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Gallagher LT, Lyttle BD, Dawson-Gore C, Vaughn AE, Breckenfelder C, Reynolds R, Zaretsky MV, Derderian SC. The Effect of Steroids on Prenatally Diagnosed Lung Lesions. J Pediatr Surg 2024; 59:969-974. [PMID: 38042733 DOI: 10.1016/j.jpedsurg.2023.11.004] [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: 07/25/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Open fetal resection for large lung lesions has virtually been replaced by maternal steroid administration. Despite this paradigm shift, little is known about the effects steroids have on lung lesion growth in utero. METHODS A 10-year retrospective review of all prenatally diagnosed lung lesions cared for at our fetal care center was performed. We evaluated the effects of prenatal steroids on congenital pulmonary airway malformation (CPAM)-volume-ratio (CVR), distinguishing change in CVR among CPAMs, bronchopulmonary sequestrations (BPS), and bronchial atresias. We also correlated fetal ultrasound and MRI findings with pathology to determine the accuracy of prenatal diagnosis. RESULTS We evaluated 199 fetuses with a prenatal lung lesion. Fifty-four (27 %) were treated with prenatal steroids with a subsequent 21 % mean reduction in the CVR (2.1 ± 1.4 to 1.1 ± 0.4, p = 0.003). Fetuses with hydrops and mediastinal shift who were treated with steroids rarely had resolution of these radiographic findings. Postnatal pathology was available for 91/199 patients (45.7 %). The most common diagnosis was CPAM (42/91, 46 %), followed by BPS (30/91, 33 %), and bronchial atresia (14/91, 15 %). Fetuses who received steroids and had pathology consistent with CPAM were more likely to have a reduction in their CVR (p = 0.02). Fetal ultrasound correctly diagnosed the type of lung lesion in 75 % of cases and fetal MRI in 81 % of cases. CONCLUSIONS Prenatally diagnosed CPAMs are more likely to respond to maternal steroids than BPS or bronchial atresias. Knowing the diagnosis in utero could aid to steward steroid usage, however, fetal imagining modalities are not perfect in distinguishing subtype. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lauren T Gallagher
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bailey D Lyttle
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Alyssa E Vaughn
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Regina Reynolds
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael V Zaretsky
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, USA
| | - S Christopher Derderian
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, USA; Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
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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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Krispin E, Javinani A, Odibo A, Carreras E, Emery SP, Sepulveda Gonzalez G, Habli M, Hecher K, Ishii K, Miller J, Papanna R, Johnson A, Khalil A, Kilby MD, Lewi L, Bennasar Sans M, Otaño L, Zaretsky MV, Sananes N, Turan OM, Slaghekke F, Stirnemann J, Van Mieghem T, Welsh AW, Yoav Y, Chmait R, Shamshirsaz AA. Consensus protocol for management of early and late twin-twin transfusion syndrome: Delphi study. Ultrasound Obstet Gynecol 2024; 63:371-377. [PMID: 37553800 DOI: 10.1002/uog.27446] [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] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/11/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVE Fetoscopic laser photocoagulation (FLP) is a well-established treatment for twin-twin transfusion syndrome (TTTS) between 16 and 26 weeks' gestation. High-quality evidence and guidelines regarding the optimal clinical management of very early (prior to 16 weeks), early (between 16 and 18 weeks) and late (after 26 weeks) TTTS are lacking. The aim of this study was to construct a structured expert-based clinical consensus for the management of early and late TTTS. METHODS A Delphi procedure was conducted among an international panel of experts. Participants were chosen based on their clinical expertise, affiliation and relevant publications. A four-round Delphi survey was conducted using an online platform and responses were collected anonymously. In the first round, a core group of experts was asked to answer open-ended questions regarding the indications, timing and modes of treatment for early and late TTTS. In the second and third rounds, participants were asked to grade each statement on a Likert scale (1, completely disagree; 5, completely agree) and to add any suggestions or modifications. At the end of each round, the median score for each statement was calculated. Statements with a median grade of 5 without suggestions for change were accepted as the consensus. Statements with a median grade of 3 or less were excluded from the Delphi process. Statements with a median grade of 4 were modified according to suggestions and reconsidered in the next round. In the last round, participants were asked to agree or disagree with the statements, and those with more than 70% agreement without suggestions for change were considered the consensus. RESULTS A total of 122 experts met the inclusion criteria and were invited to participate, of whom 53 (43.4%) agreed to take part in the study. Of those, 75.5% completed all four rounds. A consensus on the optimal management of early and late TTTS was obtained. FLP can be offered as early as 15 weeks' gestation for selected cases, and can be considered up to 28 weeks. Between 16 and 18 weeks, management should be tailored according to Doppler findings. CONCLUSIONS A consensus-based treatment protocol for early and late TTTS was agreed upon by a panel of experts. This protocol should be modified at the discretion of the operator, according to their experience and the specific demands of each case. This should advance the quality of future studies, guide clinical practice and improve patient care. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Krispin
- Maternal Fetal Care Center (MFCC), Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - A Javinani
- Maternal Fetal Care Center (MFCC), Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - A Odibo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, MO, USA
| | - E Carreras
- Maternal-Fetal Medicine Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - S P Emery
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - G Sepulveda Gonzalez
- Instituto de Salud Fetal (ISF), Hospital Regional Materno Infantil, Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
| | - M Habli
- Department of Pediatric Surgery, Fetal Care Center of Cincinnati, Good Samaritan Hospital, Cincinnati, OH, USA
| | - K Hecher
- Department of Obstetrics and Prenatal Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - K Ishii
- Maternal-Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - J Miller
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - R Papanna
- Fetal Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas McGovern Medical School at Houston, Houston, TX, USA
| | - A Johnson
- Fetal Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas McGovern Medical School at Houston, Houston, TX, USA
| | - 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
- Fetal Medicine Unit, Liverpool Women's Hospital, Liverpool, UK
| | - M D Kilby
- Fetal Medicine Center, Birmingham Women's and Children's Foundation Trust, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Illumina UK, Great Abbington, Cambridge, UK
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - M Bennasar Sans
- BCNatal, Maternal-Fetal Medicine Center, Hospital Clínic i Hospital Sant Joan de Déu, Barcelona, Spain
| | - L Otaño
- Maternal-Fetal Medicine Unit, Obstetric Division, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - M V Zaretsky
- Colorado Fetal Care Center, Children's Hospital of Colorado, University of Colorado, Denver, CO, USA
| | - N Sananes
- Obstetrics and Gynecology Department, Strasbourg University Hospital, Strasbourg, France
- Inserm 1121 'Biomaterials and Bioengineering', Strasbourg University, Strasbourg, France
| | - O M Turan
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - F Slaghekke
- Department of Obstetrics, Fetal Medicine Unit, Leiden University Medical Center, Leiden, The Netherlands
| | - J Stirnemann
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - T Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - A W Welsh
- Maternal-Fetal Medicine, Royal Hospital for Women, University of New South Wales, Sydney, Australia
| | - Y Yoav
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Chmait
- Los Angeles Fetal Surgery, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A A Shamshirsaz
- Maternal Fetal Care Center (MFCC), Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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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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Masaracchia MM, Zaretsky MV, Pan Z, Zhou W, Chow FS, Wood CL. Evolution of postoperative care: marked reduction of opioid consumption when ERAC pathway added to wound soaker therapy for cesarean delivery. J Matern Fetal Neonatal Med 2023; 36:2130241. [PMID: 36191923 DOI: 10.1080/14767058.2022.2130241] [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] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Achieving functional recovery after cesarean delivery is critical to a parturient's ability to care for herself and her newborn. Adequate pain control is vital, and without it, many other aspects of the recovery process may be delayed. Reducing opioid consumption without compromising analgesia is of paramount importance, and enhanced recovery pathways have generated considerable interest given their ability to facilitate this. Our group's process for reducing opioid consumption for cesarean delivery patients evolved over time. We first demonstrated that providing additional incisional pain control with continuous bupivacaine infusions through wound catheters, with the concurrent use of neuraxial morphine, reduced postoperative opioid use. Iterations of an enhanced recovery after cesarean (ERAC) delivery pathway were then implemented after the Society for Obstetric Anesthesia and Perinatology's consensus statement for ERAC was issued to eliminate variability in both hospital course and in the treatment of postoperative pain. In this retrospective cohort analysis, we sought to identify whether adding ERAC protocols to our existing combination of neuraxial morphine and wound soaker catheters further reduced opioid consumption after cesarean delivery. METHODS A retrospective cohort analysis of cesarean deliveries from 2015 through 2020 was performed. Deliveries were divided by analgesic pathway into four time-periods - time-point 1 [January 2015-April 2016, previous standard of care (control, N = 61)]: neuraxial morphine in addition to as needed opioid and non-opioid analgesics; time-point 2 [May 2016-May 2019, introduction of wound soaker (wound-soaker, N = 40)]: continuous wound catheter infusions of local anesthetic, neuraxial morphine in addition to as needed opioid and non-opioid analgesics; time-point 3 [May 2019-December 2019, wound soaker + early ERAC pathway (early ERAC, N = 78)]: continuous wound catheter infusion of local anesthetic, neuraxial morphine, in addition to scheduled non-opioid analgesics (acetaminophen and ibuprofen) every 6 h, alternating in relation to one another so that one is given every 3 h; time-point 4 [January 2020-July 2020, wound soaker + late ERAC pathway (late ERAC, N = 57)]: continuous wound catheter infusion of local anesthetic, neuraxial morphine in addition to non-opioid analgesics scheduled together every 6 h (to facilitate periods of uninterrupted rest). Cumulative and average daily opioid use for postoperative days (POD) 1-4 were analyzed using ANOVA and a mixed effect model, respectively. RESULTS Average daily opioid consumption and total cumulative opioid consumption POD 1-4 (morphine milligram equivalents) for both early and late ERAC groups (23.9 ± 31.1 and 29.4 ± 35.1) were significantly reduced compared to control and wound soaker groups (185.1 ± 93.7 and 134.8 ± 77.1) (p < .001). CONCLUSION The addition of ERAC protocols to our standardized multimodal analgesic regimen (local anesthetic wound infusion catheters and neuraxial morphine) for cesarean delivery significantly reduced postoperative opioid consumption.
