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Burrill N, Khalek N, Oliver ER, Linn R, Victoria T, Yates C, Moldenhauer JS. Case report of fetus with Lowe syndrome: Expanding the prenatal phenotype. Prenat Diagn 2024; 44:665-668. [PMID: 38554254 DOI: 10.1002/pd.6563] [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: 02/12/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/01/2024]
Abstract
Oculocerebrorenal syndrome (Lowe syndrome) is a rare X-linked disorder affecting 1/500,000 males that most frequently affects the eyes, central nervous system, and kidneys. Phenotypic presentation includes congenital cataracts, developmental delay, intellectual disability, and Fanconi-type renal dysfunction. Lowe Syndrome is caused by hemizygous loss of function variants in the OCRL gene. While individuals may live into the third and fourth decade of life, some will die in the first few years of either renal failure or infection. While early diagnosis is important, few cases have documented the prenatal phenotype of this condition, which has included bilateral cataracts and variable neurological abnormalities. We report a case of a family with an extensive history of congenital cataracts, immune compromise, and neonatal death in male members. The fetus was found to have a unilateral cataract, mild ventriculomegaly, vertebral anomalies, and an underlying diagnosis of Lowe Syndrome with a mutation in OCRL at c.2582-1G>C (IVS23-1G>C).
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Affiliation(s)
- Natalie Burrill
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward R Oliver
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca Linn
- Division of Anatomic Pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Teresa Victoria
- Division of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Julie S Moldenhauer
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Burrill N, Khalek N, Cristancho AG, Coleman B, Murrell J, Moldenhauer JS. Fetus with multiple congenital anomaly syndrome caused by novel variant in ATP1A2. Prenat Diagn 2024; 44:661-664. [PMID: 38549198 DOI: 10.1002/pd.6560] [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: 11/20/2023] [Revised: 02/02/2024] [Accepted: 03/10/2024] [Indexed: 05/08/2024]
Abstract
We report a 32-year-old G3P1 at 35 weeks 3 days with a dichorionic, diamniotic twin gestation who presented for evaluation secondary to ventriculomegaly (VM) in one twin. Fetal ultrasound and MRI demonstrated microcephaly, severe VM, compression of the corpus callosum, scalp and nuchal thickening, elongated ears, bilateral talipes, right-sided congenital diaphragmatic hernia (CDH), and loss of normal cerebral architecture, indicative of a prior insult in the affected twin. The co-twin was grossly normal. The family pursued a palliative care pathway for the affected twin and was delivered at 37 weeks and 6 days. The affected twin passed away within the first hour of life due to respiratory compromise. Postmortem trio exome sequencing identified a homozygous likely pathogenic variant in ATP1A2 (c.2439+1G>A). Although this variant is novel, it is predicted to affect the donor split site in intron 17, resulting in a frameshift and complete loss-of-function of the gene. Biallelic loss of function variants in this gene have been reported in seven individuals with multiple anomalies similar to those in the affected twin. However, only one other individual with a possible CDH has been previously reported. Our case suggests that CDH be included in the phenotypic spectrum of this disorder and reports the first frameshift mutation causing this autosomal recessive multiple congenital anomaly syndrome.
