita J. Moon-Grady
- Division of Cardiology, Department of Pediatrics, University of California, San Francisco
| | - Ellen Bendel-Stenzel
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Amaris M. Keiser
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland
| | - Angie C. Jelin
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Jonathan M. Davis
- Tufts Clinical and Translational Science Institute, Division of Newborn Medicine, Tufts Children’s Hospital, Tufts University, Boston, Massachusetts
| | - Daniel S. Warren
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland
| | - Joslynn A. Watkins
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joshua Samuels
- Division of Pediatric Nephrology and Hypertension, McGovern School at the University of Texas Health Science Center, Houston
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Meredith A. Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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11
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Mercer GV, Harvey NE, Steeves KL, Schneider CM, Sled JG, Macgowan CK, Baschat AA, Kingdom JC, Simpson AJ, Simpson MJ, Jobst KJ, Cahill LS. Maternal exposure to polystyrene nanoplastics alters fetal brain metabolism in mice. Metabolomics 2023; 19:96. [PMID: 37989919 DOI: 10.1007/s11306-023-02061-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION Plastics used in everyday materials accumulate as waste in the environment and degrade over time. The impacts of the resulting particulate micro- and nanoplastics on human health remain largely unknown. In pregnant mice, we recently demonstrated that exposure to nanoplastics throughout gestation and during lactation resulted in changes in brain structure detected on MRI. One possible explanation for this abnormal postnatal brain development is altered fetal brain metabolism. OBJECTIVES To determine the effect of maternal exposure to nanoplastics on fetal brain metabolism. METHODS Healthy pregnant CD-1 mice were exposed to 50 nm polystyrene nanoplastics at a concentration of 106 ng/L through drinking water during gestation. Fetal brain samples were collected at embryonic day 17.5 (n = 18-21 per group per sex) and snap-frozen in liquid nitrogen. Magic angle spinning nuclear magnetic resonance was used to determine metabolite profiles and their relative concentrations in the fetal brain. RESULTS The relative concentrations of gamma-aminobutyric acid (GABA), creatine and glucose were found to decrease by 40%, 21% and 30% respectively following maternal nanoplastic exposure when compared to the controls (p < 0.05). The change in relative concentration of asparagine with nanoplastic exposure was dependent on fetal sex (p < 0.005). CONCLUSION Maternal exposure to polystyrene nanoplastics caused abnormal fetal brain metabolism in mice. The present study demonstrates the potential impacts of nanoplastic exposure during fetal development and motivates further studies to evaluate the risk to human pregnancies.
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Affiliation(s)
- Grace V Mercer
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, St. John's, Newfoundland, NL, A1C 5S7, Canada
| | - Nikita E Harvey
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, St. John's, Newfoundland, NL, A1C 5S7, Canada
| | - Katherine L Steeves
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, St. John's, Newfoundland, NL, A1C 5S7, Canada
| | - Céline M Schneider
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, St. John's, Newfoundland, NL, A1C 5S7, Canada
| | - John G Sled
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Christopher K Macgowan
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Ahmet A Baschat
- Department of Gynecology & Obstetrics, Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD, USA
| | - John C Kingdom
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - André J Simpson
- Environmental NMR Centre, Department of Physical and Environmental Sciences, University of Toronto, Toronto, ON, Canada
| | - Myrna J Simpson
- Environmental NMR Centre, Department of Physical and Environmental Sciences, University of Toronto, Toronto, ON, Canada
| | - Karl J Jobst
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, St. John's, Newfoundland, NL, A1C 5S7, Canada
| | - Lindsay S Cahill
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, St. John's, Newfoundland, NL, A1C 5S7, Canada.
- Discipline of Radiology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada.
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12
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Penikis AB, Zhou AL, Sferra SR, Engwall-Gill AJ, Miller JL, Baschat AA, Blakemore KJ, Kunisaki SM. Serial lung mass volume ratios as prognostic indicators of neonatal respiratory morbidity in fetal pulmonary malformations. Am J Obstet Gynecol MFM 2023; 5:101128. [PMID: 37572880 DOI: 10.1016/j.ajogmf.2023.101128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/02/2023] [Accepted: 08/05/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Several studies have shown that the congenital pulmonary airway malformation volume ratio is a useful prognosticator of neonatal outcome in prenatally diagnosed lung lesions. However, there remains a lack of consensus on which congenital pulmonary airway malformation volume ratio values have the best predictive value because of operator dependence, inherent changes in lung lesion size throughout gestation, and the widespread use of maternal steroids. OBJECTIVE This study sought to determine the association between serial congenital pulmonary airway malformation volume ratio measurements and neonatal outcomes among fetuses with lung malformations. STUDY DESIGN This was a retrospective cohort study of fetuses with a prenatally diagnosed lung malformation managed at 2 major fetal centers from January 2010 to December 2021. Prenatal variables, including prospectively measured congenital pulmonary airway malformation volume ratio measurements (initial, maximum, and final), were analyzed. The results were correlated with 3 outcome measures, namely surgical resection before 30 days of life, a need for supplemental O2 at birth, and endotracheal intubation at birth. Statistical analyses were performed using receiver operating characteristic curve analyses, Welch 2 sample t tests, and multivariable logistic regressions (P<.05). RESULTS There were 123 fetuses with isolated lung lesions identified. Eight (6.5%) had hydrops. The mean initial congenital pulmonary airway malformation volume ratio was 0.67±0.61 cm2 at 22.9±3.9 weeks' gestation. The mean maximum congenital pulmonary airway malformation volume ratio was 1.08 ± 0.94 cm2 at 27.0 ± 4.0 weeks' gestation. The mean final congenital pulmonary airway malformation volume ratio was 0.58±0.60 cm2 at 33.2±4.1 weeks' gestation. At a mean gestational age at delivery of 38.3±2.6 weeks, 15 (12.2%) underwent neonatal lung resection for symptomatic disease. In a multivariable regression, all 3 congenital pulmonary airway malformation volume ratio measurements showed a significant correlation with neonatal lung resection (P<.001). Optimal congenital pulmonary airway malformation volume ratio cutoffs were established based on an initial congenital pulmonary airway malformation volume ratio of ≥0.8 cm2, maximum congenital pulmonary airway malformation volume ratio of ≥1.5 cm2, and a final congenital pulmonary airway malformation volume ratio of ≥1.3 cm2 with associated areas under the curve of 0.89, 0.97, and 0.93, respectively. The final congenital pulmonary airway malformation volume ratio had the highest specificity for predicting surgical lung resection in the early postnatal period. CONCLUSION Measuring congenital pulmonary airway malformation volume ratios throughout pregnancy in fetuses with pulmonary malformations has clinical value for prenatal counseling and planning care transition after delivery. Fetuses with a final congenital pulmonary airway malformation volume ratio of more than 1.3 cm2 are likely to require neonatal surgery and therefore should be delivered at tertiary care centers with a neonatal intensive care unit and pediatric surgical expertise.
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Affiliation(s)
- Annalise B Penikis
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Penikis, Ms Zhou, and Drs Sferra and Kunisaki)
| | - Alice L Zhou
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Penikis, Ms Zhou, and Drs Sferra and Kunisaki)
| | - Shelby R Sferra
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Penikis, Ms Zhou, and Drs Sferra and Kunisaki)
| | - Abigail J Engwall-Gill
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI (Dr Engwall-Gill)
| | - Jena L Miller
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD (Drs Miller, Baschat, and Blakemore)
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD (Drs Miller, Baschat, and Blakemore)
| | - Karin J Blakemore
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD (Drs Miller, Baschat, and Blakemore)
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Penikis, Ms Zhou, and Drs Sferra and Kunisaki).