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Affiliation(s)
- Melissa M Masaracchia
- Division of Pediatric Anesthesiology, Children's Hospital Colorado, Aurora, CO, USA.,Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael V Zaretsky
- Colorado Fetal Care Center, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Zhaoxing Pan
- School of Public Health, University of Colorado, Aurora, CO, USA
| | - Wenru Zhou
- School of Public Health, University of Colorado, Aurora, CO, USA
| | - Franklin S Chow
- Colorado Fetal Care Center, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Cristina L Wood
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
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Gallagher LT, Lyttle BD, Meyers ML, Gien J, Zaretsky MV, Galan HL, Behrendt N, Liechty KW, Derderian SC. Fetal lung volumes measured by MRI predict pulmonary morbidity among infants with giant omphaloceles. Prenat Diagn 2023; 43:1514-1519. [PMID: 37807606 DOI: 10.1002/pd.6449] [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: 04/26/2023] [Revised: 08/10/2023] [Accepted: 09/20/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE Giant omphaloceles (GO) have associated pulmonary hypoplasia and respiratory complications. Total lung volumes (TLV) on fetal MRI can prognosticate congenital diaphragmatic hernia outcomes; however, its applicability to GO is unknown. We hypothesize that late gestation TLV and observed-to-expected TLV (O/E TLV) on fetal MRI correlate with postnatal pulmonary morbidity in GO. METHOD A single-institution retrospective review of GO evaluated between 2012 and 2022 was performed. Fetal MRI TLV between 32 and 36 weeks' gestation and O/E TLV throughout gestation were calculated and correlated with postnatal outcomes. RESULTS 86 fetuses with omphaloceles were evaluated; however, only 26 met strict inclusion criteria. MRIs occurred between 18 and 36 weeks' gestation. Those requiring delivery room intubation had significantly lower late gestation TLV and O/E TLV. O/E TLV predicted tracheostomy placement and survival. Neither TLV nor O/E TLV predicted the length of hospitalization or supplemental oxygen after discharge. Three fetuses had a TLV less than 35 mL: one died of respiratory failure, and the other two required tracheostomy. CONCLUSIONS Fetal MRI TLV measured between 32 and 36 weeks' gestation and O/E TLV predict the need for delivery room intubation and tracheostomy. O/E TLV correlated with survival. These data support fetal MRI as a prognostic tool to predict GO associated pulmonary morbidity.
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Affiliation(s)
- Lauren T Gallagher
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Bailey D Lyttle
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mariana L Meyers
- Colorado Institute for Maternal and Fetal Health, Aurora, Colorado, USA
- Department of Radiology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Jason Gien
- Colorado Institute for Maternal and Fetal Health, Aurora, Colorado, USA
- Department of Pediatrics, University Colorado Denver, Aurora, Colorado, USA
| | - Michael V Zaretsky
- Colorado Institute for Maternal and Fetal Health, Aurora, Colorado, USA
- Department of Obstetrics and Gynecology, University Colorado Denver, Aurora, Colorado, USA
| | - Henry L Galan
- Colorado Institute for Maternal and Fetal Health, Aurora, Colorado, USA
- Department of Obstetrics and Gynecology, University Colorado Denver, Aurora, Colorado, USA
| | - Nicholas Behrendt
- Colorado Institute for Maternal and Fetal Health, Aurora, Colorado, USA
- Department of Obstetrics and Gynecology, University Colorado Denver, Aurora, Colorado, USA
| | - Kenneth W Liechty
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
- Colorado Institute for Maternal and Fetal Health, Aurora, Colorado, USA
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
- Department of Pediatric Surgery, University of Arizona, Tucson, Arizona, USA
| | - Sarkis Christopher Derderian
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
- Colorado Institute for Maternal and Fetal Health, Aurora, Colorado, USA
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
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7
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Cuneo BF, Buyon JP, Sammaritano L, Jaeggi E, Arya B, Behrendt N, Carvalho J, Cohen J, Cumbermack K, DeVore G, Doan T, Donofrio MT, Freud L, Galan HL, Gropler MRF, Haxel C, Hornberger LK, Howley LW, Izmirly P, Killen SS, Kaplinski M, Krishnan A, Lavasseur S, Lindblade C, Matta J, Makhoul M, Miller J, Morris S, Paul E, Perrone E, Phoon C, Pinto N, Rychik J, Satou G, Saxena A, Sklansky M, Stranic J, Strasburger JF, Srivastava S, Srinivasan S, Tacy T, Tworetzky W, Uzun O, Yagel S, Zaretsky MV, Moon-Grady AJ. Knowledge is power: regarding SMFM Consult Series #64: Systemic lupus erythematosus in pregnancy. Am J Obstet Gynecol 2023; 229:361-363. [PMID: 37394327 DOI: 10.1016/j.ajog.2023.06.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Bettina F Cuneo
- University of Colorado School of Medicine, Children's Hospital Colorado and University Hospital, Aurora, CO.
| | - Jill P Buyon
- NYU Grossman School of Medicine, NYU Langone Medical Center, New York, NY
| | | | | | - Bhawna Arya
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Nicholas Behrendt
- University of Colorado School of Medicine, Children's Hospital Colorado and University Hospital, Aurora, CO
| | - Julene Carvalho
- Royal College of Obstetrics and Gynecology, Royal Brompton Hospital, London, United Kingdom
| | - Jennifer Cohen
- Icahn School of Medicine, Mt Sinai Hospital, New York, NY
| | - Kristopher Cumbermack
- University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Greggory DeVore
- David Geffen School of Medicine, Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA
| | - Tam Doan
- Baylor University College of Medicine, Texas Children's Hospital, Houston, TX
| | - Mary T Donofrio
- George Washington School of Medicine, Children's National Hospital, Washington, DC
| | | | - Henry L Galan
- University of Colorado School of Medicine, Children's Hospital Colorado and University Hospital, Aurora, CO
| | - Melanie R F Gropler
- Case Western Reserve School of Medicine, University Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Caitlin Haxel
- University of Vermont School of Medicine, University of Vermont Medical Center, Burlington, VT
| | - Lisa K Hornberger
- Stollery Children's Hospital, University of Alberta Medical School, Edmonton, Alberta, Canada
| | | | - Peter Izmirly
- NYU Grossman School of Medicine, NYU Langone Medical Center, New York, NY
| | - Stacy S Killen
- Vanderbilt University Medical School, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - Michelle Kaplinski
- Stanford University Medical School, Lucille Packard Children's Hospital, Palo Alto, CA
| | - Anita Krishnan
- George Washington School of Medicine, Children's National Hospital, Washington, DC
| | - Stephanie Lavasseur
- New York-Presbyterian Medical School, Morgan Stanley Children's Hospital, New York, NY
| | | | - Jyothi Matta
- University of Kentucky School of Medicine, Norton Children's Hospital, Louisville, KY
| | | | - Jena Miller
- Johns Hopkins School of Medicine, Johns Hopkins Medicine, Baltimore, MD
| | - Shaine Morris
- Baylor University College of Medicine, Texas Children's Hospital, Houston, TX
| | - Erin Paul
- Icahn School of Medicine, Mt Sinai Hospital, New York, NY
| | - Erin Perrone
- University of Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Colin Phoon
- NYU Grossman School of Medicine, NYU Langone Medical Center, New York, NY
| | - Nelangi Pinto
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Jack Rychik
- University of Pennsylvania Medical School, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Gary Satou
- David Geffen School of Medicine, Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA
| | - Amit Saxena
- NYU Grossman School of Medicine, NYU Langone Medical Center, New York, NY
| | - Mark Sklansky
- David Geffen School of Medicine, Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA
| | - James Stranic
- Case Western Reserve School of Medicine, University Rainbow Babies and Children's Hospital, Cleveland, OH
| | | | | | - Sharda Srinivasan
- University of Wisconsin School of Medicine, American Children's Hospital, Madison, WI
| | - Theresa Tacy
- Stanford University Medical School, Lucille Packard Children's Hospital, Palo Alto, CA
| | - Wayne Tworetzky
- Harvard Medical School, Boston Children's Hospital, Boston, MA
| | - Orhan Uzun
- University Hospital of Wales, Cardiff, Wales, United Kingdom
| | - Simcha Yagel
- Hadassah Medical School, Hadassah-Hebrew Medical Center, Jerusalem, Israel
| | - Michael V Zaretsky
- University of Colorado School of Medicine, Children's Hospital Colorado and University Hospital, Aurora, CO
| | - Anita J Moon-Grady
- University of California San Francisco School of Medicine, Benioff Children's Hospital, San Francisco, CA
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Niemiec SM, Louiselle AE, Phillips R, Gien J, Zaretsky MV, Derderian SC, Liechty KW, Meyers ML. Third-trimester percentage predicted lung volume and percentage liver herniation as prognostic indicators in congenital diaphragmatic hernia. Pediatr Radiol 2023; 53:479-486. [PMID: 36289070 DOI: 10.1007/s00247-022-05538-w] [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: 05/05/2022] [Revised: 09/13/2022] [Accepted: 10/14/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Over the last two decades, fetal imaging has greatly improved, and new prenatal imaging measurements have been developed to characterize congenital diaphragmatic hernia (CDH) severity. OBJECTIVE To determine the best prenatal imaging predictor of postnatal CDH outcomes, including use of extracorporeal membrane oxygenation (ECMO) and in-hospital mortality, with particular attention to the percentage of liver herniation (%LH) as a predictor. Additionally, we sought to guide best practices across hospital systems including improved models of prenatal risk assessment. MATERIALS AND METHODS We conducted a retrospective review of infants with left CDH who were prenatally diagnosed. We analyzed prenatal imaging measurements including observed-to-expected (O/E) lung-to-head ratio (LHR) on US, percentage predicted lung volume (PPLV) on MRI, and O/E total fetal lung volume (TFLV) and %LH on MRI. We compared prenatal imaging characteristics for infants with (1) in-hospital postnatal mortality and (2) use of ECMO. Then we performed multivariate logistic regression to determine independent predictors of postnatal outcomes. RESULTS We included 63 infants with a median gestation of 34 weeks at the time of prenatal MRI. Low O/E LHR (31.2 vs. 50, P < 0.0001), PPLV (14.7 vs. 22.6, P < 0.0001) and O/E TLFV (24.6 vs. 38.3, P < 0.0001) and high %LH (15.1 vs. 2.1, P = 0.0006) were associated with worse postnatal outcomes; however, only PPLV was predictive of survival and need for ECMO on multivariable analysis. PPLV survival to discharge model showed an area under the curve (AUC) of 0.93 (95% confidence interval [CI]: 0.86, 0.99), P < 0.0001; and an odds ratio of 68.7 (95% CI: 6.5-2,302), P = 0.003. PPLV need for ECMO model showed AUC = 0.87 (95% CI: 0.78, 0.96), P < 0.0001; and odds ratio = 20.1 (95% CI: 3.1-226.3), P = 0.011. CONCLUSION Low O/E LHR, PPLV and O/E TFLV and high %LH in the third trimester are associated with worse postnatal outcomes. PPLV most strongly predicted outcome using a logistic regression model. Percentage of liver herniation was not an independent predictor of outcomes.