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Affiliation(s)
- Natalie Burrill
- Children's Hospital of Philadelphia, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Children's Hospital of Philadelphia, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Philadelphia, Pennsylvania, USA
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ana G Cristancho
- Children's Hospital of Philadelphia, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Philadelphia, Pennsylvania, USA
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Beverly Coleman
- Children's Hospital of Philadelphia, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Philadelphia, Pennsylvania, USA
- Department of Clinical Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jill Murrell
- Division of Genomic Diagnostics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- Children's Hospital of Philadelphia, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Philadelphia, Pennsylvania, USA
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Berger JA, Nelson O, Staben J, Javia LR, Simpao AF, Khalek N, Oliver ER, Adzick NS, Lin EE. Immediate postdelivery airway management of neonates with prenatally diagnosed micrognathia: A retrospective observational study. Paediatr Anaesth 2024; 34:267-273. [PMID: 38069629 DOI: 10.1111/pan.14806] [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: 06/30/2023] [Revised: 10/23/2023] [Accepted: 11/21/2023] [Indexed: 02/08/2024]
Abstract
INTRODUCTION Micrognathic neonates are at risk for upper airway obstruction, and many require intubation in the delivery room. Ex-utero intrapartum treatment is one technique for managing airway obstruction but poses substantial maternal risks. Procedure requiring a second team in the operating room is an alternative approach to secure the obstructed airway while minimizing maternal risk. The aim of this study was to describe the patient characteristics, airway management, and outcomes for micrognathic neonates and their mothers undergoing a procedure requiring a second team in the operating room at a single quaternary care children's hospital. METHODS This was a retrospective descriptive study. Subjects had prenatally diagnosed micrognathia and underwent procedure requiring a second team in the operating room between 2009 and 2021. Collected data included infant characteristics, delivery room airway management, critical events, and medications. Follow-up data included genetic testing and subsequent procedures within 90 days. Maternal data included type of anesthetic, blood loss, and incidence of transfusion. RESULTS Fourteen deliveries were performed via procedure requiring a second team in the operating room during the study period. 85.7% were male, and 50% had a genetic syndrome. Spontaneous respiratory efforts were observed in 93%. Twelve patients (85.7%) required an endotracheal tube or tracheostomy. Management approaches varied. Medications were primarily a combination of atropine, ketamine, and dexmedetomidine. Oxygen desaturation was common, and three patients experienced bradycardia. There were no periprocedural deaths. Follow-up at 90 days revealed that 78% of patients underwent at least one additional procedure, and one patient died due to an unrelated cause. All mothers underwent cesarean deliveries under neuraxial anesthesia. Median blood loss was 700 mL [IQR 700 mL, 800 mL]. Only one mother required a blood transfusion for pre-procedural placental abruption. DISCUSSION Procedure requiring a second team in the operating room is a safe and effective approach to manage airway obstruction in micrognathic neonates while minimizing maternal morbidity. CONCLUSIONS Though shown to be safe and effective, more data are needed to support the use of procedure requiring a second team in the operating room as an alternative to ex-utero intrapartum treatment for micrognathia outside of highly specialized maternal-fetal centers.
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Affiliation(s)
- Jessica A Berger
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James Staben
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Luv R Javia
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Clinical Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Allan F Simpao
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward R Oliver
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elaina E Lin
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Soni S, Gebb J, Miller K, Oliver ER, Teefey CP, Moldenhauer JS, Khalek N. Predictors of poor outcomes in monochorionic diamniotic twin pregnancies complicated by selective fetal growth restriction. Fetal Diagn Ther 2024:000537861. [PMID: 38368864 DOI: 10.1159/000537861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/01/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION To identify predictors of poor outcomes in monochorionic diamniotic twin (MCDA) pregnancies with selective fetal growth restriction (sFGR) irrespective of the umbilical artery (UA) Doppler abnormalities. METHODS Single center retrospective analysis of MCDA twins diagnosed with sFGR that opted for expectant management between 2010-2021. The presence of any of the following variables in the growth restricted fetus: low amniotic fluid volume (DVP≤2cm), lack of a cycling bladder, absent or reversed flow in the ductus venosus (DV) with atrial contraction and elevated middle cerebral artery peak systolic velocity (MCA-PSV) defined as ≥1.50 multiples of the median was categorized as complicated. sFGR cases were classified as simple in the absence of the above-mentioned variables. RESULTS 63.3% cases qualified as simple and 36.7% were complicated. Intertwin EFW discordance was higher in the complicated category (26% vs 33%, p=0.0002). The median gestational age at delivery was earlier (33 weeks vs 30.5 weeks, p=0.002) and the likelihood of survival was lower in the complicated category (p<0.0001). The likelihood of two survivors to discharge was lower in type I complicated cases (70% in complicated type I versus 97.1% in simple type I, p=0.0003). On logistic regression analysis, an increase in the "complicated" score negatively correlated with two survivors to discharge (p<0.0001). An ROC curve was created, and the AUC was 0.79. Increasing intertwin EFW discordance also decreased the probability of two survivors to discharge. CONCLUSION The presence of oligohydramnios, lack of a cycling bladder, abnormal DV Doppler, and elevated MCA-PSV in the growth restricted fetus is associated with poor perinatal outcomes and a lower likelihood of having two survivors to discharge. The addition of intertwin EFW discordance to these variables helped improve the survival predictability.