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13
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Stapleton D, Darmonkow A, Ravi Chandran A, Milligan N, Saghian R, Shinar S, Whitehead CL, Hobson SR, Serghides L, Macgowan CK, Sled JG, Kingdom JC, Baschat AA, Parks WT, Cahill LS. Peripheral cord insertion is associated with adverse pregnancy outcome only when accompanied by clinically significant placental pathology. Ultrasound Obstet Gynecol 2023; 62:248-254. [PMID: 36971026 DOI: 10.1002/uog.26206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/17/2023] [Accepted: 03/08/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To examine the relationship between umbilical cord insertion site, placental pathology and adverse pregnancy outcome in a cohort of normal and complicated pregnancies. METHODS Sonographic measurement of the cord insertion and detailed placental pathology were performed in 309 participants. Associations between cord insertion site, placental pathology and adverse pregnancy outcome (pre-eclampsia, preterm birth, small-for-gestational age) were examined. RESULTS A total of 93 (30%) participants were identified by pathological examination to have a peripheral cord insertion site. Only 41 of the 93 (44%) peripheral cords were detected by prenatal ultrasound. Peripherally inserted cords were associated significantly (P < 0.0001) with diagnostic placental pathology (most commonly with maternal vascular malperfusion (MVM)); of which 85% had an adverse pregnancy outcome. In cases of isolated peripheral cords, without placental pathology, the incidence of adverse outcome was not statistically different when compared to those with central cord insertion and no placental pathology (31% vs 18%; P = 0.3). A peripheral cord with an abnormal umbilical artery (UA) pulsatility index (PI) corresponded to an adverse outcome in 96% of cases compared to 29% when the UA-PI was normal. CONCLUSIONS This study demonstrates that peripheral cord insertion is often part of the spectrum of findings of MVM disease and is associated with adverse pregnancy outcome. However, adverse outcome was uncommon when there was an isolated peripheral cord insertion and no placental pathology. Therefore, additional sonographic and biochemical features of MVM should be sought when a peripheral cord is observed. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Stapleton
- Department of Chemistry, Memorial University of Newfoundland, St John's, NL, Canada
| | - A Darmonkow
- Department of Chemistry, Memorial University of Newfoundland, St John's, NL, Canada
| | - A Ravi Chandran
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - N Milligan
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - R Saghian
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - S Shinar
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - C L Whitehead
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Pregnancy Research Centre, Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Australia
| | - S R Hobson
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - L Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Department of Immunology and Institutes of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - C K Macgowan
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - J G Sled
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - J C Kingdom
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - A A Baschat
- Center for Fetal Therapy, Johns Hopkins Medicine, Baltimore, MD, USA
| | - W T Parks
- Department of Pathology, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - L S Cahill
- Department of Chemistry, Memorial University of Newfoundland, St John's, NL, Canada
- Discipline of Radiology, Memorial University of Newfoundland, St John's, NL, Canada
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14
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Spoor JKH, Kik CC, van Veelen MLC, Dirven C, Miller JL, Groves ML, DeKoninck PLJ, Baschat AA, Eggink AJ. Potential higher risk of tethered spinal cord in children after prenatal surgery for myelomeningocele: A systematic review and meta-analysis. PLoS One 2023; 18:e0287175. [PMID: 37379312 DOI: 10.1371/journal.pone.0287175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/31/2023] [Indexed: 06/30/2023] Open
Abstract
INTRODUCTION We performed a systematic review and meta-analysis on the incidence of secondary tethered spinal cord (TSC) between prenatal and postnatal closure in patients with MMC. The objectives was to understand the incidence of secondary TSC after prenatal surgery for MMC compared to postnatal surgery for MMC. MATERIAL AND METHODS On May 4, 2023, a systematic search was conducted in Medline, Embase, and the Cochrane Library to gather relevant data. Primary studies focusing on repair type, lesion level, and TSC were included, while non-English or non-Dutch reports, case reports, conference abstracts, editorials, letters, comments, and animal studies were excluded. Two reviewers assessed the included studies for bias risk, following PRISMA guidelines. TSC frequency in MMC closure types was determined, and the relationship between TSC occurrence and closure technique was analyzed using relative risk and Fisher's exact test. Subgroup analysis revealed relative risk differences based on study designs and follow-up periods. A total of ten studies, involving 2,724 patients, were assessed. Among them, 2,293 patients underwent postnatal closure, while 431 received prenatal closure for the MMC defect. In the prenatal closure group, TSC occurred in 21.6% (n = 93), compared to 18.8% (n = 432) in the postnatal closure group. The relative risk (RR) of TSC in patients with prenatal MMC closure versus postnatal MMC closure was 1.145 (95%CI 0.939 to 1.398). Fisher's exact test indicated a statistically non-significant association (p = 0.106) between TSC and closure technique. When considering only RCT and controlled cohort studies, the overall RR for TSC was 1.308 (95%CI 1.007 to 1.698) with a non-significant association (p = .053). For studies focusing on children up until early puberty (maximum 12 years follow-up), the RR for tethering was 1.104 (95%CI 0.876 to 1.391), with a non-significant association (p = 0.409). CONCLUSION AND DISCUSSION This review found no significant increase in relative risk of TSC between prenatal and postnatal closure in MMC patients, but a trend of increased TSC in the prenatal group. More long-term data on TSC after fetal closure is needed for better counseling and outcomes in MMC.
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Affiliation(s)
- Jochem K H Spoor
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Charlotte C Kik
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marie-Lise C van Veelen
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Clemens Dirven
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynaecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Mari L Groves
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynaecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Alex J Eggink
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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15
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Spoor JKH, van Gastel L, Tahib F, van Grieken A, van Weteringen W, Sterke F, Baschat AA, Miller JL, de Jong THR, Wijnen RMH, Eggink AE, DeKoninck PLJ. Development of a simulator for training of fetoscopic myelomeningocele surgery. Prenat Diagn 2023; 43:355-358. [PMID: 36627260 DOI: 10.1002/pd.6308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/19/2022] [Accepted: 01/02/2023] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop a realistic simulation model for laparotomy-assisted fetoscopic spina bifida aperta (SBa) surgery, to be used for training purposes and preoperative planning. METHODS The predefined general requirement was a realistic model of an exteriorized uterus, allowing all neurosurgical steps of the intervention. The uterus was modelled using ultrasound and MRI images of a 25 weeks' gravid uterus, consisting of flexible polyurethane foam coated with pigmented silicone. The fetal model, contained an opening on the dorsal side for a customizable spinal insert with all the aspects of a SBa, including a cele, placode, and myofascial and skin layer. The model was assessed in a series of validation experiments. RESULTS Production costs are low, uterus and fetus are reusable. Placental localization and the level and size of the spinal defect are adjustable, enabling case-specific adaptations. All aspects of the simulator were scored close to realistic or higher for both appearance and functional capacities. CONCLUSIONS This innovative model provides an excellent training opportunity for centers that are starting a fetoscopic SBa repair program. It is the first simulation model with adjustable spinal defect and placental localisation. Further objective validation is required, but the potential for using this model in preoperative planning is promising.
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Affiliation(s)
- Jochem K H Spoor
- Departments of Neurosurgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lis van Gastel
- Departments of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Fatima Tahib
- Departments of Neurosurgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Amanda van Grieken
- Departments of Neurosurgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Willem van Weteringen
- Departments of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Frank Sterke
- Departments of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Ahmet A Baschat
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jena L Miller
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tjeerd H R de Jong
- Departments of Neurosurgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - René M H Wijnen
- Departments of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alex E Eggink
- Departments of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Departments of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Miller JL, Chang RH, Ong CS, Miller GT, Garcia JR, Groves ML, Rosner MK, Baschat AA. Patient-matched fetal simulator for fetoscopic myelomeningocele closure. Ultrasound Obstet Gynecol 2023; 61:270-272. [PMID: 36178849 DOI: 10.1002/uog.26081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/31/2022] [Accepted: 09/22/2022] [Indexed: 05/27/2023]
Affiliation(s)
- J L Miller
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
| | - R H Chang
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
| | - C S Ong
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
| | - G T Miller
- The Johns Hopkins Medicine Simulation Center, Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - J R Garcia
- Department of Art as Applied to Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - M L Groves
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - M K Rosner
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
| | - A A Baschat
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
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Baschat AA, Rosner M, Kyvernitakis J, Miller JL. Phenotype based staging of disease severity in twin-to-twin transfusion syndrome (TTTS). Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Bergh EP, Baschat AA, Hedrick H, Lim FY, Magee K, Ryan G, Cortes MS, Schenone M, Zaretsky MV, Johnson A. Fetoscopic endoluminal tracheal occlusion (FETO) versus expectant care of severe left-diaphragmatic hernia in north america. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Thompson MG, Baschat AA, Sagaser K, Forster K, Voegtline K, Olson S, Jelin A, Blakemore K, Kush M, Miller JL, Rosner M. Discordant or abnormal nuchal translucency in patients with TTTS requiring laser. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Miller JL, Baschat AA, Rosner M, Blumenfeld YJ, Moldenhauer J, Johnson A, Schenone M, Zaretsky MV, Chmait RH, Velez JG, Miller RS, Moon-Grady AJ, Bendel-Stenzel EM, Keiser A, Avadhani R, Jelin A, Davis J, Warren D, Hanley D, Atkinson M. Neonatal survival after serial amnioinfusions for fetal bilateral renal agenesis: report from the raft trial. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Birk A, Baschat AA, Rosner M, Kush M, Miller JL. Antepartum hemorrhage at delivery after Solomon laser for Twin-Twin Transfusion Syndrome. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Birk A, Shantz C, Jin J, Voegtline K, Olson S, Kush M, Baschat AA, Miller JL, Rosner M. Implications of repeat fetoscopic laser surgery in Twin Twin Transfusion Syndrome. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Kyvernitakis J, Rosner M, Wohlmuth P, Maul H, Miller JL, Baschat AA. Stage based survival after fetoscopic laser ablation treatment of twin-transfusion syndrome using the ‘Solomon technique’. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Sferra SR, Nies MK, Miller JL, Garcia AV, Hodgman EI, Penikis AB, Engwall-Gill AJ, Burton VJ, Rice JL, Mogayzel PJ, Baschat AA, Kunisaki SM. Morbidity in children after fetoscopic endoluminal tracheal occlusion for severe congenital diaphragmatic hernia: Results from a multidisciplinary clinic. J Pediatr Surg 2023; 58:14-19. [PMID: 36333128 DOI: 10.1016/j.jpedsurg.2022.09.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/16/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although fetoscopic endoluminal tracheal occlusion (FETO) was recently shown to improve survival in a multicenter, randomized trial of severe congenital diaphragmatic hernia (CDH), morbidity outcomes remain essentially unknown. The purpose of this study was to assess long-term outcomes in children with severe CDH who underwent FETO. METHODS We conducted a prospective study of severe CDH patients undergoing FETO at an experienced North American center from 2015-2021 (NCT02710968). This group was compared to a cohort of non-FETO CDH patients with severe disease as defined by liver herniation, large defect size, and/or ECMO use. Clinical data were collected through a multidisciplinary CDH clinic. Statistics were performed with t-tests and Chi-squared analyses (p≤0.05). RESULTS There were 18 FETO and 17 non-FETO patients. ECMO utilization was 56% in the FETO cohort. Despite significantly lower median observed/expected lung-to-head ratio (O/E LHR) in the FETO group, [FETO: 23% (IQR:18-25) vs. non-FETO: 36% (IQR: 28-41), p<0.001], there were comparable survival rates at discharge (FETO: 78% vs. non-FETO: 59%, p = 0.23) and at 5-years (FETO: 67% vs. non-FETO: 59%, p = 0.53) between the two cohorts. At a median follow up of 5.8 years, metrics of pulmonary hypertension, pulmonary morbidity, and gastroesophageal reflux disease improved among patients after FETO. However, most FETO patients remained on bronchodilators/inhaled corticosteroids (58%) and were feeding tube dependent (67%). CONCLUSIONS These North American data show that prenatal tracheal occlusion, in conjunction with a long-term multidisciplinary CDH clinic, is associated with acceptable long-term survival and morbidity in children after FETO. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Shelby R Sferra
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Melanie K Nies
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alejandro V Garcia
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Erica I Hodgman
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Annalise B Penikis
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Abigail J Engwall-Gill
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Vera Joanna Burton
- Neurology and Developmental Medicine, Department of Neurology, Johns Hopkins University School of Medicine, Kennedy Krieger Institute, Baltimore, MD, United States
| | - Jessica L Rice
- Division of Pediatric Pulmonary, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Peter J Mogayzel
- Division of Pediatric Pulmonary, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Aghaei Z, Mercer GV, Schneider CM, Sled JG, Macgowan CK, Baschat AA, Kingdom JC, Helm PA, Simpson AJ, Simpson MJ, Jobst KJ, Cahill LS. Maternal exposure to polystyrene microplastics alters placental metabolism in mice. Metabolomics 2022; 19:1. [PMID: 36538272 DOI: 10.1007/s11306-022-01967-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The rapid growth in the worldwide use of plastics has resulted in a vast accumulation of microplastics in the air, soil and water. The impact of these microplastics on pregnancy and fetal development remains largely unknown. In pregnant mice, we recently demonstrated that exposure to micro- and nanoplastics throughout gestation resulted in significant fetal growth restriction. One possible explanation for reduced fetal growth is abnormal placental metabolism. OBJECTIVES To evaluate the effect of maternal exposure to microplastics on placental metabolism. METHODS In the present study, CD-1 pregnant mice were exposed to 5 μm polystyrene microplastics in filtered drinking water at one of four concentrations (0 ng/L (controls), 102 ng/L, 104 ng/L, 106 ng/L) throughout gestation (n = 7-11/group). At embryonic day 17.5, placental tissue samples were collected (n = 28-44/group). Metabolite profiles were determined using 1 H high-resolution magic angle spinning magnetic resonance spectroscopy. RESULTS The relative concentration of lysine (p = 0.003) and glucose (p < 0.0001) in the placenta were found to decrease with increasing microplastic concentrations, with a significant reduction at the highest exposure concentration. Multivariate analysis identified shifts in the metabolic profile with MP exposure and pathway analysis identified perturbations in the biotin metabolism, lysine degradation, and glycolysis/gluconeogenesis pathways. CONCLUSION Maternal exposure to microplastics resulted in significant alterations in placental metabolism. This study highlights the potential impact of microplastic exposure on pregnancy outcomes and that efforts should be made to minimize exposure to plastics, particularly during pregnancy.