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Affiliation(s)
- Stephen M Niemiec
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amanda E Louiselle
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Phillips
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jason Gien
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Pediatrics Section of Neonatology, Children's Hospital of Colorado, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Michael V Zaretsky
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Sarkis C Derderian
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Kenneth W Liechty
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Mariana L Meyers
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA. .,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA. .,Department of Radiology, Division of Pediatric Radiology, University of Colorado School of Medicine, Aurora, CO, USA.
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Micke KC, Elfman HM, Fantauzzo KA, McGrath PS, Clouthier DE, McCandless SE, Larson A, Putra M, Cuneo BF, Reynolds RM, Zaretsky MV. Piloting a multidisciplinary approach to improve outcomes of fetal whole exome sequencing: An overview of workflow and case example. Prenat Diagn 2023; 43:544-552. [PMID: 36759743 DOI: 10.1002/pd.6332] [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: 10/03/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Whole exome sequencing (WES) has increasingly become integrated into prenatal care and genetic testing pathways. Current studies of prenatal WES have focused on diagnostic yield. The possibility of obtaining a variant of uncertain significance and lack of provider expertise are frequently described as common barriers to clinical integration of prenatal WES. We describe the implementation and workflow for a multidisciplinary approach to effectively integrate prenatal WES into maternal-fetal care to overcome these barriers. METHODS A multidisciplinary team reviews and approves potential cases for WES. This team reviews WES results, reclassifying variants as appropriate and provides recommendations for postnatal care. A detailed description of this workflow is provided, and a case example is included to demonstrate effectiveness of this approach. Our team has approved 62 cases for WES with 45 patients ultimately pursuing WES. We have achieved a diagnostic yield of 40% and the multidisciplinary team has played a role in variant interpretation in 50% of the reported variants of uncertain significance. CONCLUSIONS This approach facilitates communication between prenatal and postnatal care teams and provides accurate interpretation and recommendations for identified fetal variants. This model can be replicated to ensure appropriate patient care and effective integration of novel genomic technologies into prenatal settings.
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Affiliation(s)
- Kestutis C Micke
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
| | - Hannah M Elfman
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
| | | | - Patrick S McGrath
- Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - David E Clouthier
- Department of Craniofacial Biology, University of Colorado, Aurora, Colorado, USA
| | | | - Austin Larson
- Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - Manesha Putra
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA.,Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - Bettina F Cuneo
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - Regina M Reynolds
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - Michael V Zaretsky
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
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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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11
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Kops S, Cuneo B, Kaizer A, Wautlet CK, Gilbert L, Snyder K, Zaretsky MV, Behrendt N, Galan HL, Grenier M. Fetal characteristics and neonatal outcomes in single ventricle cardiac defects diagnosed in utero. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.410] [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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12
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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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13
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Wautlet CK, Cuneo B, Kops S, Solomon B, Snyder K, Silveira L, Behrendt N, Zaretsky MV, Galan HL. Fetal single ventricle defects are associated with high rates of growth restriction and intrauterine demise. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.239] [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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Micke K, Elfman H, Reynolds R, Austin L, Shawn M, Zaretsky MV. Multidisciplinary committee's impact on prenatal whole exome sequencing variant interpretation. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.606] [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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15
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Niemiec SM, Louiselle AE, Phillips R, Hilton SA, Derderian SC, Zaretsky MV, Galan HL, Behrendt N, Kinsella JP, Liechty KW, Gien J. Reduction in blood product transfusion requirements with early on-ECMO repair of congenital diaphragmatic hernia. Ann Pediatr Surg 2022. [DOI: 10.1186/s43159-021-00140-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
For infants with severe congenital diaphragmatic hernia (CDH) stabilized with extracorporeal membrane oxygenation (ECMO), early repair on ECMO improves outcome; however when compared to operative repair after ECMO, repair on ECMO is associated with increase bleeding risk and need for blood product transfusions.
Methods
A retrospective review of 54 patients with CDH placed on ECMO prior to CDH repair was performed. For the subset of patients repaired on ECMO, analysis comparing those repaired early (within 48 h of cannulation) and late (beyond 48 h) on ECMO was performed. Outcomes of interest included survival to discharge, days on ECMO, and postoperative blood product utilization.
Results
When compared to those patients repaired prior to 48 h of ECMO initiation, 57.7% of patients survived versus 40.9% of late repair patients. For those repaired early, blood product utilization was significantly less. Early repair patients received a median of 72 mL/kg packed red blood cells (PRBC) and 75 mL/kg platelets compared to 151.9 mL/kg and 98.7 mL/kg, respectively (p < 0.05 respectively). There was no difference in median days on ECMO (p = 0.38).
Conclusion
Our data supports prior reports of improved outcome with repair with 48 h of ECMO initiation and suggests early repair on ECMO is associated with less bleeding and decreased blood product requirement in the postoperative period.
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Zaretsky MV, Behrendt NJ, Derderian S, Galan HL, Liechty K, Silveira L. Association of open fetal MMC repair post-operative cervical length and gestational age at delivery. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.626] [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: 11/27/2022]
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Lillegard JB, Eyerly-Webb SA, Watson DA, Bahtiyar MO, Bennett KA, Emery SP, Fisher AJ, Goldstein RB, Goodnight WH, Lim FY, McCullough LB, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Treadwell MC, Tsao K, Wagner AJ, Zaretsky MV. Placental Location in Maternal-Fetal Surgery for Myelomeningocele. Fetal Diagn Ther 2021; 49:117-124. [PMID: 34915495 DOI: 10.1159/000521379] [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: 08/19/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Uterine incision based on placental location in open maternal-fetal surgery (OMFS) has never been evaluated in regards to maternal or fetal outcomes. OBJECTIVE To investigate whether an anterior placenta was associated with increased rates of intraoperative, perioperative, antepartum, obstetric, or neonatal complications in mothers and babies who underwent OMFS for myelomeningocele (fMMC) closure. METHODS Data from the international multi-center prospective registry of patients who underwent OMFS for fMMC closure (fMMC Consortium Registry, 12/15/2010-7/31/2019) was used to compare fetal and maternal outcomes between anterior and posterior placental locations. RESULTS Placental location for 623 patients was evenly distributed between anterior (51%) or posterior (49%). Intraoperative fetal bradycardia (8.3% vs 3.0%, p=0.005) and performance of fetal resuscitation (3.6% vs 1.0%, p=0.034) occurred more frequently in cases with an anterior placenta when compared to those with a posterior placenta. Obstetric outcomes including membrane separation, placental abruption, and spontaneous rupture of membranes were not different among the two groups. However, thinning of the hysterotomy site (27.7% vs 17.7%, p=0.008) occurred more frequently in cases of anterior placenta. Gestational age at delivery (p=0.583) and length of stay in the neonatal intensive care unit (p=0.655) were similar between the two groups. Fetal incision dehiscence and wound revision were not significantly different between groups. Critical clinical outcomes including fetal demise, perinatal death, and neonatal death were all infrequent occurrences and not associated with placental location. CONCLUSIONS Anterior placental location is associated with increased risk of intraoperative fetal resuscitation and increased thinning at the hysterotomy closure site. Individual institutional experiences may have varied but the aggregate data from the fMMC Consortium did not show a significant impact on the gestational age at delivery or maternal or fetal clinical outcomes.