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Soni S, Paidas Teefey C, Gebb JS, Khalek N, Neary K, Miller K, Moldenhauer JS. Amnioreduction vs expectant management in pregnancies with moderate to severe polyhydramnios. Am J Obstet Gynecol MFM 2023; 5:101192. [PMID: 37858792 DOI: 10.1016/j.ajogmf.2023.101192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/20/2023] [Accepted: 10/09/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND The rate of polyhydramnios is higher in pregnancies complicated by congenital anomalies. These pregnancies have higher rates of peripartum complications. Amnioreduction is offered to relieve maternal symptoms such as dyspnea, abdominal and respiratory discomfort, and other issues like satiety. OBJECTIVE This study aimed to report the rates of amnioreduction and its associated complications in pregnancies with moderate to severe polyhydramnios secondary to fetal anomalies. We also sought to determine if amnioreduction provided additional benefits, including prolongation of pregnancy and a decrease in the rates of peripartum morbidities associated with moderate to severe polyhydramnios. STUDY DESIGN This was a retrospective review of anomalous singleton pregnancies with moderate to severe polyhydramnios that were evaluated and delivered at a single center between 2013 and 2021. Peripartum outcomes were compared between pregnancies that underwent amnioreduction and those that were expectantly managed. Mann-Whitney U tests were used to compare continuous variables and Fisher's exact tests were used for categorical variables. A multiple regression model was created to understand the effects of amnioreduction on gestational age at delivery. RESULTS A total of 218 singleton pregnancies met the inclusion criteria of moderate to severe polyhydramnios in the study period. Of those, 110 patients (50.5%) underwent amnioreduction and 108 patients (49.5%) opted for expectant management. A total of 147 procedures were performed at a median gestational age of 32.5 weeks and a median of 1900 mL of amniotic fluid was removed per procedure. Complications occurred in 10.9% (n=16) of procedures, including preterm delivery within 48 hours in 5.4% cases (n=8). The median amniotic fluid index was higher in the amnioreduction group than in the expectant group (38.9 cm vs 35.5 cm; P<.0001). Patients who underwent amnioreduction had an earlier median gestational age at delivery (36.3 weeks vs 37.0 weeks; P=.048), however, the rates of spontaneous preterm delivery were similar. A higher percentage of women in the amnioreduction group had vaginal delivery (49.4% vs 30.5%; P=.01) and lower rates of uterine atony (2.4% vs 13.7%; P=.006). In the multiple linear regression analysis, the gestational age at delivery positively correlated with gestational age at amnioreduction after controlling for amniotic fluid volume (P<.0001; 95% confidence interval, 0.34-0.71). In addition, the patients in the amnioreduction group were twice as likely to have a vaginal delivery (P=.02). CONCLUSION Amnioreduction in the setting of moderate-severe polyhydramnios has a reasonably low rate of complications but does not provide any benefits in terms of prolonging the pregnancy. The procedure may increase the likelihood of vaginal delivery and lower the rates of uterine atony.
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Affiliation(s)
- Shelly Soni
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, Neary, Miller, and Moldenhauer); Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, and Moldenhauer).