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Affiliation(s)
- Zahra Aghaei
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, A1C 5S7, Newfoundland, NL, Canada
| | - Grace V Mercer
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, A1C 5S7, Newfoundland, NL, Canada
| | - Céline M Schneider
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, A1C 5S7, Newfoundland, NL, Canada
| | - John G Sled
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Christopher K Macgowan
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Ahmet A Baschat
- Department of Gynecology & Obstetrics, Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD, USA
| | - John C Kingdom
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Paul A Helm
- School of the Environment, University of Toronto, Toronto, ON, Canada
| | - André J Simpson
- Environmental NMR Centre, Department of Physical and Environmental Sciences, University of Toronto, Toronto, ON, Canada
| | - Myrna J Simpson
- Environmental NMR Centre, Department of Physical and Environmental Sciences, University of Toronto, Toronto, ON, Canada
| | - Karl J Jobst
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, A1C 5S7, Newfoundland, NL, Canada
| | - Lindsay S Cahill
- Department of Chemistry, Memorial University of Newfoundland, Arctic Avenue St. John's, A1C 5S7, Newfoundland, NL, Canada.
- Discipline of Radiology, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada.
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Sferra SR, Miller JL, Cortes M S, Belfort MA, Cruz-Martínez R, Kunisaki SM, Baschat AA. Postnatal care setting and survival after fetoscopic tracheal occlusion for severe congenital diaphragmatic hernia: A systematic review and meta-analysis. J Pediatr Surg 2022; 57:819-825. [PMID: 35680463 DOI: 10.1016/j.jpedsurg.2022.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/03/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fetoscopic endoluminal tracheal occlusion (FETO) was recently shown to improve postnatal survival in a multicenter, randomized controlled trial of infants with severe congenital diaphragmatic hernia (CDH). However, the external validity of this study remains unclear given a lack of standardization in postnatal management approaches. The purpose of this study was to evaluate the impact of an integrated prenatal and postnatal care setting on survival outcomes in severe CDH after FETO. STUDY DESIGN A systematic review, meta-analysis, and individual participant analysis of FETO outcomes in severe CDH were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was survival to discharge. Subgroup analyses of patients managed in integrated versus nonintegrated settings were performed to identify predictors of outcome. RESULTS The review generated five studies (n = 192) for the meta-analysis of FETO versus expectant prenatal management. These data revealed a significant survival benefit after FETO that was restricted to an integrated setting (OR 2.97, 95% Confidence Interval 1.69-4.26). There were nine studies (n = 150) for the individual participant analysis, which showed that FETO managed in an integrated setting had significantly increased survival rates when compared to FETO treated in a nonintegrated setting (70.7% vs. 45.7%, p = 0.003). Multi-level logistic regression identified increased availability of extracorporeal membrane oxygenation (ECMO) as the strongest determinant of postnatal survival (OR=18.8, p = 0.049). CONCLUSION This systematic review shows that institutional integration of prenatal and postnatal care is associated with the highest overall survival in children with severe CDH. These data highlight the importance of a standardized, multidisciplinary approach, including access to ECMO, as a critical postnatal component in optimizing FETO outcomes in CDH.
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Affiliation(s)
- Shelby R Sferra
- Department of Surgery, Division of General Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jena L Miller
- Department of Gynecology and Obstetrics, Johns Hopkins Center for Fetal Therapy, Johns Hopkins University School of Medicine, 600N. Wolfe Street, Baltimore 21287, MD, United States
| | - Sanz Cortes M
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Rogelio Cruz-Martínez
- Department of Maternal Fetal Medicine, Fetal Medicine and Surgery Center, Medicina Fetal Mexico, Santiago de Querétaro, Mexico
| | - Shaun M Kunisaki
- Department of Surgery, Division of General Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, Johns Hopkins Center for Fetal Therapy, Johns Hopkins University School of Medicine, 600N. Wolfe Street, Baltimore 21287, MD, United States.
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Moise KJ, Vlastos EJ, Papanna R, Chmait RH, Baschat AA, Lim FY. Current Status of the Workforce and Training at Fetal Therapy Centers in the North America. Fetal Diagn Ther 2022; 49:333-339. [PMID: 36041413 DOI: 10.1159/000525529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022]
Abstract
An anonymous electronic survey was developed to query the 34 centers in the North American Fetal Treatment Network (NAFTNet) regarding the demographics and training of their faculty. Telephone surveys were conducted with directors of known fetal intervention fellowships. More than 50% of Maternal-Fetal Medicine (MFM) faculty at fetal centers were female; more than two thirds of pediatric surgical faculty were male. Most of the training of faculty was undertaken by visiting more experienced centers or having new faculty work with more experienced ones at the same center. Current fetal intervention fellowships appear to achieve levels of competency for intrauterine transfusions and laser therapy for twin-twin transfusion syndrome. Two thirds of centers stated that they would be able to offer a position to an MFM who completed a formal fellowship in fetal intervention.
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Affiliation(s)
- Kenneth Joseph Moise
- Department of Women's Health, Dell Medical School, UT Health Austin, Comprehensive Fetal Care Center, Dell Children's Medical Center, Austin, Texas, USA
| | - Emanuel Joseph Vlastos
- Obstetrics and Gynecology, University of Missouri-Kansas School of Medicine, Kansas City, Missouri, USA
- Fetal Therapy Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology and Reproductive Medicine, McGovern School of Medicine - UT Health Houston, Houston, Texas, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Keck School of Medicine at the Medical University of Southern California, Los Angeles, California, USA
- Los Angeles Fetal Surgery, CHLA-USC Fetal-Maternal Center, Los Angeles, California, USA
| | - Ahmet A Baschat
- Department of Obstetrics and Gynecology, John Hopkins School of Medicine, Baltimore, Maryland, USA
- Center for Fetal Therapy, Baltimore, Maryland, USA
| | - Foong-Yen Lim
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
- Fetal Care Center, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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Tedjawirja VN, van Klink JM, Haak MC, Klumper FJ, Middeldorp JM, Miller JL, Rosner M, Baschat AA, Lopriore E, Oepkes D. Questionable benefit of intrauterine transfusion following single fetal death in monochorionic twin pregnancy. Ultrasound Obstet Gynecol 2022; 59:824-825. [PMID: 35137996 DOI: 10.1002/uog.24876] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Affiliation(s)
- V N Tedjawirja
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M van Klink
- Department of Medical Psychology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - M Rosner
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - A A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - E Lopriore
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Baschat AA, Blackwell SB, Chatterjee D, Cummings JJ, Emery SP, Hirose S, Hollier LM, Johnson A, Kilpatrick SJ, Luks FI, Menard MK, McCullough LB, Moldenhauer JS, Moon-Grady AJ, Mychaliska GB, Narvey M, Norton ME, Rollins MD, Skarsgard ED, Tsao K, Warner BB, Wilpers A, Ryan G. Care Levels for Fetal Therapy Centers. Obstet Gynecol 2022; 139:1027-1042. [PMID: 35675600 PMCID: PMC9202072 DOI: 10.1097/aog.0000000000004793] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/03/2022] [Indexed: 01/05/2023]
Abstract
Fetal therapies undertaken to improve fetal outcome or to optimize transition to neonate life often entail some level of maternal, fetal, or neonatal risk. A fetal therapy center needs access to resources to carry out such therapies and to manage maternal, fetal, and neonatal complications that might arise, either related to the therapy per se or as part of the underlying fetal or maternal condition. Accordingly, a fetal therapy center requires a dedicated operational infrastructure and necessary resources to allow for appropriate oversight and monitoring of clinical performance and to facilitate multidisciplinary collaboration between the relevant specialties. Three care levels for fetal therapy centers are proposed to match the anticipated care complexity, with appropriate resources to achieve an optimal outcome at an institutional and regional level. A level I fetal therapy center should be capable of offering fetal interventions that may be associated with obstetric risks of preterm birth or membrane rupture but that would be very unlikely to require maternal medical subspecialty or intensive care, with neonatal risks not exceeding those of moderate prematurity. A level II center should have the incremental capacity to provide maternal intensive care and to manage extreme neonatal prematurity. A level III therapy center should offer the full range of fetal interventions (including open fetal surgery) and be able manage any of the associated maternal complications and comorbidities, as well as have access to neonatal and pediatric surgical intervention including indicated surgery for neonates with congenital anomalies.