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Affiliation(s)
- Joseph B Lillegard
- Midwest Fetal Care Center, Children's Minnesota, Minneapolis, Minnesota, USA
- Division of General Surgery Research, Mayo Clinic, Rochester, Minnesota, USA
- Pediatric Surgical Associates, Minneapolis, Minnesota, USA
| | | | - David A Watson
- Research Design and Analytics, Children's Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | | | - Ruth B Goldstein
- University of California San Francisco, San Francisco, California, USA
| | - William H Goodnight
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Foong-Yen Lim
- Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | | | | | | | - Rodrigo Ruano
- University of Texas Health Science Center, Houston, Texas, USA
| | | | | | - KuoJen Tsao
- University of Texas Health Science Center, Houston, Texas, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin Fetal Concerns Center, Milwaukee, Wisconsin, USA
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Bischoff A, Guimaraes CVA, Mirsky DM, Santos-Jasso KA, Zaretsky MV, Ketzer J, Hall J, Mueller C, de La Torre L, Peña A, Meyers ML. Visualization of the fetal anus by prenatal ultrasound for the diagnosis of anorectal malformations: is it feasible? Pediatr Surg Int 2021; 37:425-430. [PMID: 33399927 DOI: 10.1007/s00383-020-04840-8] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The goal of this study was to determine the feasibility of identifying the anal dimple (AD) on routine prenatal ultrasound. Using the presence, absence, appearance, and location of the anal dimple as an indirect sign for possible underlying anorectal malformations (ARM), we hypothesize that evaluation of the anal dimple as part of the fetal anatomic survey may increase the sensitivity in detecting less severe ARMs. METHODS In a prospective longitudinal observational study, pregnant women who underwent prenatal ultrasound (US) at the Colorado Fetal Care Center between January 2019 and 2020 were enrolled. The variables recorded included gestational age, singleton versus multiple pregnancy, gender of the fetus, visualization of the AD, and reason for non-visualization of the AD. RESULTS A total of 900 ultrasounds were performed, evaluating 1044 fetuses, in 372 different pregnant women. Gestational ages ranged from 16 to 38 weeks. The AD was visualized in 612 fetuses (58.6%) and not seen in 432 (41.4%). The two most common reasons for non-visualization were extremes in gestational age (n = 155; 36%) and fetal position (n = 152; 35.3%). The optimal gestational age range for AD visualization was 28-33 weeks + 6 days, with 78.1% visualization rate. CONCLUSION Visualization of the anal dimple by ultrasound is feasible and may aid in the detection of less severe ARMs, ultimately impacting pregnancy management and family counseling. The optimal timing for anal dimple visualization is late second and third trimester.
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Affiliation(s)
- Andrea Bischoff
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO, 80045, USA. .,University of Colorado School of Medicine, Aurora, USA.
| | | | - David M Mirsky
- University of Colorado School of Medicine, Aurora, USA.,Department of Radiology, Children's Hospital Colorado, Aurora, USA.,Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, USA
| | - Karla A Santos-Jasso
- Department of Pediatric Surgery, Instituto Nacional de Pediatria, Mexico, Mexico
| | - Michael V Zaretsky
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO, 80045, USA.,Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, USA
| | - Jill Ketzer
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Jennifer Hall
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Claudia Mueller
- Department of Pediatric Surgery, Lucile Packard Children's Hospital, Palo Alto, USA
| | - Luis de La Torre
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO, 80045, USA.,University of Colorado School of Medicine, Aurora, USA
| | - Alberto Peña
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO, 80045, USA.,University of Colorado School of Medicine, Aurora, USA
| | - Mariana L Meyers
- University of Colorado School of Medicine, Aurora, USA.,Department of Radiology, Children's Hospital Colorado, Aurora, USA.,Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, USA
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Masaracchia MM, Wood C, Zaretsky MV, Zhou W, Pan Z, Hernandez M, Chow FS. 286 Enhanced recovery after cesarean (ERAC) delivery with local bupivacaine wound infusion. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.308] [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: 11/29/2022]
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Porter AC, Behrendt NJ, Zaretsky MV, Liechty KW, Wood C, Chow F, Galan HL. Continuous local bupivacaine wound infusion reduces oral opioid use for acute postoperative pain control following myelomeningocele repair. Am J Obstet Gynecol MFM 2020; 3:100296. [PMID: 33485023 DOI: 10.1016/j.ajogmf.2020.100296] [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: 10/19/2020] [Revised: 12/05/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND For pregnancies complicated by fetal myelomeningocele who meet the established criteria, prenatal closure is a viable management option. Prenatal closure is an open procedure, with some techniques requiring greater dissection of maternal tissue than cesarean delivery; pain control is an important postoperative goal. Given the rising rates of opioid dependence and concerns regarding the fetal and neonatal effects of opioid use, our practice has turned to nonopioid pain management techniques. OBJECTIVE This study aimed to compare postoperative opioid use and pain scores in women undergoing open fetal myelomeningocele repair with and without continuous local bupivacaine wound infusion. STUDY DESIGN This was a retrospective, single-center chart review of all consecutive patients who underwent open myelomeningocele repair from March 2013 to December 2019. Women were enrolled at the time of referral and locally followed for 2 weeks postoperatively. The control group received patient-controlled epidural analgesia for 48 hours with acetaminophen and oral and intravenous opioids as needed. The treatment group received patient-controlled epidural analgesia for 24 hours with acetaminophen, oral and intravenous opioids, and continuous local bupivacaine infusion. Pain scores, medication use, and postoperative milestones and complications through discharge were abstracted from the chart and compared. RESULTS Of 72 subjects, 51 were in the control group and 21 in the treatment group. Total opioid use, including intravenous doses (165 vs 52.5 mg; P=.001) and daily average oral opioid use (30 vs 10.5 mg; P=.002) were lower in the treatment group. In addition, 24% of women in the treatment group used no opioid postoperatively, compared with 4% in the control group. There was no difference in postoperative day 1 to 4 pain scores, antiemetic use, or bowel function; the treatment group was discharged significantly earlier. CONCLUSION Postoperative opioid use was reduced in women who received continuous local wound infusion of bupivacaine for incisional pain control after prenatal myelomeningocele repair. Pain control is paramount following open myelomeningocele repair; local bupivacaine wound infusion is an important adjunct to reduce opioid use postoperatively.
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Affiliation(s)
- Anne C Porter
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO.
| | - Nicholas J Behrendt
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Michael V Zaretsky
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Kenneth W Liechty
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO; Division of Pediatric Surgery; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Cristina Wood
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Franklin Chow
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Henry L Galan
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO; Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
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Dewberry LC, Kalia N, Vazquez J, Hilton SA, Zaretsky MV, Behrendt N, Galan HL, Marwan AI, Liechty KW. Determining maternal risk factors for gastroschisis using colorado's birth registry database. J Pediatr Surg 2020; 55:1002-1005. [PMID: 32173119 DOI: 10.1016/j.jpedsurg.2020.02.030] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 02/20/2020] [Indexed: 11/18/2022]
Abstract
AIM OF STUDY Gastroschisis is a congenital abdominal wall defect which results in herniation of abdominal contents. The objective of this study was to determine the maternal risk factors for gastroschisis in Colorado. METHODS A case-control study was performed using the Birth Registry database from 2007 to 2016. The outcome was gastroschisis, and the main variable was maternal age which was divided into <21, 21-30, and >30 years of age. Descriptive analysis, bivariate analysis, and logistic regression was performed. RESULTS There were 236 cases of gastroschisis compared to 944 controls. Maternal age did vary significantly between groups (23.4 ± 5 years (cases) vs. 28.7 ± 5.9 years (controls); p < 0.0001). Unadjusted analysis demonstrated that those with young maternal age (<21 years of age) had a 14.14 (95% CI 8.44-23.67) higher odds of gastroschisis compared to those >30 years of age. Independent risk factors for gastroschisis were exposure to prenatal and first trimester cigarettes, prenatal and first trimester alcohol, and chlamydia infection. The odds (4.41, 95% CI 1.36-14.26) of gastroschisis were highest in those with first trimester cigarette exposure and young maternal age (p = 0.03). CONCLUSIONS Young maternal age, cigarette exposure, alcohol exposure, and chlamydia infection increase the odds of gastroschisis. The interaction between young maternal age and first trimester cigarette exposure significantly increases the odds of gastroschisis. TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Lindel C Dewberry
- Department of Surgery, University of Colorado, 1016 Cook Street, Denver, CO 80206.