| | - Christina Paidas Teefey
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, Neary, Miller, and Moldenhauer); Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, and Moldenhauer)
| | - Juliana S Gebb
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, Neary, Miller, and Moldenhauer); Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, and Moldenhauer)
| | - Nahla Khalek
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, Neary, Miller, and Moldenhauer); Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, and Moldenhauer)
| | - Kayla Neary
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, Neary, Miller, and Moldenhauer)
| | - Kendra Miller
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, Neary, Miller, and Moldenhauer)
| | - Julie S Moldenhauer
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, Neary, Miller, and Moldenhauer); Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Drs Soni, Paidas Teefey, Gebb, Khalek, and Moldenhauer)
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Bose SK, Stratigis JD, Ahn N, Pogoriler J, Hedrick HL, Rintoul NE, Partridge EA, Flake AW, Khalek N, Gebb J, Teefey CP, Soni S, Hamaguchi R, Moldenhauer J, Adzick NS, Peranteau WH. Prenatally Diagnosed Large Lung Lesions: Timing of Resection and Perinatal Outcomes. J Pediatr Surg 2023; 58:2384-2390. [PMID: 37813715 DOI: 10.1016/j.jpedsurg.2023.09.002] [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: 04/24/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Fetuses with large lung lesions including congenital cystic adenomatoid malformations (CCAMs) are at risk for cardiopulmonary compromise. Prenatal maternal betamethasone and cyst drainage for micro- and macrocystic lesions respectively have improved outcomes yet some lesions remain large and require resection before birth (open fetal surgery, OFS), at delivery via an Ex Utero Intrapartum Treatment (EXIT), or immediately post cesarean section (section-to-resection, STR). We sought to compare prenatal characteristics and outcomes in fetuses undergoing OFS, EXIT, or STR to inform decision-making and prenatal counseling. METHODS A single institution retrospective review was conducted evaluating patients undergoing OFS, EXIT, or STR for prenatally diagnosed lung lesions from 2000 to 2021. Specimens were reviewed by an anatomic pathologist. Lesions were divided into "CCAMs" (the largest pathology group) and "all lung lesions" since pathologic diagnosis is not possible during prenatal evaluation when care decisions are made. Prenatal variables included initial, greatest, and final CCAM volume-ratio (CVR), betamethasone use/frequency, cyst drainage, and the presence of hydrops. Outcomes included survival, ECMO utilization, NICU length of stay (LOS), postnatal nitric oxide use, and ventilator days. RESULTS Sixty-nine percent (59 of 85 patients) of lung lesions undergoing resection were CCAMs. Among patients with pathologic diagnosis of CCAM, the initial, largest, and final CVRs were greatest in OFS followed by EXIT and STR patients. Similarly, the incidence of hydrops was significantly greater and the rate of hydrops resolution was lower in the OFS group. Although the rate of cyst drainage did not differ between groups, maternal betamethasone use varied significantly (OFS 60.0%, EXIT 100.0%, STR 74.3%; p = 0.0378). Notably, all OFS took place prior to 2014. There was no difference in survival, ventilator days, nitric oxide, NICU LOS, or ECMO between groups. In multiple variable logistic modeling, determinants of survival to NICU discharge among patients undergoing resection with a pathologic diagnosis of CCAM included initial CVR <3.5 and need for <3 maternal betamethasone doses. CONCLUSION For CCAMs that remain large despite maternal betamethasone or cyst drainage, surgical resection via OFS, EXIT, or STR are viable options with favorable and comparable survival between groups. In the modern era there has been a shift from OFS and EXIT procedures to STR for fetuses with persistently large lung lesions. This shift has been fueled by the increased use of maternal betamethasone and introduction of a Special Delivery Unit during the study period and the appreciation of similar fetal and neonatal outcomes for STR vs. EXIT and OFS with reduced maternal morbidity associated with a STR. Accordingly, efforts to optimize multidisciplinary perinatal care for fetuses with large lung lesions are important to inform patient selection criteria and promote STR as the preferred surgical approach in the modern era. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sourav K Bose
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John D Stratigis
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicholas Ahn
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Pogoriler
- Department of Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily A Partridge
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nahla Khalek
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julianna Gebb
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina Paidas Teefey
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shelly Soni