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Affiliation(s)
- Ahmet A. Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology &Obstetrics, Johns Hopkins University
| | - Sean B Blackwell
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas, Mc Govern Medical School
| | - Debnath Chatterjee
- Department of Anesthesiology, Children’s Hospital Colorado/Colorado Fetal Care Center, University of Colorado School of Medicine
| | | | - Stephen P. Emery
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine
| | - Shinjiro Hirose
- Division of Pediatric, General, Thoracic and Fetal Surgery, Department of Surgery, University of California Davis Medical Center
| | - Lisa M. Hollier
- Division of Maternal-Fetal; Medicine, Department of Obstetrics & Gynecology, Baylor College of Medicine
| | - Anthony Johnson
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas, Mc Govern Medical School
| | | | - Francois I Luks
- Department of Surgery, Alpert Medical School of Brown University and Hasbro Children’s Hospital
| | - M. Kathryn Menard
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill
| | | | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Anita J. Moon-Grady
- Division of Pediatric Cardiology, Department of Clinical Pediatrics, University of California, San Francisco
| | - George B. Mychaliska
- Department of Pediatric Surgery, C.S. Mott Children’s Hospital, University of Michigan
| | - Michael Narvey
- Division of Neonatology, Department of Pediatrics, University of Manitoba
| | - Mary E. Norton
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | | | - Eric D. Skarsgard
- Centre for Surgical Research, Department of Surgery, BC Children’s Hospital, University of British Columbia
| | - KuoJen Tsao
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Texas, Mc Govern Medical School
| | - Barbara B. Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine
| | | | - Greg Ryan
- Ontario Fetal Care Centre, Mount Sinai Hospital, University of Toronto
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Baschat AA, Galan HL, Lee W, DeVore GR, Mari G, Hobbins J, Vintzileos A, Platt LD, Manning FA. The role of the fetal biophysical profile in the management of fetal growth restriction. Am J Obstet Gynecol 2022; 226:475-486. [PMID: 35369904 DOI: 10.1016/j.ajog.2022.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/01/2022]
Abstract
Growth-restricted fetuses are at risk of hypoxemia, acidemia, and stillbirth because of progressive placental dysfunction. Current fetal well-being, neonatal risks following delivery, and the anticipated rate of fetal deterioration are the major management considerations in fetal growth restriction. Surveillance has to quantify the fetal risks accurately to determine the delivery threshold and identify the testing frequency most likely to capture future deterioration and prevent stillbirth. From the second trimester onward, the biophysical profile score correlates over 90% with the current fetal pH, and a normal score predicts a pH >7.25 with a 100% positive predictive value; an abnormal score on the other hand predicts current fetal acidemia with similar certainty. Between 30% and 70% of growth-restricted fetuses with a nonreactive heart rate require biophysical profile scoring to verify fetal well-being, and an abnormal score in 8% to 27% identifies the need for delivery, which is not suspected by Doppler findings. Future fetal well-being is not predicted by the biophysical profile score, which emphasizes the importance of umbilical artery Doppler and amniotic fluid volume to determine surveillance frequency. Studies with integrated surveillance strategies that combine frequent heart rate monitoring with biophysical profile scoring and Doppler report better outcomes and stillbirth rates of between 0% and 4%, compared with those between 8% and 11% with empirically determined surveillance frequency. The variations in clinical behavior and management challenges across gestational age are better addressed when biophysical profile scoring is integrated into the surveillance of fetal growth restriction. This review aims to provide guidance on biophysical profile scoring in the in- and outpatient management of fetal growth restriction.
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Cahill LS, Mercer GV, Jagota D, Ravi Chandran A, Milligan N, Shinar S, Whitehead CL, Hobson SR, Serghides L, Parks WT, Macgowan CK, Kingdom JC, Sled JG, Baschat AA. Doppler Ultrasound of the Fetal Descending Aorta: An Objective Tool to Assess Placental Blood Flow Resistance in Pregnancies With Discordant Umbilical Arteries. J Ultrasound Med 2022; 41:899-905. [PMID: 34228375 PMCID: PMC8733057 DOI: 10.1002/jum.15773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/10/2021] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To determine the relationship between blood flow in the fetal descending aorta and discordant umbilical arteries (UAs). METHODS Pulsed wave Doppler of both UAs and the descending aorta was performed at 4-weekly intervals between 14 and 40 weeks of gestation in 209 pregnant women. In datasets with discordant UAs, a linear mixed effects model was used to determine the categorical relationship between the UA pulsatility index (PI) (high, low and average) and the descending aorta PI. RESULTS Of the 209 cases, 81 had a discordance of greater than 25% in UA PI during one of their visits. There were no differences in birth outcomes between the groups with concordant and discordant UA PIs. In the cases with discordant UA PIs, the descending aorta PI was most strongly associated with both the average UA PI (P = .008), and with the UA with the lower PI (P = .008). CONCLUSIONS The relationship between blood flow in the descending aorta and UAs is consistent with the law for combining resistances in parallel. Measurements of the descending aorta PI, particularly in a scenario with discordant UAs, may inform the stability of the feto-placental circulation where discordant UA PIs are found.
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Affiliation(s)
- Lindsay S Cahill
- Department of Chemistry, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Grace V Mercer
- Department of Chemistry, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Dakshita Jagota
- Department of Chemistry, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | | | - Natasha Milligan
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Clare L Whitehead
- Pregnancy Research Centre, Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Australia
| | | | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - W Tony Parks
- Department of Pathology, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Christopher K Macgowan
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - John C Kingdom
- Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - John G Sled
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ahmet A Baschat
- Centre for Fetal Therapy, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Baschat AA, Miller JL. Pathophysiology, diagnosis, and management of twin anemia polycythemia sequence in monochorionic multiple gestations. Best Pract Res Clin Obstet Gynaecol 2022; 84:115-126. [PMID: 35450772 DOI: 10.1016/j.bpobgyn.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/11/2022] [Indexed: 11/02/2022]
Abstract
Twin anemia polycythemia sequence (TAPS) is a consequence of unequal sharing of red blood cells between monochorionic twins resulting in anemia in the donor and polycythemia in the recipient twin. Prenatally TAPS can occur spontaneously or complicate incomplete laser surgery for twin transfusion syndrome. While there may be clinical overlap with twin transfusion syndrome or selective fetal growth restriction, diagnosis relies on Doppler measurement of middle cerebral artery peak systolic velocities. Significantly discordant velocities are diagnostic, while severity staging is based on signs of cardiovascular compromise. Conservative management, fetoscopic laser coagulation, selective twin reduction, fetal blood and exchange transfusion, and delivery may be selected guided by the gestational age of diagnosis, the severity of the condition, the likelihood of success, and the patients' priorities. Prenatal curative treatment that minimizes the risk for prematurity and residual morbidity at birth is most likely to offer the greatest short-term and long-term benefits.
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Affiliation(s)
- Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, USA.
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, USA
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Lees CC, Romero R, Stampalija T, Dall'Asta A, DeVore GA, Prefumo F, Frusca T, Visser GHA, Hobbins JC, Baschat AA, Bilardo CM, Galan HL, Campbell S, Maulik D, Figueras F, Lee W, Unterscheider J, Valensise H, Da Silva Costa F, Salomon LJ, Poon LC, Ferrazzi E, Mari G, Rizzo G, Kingdom JC, Kiserud T, Hecher K. Clinical Opinion: The diagnosis and management of suspected fetal growth restriction: an evidence-based approach. Am J Obstet Gynecol 2022; 226:366-378. [PMID: 35026129 PMCID: PMC9125563 DOI: 10.1016/j.ajog.2021.11.1357] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/01/2022]
Abstract
This study reviewed the literature about the diagnosis, antepartum surveillance, and time of delivery of fetuses suspected to be small for gestational age or growth restricted. Several guidelines have been issued by major professional organizations, including the International Society of Ultrasound in Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine. The differences in recommendations, in particular about Doppler velocimetry of the ductus venosus and middle cerebral artery, have created confusion among clinicians, and this review has intended to clarify and highlight the available evidence that is pertinent to clinical management. A fetus who is small for gestational age is frequently defined as one with an estimated fetal weight of <10th percentile. This condition has been considered syndromic and has been frequently attributed to fetal growth restriction, a constitutionally small fetus, congenital infections, chromosomal abnormalities, or genetic conditions. Small for gestational age is not synonymous with fetal growth restriction, which is defined by deceleration of fetal growth determined by a change in fetal growth velocity. An abnormal umbilical artery Doppler pulsatility index reflects an increased impedance to flow in the umbilical circulation and is considered to be an indicator of placental disease. The combined finding of an estimated fetal weight of <10th percentile and abnormal umbilical artery Doppler velocimetry has been widely accepted as indicative of fetal growth restriction. Clinical studies have shown that the gestational age at diagnosis can be used to subclassify suspected fetal growth restriction into early and late, depending on whether the condition is diagnosed before or after 32 weeks of gestation. The early type is associated with umbilical artery Doppler abnormalities, whereas the late type is often associated with a low pulsatility index in the middle cerebral artery. A large randomized clinical trial indicated that in the context of early suspected fetal growth restriction, the combination of computerized cardiotocography and fetal ductus venosus Doppler improves outcomes, such that 95% of surviving infants have a normal neurodevelopmental outcome at 2 years of age. A low middle cerebral artery pulsatility index is associated with an adverse perinatal outcome in late fetal growth restriction; however, there is no evidence supporting its use to determine the time of delivery. Nonetheless, an abnormality in middle cerebral artery Doppler could be valuable to increase the surveillance of the fetus at risk. We propose that fetal size, growth rate, uteroplacental Doppler indices, cardiotocography, and maternal conditions (ie, hypertension) according to gestational age are important factors in optimizing the outcome of suspected fetal growth restriction.