| | | | | | - Sarah A Hilton
- Department of Surgery, University of Colorado, Denver, CO
| | | | - Nicholas Behrendt
- Colorado Fetal Care Center, Children's Hospital Colorado, Denver, CO
| | - Henry L Galan
- Colorado Fetal Care Center, Children's Hospital Colorado, Denver, CO
| | - Ahmed I Marwan
- Colorado Fetal Care Center, Children's Hospital Colorado, Denver, CO
| | - Kenneth W Liechty
- Colorado Fetal Care Center, Children's Hospital Colorado, Denver, CO
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Moldenhauer J, Soni S, Bennett K, Crombleholme T, Fisher A, Goldstein R, Goodnight W, Hirose S, Jatres J, Lillegard J, McCullough L, Lim FY, Moehrlen U, Moon-Grady A, Skupski D, Thom E, Treadwell M, Tsao K, Wagner A, Zaretsky MV. 497: Does parity impact outcomes with open maternal-fetal surgery for myelomeningocele closure? Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.513] [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: 10/25/2022]
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23
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Lagueux M, Silveira L, Cuneo B, Liechty K, Marwan A, Behrendt NJ, Galan HL, Zaretsky MV. 616: Delivery outcomes of monochorionic twins without standard twin twin transfusion staging criteria undergoing laser photocoagulation. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.632] [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: 10/25/2022]
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Dewberry LC, Trecartin A, Galambos C, Hilton SA, Dannull K, Zaretsky MV, Behrendt N, Galan HL, Marwan AI, Liechty KW. A congenital cystic pulmonary airway malformation occurring together with both an extralobar pulmonary sequestration and an esophageal duplication cyst. Clin Case Rep 2020; 8:18-23. [PMID: 31998479 PMCID: PMC6982492 DOI: 10.1002/ccr3.2455] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/15/2019] [Accepted: 08/23/2019] [Indexed: 12/28/2022] Open
Abstract
A foregut duplication cyst occurring together with both a congenital cystic pulmonary airway malformation and extralobar pulmonary sequestration is an unusual combination. Prenatal ultrasound, MRI, and postnatal CT are helpful for operative planning. Surgical resection is the definitive management for all three anomalies.
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Affiliation(s)
- Lindel C. Dewberry
- Department of SurgeryLaboratory for Fetal and Regenerative BiologyUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColorado
| | - Andrew Trecartin
- Division of Pediatric SurgeryDepartment of SurgeryChildren's Hospital of ColoradoAuroraColorado
| | - Csaba Galambos
- Department of PathologyUniversity of Colorado School of Medicine and Children's Hospital ColoradoAuroraColorado
| | - Sarah A. Hilton
- Department of SurgeryLaboratory for Fetal and Regenerative BiologyUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColorado
| | - Kimberly Dannull
- Department of RadiologyUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColorado
| | - Michael V. Zaretsky
- Colorado Fetal Care CenterColorado Institute for Fetal & Maternal HealthChildren's Hospital of ColoradoAuroraColorado
- Division of Maternal Fetal MedicineUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColorado
| | - Nicholas Behrendt
- Colorado Fetal Care CenterColorado Institute for Fetal & Maternal HealthChildren's Hospital of ColoradoAuroraColorado
- Division of Maternal Fetal MedicineUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColorado
| | - Henry L. Galan
- Colorado Fetal Care CenterColorado Institute for Fetal & Maternal HealthChildren's Hospital of ColoradoAuroraColorado
- Division of Maternal Fetal MedicineUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColorado
| | - Ahmed I. Marwan
- Colorado Fetal Care CenterColorado Institute for Fetal & Maternal HealthChildren's Hospital of ColoradoAuroraColorado
| | - Kenneth W. Liechty
- Department of SurgeryLaboratory for Fetal and Regenerative BiologyUniversity of Colorado Denver School of Medicine and Children's Hospital ColoradoAuroraColorado
- Colorado Fetal Care CenterColorado Institute for Fetal & Maternal HealthChildren's Hospital of ColoradoAuroraColorado
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Peterson E, Bennett K, Crombleholme T, Fisher A, Goldstein R, Goodnight W, Hirose S, Jatres J, Lillegard J, Lim FY, Laurence M, Moehrlen U, Moldenhauer J, Moon-Grady A, Skupski D, Thom E, Treadwell M, Tsao K, Wagner A, Zaretsky MV. 817: Perinatal outcomes after fetal resuscitation during fetal MMC closure. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.832] [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: 10/25/2022]
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Dewberry LC, Hilton SA, Zaretsky MV, Behrendt N, Galan HL, Marwan AI, Liechty KW. Examination of Prenatal Sonographic Findings: Intra-Abdominal Bowel Dilation Predicts Poor Gastroschisis Outcomes. Fetal Diagn Ther 2019; 47:245-250. [PMID: 31454815 DOI: 10.1159/000501592] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 02/13/2019] [Accepted: 06/19/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gastroschisis is an anterior abdominal wall defect with variable outcomes. There are conflicting data regarding the prognostic value of sonographic findings. OBJECTIVES The aim of this study was to identify prenatal ultrasonographic features associated with poor neonatal outcomes. METHOD A retrospective review of 55 patients with gastroschisis from 2007 to 2017 was completed. Ultrasounds were reviewed for extra-abdominal intestinal diameter (EAID) and intra-abdominal intestinal diameter (IAID), echogenicity, visceral content within the herniation, amniotic fluid index, defect size, and abdominal circumference (AC). Ultrasound variables were correlated with full enteral feeding and the diagnosis of a complex gastroschisis. RESULTS Bivariate analysis demonstrated an increased time to full enteral feeds with increasing number of surgeries, EAID, and IAID. Additionally, there was a significant relationship between IAID and AC percentile with the diagnosis of complex gastroschisis. On multivariate analysis, only IAID was significant and increasing diameter had a 2.82 (95% CI 1.02-7.78) higher odds of a longer time to full enteral feeds and a 1.2 (95% CI 1.05-1.36) greater odds of the diagnosis of a complex gastroschisis. CONCLUSIONS Based on these findings, IAID is associated with a longer time to full enteral feeding and the diagnosis of complex gastroschisis.
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Affiliation(s)
- Lindel C Dewberry
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Sarah A Hilton
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Michael V Zaretsky
- Colorado Fetal Care Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nicholas Behrendt
- Colorado Fetal Care Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Henry L Galan
- Colorado Fetal Care Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ahmed I Marwan
- Division of Pediatric Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Kenneth W Liechty
- Division of Pediatric Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA,
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Zaretsky MV, Rodriguez Riesco LG, Pan Z, Galan HL. Comparison of obstetrical outcomes in patients undergoing cerclage with or without amniocentesis. J Matern Fetal Neonatal Med 2019; 34:1104-1108. [PMID: 31177883 DOI: 10.1080/14767058.2019.1625882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE We sought to compare the obstetrical outcomes in patients who underwent midtrimester cerclage placement with or without prior amniocentesis in a single center cohort. METHODS A retrospective medical record review in a single academic institution was undertaken of all patients who underwent either an exam or ultrasound indicated cerclage. This group was then divided into two groups: amniocentesis or no amniocentesis groups. Detailed maternal data was abstracted from the prenatal and hospital records. Amniocentesis fluid specimens were sent for Gram stain, aerobic and anaerobic bacterial culture, including mycoplasma and ureaplasma, as well as for glucose. Comparisons were performed utilizing Parametric 2-sample t-test for continuous variables and Fisher's exact test was utilized to compare categorical variables. RESULTS A total of 160 patients who underwent a cerclage were utilized for comparison. Sixty-five patients who had an amniocentesis performed prior to the cerclage were compared with 95 patients who underwent a cerclage without an amniocentesis. None of the amniocentesis results were positive for infection in those that received a cerclage. Patients that had an amniocentesis before cerclage were found to have an earlier gestational age at time of the procedure (20.30 ± 2.29 weeks versus 21.32 ± 1.81 weeks, p < .001), a shorter cervical length on presentation (0.93 ± 0.61 cm versus 1.45 ± 0.66 cm, p < .001), delivered at an earlier gestational age (GA 32.2 [30.3 to 34.2] versus 36.3 [35.2 to 37.3] weeks, p < .001) with shorter time from cerclage placement until delivery (13.9 [0.0 to 24.0] versus 16.3 [0.3 to 23.2] weeks, p = .010). The rates of chorioamnionitis and PPROM were significantly higher in the amniocentesis group (17 versus 2%, p = .0008 and 26 versus 13%, p = .03 respectively). Five patients who underwent an amniocentesis did not receive a cerclage, with one having a positive Gram stain and culture. CONCLUSION Amniocentesis use prior to cerclage placement in this single institution cohort was utilized in patients who presented earlier in gestation with shorter cervical length and more cervical dilation. The severity of presentation was the determining factor in the decision to perform an amniocentesis prior to cerclage placement, and, because of this difference in severity, outcomes for the amniocentesis group were predictably worse than those who did not undergo amniocentesis.
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Affiliation(s)
- Michael V Zaretsky
- Department of Obstetrics and Gynecology, Division Maternal Fetal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, USA
| | - Laura G Rodriguez Riesco
- Department of Obstetrics and Gynecology, Division Maternal Fetal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Zhaoxing Pan
- Department of Obstetrics and Gynecology, Division Maternal Fetal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Henry L Galan
- Department of Obstetrics and Gynecology, Division Maternal Fetal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, USA
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Hilton SA, Hodges MM, Dewberry LC, Handler M, Galan HL, Zaretsky MV, Behrendt N, Marwan AI, Liechty KW. MOMS Plus: Single-Institution Review of Outcomes for Extended BMI Criteria for Open Fetal Repair of Myelomeningocele. Fetal Diagn Ther 2019; 46:411-414. [PMID: 31048584 DOI: 10.1159/000499484] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 02/13/2019] [Accepted: 03/07/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND In utero repair has become an accepted therapy to decrease the rate of ventriculoperitoneal shunting and improve neurologic function in select cases of myelomeningocele. The Management of Myelomeningocele Study (MOMS) trial excluded patients with a BMI >35 due to concerns for increased maternal complications and preterm delivery, limiting the population that may benefit from this intervention. OBJECTIVES The aim of this study was to evaluate outcomes associated with extending the maternal BMI criteria to 40 in open fetal repair of myelomeningocele. METHOD Retrospective review of fetal closure of myelomeningocele at a quaternary referral center between 2013 and 2016 with maternal BMI ranging from 35 to 40. RESULTS Eleven patients with a BMI >35 were identified. The average BMI was 37. The average maternal age at the time of evaluation was 27 years. The average gestational age at fetal surgery was 24 weeks. Gestational age at birth was an average of 32 weeks. There was one perinatal death immediately following the fetal intervention. The shunt rate at 1 year was 45% (5/11 patients). CONCLUSIONS In this single-institution review of expanded BMI criteria for fetal repair of myelomeningocele, we did not observe any adverse maternal outcomes associated with maternal obesity; however, the gestational age at delivery was 2 weeks earlier compared to the MOMS trial.