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryoko Hamaguchi
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie Moldenhauer
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William H Peranteau
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Sheppard SE, March ME, Seiler C, Matsuoka LS, Kim SE, Kao C, Rubin AI, Battig MR, Khalek N, Schindewolf E, O'Connor N, Pinto E, Priestley JR, Sanders VR, Niazi R, Ganguly A, Hou C, Slater D, Frieden IJ, Huynh T, Shieh JT, Krantz ID, Guerrero JC, Surrey LF, Biko DM, Laje P, Castelo-Soccio L, Nakano TA, Snyder K, Smith CL, Li D, Dori Y, Hakonarson H. Lymphatic disorders caused by mosaic, activating KRAS variants respond to MEK inhibition. JCI Insight 2023; 8:155888. [PMID: 37154160 DOI: 10.1172/jci.insight.155888] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 10/19/2021] [Accepted: 03/17/2023] [Indexed: 05/10/2023] Open
Abstract
Central conducting lymphatic anomaly (CCLA) due to congenital maldevelopment of the lymphatics can result in debilitating and life-threatening disease with limited treatment options. We identified 4 individuals with CCLA, lymphedema, and microcystic lymphatic malformation due to pathogenic, mosaic variants in KRAS. To determine the functional impact of these variants and identify a targeted therapy for these individuals, we used primary human dermal lymphatic endothelial cells (HDLECs) and zebrafish larvae to model the lymphatic dysplasia. Expression of the p.Gly12Asp and p.Gly13Asp variants in HDLECs in a 2‑dimensional (2D) model and 3D organoid model led to increased ERK phosphorylation, demonstrating these variants activate the RAS/MAPK pathway. Expression of activating KRAS variants in the venous and lymphatic endothelium in zebrafish resulted in lymphatic dysplasia and edema similar to the individuals in the study. Treatment with MEK inhibition significantly reduced the phenotypes in both the organoid and the zebrafish model systems. In conclusion, we present the molecular characterization of the observed lymphatic anomalies due to pathogenic, somatic, activating KRAS variants in humans. Our preclinical studies suggest that MEK inhibition should be studied in future clinical trials for CCLA due to activating KRAS pathogenic variants.
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Affiliation(s)
| | | | - Christoph Seiler
- Zebrafish Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | | | - Adam I Rubin
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Nahla Khalek
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment and
| | | | | | - Erin Pinto
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | - Rojeen Niazi
- Genetic Diagnostic Laboratory, Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arupa Ganguly
- Genetic Diagnostic Laboratory, Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | - Joseph T Shieh
- Division of Medical Genetics, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Ian D Krantz
- Division of Human Genetics, and
- Roberts Individualized Medical Genetics Center, Division of Human Genetics
| | | | | | | | | | - Leslie Castelo-Soccio
- Dermatology Section, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Taizo A Nakano
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Kristen Snyder
- Division of Oncology, Cancer Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Nelson O, Khalek N, Wu L, William MS, Wohler B, Lin EE, Tran KM, Simpao AF. Perioperative Maternal-Fetal Outcomes in the Setting of Minimally Invasive Fetal Therapy for Complex Monochorionic Pregnancies with Monitored Anesthesia Care. Fetal Diagn Ther 2023; 50:387-396. [PMID: 37094556 DOI: 10.1159/000530737] [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: 12/15/2022] [Accepted: 03/28/2023] [Indexed: 04/26/2023]
Abstract
INTRODUCTION Fetoscopic selective laser photocoagulation (FSLPC) and selective cord occlusion with radiofrequency ablation (RFA) can improve fetal outcomes when vascular anastomoses between fetuses cause twin-to-twin transfusion syndrome (TTTS) or selective fetal growth restriction (sFGR) in multiple gestation pregnancies with monochorionic placentation. This study analyzed perioperative maternal-fetal complications and anesthetic management in a high-volume fetal therapy center over a 4-year period. METHODS Included patients received MAC for minimally invasive fetal procedures for complex multiple gestation pregnancies between January 1, 2015, and September 20, 2019. Maternal and fetal complications, intraoperative maternal hemodynamics, medication usage, and reasons for conversion to general anesthesia, if applicable, were analyzed. RESULTS A total of 203 (59%) patients underwent FSLPC and 141 (41%) had RFA. Four patients (2%; rate 95% CI: 0.00039, 0.03901) undergoing FSLPC had conversion to general anesthesia. No conversions to general anesthesia occurred in the RFA group. The incidence of maternal complications was higher in those who underwent FSLPC. No aspiration or postoperative pneumonia events were observed. Medication usage was similar in FSLPC and RFA groups. CONCLUSION A low rate of conversion to general anesthesia and no serious adverse maternal events were observed in patients receiving MAC.