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Affiliation(s)
- Christoph C Lees
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
| | - Tamara Stampalija
- Department of Obstetrics and Gynecology, Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, Scientific Institute for Research, Hospitalization and Healthcare Burlo Garofolo, Trieste, Italy; Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Andrea Dall'Asta
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Greggory A DeVore
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Federico Prefumo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Tiziana Frusca
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Gerard H A Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - John C Hobbins
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, John Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD
| | - Caterina M Bilardo
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, the Netherlands
| | - Henry L Galan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital of Colorado, Aurora, CO
| | | | - Dev Maulik
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Francesc Figueras
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX
| | - Julia Unterscheider
- Department of Maternal-Fetal Medicine, Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Australia
| | - Herbert Valensise
- University of Rome Tor Vergata, Rome, Italy; Department of Surgery, Policlinico Casilino, Rome, Italy
| | - Fabricio Da Silva Costa
- Maternal-Fetal Medicine Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia; School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Laurent J Salomon
- Obstétrique et Plateforme LUMIERE, Hôpital Necker-Enfants Malades (AP-HP) et Université de Paris, Paris, France
| | - Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, Special Administrative Region of China
| | - Enrico Ferrazzi
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giancarlo Mari
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Giuseppe Rizzo
- Università di Roma Tor Vergata, Department of Obstetrics and Gynecology, Fondazione Policinico Tor Vergata, Rome, Italy; The First I.M. Sechenov Moscow State Medical University, Department of Obstetrics and Gynaecology, Moscow, Russian Federation
| | - John C Kingdom
- Placenta Program, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Torvid Kiserud
- Department of Obstetrics and Gynecology, Haukeland University Hospital, and Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Faden MS, Laurie M, Miller JL, Millard S, Rosner M, Baschat AA. Precise anatomical definition of fetal spina bifida using standardized three-dimensional annotation-assisted multiplanar volume contrast ultrasound imaging. Ultrasound Obstet Gynecol 2022; 59:122-124. [PMID: 34254390 DOI: 10.1002/uog.23737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/15/2021] [Accepted: 07/01/2021] [Indexed: 06/13/2023]
Affiliation(s)
- M S Faden
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M Laurie
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J L Miller
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S Millard
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M Rosner
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A A Baschat
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Allotey J, Snell KI, Smuk M, Hooper R, Chan CL, Ahmed A, Chappell LC, von Dadelszen P, Dodds J, Green M, Kenny L, Khalil A, Khan KS, Mol BW, Myers J, Poston L, Thilaganathan B, Staff AC, Smith GC, Ganzevoort W, Laivuori H, Odibo AO, Ramírez JA, Kingdom J, Daskalakis G, Farrar D, Baschat AA, Seed PT, Prefumo F, da Silva Costa F, Groen H, Audibert F, Masse J, Skråstad RB, Salvesen KÅ, Haavaldsen C, Nagata C, Rumbold AR, Heinonen S, Askie LM, Smits LJ, Vinter CA, Magnus PM, Eero K, Villa PM, Jenum AK, Andersen LB, Norman JE, Ohkuchi A, Eskild A, Bhattacharya S, McAuliffe FM, Galindo A, Herraiz I, Carbillon L, Klipstein-Grobusch K, Yeo S, Teede HJ, Browne JL, Moons KG, Riley RD, Thangaratinam S. Validation and development of models using clinical, biochemical and ultrasound markers for predicting pre-eclampsia: an individual participant data meta-analysis. Health Technol Assess 2021; 24:1-252. [PMID: 33336645 DOI: 10.3310/hta24720] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk is needed to plan management. OBJECTIVES To assess the performance of existing pre-eclampsia prediction models and to develop and validate models for pre-eclampsia using individual participant data meta-analysis. We also estimated the prognostic value of individual markers. DESIGN This was an individual participant data meta-analysis of cohort studies. SETTING Source data from secondary and tertiary care. PREDICTORS We identified predictors from systematic reviews, and prioritised for importance in an international survey. PRIMARY OUTCOMES Early-onset (delivery at < 34 weeks' gestation), late-onset (delivery at ≥ 34 weeks' gestation) and any-onset pre-eclampsia. ANALYSIS We externally validated existing prediction models in UK cohorts and reported their performance in terms of discrimination and calibration. We developed and validated 12 new models based on clinical characteristics, clinical characteristics and biochemical markers, and clinical characteristics and ultrasound markers in the first and second trimesters. We summarised the data set-specific performance of each model using a random-effects meta-analysis. Discrimination was considered promising for C-statistics of ≥ 0.7, and calibration was considered good if the slope was near 1 and calibration-in-the-large was near 0. Heterogeneity was quantified using I 2 and τ2. A decision curve analysis was undertaken to determine the clinical utility (net benefit) of the models. We reported the unadjusted prognostic value of individual predictors for pre-eclampsia as odds ratios with 95% confidence and prediction intervals. RESULTS The International Prediction of Pregnancy Complications network comprised 78 studies (3,570,993 singleton pregnancies) identified from systematic reviews of tests to predict pre-eclampsia. Twenty-four of the 131 published prediction models could be validated in 11 UK cohorts. Summary C-statistics were between 0.6 and 0.7 for most models, and calibration was generally poor owing to large between-study heterogeneity, suggesting model overfitting. The clinical utility of the models varied between showing net harm to showing minimal or no net benefit. The average discrimination for IPPIC models ranged between 0.68 and 0.83. This was highest for the second-trimester clinical characteristics and biochemical markers model to predict early-onset pre-eclampsia, and lowest for the first-trimester clinical characteristics models to predict any pre-eclampsia. Calibration performance was heterogeneous across studies. Net benefit was observed for International Prediction of Pregnancy Complications first and second-trimester clinical characteristics and clinical characteristics and biochemical markers models predicting any pre-eclampsia, when validated in singleton nulliparous women managed in the UK NHS. History of hypertension, parity, smoking, mode of conception, placental growth factor and uterine artery pulsatility index had the strongest unadjusted associations with pre-eclampsia. LIMITATIONS Variations in study population characteristics, type of predictors reported, too few events in some validation cohorts and the type of measurements contributed to heterogeneity in performance of the International Prediction of Pregnancy Complications models. Some published models were not validated because model predictors were unavailable in the individual participant data. CONCLUSION For models that could be validated, predictive performance was generally poor across data sets. Although the International Prediction of Pregnancy Complications models show good predictive performance on average, and in the singleton nulliparous population, heterogeneity in calibration performance is likely across settings. FUTURE WORK Recalibration of model parameters within populations may improve calibration performance. Additional strong predictors need to be identified to improve model performance and consistency. Validation, including examination of calibration heterogeneity, is required for the models we could not validate. STUDY REGISTRATION This study is registered as PROSPERO CRD42015029349. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 72. See the NIHR Journals Library website for further project information.
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Miller JL, Groves ML, Ahn ES, Berman DJ, Murphy JD, Rosner MK, Wolfson D, Jelin EB, Korth SA, Keiser AM, Laurie M, Millard SE, Tekes A, Baschat AA. Implementation Process and Evolution of a Laparotomy-Assisted 2-Port Fetoscopic Spina Bifida Closure Program. Fetal Diagn Ther 2021; 48:603-610. [PMID: 34518445 DOI: 10.1159/000518507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Prenatal closure of open spina bifida via open fetal surgery improves neurologic outcomes for infants in selected pregnancies. Fetoscopic techniques that are minimally invasive to the uterus aim to provide equivalent fetal benefits while minimizing maternal morbidities, but the optimal technique is undetermined. We describe the development, evolution, and feasibility of the laparotomy-assisted 2-port fetoscopic technique for prenatal closure of fetal spina bifida in a newly established program. METHODS We conducted a retrospective cohort study of women consented for laparotomy-assisted fetoscopic closure of isolated fetal spina bifida. Inclusion and exclusion criteria followed the Management of Myelomeningocele Study (MOMS). Team preparation involved observation at the originating center, protocol development, ancillary staff training, and surgical rehearsal using patient-matched models through simulation prior to program implementation. The primary outcome was the ability to complete the repair fetoscopically. Secondary maternal and fetal outcomes to assess performance of the technique were collected prospectively. RESULTS Of 57 women screened, 19 (33%) consented for laparotomy-assisted 2-port fetoscopy between February 2017 and December 2019. Fetoscopic closure was completed in 84% (16/19) cases. Over time, the technique was modified from a single- to a multilayer closure. In utero hindbrain herniation improved in 86% (12/14) of undelivered patients at 6 weeks postoperatively. Spontaneous rupture of membranes occurred in 31% (5/16) of fetoscopic cases. For completed cases, median gestational age at birth was 37 (range 27-39.6) weeks and 50% (8/16) of women delivered at term. Vaginal birth was achieved in 56% (9/16) of patients. One newborn had a cerebrospinal fluid leak that required postnatal surgical repair. CONCLUSION Implementation of a laparotomy-assisted 2-port fetoscopic spina bifida closure program through rigorous preparation and multispecialty team training may accelerate the learning curve and demonstrates favorable obstetric and perinatal outcomes.