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Affiliation(s)
- Sarah A Hilton
- Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.,Colorado Fetal Care Center, Colorado Institute for Fetal and Maternal Health, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Maggie M Hodges
- Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.,Colorado Fetal Care Center, Colorado Institute for Fetal and Maternal Health, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Lindel C Dewberry
- Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.,Colorado Fetal Care Center, Colorado Institute for Fetal and Maternal Health, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Michael Handler
- Colorado Fetal Care Center, Colorado Institute for Fetal and Maternal Health, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Neurosurgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Henry L Galan
- Colorado Fetal Care Center, Colorado Institute for Fetal and Maternal Health, Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Maternal Fetal Medicine, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Michael V Zaretsky
- Colorado Fetal Care Center, Colorado Institute for Fetal and Maternal Health, Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Maternal Fetal Medicine, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Nicholas Behrendt
- Department of Neurosurgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Maternal Fetal Medicine, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Ahmed I Marwan
- Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.,Colorado Fetal Care Center, Colorado Institute for Fetal and Maternal Health, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Kenneth W Liechty
- Laboratory for Fetal and Regenerative Biology, Department of Surgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA, .,Colorado Fetal Care Center, Colorado Institute for Fetal and Maternal Health, Children's Hospital Colorado, Aurora, Colorado, USA,
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Neistadt B, Carrubba A, Zaretsky MV. Natural killer/T-cell lymphoma and secondary haemophagocytic lymphohistiocytosis in pregnancy. BMJ Case Rep 2018; 2018:bcr-2018-224832. [PMID: 30219776 DOI: 10.1136/bcr-2018-224832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare and potentially fatal disorder. It is challenging to diagnose due to its rarity and variation in clinical presentation, laboratory abnormalities and underlying aetiologies. A reproductive-aged woman, gravida 2 para 1001 at 27 weeks gestation presented with fever, hypotension and subacute upper respiratory infection. She delivered a male infant by caesarean section secondary to fetal distress. Subsequently, she was diagnosed with T-cell lymphoma and secondary HLH. Despite management with supportive care and multiple chemotherapeutic agents, she ultimately died of multiorgan failure. Patients with HLH secondary to malignancy have a particularly poor prognosis. This case highlights the importance of considering secondary HLH in the differential diagnosis of a patient with fever, pancytopenia and systemic symptoms of unclear aetiology in pregnancy.
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Affiliation(s)
- Barbara Neistadt
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Aakriti Carrubba
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael V Zaretsky
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Aurora, Colorado, USA
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Howley LW, Chatterjee D, Patel SS, Cuneo BF, Crombleholme TM, Behrendt N, Zaretsky MV, Marwan AI, Zuk J, Galan HL, Wood C. Indomethacin Dosing and Constriction of the Ductus Arteriosus During Open Fetal Surgery for Myelomeningocele Repair. Fetal Diagn Ther 2018; 45:339-344. [PMID: 30157479 DOI: 10.1159/000491748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/01/2017] [Accepted: 07/02/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The use of perioperative tocolytic agents in fetal surgery is imperative to prevent preterm labor. Indomethacin, a well-known tocolytic agent, can cause ductus arteriosus (DA) constriction. We sought to determine whether a relationship exists between preoperative indomethacin dosing and fetal DA constriction. MATERIALS AND METHODS This is an IRB-approved, single-center retrospective observational case series of 42 pregnant mothers who underwent open fetal myelomeningocele repair. Preoperatively, mothers received either 1 (QD) or 2 (BID) indomethacin doses. Maternal anesthetic drug exposures and fetal cardiac dysfunction measures were collected from surgical and anesthesia records and intraoperative fetal echocardiography. Pulsatility Index was used to calculate DA constriction severity. Comparative testing between groups was performed using t- and chi-square testing. RESULTS DA constriction was observed in all fetuses receiving BID indomethacin and in 71.4% of those receiving QD dosing (p = 0.0002). Severe DA constriction was observed only in the BID group (35.7%). QD indomethacin group received more intraoperative magnesium sulfate (p < 0.0001). Minimal fetal cardiac dysfunction (9.5%) and bradycardia (9.5%) were observed in all groups independent of indomethacin dosing. CONCLUSIONS DA constriction was the most frequent and severe in the BID indomethacin group. QD indomethacin and greater magnesium sulfate dosing was associated with reduced DA constriction.
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Affiliation(s)
- Lisa W Howley
- University of Colorado School of Medicine, Aurora, Colorado, USA, .,Colorado Fetal Care Center, Aurora, Colorado, USA, .,Department of Pediatrics, Section of Cardiology, Aurora, Colorado, USA,
| | - Debnath Chatterjee
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Aurora, Colorado, USA.,Department of Anesthesiology, Aurora, Colorado, USA
| | - Sonali S Patel
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Pediatrics, Section of Cardiology, Aurora, Colorado, USA
| | - Bettina F Cuneo
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Aurora, Colorado, USA.,Department of Pediatrics, Section of Cardiology, Aurora, Colorado, USA
| | - Timothy M Crombleholme
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Aurora, Colorado, USA.,Department of Fetal and Pediatric Surgery, Aurora, Colorado, USA
| | - Nicholas Behrendt
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Aurora, Colorado, USA.,Department of Maternal-Fetal Medicine, Aurora, Colorado, USA
| | - Michael V Zaretsky
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Aurora, Colorado, USA.,Department of Maternal-Fetal Medicine, Aurora, Colorado, USA
| | - Ahmed I Marwan
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Aurora, Colorado, USA.,Department of Fetal and Pediatric Surgery, Aurora, Colorado, USA
| | - Jeannie Zuk
- Colorado Fetal Care Center, Aurora, Colorado, USA.,Department of Fetal and Pediatric Surgery, Aurora, Colorado, USA
| | - Henry L Galan
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Aurora, Colorado, USA.,Department of Maternal-Fetal Medicine, Aurora, Colorado, USA
| | - Cristina Wood
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Aurora, Colorado, USA.,Department of Anesthesiology, Aurora, Colorado, USA
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Dewberry L, Bunn J, Galambos C, Galan HL, Zaretsky MV, Behrendt N, Reynolds R, Meyers M, Marwan AI, Liechty KW. Concurrent extrapulmonary bronchopulmonary sequestration and bronchogenic cyst. Journal of Pediatric Surgery Case Reports 2018. [DOI: 10.1016/j.epsc.2018.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Ehrig J, Paulsen K, Tong S, Meier MR, Lagueux M, Galan HL, Zaretsky MV, Behrendt N. 422: Use of virtual organ computer-aided analysis (VOCAL) for volume calculation compared to traditional volume calculations of fetal thoracic tumors. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.358] [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: 11/15/2022]
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Zaretsky MV, Devore GR, Gumina D, Driscoll B, Hobbins J. 455: Fetal growth restriction cardiac dysfunction is independent of Doppler indices. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.391] [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: 10/18/2022]
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McKinney JR, Euser AG, Meyers ML, Mirsky DM, Zaretsky MV. 494: Prediction of myelomeningocele/myeloschisis size and repair type by preoperative imaging. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.020] [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: 11/30/2022]
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35
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Zaretsky MV, Behrendt NJ, Lagueux M, Pan Z, Marwan AI, Liechty KW, Galan HL. 527: Best predictors of duration of pregnancy and gestational age at delivery after fetoscopic laser photocoagulation for twin-twin transfusion syndrome. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.054] [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: 12/01/2022]
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Zaretsky MV, Liechty KW, Galan HL, Behrendt NJ, Reeves S, Marwan AI, Wilkinson C, Handler M, Lagueux M, Crombleholme TM. Modified Hysterotomy Closure Technique for Open Fetal Surgery. Fetal Diagn Ther 2017; 44:105-111. [DOI: 10.1159/000479683] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/19/2017] [Indexed: 11/19/2022]
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37
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Johnson MP, Danzer E, Koh J, Polzin W, Harman C, O'Shaughnessy R, Brown R, Zaretsky MV. Natural History of Fetal Lower Urinary Tract Obstruction with Normal Amniotic Fluid Volume at Initial Diagnosis. Fetal Diagn Ther 2017; 44:10-17. [PMID: 28700992 DOI: 10.1159/000478011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 04/07/2017] [Accepted: 05/18/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to define the natural history of lower urinary tract obstruction (LUTO) with normal midgestational amniotic fluid volumes. MATERIALS AND METHODS We performed a retrospective review of 32 consecutive patients with LUTO with normal midgestational amniotic fluid volume followed at 11 North American Fetal Therapy Network (NAFTNet) centers from August 2007 to May 2012. Normal amniotic fluid volume was defined as an amniotic fluid index (AFI) of ≥9 cm. RESULTS The mean gestational age (GA) and AFI at enrollment were 23.1 ± 2.1 weeks and 15.8 ± 3.9 cm, respectively. The mean GA at delivery was 37.3 ± 2.8 weeks. The mean creatinine level at discharge was 1.2 ± 0.8 mg/dL. Perinatal survival was 97%. Twenty-five patients returned for serial postnatal assessment. Renal replacement therapy (RRT) was required in 32%. Development of oligohydramnios and/or anhydramnios, development of cortical renal cysts, posterior urethral valves, prematurity, and prolonged neonatal intensive care unit stay were associated with need for RRT (p < 0.05) by univariate analysis. By multivariate analysis, preterm delivery remained predictive of need for RRT (p = 0.004). CONCLUSION Prenatal diagnosis of LUTO with normal midgestational amniotic fluid volumes is associated with acceptable renal function in the majority of patients. Approximately one-third of these children require RRT. Surrogate markers of disease severity appear to be predictive of need for RRT.