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Affiliation(s)
- Olivia Nelson
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment (CFDT) at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment (CFDT) at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lezhou Wu
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Meryl S William
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brittany Wohler
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elaina E Lin
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment (CFDT) at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kha M Tran
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment (CFDT) at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allan F Simpao
- Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment (CFDT) at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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9
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Matalon DR, Bhoj EJ, Li D, McDougall C, Schindewolf E, Khalek N, Wilkens A, McManus M, Deardorff MA, Zackai EH. Genomic sequencing in a cohort of individuals with fibular aplasia, tibial campomelia, and oligosyndactyly (FATCO) syndrome. Am J Med Genet A 2023; 191:977-982. [PMID: 36610046 DOI: 10.1002/ajmg.a.63105] [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: 06/10/2022] [Revised: 11/19/2022] [Accepted: 12/16/2022] [Indexed: 01/09/2023]
Abstract
Fibular aplasia, tibial campomelia, and oligosyndactyly (FATCO) syndrome (MIM 246570) is a rare disorder characterized by specific skeletal findings (fibular aplasia, shortened or bowed tibia, and oligosyndactyly of the foot and/or hand). Typically, no other anomalies, craniofacial dysmorphism, or developmental delays are associated. Here we report three unrelated individuals with limb anomalies consistent with FATCO syndrome who have been followed clinically for 5 years. Genetic testing of previously reported individuals with FATCO syndrome has not revealed a genetic diagnosis. However, no broader sequencing approaches have been reported. We describe the results of the three individuals with FATCO syndrome from exome and genome sequencing, all of which was nondiagnostic. Our study suggests that FATCO syndrome is not the result of a simple monogenic etiology.
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Affiliation(s)
- Dena R Matalon
- Division of Medical Genetics, Stanford University, Stanford, California, USA
| | - Elizabeth J Bhoj
- Division of Human Genetics and Molecular Biology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dong Li
- Division of Human Genetics and Molecular Biology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Carey McDougall
- Division of Human Genetics and Molecular Biology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Erica Schindewolf
- Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alisha Wilkens
- Division of Human Genetics and Molecular Biology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Morgan McManus
- Division of Human Genetics and Molecular Biology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew A Deardorff
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Elaine H Zackai
- Division of Human Genetics and Molecular Biology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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10
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Soni S, Gebb JS, Moldenhauer JS, Hwang R, Paidas Teefey C, Oliver ER, Khalek N. Predictors of dual demise within the first week after selective cord occlusion via radiofrequency ablation for complex monochorionic pregnancies. Am J Obstet Gynecol MFM 2023; 5:100842. [PMID: 36543290 DOI: 10.1016/j.ajogmf.2022.100842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Selective cord occlusion is an option in complicated monochorionic multiple gestations with the goal of reducing the pregnancy by one fetus and to optimize the outcomes for the remaining fetus(es). OBJECTIVE This study aimed to determine the rate and associated risk factors of dual demise in complex monochorionic pregnancies after selective cord occlusion via radiofrequency ablation. STUDY DESIGN This was a single-center analysis of a prospective registry cohort of complex monochorionic pregnancies managed with selective cord occlusion via radiofrequency ablation between 2014 and 2021. A total of 167 pregnancies met the inclusion criteria and were evaluated on the basis of the intended outcome of dual demise vs singleton survival. Risk factors were compared between the 2 groups. The Mann-Whitney U test was used for continuous variables and the Fisher exact test was used for categorical variables. RESULTS The incidence of postprocedure dual demise within the first week after performing radiofrequency ablation was 10.8% (18/167). The risk was higher in pregnancies undergoing radiofrequency ablation for discordant anomaly, and this subcategory constituted 38.9% of pregnancies in the dual demise subgroup (P=.02). Lower intertwin estimated fetal weight discordance (P=.01) was associated with dual demise. Perioperative variables including gestational age at procedure, placental cord insertion distance, operative time, and radiofrequency ablation time were similar in those with and without dual demise. CONCLUSION Our results show that selective cord occlusion via radiofrequency ablation is a safe and reasonable option in complicated monochorionic pregnancies, with low rates of dual demise within the first week after the procedure.