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Affiliation(s)
- Jena L Miller
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mari L Groves
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Edward S Ahn
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David J Berman
- Division of Obstetric, Gynecologic and Fetal Anesthesiology, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jamie D Murphy
- Division of Obstetric, Gynecologic and Fetal Anesthesiology, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mara K Rosner
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Denise Wolfson
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric B Jelin
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sarah A Korth
- Keelty Center for Spina Bifida and Related Conditions, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Amaris M Keiser
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Melissa Laurie
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sarah E Millard
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Aylin Tekes
- Division of Pediatric Radiology and Pediatric Neuroradiology, Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet A Baschat
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
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Darwin KC, Federspiel JJ, Schuh BL, Baschat AA, Vaught AJ. ACC-AHA Diagnostic Criteria for Hypertension in Pregnancy Identifies Patients at Intermediate Risk of Adverse Outcomes. Am J Perinatol 2021; 38:e249-e255. [PMID: 32446257 PMCID: PMC8923636 DOI: 10.1055/s-0040-1709465] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The aim of the study is to compare maternal and neonatal outcomes among patients who are normotensive, hypertensive by Stage I American College of Cardiology-American Heart Association (ACC-AHA) criteria, and hypertensive by American College of Obstetricians and Gynecologists (ACOG) criteria. STUDY DESIGN Secondary analysis of a prospective first trimester cohort study between 2007 and 2010 at three institutions in Baltimore, MD, was conducted. Blood pressure at 11 to 14 weeks' gestation was classified as (1) normotensive (systolic blood pressure [SBP] <130 mm Hg and diastolic blood pressure [DBP] <80 mm Hg); (2) hypertensive by Stage I ACC-AHA criteria (SBP 130-139 mm Hg or DBP 80-89 mm Hg); or (3) hypertensive by ACOG criteria (SBP ≥140 mm Hg or DBP ≥90 mm Hg). Primary outcomes included preeclampsia, small for gestational age (SGA) neonate, and preterm birth. RESULTS Among 3,422 women enrolled, 2,976 with delivery data from singleton pregnancies of nonanomalous fetuses were included. In total, 20.2% met hypertension criteria (Stage I ACC-AHA n = 254, 8.5%; ACOG n = 347, 11.7%). The Stage I ACC-AHA group's risk for developing preeclampsia was threefold higher than the normotensive group (adjusted relative risk [aRR] 3.70, 95% confidence interval [CI] 2.40-5.70). The Stage I ACC-AHA group had lower preeclampsia risk than the ACOG group but the difference was not significant (aRR 0.87, 95% CI 0.55-1.37). The Stage I ACC-AHA group was more likely than the normotensive group to deliver preterm (aRR 1.44, 95% CI 1.02-2.01) and deliver an SGA neonate (aRR 1.51, 95% CI 1.07-2.12). The Stage I ACC-AHA group was less likely to deliver preterm compared with the ACOG group (aRR 0.65, 95% CI 0.45-0.93), but differences in SGA were not significant (aRR 1.31, 95% CI 0.84-2.03). CONCLUSION Pregnant patients with Stage I ACC-AHA hypertension in the first trimester had higher rates of preeclampsia, preterm birth, and SGA neonates compared with normotensive women. Adverse maternal and neonatal outcomes were numerically lower in the Stage I ACC-AHA group compared with the ACOG group, but these comparisons only reached statistical significance for preterm birth. Optimal pregnancy management for first trimester Stage I ACC-AHA hypertension requires active study. KEY POINTS · Women with first trimester American College of Cardiology-American Heart Association (ACC-AHA) Stage I hypertension were more likely to develop preeclampsia, deliver preterm, and deliver a small-for-gestational age neonate than normotensive women.. · Women with first trimester American College of Obstetricians and Gynecologists (ACOG) hypertension (consistent with stage II ACC-AHA hypertension) had the highest numeric rate of adverse outcomes; however, compared with Stage I ACC-AHA hypertension, there was only statistically significant difference for preterm delivery.. · The risk profile for pregnant women with Stage I ACC-AHA hypertension and women with hypertension by conventional ACOG criteria may be more similar than previously understood..
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Affiliation(s)
- Kristin C. Darwin
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jerome J. Federspiel
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Brittany L. Schuh
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmet A. Baschat
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arthur J. Vaught
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Verweij EJ, de Vries MC, Oldekamp EJ, Eggink AJ, Oepkes D, Slaghekke F, Spoor JKH, Deprest JA, Miller JL, Baschat AA, DeKoninck PLJ. Fetoscopic myelomeningocoele closure: Is the scientific evidence enough to challenge the gold standard for prenatal surgery? Prenat Diagn 2021; 41:949-956. [PMID: 33778976 PMCID: PMC8360048 DOI: 10.1002/pd.5940] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022]
Abstract
Since the completion of the Management of Myelomeningocoele Study, maternal-fetal surgery for spina bifida has become a valid option for expecting parents. More recently, multiple groups are exploring a minimally invasive approach and recent outcomes have addressed many of the initial concerns with this approach. Based on a previously published framework, we attempt to delineate the developmental stage of the surgical techniques. Furthermore, we discuss the barriers of performing randomized controlled trials comparing two surgical interventions and suggest that data collection through registries is an alternative method to gather high-grade evidence.
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Affiliation(s)
- E Joanne Verweij
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther J Oldekamp
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem K H Spoor
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan A Deprest
- Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Jagota D, George H, Walker M, Ravi Chandran A, Milligan N, Shinar S, Whitehead CL, Hobson SR, Serghides L, Parks WT, Baschat AA, Macgowan CK, Sled JG, Kingdom JC, Cahill LS. Sex differences in fetal Doppler parameters during gestation. Biol Sex Differ 2021; 12:26. [PMID: 33691774 PMCID: PMC7944891 DOI: 10.1186/s13293-021-00370-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Fetal sex is known to affect pregnancy outcomes. In current clinical practice, monitoring of fetal well-being is based on Doppler ultrasound measurements of major placental and fetal vessels. The objective of this study was to investigate the effect of fetal sex on Doppler parameters throughout gestation in healthy pregnancy. METHODS A prospective study was conducted in 240 pregnant women with ultrasound examinations at a 4-weekly interval between 12 and 38 weeks of gestation. Pulsed Doppler spectra were collected for the umbilical arteries (UAs), middle cerebral artery (MCA), descending abdominal aorta (DAo), and ductus venosus (DV). Linear mixed effects models were used to determine if the pulsatility indices (PIs) of these vessels depended on gestational age and fetal sex. RESULTS While there were no differences in the MCA PI and DV PIV over gestation between female and male fetuses, the trajectory of the UA and DAo PIs differed by fetal sex (p = 0.02 and p = 0.01, respectively). CONCLUSIONS Doppler ultrasound parameters were found to be dependent on fetal sex for some vessels and not for others in healthy pregnancies. Further investigations are needed to understand the physiological mechanisms for these sex differences and the relevance for disease processes in pregnancy.
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Affiliation(s)
- Dakshita Jagota
- Department of Chemistry, Memorial University of Newfoundland, 283 Prince Philip Drive, St. John's, NL, A1B 3X7, Canada
| | - Hannah George
- Department of Chemistry, Memorial University of Newfoundland, 283 Prince Philip Drive, St. John's, NL, A1B 3X7, Canada
| | - Melissa Walker
- Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | | | - Natasha Milligan
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Clare L Whitehead
- Pregnancy Research Centre, Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Australia
| | | | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - W Tony Parks
- Department of Pathology, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ahmet A Baschat
- Centre for Fetal Therapy, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Christopher K Macgowan
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - John G Sled
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - John C Kingdom
- Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Lindsay S Cahill
- Department of Chemistry, Memorial University of Newfoundland, 283 Prince Philip Drive, St. John's, NL, A1B 3X7, Canada.
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Paranavitana L, Walker M, Chandran AR, Milligan N, Shinar S, Whitehead CL, Hobson SR, Serghides L, Parks WT, Baschat AA, Macgowan CK, Sled JG, Kingdom JC, Cahill LS. Sex differences in uterine artery Doppler during gestation in pregnancies complicated by placental dysfunction. Biol Sex Differ 2021; 12:19. [PMID: 33531040 PMCID: PMC7852081 DOI: 10.1186/s13293-021-00362-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/20/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND There is growing evidence of sex differences in placental vascular development. The objective of this study was to investigate the effect of fetal sex on uterine artery pulsatility index (PI) throughout gestation in a cohort of normal and complicated pregnancies. METHODS A prospective longitudinal study was conducted in 240 pregnant women. Pulsed wave Doppler ultrasound of the proximal uterine arteries was performed at a 4-weekly interval between 14 and 40 weeks of gestation. The patients were classified retrospectively as normal or complicated (one or more of maternal preeclampsia, preterm birth, or small for gestational age). To assess if the change in uterine artery PI during gestation differed between normal and complicated pregnancies and between fetal sexes, the uterine artery PI was modeled using a linear function of gestational age and the rate of change was estimated from the slope. RESULTS While the uterine artery PI did not differ over gestation between females and males for normal pregnancies, the trajectory of this index differed by fetal sex for pregnancies complicated by either preeclampsia, preterm birth, or fetal growth restriction (p < 0.0001). The male fetuses in the complicated pregnancy group had an elevated slope compared to the other groups (p < 0.0001), suggesting a more progressive deterioration in uteroplacental perfusion over gestation. CONCLUSIONS The uterine artery PI is widely used to assess uteroplacental function in clinical settings. The observation that this metric changes more rapidly in complicated pregnancies where the fetus was male highlights the importance of sex when interpreting hemodynamic markers of placental maturation.
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Affiliation(s)
- Leah Paranavitana
- Department of Chemistry, Memorial University of Newfoundland, 283 Prince Philip Drive, St John's, Newfoundland and Labrador, A1B 3X7, Canada
| | - Melissa Walker
- Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | | | - Natasha Milligan
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Clare L Whitehead
- Pregnancy Research Centre, Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Australia
| | | | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - W Tony Parks
- Department of Pathology, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ahmet A Baschat
- Centre for Fetal Therapy, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Christopher K Macgowan
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - John G Sled
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - John C Kingdom
- Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Lindsay S Cahill
- Department of Chemistry, Memorial University of Newfoundland, 283 Prince Philip Drive, St John's, Newfoundland and Labrador, A1B 3X7, Canada.