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Affiliation(s)
- Mark P Johnson
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Zaretsky MV, Manchester DK, Galan HL, Behrendt NJ, Marwan AI, Liechty KW, Crombleholme TM. Case report of myometrial window following fetoscopic treatment of twin-twin transfusion syndrome: indications of underlying collagen vascular disease? Clin Case Rep 2017; 5:975-979. [PMID: 28588850 PMCID: PMC5457978 DOI: 10.1002/ccr3.885] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/31/2017] [Accepted: 02/04/2017] [Indexed: 11/21/2022] Open
Abstract
Intraperitoneal amniotic fluid leak is a known complication of fetoscopic procedures that usually resolves spontaneously with expectant management. Intraperitoneal amniotic fluid leak may persist after fetoscopic procedures due to a myometrial window as well as to persistent chorioamniotic membrane disruption, which may be amenable to surgical repair.
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Affiliation(s)
- Michael V Zaretsky
- Colorado Fetal Center Colorado Institute for Maternal and Fetal Health Aurora Colorado USA.,Division of Maternal Fetal Medicine Children's Hospital Colorado University of Colorado School of Medicine Aurora Colorado USA
| | - David K Manchester
- Colorado Fetal Center Colorado Institute for Maternal and Fetal Health Aurora Colorado USA.,Division of Genetics Children's Hospital Colorado University of Colorado School of Medicine Aurora Colorado USA
| | - Henry L Galan
- Colorado Fetal Center Colorado Institute for Maternal and Fetal Health Aurora Colorado USA.,Division of Maternal Fetal Medicine Children's Hospital Colorado University of Colorado School of Medicine Aurora Colorado USA
| | - Nicholas J Behrendt
- Colorado Fetal Center Colorado Institute for Maternal and Fetal Health Aurora Colorado USA.,Division of Maternal Fetal Medicine Children's Hospital Colorado University of Colorado School of Medicine Aurora Colorado USA
| | - Ahmed I Marwan
- Colorado Fetal Center Colorado Institute for Maternal and Fetal Health Aurora Colorado USA.,Division of Pediatric General, Thoracic and Fetal Surgery Children's Hospital Colorado University of Colorado School of Medicine Aurora Colorado USA
| | - Kenneth W Liechty
- Colorado Fetal Center Colorado Institute for Maternal and Fetal Health Aurora Colorado USA.,Division of Pediatric General, Thoracic and Fetal Surgery Children's Hospital Colorado University of Colorado School of Medicine Aurora Colorado USA
| | - Timothy M Crombleholme
- Colorado Fetal Center Colorado Institute for Maternal and Fetal Health Aurora Colorado USA.,Division of Pediatric General, Thoracic and Fetal Surgery Children's Hospital Colorado University of Colorado School of Medicine Aurora Colorado USA
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Zaretsky MV, Patel S, Howley L, Galan H, Behrendt N, Liechty K, Cuneo B. 127: Biventricular diastolic but not systolic function is impaired in fetal lower urinary tract obstruction. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.031] [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: 10/20/2022]
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Boehnke M, Zaretsky MV, Soranno DE, Dannull KA, Tucker BD, Marwan AI. Uterine didelphys with concomitant renal anomalies in both mother and fetus. Journal of Pediatric Surgery Case Reports 2016. [DOI: 10.1016/j.epsc.2016.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Behrendt N, Zaretsky MV, West NA, Galan HL, Crombleholme TM, Meyers ML. Ultrasound versus MRI: is there a difference in measurements of the fetal lateral ventricles? J Matern Fetal Neonatal Med 2016; 30:298-301. [DOI: 10.3109/14767058.2016.1171310] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Nicholas Behrendt
- Department of Obstetrics and Gynecology, University Colorado Denver, Aurora, CO, USA,
- Colorado Institute for Maternal and Fetal Health, Aurora, CO, USA,
| | - Michael V. Zaretsky
- Department of Obstetrics and Gynecology, University Colorado Denver, Aurora, CO, USA,
- Colorado Institute for Maternal and Fetal Health, Aurora, CO, USA,
| | - Nancy A. West
- Department of Epidemiology, Colorado School of Public Health, CO, USA,
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA,
| | - Henry L. Galan
- Department of Obstetrics and Gynecology, University Colorado Denver, Aurora, CO, USA,
- Colorado Institute for Maternal and Fetal Health, Aurora, CO, USA,
| | - Timothy M. Crombleholme
- Colorado Institute for Maternal and Fetal Health, Aurora, CO, USA,
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA,
- Department of Pediatric Surgery, Children’s Hospital Colorado, Aurora, CO, USA,
| | - Mariana L. Meyers
- Colorado Institute for Maternal and Fetal Health, Aurora, CO, USA,
- Department of Pediatric Radiology, Children’s Hospital Colorado, Aurora, CO, USA, and
- Department of Radiology, University of Colorado Denver School of Medicine, Aurora, CO, USA
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Euser AG, Meyers ML, Zaretsky MV, Crombleholme TM. Comparison of congenital pulmonary airway malformation volume ratios calculated by ultrasound and magnetic resonance imaging. J Matern Fetal Neonatal Med 2015; 29:3172-7. [DOI: 10.3109/14767058.2015.1118038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Anna G. Euser
- Colorado Institute for Maternal and Fetal Health, Children’s Hospital of Colorado, Aurora, CO, USA,
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO, USA,
| | - Mariana L. Meyers
- Colorado Institute for Maternal and Fetal Health, Children’s Hospital of Colorado, Aurora, CO, USA,
- Department of Radiology, University of Colorado Denver, Aurora, CO, USA, and
| | - Michael V. Zaretsky
- Colorado Institute for Maternal and Fetal Health, Children’s Hospital of Colorado, Aurora, CO, USA,
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO, USA,
| | - Timothy M. Crombleholme
- Colorado Institute for Maternal and Fetal Health, Children’s Hospital of Colorado, Aurora, CO, USA,
- Department of Surgery, Children’s Hospital of Colorado, Aurora, CO, USA
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Howley L, Wood C, Patel SS, Zaretsky MV, Crombleholme T, Cuneo B. Flow patterns in the ductus arteriosus during open fetal myelomeningocele repair. Prenat Diagn 2015; 35:564-70. [DOI: 10.1002/pd.4573] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 01/28/2015] [Accepted: 02/01/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Lisa Howley
- Department of Pediatric Cardiology, The Fetal Heart Program, Colorado Fetal Care Center; Colorado Institute for Maternal Fetal Health, Children's Hospital Colorado, University of Colorado School of Medicine; Aurora CO USA
| | - Cristina Wood
- Department of Anesthesiology; Colorado Institute for Maternal Fetal Health, Children's Hospital Colorado, University of Colorado School of Medicine; Aurora CO USA
| | - Sonali S. Patel
- Department of Pediatric Cardiology, The Fetal Heart Program, Colorado Fetal Care Center; Colorado Institute for Maternal Fetal Health, Children's Hospital Colorado, University of Colorado School of Medicine; Aurora CO USA
| | - Michael V. Zaretsky
- Department of Maternal-Fetal Medicine; Colorado Institute for Maternal Fetal Health, Children's Hospital Colorado, University of Colorado School of Medicine; Aurora CO USA
- Department of Fetal Surgery; Colorado Institute for Maternal Fetal Health, Children's Hospital Colorado, University of Colorado School of Medicine; Aurora CO USA
| | - Timothy Crombleholme
- Department of Fetal Surgery; Colorado Institute for Maternal Fetal Health, Children's Hospital Colorado, University of Colorado School of Medicine; Aurora CO USA
| | - Bettina Cuneo
- Department of Pediatric Cardiology, The Fetal Heart Program, Colorado Fetal Care Center; Colorado Institute for Maternal Fetal Health, Children's Hospital Colorado, University of Colorado School of Medicine; Aurora CO USA
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Zaretsky MV, Somme S, Crombleholme TM. Role of adjunctive medical therapy in the fetoscopic surgical treatment of twin-twin transfusion syndrome. Am J Perinatol 2014; 31 Suppl 1:S39-46. [PMID: 25077476 DOI: 10.1055/s-0034-1384641] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The underlying etiology of twin-twin transfusion syndrome (TTTS) is unknown, but our growing understanding of the cardiovascular features of TTTS suggests this may be a disease that could respond to transplacental medical therapy. Adjunctive medical therapy in TTTS with the calcium channel blocker nifedipine has been shown to improve recipient survival while having no effect on the donor. There is no significant difference in recipient survival from postoperative day 5 to birth suggesting that the survival benefit is confined to the effects of nifedipine in the perioperative period. Also, there is no significant effect of nifedipine on gestational age at delivery suggesting the survival benefit was unrelated to the tocolytic effects of nifedipine and more likely a result of hemodynamic effects in the recipient twins' cardiovascular system during the perioperative period. TTTS remains poorly understood but there appears to be good evidence suggesting twin-twin hypertensive cardiomyopathy is a large component of the pathophysiology in recipient twins. The initial findings of nifedipine's effectiveness as a targeted medical therapy to address TTTS cardiomyopathy and improve survival of recipient twins opens the door for further research for adjunctive medical therapies in TTTS.