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Affiliation(s)
- Shelly Soni
- Division of Pediatric General, Thoracic and Fetal Surgery, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Ms Hwang, Dr Paidas Teefey, Dr Oliver, and Dr Khalek); XXX, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Dr Paidas Teefey, Dr Oliver, and Dr Khalek).
| | - Juliana S Gebb
- Division of Pediatric General, Thoracic and Fetal Surgery, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Ms Hwang, Dr Paidas Teefey, Dr Oliver, and Dr Khalek); XXX, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Dr Paidas Teefey, Dr Oliver, and Dr Khalek)
| | - Julie S Moldenhauer
- Division of Pediatric General, Thoracic and Fetal Surgery, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Ms Hwang, Dr Paidas Teefey, Dr Oliver, and Dr Khalek); XXX, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Dr Paidas Teefey, Dr Oliver, and Dr Khalek)
| | - Rosa Hwang
- Division of Pediatric General, Thoracic and Fetal Surgery, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Ms Hwang, Dr Paidas Teefey, Dr Oliver, and Dr Khalek)
| | - Christina Paidas Teefey
- Division of Pediatric General, Thoracic and Fetal Surgery, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Ms Hwang, Dr Paidas Teefey, Dr Oliver, and Dr Khalek); XXX, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Dr Paidas Teefey, Dr Oliver, and Dr Khalek)
| | - Edward R Oliver
- Division of Pediatric General, Thoracic and Fetal Surgery, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Ms Hwang, Dr Paidas Teefey, Dr Oliver, and Dr Khalek); XXX, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Dr Paidas Teefey, Dr Oliver, and Dr Khalek); Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA (Dr Oliver)
| | - Nahla Khalek
- Division of Pediatric General, Thoracic and Fetal Surgery, Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Ms Hwang, Dr Paidas Teefey, Dr Oliver, and Dr Khalek); XXX, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Dr Soni, Dr Gebb, Dr Moldenhauer, Dr Paidas Teefey, Dr Oliver, and Dr Khalek)
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11
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Adutwum M, Hurst A, Mirzaa G, Kushner JD, Rogers C, Khalek N, Cristancho AG, Burrill N, Seifert ME, Scarano MI, Schnur RE, Slavotinek A. Six new cases of CRB2-related syndrome and a review of clinical findings in 28 reported patients. Clin Genet 2023; 103:97-102. [PMID: 36071576 DOI: 10.1111/cge.14222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 12/14/2022]
Abstract
The Crumbs homolog-2 (CRB2)-related syndrome (CRBS-RS) is a rarely encountered condition initially described as a triad comprising ventriculomegaly, Finnish nephrosis, and elevated alpha-fetoprotein levels in maternal serum and amniotic fluid. CRB2-related syndrome is caused by biallelic, pathogenic variants in the CRB2 gene. Recent reports of CRB2-RS have highlighted renal disease with persistent proteinuria and steroid-resistant nephrotic syndrome (SRNS). We report six new and review 28 reported patients with pathogenic variants in CRB2. We compare clinical features and variant information in CRB2 in patients with CRB2-RS and in those with isolated renal disease. The kidneys were the most frequently involved body system and 11 patients had only renal manifestations with SRNS or nephrotic syndrome. Central nervous system involvement was the next most common manifestation, followed by cardiac findings that included Scimitar syndrome. There was a significant clustering of pathogenic variants for CRB2-RS in exons 8 and 10, whereas pathogenic variants in exons 12 and 13 were associated with isolated renal disease. Further information is needed to determine optimal management but monitoring for renal and ocular complications should be considered.