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Buskmiller C, Bergh EP, Miller JL, Baschat AA, Galan HL, Behrendt NJ, Habli M, Piero JL, Snowise S, Fisher J, MacPherson C, Thom E, Johnson A, Blackwell SC, Papanna R. 85 Prevention of preterm delivery after fetoscopy for twin-twin transfusion: a multicenter prospective cohort study. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Cahill LS, Stortz G, Chandran AR, Milligan N, Shinar S, Whitehead CL, Hobson SR, Millard S, Macgowan CK, Kingdom JC, Sled JG, Baschat AA. Determination of fetal heart rate short-term variation from umbilical artery Doppler waveforms. Ultrasound Obstet Gynecol 2021; 57:70-74. [PMID: 33030756 PMCID: PMC7779755 DOI: 10.1002/uog.23145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To evaluate the feasibility of using umbilical artery (UA) Doppler waveforms to measure fetal heart rate (FHR) short-term variation (STV) across gestation. METHODS This was a prospective longitudinal study, conducted at two study sites, of 195 pregnancies considered low risk. Pulsed-wave Doppler of the UAs was performed at 4-weekly intervals, between 14 and 40 weeks of gestation, using a standardized imaging protocol. Up to 12 consecutive UA Doppler waveforms were analyzed using offline processing software. FHR STV was calculated using average R-R intervals extracted from the waveforms and baseline corrected for FHR. RESULTS Baseline-corrected FHR STV increased significantly with gestational age (conditional R2 = 0.37; P < 0.0001) and was correlated inversely with FHR (conditional R2 = 0.54; P < 0.0001). The STV ranged (median (interquartile range)) from 3.5 (2.9-4.1) ms at 14-20 weeks' gestation to 6.3 (4.8-7.7) ms at 34-40 weeks' gestation. The change in heart rate STV did not differ between study sites or individual sonographers. CONCLUSIONS UA Doppler waveforms offer a robust and feasible method to derive STV of the FHR. It should be emphasized that the UA Doppler-derived STV is not interchangeable with measurements derived with computerized cardiotocography. Accordingly, further investigations are needed to validate associations with outcome, in order to determine the value of concurrent fetal cardiovascular and heart rate evaluations that are possible with the technique described here. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Lindsay S. Cahill
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Chemistry, Memorial University of Newfoundland, St John’s, Newfoundland and Labrador, Canada
| | - Greg Stortz
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anjana Ravi Chandran
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Natasha Milligan
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shiri Shinar
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Clare L. Whitehead
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
- Pregnancy Research Centre, Department of Obstetrics and Gynaecology, Royal Women’s Hospital, Parkville, Australia
| | - Sebastian R. Hobson
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sarah Millard
- Centre for Fetal Therapy, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Christopher K. Macgowan
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - John C. Kingdom
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - John G. Sled
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Ahmet A. Baschat
- Centre for Fetal Therapy, Johns Hopkins Medicine, Baltimore, Maryland, USA
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44
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Baschat AA. Considering evidence in the management of fetal growth restriction. Ultrasound Obstet Gynecol 2021; 57:25-28. [PMID: 33387406 DOI: 10.1002/uog.23557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 06/12/2023]
Affiliation(s)
- A A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Snell KIE, Allotey J, Smuk M, Hooper R, Chan C, Ahmed A, Chappell LC, Von Dadelszen P, Green M, Kenny L, Khalil A, Khan KS, Mol BW, Myers J, Poston L, Thilaganathan B, Staff AC, Smith GCS, Ganzevoort W, Laivuori H, Odibo AO, Arenas Ramírez J, Kingdom J, Daskalakis G, Farrar D, Baschat AA, Seed PT, Prefumo F, da Silva Costa F, Groen H, Audibert F, Masse J, Skråstad RB, Salvesen KÅ, Haavaldsen C, Nagata C, Rumbold AR, Heinonen S, Askie LM, Smits LJM, Vinter CA, Magnus P, Eero K, Villa PM, Jenum AK, Andersen LB, Norman JE, Ohkuchi A, Eskild A, Bhattacharya S, McAuliffe FM, Galindo A, Herraiz I, Carbillon L, Klipstein-Grobusch K, Yeo SA, Browne JL, Moons KGM, Riley RD, Thangaratinam S. External validation of prognostic models predicting pre-eclampsia: individual participant data meta-analysis. BMC Med 2020; 18:302. [PMID: 33131506 PMCID: PMC7604970 DOI: 10.1186/s12916-020-01766-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/26/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk during pregnancy is required to plan management. Although there are many published prediction models for pre-eclampsia, few have been validated in external data. Our objective was to externally validate published prediction models for pre-eclampsia using individual participant data (IPD) from UK studies, to evaluate whether any of the models can accurately predict the condition when used within the UK healthcare setting. METHODS IPD from 11 UK cohort studies (217,415 pregnant women) within the International Prediction of Pregnancy Complications (IPPIC) pre-eclampsia network contributed to external validation of published prediction models, identified by systematic review. Cohorts that measured all predictor variables in at least one of the identified models and reported pre-eclampsia as an outcome were included for validation. We reported the model predictive performance as discrimination (C-statistic), calibration (calibration plots, calibration slope, calibration-in-the-large), and net benefit. Performance measures were estimated separately in each available study and then, where possible, combined across studies in a random-effects meta-analysis. RESULTS Of 131 published models, 67 provided the full model equation and 24 could be validated in 11 UK cohorts. Most of the models showed modest discrimination with summary C-statistics between 0.6 and 0.7. The calibration of the predicted compared to observed risk was generally poor for most models with observed calibration slopes less than 1, indicating that predictions were generally too extreme, although confidence intervals were wide. There was large between-study heterogeneity in each model's calibration-in-the-large, suggesting poor calibration of the predicted overall risk across populations. In a subset of models, the net benefit of using the models to inform clinical decisions appeared small and limited to probability thresholds between 5 and 7%. CONCLUSIONS The evaluated models had modest predictive performance, with key limitations such as poor calibration (likely due to overfitting in the original development datasets), substantial heterogeneity, and small net benefit across settings. The evidence to support the use of these prediction models for pre-eclampsia in clinical decision-making is limited. Any models that we could not validate should be examined in terms of their predictive performance, net benefit, and heterogeneity across multiple UK settings before consideration for use in practice. TRIAL REGISTRATION PROSPERO ID: CRD42015029349 .
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Affiliation(s)
- Kym I E Snell
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Keele, UK.
| | - John Allotey
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Melanie Smuk
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Richard Hooper
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Claire Chan
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Asif Ahmed
- MirZyme Therapeutics, Innovation Birmingham Campus, Birmingham, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter Von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Marcus Green
- Action on Pre-eclampsia (APEC) Charity, Worcestershire, UK
| | - Louise Kenny
- Faculty Health & Life Sciences, University of Liverpool, Liverpool, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Khalid S Khan
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - Jenny Myers
- Maternal and Fetal Health Research Centre, Manchester Academic Health Science Centre, University of Manchester, Central Manchester NHS Trust, Manchester, UK
| | - Lucilla Poston
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Anne C Staff
- Division of Obstetrics and Gynaecology, Oslo University Hospital, and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, NIHR Biomedical Research Centre, Cambridge University, Cambridge, UK
| | - Wessel Ganzevoort
- Department of Obstetrics, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Hannele Laivuori
- Department of Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Technology, Tampere University Hospital and Tampere University, Tampere, Finland
| | | | - Javier Arenas Ramírez
- Department of Obstetrics and Gynaecology, University Hospital de Cabueñes, Gijón, Spain
| | - John Kingdom
- Maternal-Fetal Medicine Division, Department OBGYN, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - George Daskalakis
- Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Diane Farrar
- Bradford Institute for Health Research, Bradford Teaching Hospitals, Bradford, UK
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Federico Prefumo
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
| | - Fabricio da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Francois Audibert
- Department of Obstetrics and Gynecology, CHU Ste Justine, Université de Montréal, Montreal, Canada
| | - Jacques Masse
- Department of Molecular Biology, Medical Biochemistry and Pathology, Laval University, Quebec City, Canada
| | - Ragnhild B Skråstad
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology - NTNU, Trondheim, Norway
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
| | - Kjell Å Salvesen
- Department of Obstetrics and Gynecology, Trondheim University Hospital, Trondheim, Norway
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Camilla Haavaldsen
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
| | - Chie Nagata
- Department of Education for Clinical Research, National Center for Child Health and Development, Tokyo, Japan
| | - Alice R Rumbold
- South Australian Health and Medical Research Institute and Robinson Research Institute, The University of Adelaide, Adelaide, Australia
| | - Seppo Heinonen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lisa M Askie
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Luc J M Smits
- Care and Public Health Research Institute, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Christina A Vinter
- Department of Gynecology and Obstetrics, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Per Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Kajantie Eero
- National Institute for Health and Welfare, Helsinki, Finland
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pia M Villa
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne K Jenum
- General Practice Research Unit (AFE), Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Louise B Andersen
- Institute for Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - Jane E Norman
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Akihide Ohkuchi
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Shimotsuke-shi, Tochigi, Japan
| | - Anne Eskild
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Sohinee Bhattacharya
- Obstetrics & Gynaecology, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Alberto Galindo
- Fetal Medicine Unit, Maternal and Child Health and Development Network (SAMID), Department of Obstetrics and Gynaecology, Hospital Universitario, Instituto de Investigación Hospital, Universidad Complutense de Madrid, Madrid, Spain
| | - Ignacio Herraiz
- Fetal Medicine Unit, Maternal and Child Health and Development Network (SAMID), Department of Obstetrics and Gynaecology, Hospital Universitario, Instituto de Investigación Hospital, Universidad Complutense de Madrid, Madrid, Spain
| | - Lionel Carbillon
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris Université Paris, Paris, France
| | - Kerstin Klipstein-Grobusch
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Seon Ae Yeo
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joyce L Browne
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karel G M Moons
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Cochrane Netherlands, Utrecht, The Netherlands
| | - Richard D Riley
- Centre for Prognosis Research, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, WHO Collaborating Centre for Women's Health, University of Birmingham, Birmingham, UK
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Kelleher MA, Lee JY, Roberts VHJ, Novak CM, Baschat AA, Morgan TK, Novy MJ, Räsänen JP, Frias AE, Burd I. Maternal azithromycin therapy for Ureaplasma parvum intraamniotic infection improves fetal hemodynamics in a nonhuman primate model. Am J Obstet Gynecol 2020; 223:578.e1-578.e11. [PMID: 32343954 PMCID: PMC7591241 DOI: 10.1016/j.ajog.2020.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 04/09/2020] [Accepted: 04/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ureaplasma parvum infection is a prevalent cause of intrauterine infection associated with preterm birth, preterm premature rupture of membranes, fetal inflammatory response syndrome, and adverse postnatal sequelae. Elucidation of diagnostic and treatment strategies for infection-associated preterm labor may improve perinatal and long-term outcomes for these cases. OBJECTIVE This study assessed the effect of intraamniotic Ureaplasma infection on fetal hemodynamic and cardiac function and the effect of maternal antibiotic treatment on these outcomes. STUDY DESIGN Chronically catheterized pregnant rhesus monkeys were assigned to control (n=6), intraamniotic inoculation with Ureaplasma parvum (107 colony-forming units/mL, n=15), and intraamniotic infection plus azithromycin treatment (12.5 mg/kg twice a day intravenously, n=8) groups. At approximately 135 days' gestation (term=165 days), pulsed and color Doppler ultrasonography was used to obtain measurements of fetal hemodynamics (pulsatility index of umbilical artery, ductus venosus, descending aorta, ductus arteriosus, aortic isthmus, right pulmonary artery, middle cerebral artery and cerebroplacental ratio, and left and right ventricular cardiac outputs) and cardiac function (ratio of peak early vs late transmitral flow velocity [marker of ventricular function], Tei index [myocardial performance index]). These indices were stratified by amniotic fluid proinflammatory mediator levels and cardiac histology. RESULTS Umbilical and fetal pulmonary artery vascular impedances were significantly increased in animals from the intraamniotic inoculation with Ureaplasma parvum group (P<.05). Azithromycin treatment restored values to control levels. Amniotic fluid prostaglandin F2 alpha levels were significantly higher in animals with abnormal umbilical artery pulsatility index (>1.1) than in those with normal blood flow (P<.05; Spearman ρ=0.6, P<.05). In the intraamniotic inoculation with Ureaplasma parvum group, left ventricular cardiac output was significantly decreased (P<.001), and more animals had abnormal right-to-left ventricular cardiac output ratios (defined as >1.6, P<.05). Amniotic fluid interleukin-6 concentrations were elevated in cases of abnormal right-to-left ventricular cardiac output ratios compared with those in normal cases (P<.05). CONCLUSION Fetal hemodynamic alterations were associated with intraamniotic Ureaplasma infection and ameliorated after maternal antibiotic treatment. Doppler ultrasonographic measurements merit continuing investigation as a diagnostic method to identify fetal cardiovascular and hemodynamic compromise associated with intrauterine infection or inflammation and in the evaluation of therapeutic interventions or clinical management of preterm labor.