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Affiliation(s)
- Michael V Zaretsky
- Division of Maternal Fetal-Medicine, Colorado Institute of Maternal Fetal Health, The University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Stig Somme
- Department of Pediatric General Thoracic and Fetal Surgery, Colorado Institute of Maternal Fetal Health, The University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Timothy M Crombleholme
- Department of Pediatric General Thoracic and Fetal Surgery, Colorado Institute of Maternal Fetal Health, The University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
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Bleich A, Alexander JM, Zaretsky MV, Mcintire DD, Hatab MR, Twickler DM. 340: The utility of MR fetal volume and maternal pelvimetry estimates to predict labor dystocia. Am J Obstet Gynecol 2009. [DOI: 10.1016/j.ajog.2009.10.355] [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: 10/20/2022]
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Abstract
OBJECTIVE To determine whether the magnetic resonance assessment of cervical water content using the T2 relaxation time correlated with cervical ripening, as evidenced by the time to onset of spontaneous labor, need for induction, and the incidence of cesarean delivery in women whose pregnancy reached 41 weeks of gestation. METHODS The cervical T2 relaxation time was calculated from magnetic resonance data obtained in a previous study of magnetic resonance pelvimetry. After consent was obtained, the patients underwent a magnetic resonance imaging (MRI) protocol consisting of a dual fast spin echo T2-weighted scan. From images of a single slice, the cervical T2 relaxation time was calculated from two different regions of interest (anterior and posterior) on the cervix. The average cervical T2 relaxation time was then correlated to obstetric outcomes linked with cervical ripening. RESULTS A total of 119 patients gave their consent for the study. Of these patients, 93 had optimal imaging of the cervical stroma and were included in the analysis. There was no significant correlation between the cervical T2 relaxation time and any individual component of the Bishop score or the total score. The cervical T2 relaxation time did not predict whether labor was spontaneous or induced and whether or not a woman underwent cesarean delivery. CONCLUSION Cervical magnetic resonance T2 relaxation times did not correlate with the clinical Bishop score or predict labor outcome in our series of women whose pregnancies reached 41 weeks of gestation. Quantifying the magnetic resonance T2 relaxation time does not appear to be useful in the assessment of cervical ripening. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jason A Pates
- Department of Obstetrics & Gynecology, The University of Texas Southwestern Medical Center at Dallas, 323 Harry Hines Boulevard, Dallas, TX 75235, USA.
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Abstract
OBJECTIVE To study whether magnetic resonance imaging (MRI) pelvimetry has the ability to identify those women who require cesarean delivery for labor dystocia. METHODS From July 2003 to April 2004, nulliparous women scheduled for a labor induction for prolonged pregnancy (42 weeks) were asked to participate in a pelvimetry study. Those who consented underwent fast-acquisition MRI that included two 90-second acquisitions to evaluate fetal biometry and volumetry and maternal pelvimetry, including novel measurements of pelvic bony and soft tissue volumes as determined by MRI. Information about each patient's pregnancy, labor course, and neonatal outcome was prospectively collected. Pelvimetry results for those women undergoing operative delivery for labor dystocia were compared with those who did not. Single fetal and maternal pelvic measurements, as well as ratios of both, were analyzed. In addition, previously described radiographic pelvimetry techniques and formulas to predict dystocia were used. RESULTS One hundred one women underwent MRI, and 22 of these underwent cesarean delivery for dystocia. No single fetal measurement was statistically associated with dystocia. Several maternal pelvic measures, fetal-to-maternal ratios, and previously reported pelvimetric techniques were significantly associated with dystocia. The ratio of magnetic resonance (MR) fetal head volume to pelvic soft tissue volume had statistical significance (P = .04). Receiver operator characteristic curves were developed for the different measurements, ratios, and formulas studied to assess whether any of the techniques could accurately predict labor dystocia requiring operative delivery. The area under the curve values ranged from 0.6 to 0.8, with the ratio of MR head volume to pelvic soft tissue being 0.7. These values suggest that MRI can identify those women at greatest risk for dystocia, but it cannot with accuracy predict which ones will require a cesarean. CONCLUSION We found significant associations with MRI pelvimetry and labor dystocia, but MRI was not a significant improvement over previously described pelvimetric techniques. LEVEL OF EVIDENCE II-3.
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Affiliation(s)
- Michael V Zaretsky
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75235-9032, USA
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Boreham MK, Zaretsky MV, Corton MM, Alexander JM, McIntire DD, Twickler DM. Appearance of the levator ani muscle in pregnancy as assessed by 3-D MRI. Am J Obstet Gynecol 2005; 193:2159-64. [PMID: 16325634 DOI: 10.1016/j.ajog.2005.07.094] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [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: 01/17/2005] [Revised: 07/15/2005] [Accepted: 07/27/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to describe levator ani (LA) anatomy in postterm nulliparas using 3-dimensional (3-D) magnetic resonance (MR). STUDY DESIGN Nulliparas (n = 84) with uncomplicated, postterm pregnancies underwent an MR (4 mm slices, 0 gap) of the uterus and pelvis. LA volume and morphometry were assessed using 3-D post-processing software. RESULTS LA insertion into the symphysis was visible in 93%, and the iliococcygeus muscle assumed a convex shape (arch) in the 92% of the 84 women. The LA shape was characterized as "U" in 53% and "V" in 47%. Mean LA volume was 13.5 (3.7) cm3. There was a positive association between LA volume and higher fetal station (P = .02) and increasing BMI (P < .001). However, no relationship between LA volume and station was found after adjusting for BMI. CONCLUSION BMI was correlated with LA volume in postterm nulliparas. LA insertion into the symphysis and the iliococcygeus arch were well-preserved overall and morphometry was variable.
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Affiliation(s)
- Muriel K Boreham
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Zaretsky MV, McIntire DD, Reichel TF, Twickler DM. Correlation of measured amnionic fluid volume to sonographic and magnetic resonance predictions. Am J Obstet Gynecol 2004; 191:2148-53. [PMID: 15592305 DOI: 10.1016/j.ajog.2004.04.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the relationship between the actual amnionic fluid volume that was measured at delivery and magnetic resonance amnionic fluid volume determination, largest vertical pocket, and amnionic fluid index. STUDY DESIGN Three hours before cesarean delivery, 80 women had sonographic measurement of the amnionic fluid index and the largest vertical pocket. Magnetic resonance imaging was then completed, and the magnetic resonance amnionic fluid volume was determined. At surgery, the amnionic fluid was collected. Pearson correlations were determined. Receiver operating characteristic curves were developed for each method as a measure of predictability for oligohydramnios. RESULTS The correlations for the magnetic resonance amnionic fluid volume, amnionic fluid index, and largest vertical pocket to amnionic fluid volume was 0.84, 0.77, and 0.71, respectively. Magnetic resonance amnionic fluid volume has a statistically higher correlation than the largest vertical pocket ( P = .046). The 3 methods, however, are statistically comparable for identifying oligohydramnios. CONCLUSION Magnetic resonance imaging is comparable with ultrasound evaluation for the prediction of oligohydramnios. Correlations to actual amnionic fluid volume are also comparable.
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Affiliation(s)
- Michael V Zaretsky
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, Tex, USA
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Abstract
OBJECTIVE The purpose of this study was to determine whether the placental transfer of interleukin (IL)-1alpha, IL-6, and tumor necrosis factor-alpha (TNF-alpha) occurs. METHODS Four normal-term placentas were perfused for maternal-fetal transfer of the cytokines, 2 placentas for fetal-maternal transfer, and 4 additional placentas were used for an endogenous control. The ex vivo isolated cotyledon human placental perfusion model was used. The reference compound antipyrine was used to determine the transport fraction and clearance index of the cytokines. The cytokines were added to either the maternal or fetal circulations, and samples were collected for 1 hour in a constant-flow open circulation. Cytokine levels were compared between the study and control placentas. Concentrations of the cytokines were measured by sandwich enzyme immunoassay. RESULTS The clearance index for the maternal-fetal transfer of IL-1alpha and TNF-alpha was 0.001, suggesting minimal transfer to the fetal circulation. The clearance index for IL-6 was 0.30, indicating transfer to the fetal circulation. When the cytokines were added to the fetal circulation, the clearance index for IL-1alpha was 0.001, again indicating minimal transfer. The clearance index for TNF-alpha in the fetal-maternal study was not determined. IL-6 had a clearance index of 0.23, which was similar to that observed with maternal-fetal transfer. IL-6 concentrations in the study placentas were higher than the concentrations found in the controls. CONCLUSION There appears to be bidirectional transfer of IL-6 in the healthy-term human placental perfusion model. LEVEL OF EVIDENCE II-2
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Affiliation(s)
- Michael V Zaretsky
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9032, USA.
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