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Affiliation(s)
- Meredith A Kelleher
- Division of Reproductive and Development Sciences, Oregon National Primate Research Center, Beaverton, OR.
| | - Ji Yeon Lee
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victoria H J Roberts
- Division of Reproductive and Development Sciences, Oregon National Primate Research Center, Beaverton, OR
| | - Christopher M Novak
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Terry K Morgan
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Miles J Novy
- Division of Reproductive and Development Sciences, Oregon National Primate Research Center, Beaverton, OR
| | - Juha P Räsänen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR; University of Helsinki, Helsinki, Finland
| | - Antonio E Frias
- Division of Reproductive and Development Sciences, Oregon National Primate Research Center, Beaverton, OR; Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Irina Burd
- Integrated Research Center for Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
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Khalil A, Gordijn S, Ganzevoort W, Thilaganathan B, Johnson A, Baschat AA, Hecher K, Reed K, Lewi L, Deprest J, Oepkes D, Lopriore E. Consensus diagnostic criteria and monitoring of twin anemia-polycythemia sequence: Delphi procedure. Ultrasound Obstet Gynecol 2020; 56:388-394. [PMID: 31605505 DOI: 10.1002/uog.21882] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 09/22/2019] [Accepted: 09/24/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Twin anemia-polycythemia sequence (TAPS) is associated with increased perinatal morbidity and mortality. Inconsistencies in the diagnostic criteria for TAPS exist, which hinder the ability to establish robust evidence-based management or monitoring protocols. The main aim of this study was to determine, by expert consensus using a Delphi procedure, the key diagnostic features and optimal monitoring approach for TAPS. METHODS A Delphi process was conducted among an international panel of experts on TAPS. Panel members were provided with a list of literature-based parameters for diagnosing and monitoring TAPS. They were asked to rate the importance of the parameters on a five-point Likert scale. Consensus was sought to determine the cut-off values for accepted parameters, as well as parameters used in the monitoring of and assessment of outcome in twin pregnancy complicated by TAPS. RESULTS A total of 132 experts were approached. Fifty experts joined the first round, of whom 33 (66%) completed all three rounds. There was agreement that the monitoring interval for the development of TAPS should be every 2 weeks and that the severity should be assessed antenatally using a classification system based on middle cerebral artery (MCA) peak systolic velocity (PSV), but there was no agreement on the gestational age at which to start monitoring. Once the diagnosis of TAPS is made, monitoring should be scheduled weekly. For the antenatal diagnosis of TAPS, the combination of MCA-PSV ≥ 1.5 MoM in the anemic twin and ≤ 0.8 MoM in the polycythemic twin was agreed. Alternatively, MCA-PSV discordance ≥ 1 MoM can be used to diagnose TAPS. Postnatally, hemoglobin difference ≥ 8 g/dL and intertwin reticulocyte ratio ≥ 1.7 were agreed criteria for diagnosis of TAPS. There was no agreement on the cut-off of MCA-PSV or its discordance for prenatal intervention. The panel agreed on prioritizing perinatal and long-term survival outcomes in follow-up studies. CONCLUSIONS Consensus-based diagnostic features of TAPS, as well as cut-off values for the parameters involved, were agreed upon by a panel of experts. Future studies are needed to validate these diagnostic features before they can be used in clinical trials of interventions. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - S Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Johnson
- Departments of Obstetrics/Gynecology & Pediatric Surgery, The University of Texas Health Science Center, The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - A A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - K Reed
- Twins Trust, Aldershot, UK
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Townsend R, Duffy JMN, Sileo F, Perry H, Ganzevoort W, Reed K, Baschat AA, Deprest J, Gratacos E, Hecher K, Lewi L, Lopriore E, Oepkes D, Papageorghiou A, Gordijn SJ, Khalil A. Core outcome set for studies investigating management of selective fetal growth restriction in twins. Ultrasound Obstet Gynecol 2020; 55:652-660. [PMID: 31273879 DOI: 10.1002/uog.20388] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/07/2019] [Accepted: 06/21/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Selective fetal growth restriction (sFGR) occurs in monochorionic twin pregnancies when unequal placental sharing leads to restriction in the growth of just one twin. Management options include laser separation of the fetal circulations, selective reduction or expectant management, but what constitutes the best treatment is not yet known. New trials in this area are urgently needed but, in this rare and complex group, maximizing the relevance and utility of clinical research design and outputs is paramount. A core outcome set ensures standardized outcome collection and reporting in future research. The objective of this study was to develop a core outcome set for studies evaluating treatments for sFGR in monochorionic twins. METHODS An international steering group of clinicians, researchers and patients with experience of sFGR was established to oversee the process of development of a core outcome set for studies investigating the management of sFGR. Outcomes reported in the literature were identified through a systematic review and informed the design of a three-round Delphi survey. Clinicians, researchers, and patients and family representatives participated in the survey. Outcomes were scored on a Likert scale from 1 (limited importance for making a decision) to 9 (critical for making a decision). Consensus was defined a priori as a Likert score of ≥ 8 in the third round of the Delphi survey. Participants were then invited to take part in an international meeting of stakeholders in which the modified nominal group technique was used to consider the consensus outcomes and agree on a final core outcome set. RESULTS Ninety-six outcomes were identified from 39 studies in the systematic review. One hundred and three participants from 23 countries completed the first round of the Delphi survey, of whom 88 completed all three rounds. Twenty-nine outcomes met the a priori criteria for consensus and, along with six additional outcomes, were prioritized in a consensus development meeting, using the modified nominal group technique. Twenty-five stakeholders participated in this meeting, including researchers (n = 3), fetal medicine specialists (n = 3), obstetricians (n = 2), neonatologists (n = 3), midwives (n = 4), parents and family members (n = 6), patient group representatives (n = 3), and a sonographer. Eleven core outcomes were agreed upon. These were live birth, gestational age at birth, birth weight, intertwin birth-weight discordance, death of surviving twin after death of cotwin, loss during pregnancy or before final hospital discharge, parental stress, procedure-related adverse maternal outcome, length of neonatal stay in hospital, neurological abnormality on postnatal imaging and childhood disability. CONCLUSIONS This core outcome set for studies investigating the management of sFGR represents the consensus of a large and diverse group of international collaborators. Use of these outcomes in future trials should help to increase the clinical relevance of research on this condition. Consensus agreement on core outcome definitions and measures is now required. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Townsend
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J M N Duffy
- Balliol College, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - F Sileo
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - K Reed
- Twin and Multiple Births Association (TAMBA), Aldershot, UK
| | - A A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - J Deprest
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Leuven, Belgium
| | - E Gratacos
- Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Leuven, Belgium
| | - E Lopriore
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A Papageorghiou
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - S J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Seravalli V, Miller JL, Blitzer MG, Baschat AA. A comparison of first trimester blood pressures obtained at the time of first trimester pre-eclampsia screening and those obtained during prenatal care visits. Eur J Obstet Gynecol Reprod Biol 2020; 248:77-80. [PMID: 32199296 DOI: 10.1016/j.ejogrb.2020.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/04/2020] [Accepted: 03/06/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine if enrollment blood pressures in a study on first trimester preeclampsia prediction significantly differed from those obtained during routine prenatal care visits in the first trimester. STUDY DESIGN Women carrying a singleton gestation were prospectively enrolled in a first trimester study on preeclampsia prediction, and had systolic and diastolic blood pressure (SBP, DBP) measured at the time of enrollment. Blood pressure was also measured with the same technique by clinic nurses during the routine prenatal visits throughout the first trimester of pregnancy (9-14 weeks). The enrollment-BP (E-BP) and average first trimester-BP (aFT-BP) were compared using a paired samples t-test or Wilcoxon test, as appropriate. Smokers and patients on antihypertensive medications were excluded from the analysis. test. RESULTS 644 women had prenatal care in the primary study center and met study criteria. The mean gestational age at study enrollment was 12.5 weeks. No significant difference was found between E-SBP and aFT-SBP (p = 0.10). Enrollment DBP and mean arterial pressure (MAP) were significantly lower than the aFT- DBP and -MAP (median DPB 67 vs 70 mm Hg and median MAP 83.7 vs 85 mmHg, respectively, p < 0.001). However, the difference was not clinically relevant (3 mmHg for DBP, and 1.3 mmHg for MAP). CONCLUSIONS Blood pressures obtained in a setting of preeclampsia screening are not higher than those obtained during regular prenatal care in the first trimester. This suggests that the setting in which pre-eclampsia screening is performed is unlikely to be a confounder for blood pressure measurements and the risk assessment.
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Affiliation(s)
- Viola Seravalli
- Department of Health Sciences, Division of Obstetrics and Gynecology, University of Florence, Largo Brambilla 3, 50134, Florence, Italy.
| | - Jena L Miller
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Miriam G Blitzer
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ahmet A Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
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Rosner M, Miller JL, Baschat AA. 552: Management of twin to twin transfusion in patients with high preoperative risk factors. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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