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Affiliation(s)
- Michelle Adutwum
- Children's Hospital Oakland Research Institute Summer Program, University of California San Francisco, San Francisco, California, USA
| | - Anna Hurst
- Department of Genetics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ghayda Mirzaa
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jessica D Kushner
- Department of Molecular and Medical Genetics, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Caleb Rogers
- Department of Molecular and Medical Genetics, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Nahla Khalek
- Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ana G Cristancho
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie Burrill
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael E Seifert
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maria I Scarano
- Department of Pediatrics, Cooper University Health Care, Camden, New Jersey, USA
| | - Rhonda E Schnur
- Department of Pediatrics, Cooper University Health Care, Camden, New Jersey, USA.,Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Anne Slavotinek
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
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12
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Teefey CP, Budney A, Gebb JS, Khalek N, Soni S, Moldenhauer JS, Cole J. Symptoms of perinatal mood disorders in expectant parents with a diagnosis of a congenital anomaly. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.228] [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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Teefey CP, Budney A, Jay L, Dicicco R, Hedrick H, Khalek N, Soni S, Gebb JS, Moldenhauer JS, Cole J. Impact of psychosocial collaboration on parental psychological distress in the setting of congenital diaphragmatic hernia. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.779] [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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14
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Gebb JS, Miller K, Hwang R, Soni S, Teefey CP, Moldenhauer JS, Khalek N. Outcomes with early and late laser for severe twin twin transfusion syndrome. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1121] [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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Soni S, Gebb JS, Miller K, Oliver ER, Teefey CP, Moldenhauer JS, Khalek N. Predictors of poor outcomes in monochorionic diamniotic twin pregnancies complicated by selective fetal growth restriction. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1235] [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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16
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Gebb J, Miller K, Hwang R, Soni S, Paidas Teefey C, Didier R, Oliver ER, Rychik J, Moldenhauer JS, Khalek N. Risks of Single Fetal Demise after Laser for Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2022; 49:403-410. [PMID: 36044872 DOI: 10.1159/000526799] [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: 05/18/2022] [Accepted: 08/22/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The aim of the study was to determine if markers of donor placental insufficiency and recipient cardiac dysfunction increase the risk for single fetal demise (SFD) after laser for twin-twin transfusion syndrome (TTTS). METHODS Single-center retrospective review of patients who had laser for TTTS. Risk factors for donor and recipient demise within 1 week were compared in pregnancies with SFD and pregnancies with dual survival using χ2 or Fisher's exact test. Multivariate logistic regression was then performed. RESULTS Of 398 procedures, 305 (76.6%) had dual survival, 36 (9.0%) had donor demise, 28 (7.0%) had recipient demise, and 9 (2.3%) had dual demise. The remaining 20 (5.0%) patients had complicated courses with pregnancy loss or further intervention. In the 64 pregnancies with SFD, 29 (81%) in the donor group and 20 (71%) in the recipient group occurred in the first postoperative week. For the donor demise group, estimated fetal weight (EFW) <10%, EFW <3%, EFW <1%, EFW discordance >25%, and EFW discordance >30% did not increase the risk for donor demise except in cases that also had umbilical artery absent or reversed end diastolic flow (AREDF). Donor AREDF was the only independent risk factor for early donor demise. For the recipient demise group, recipient abnormal venous Dopplers were associated with increased risk while EFW discordance >25% was associated with decreased risk of recipient loss. DISCUSSION/CONCLUSION In our cohort, donor growth restriction did not increase the risk of early donor demise after laser unless there was also donor AREDF. Donor AREDF was an independent risk factor for donor demise likely due to the severity of placental insufficiency. Abnormal recipient venous Doppler indices increased the risk of early recipient loss while a large intertwin discordance decreased the risk. This may be explained by profound overload in cases with recipient abnormal venous Doppler velocimetry and a lower risk of substantial fluid shifts from a relatively smaller donor territory when there is a large discordance.
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Affiliation(s)
- Juliana Gebb
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kendra Miller
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rosa Hwang
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shelly Soni
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christina Paidas Teefey
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryne Didier
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Edward R Oliver
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jack Rychik
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Fetal Heart Program and Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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17
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Gebb JS, Khalek N, Miller K, Hwang R, Paidas Teefey C, Soni S, Tran KM, Moldenhauer JS. Impact of obesity on pregnancies undergoing laser therapy for twin-twin transfusion syndrome. Fetal Diagn Ther 2022; 49:340-346. [PMID: 35973402 DOI: 10.1159/000526484] [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: 05/26/2022] [Accepted: 07/26/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We sought to determine if maternal obesity, defined by BMI 30-34.9 or BMI 35, negatively impacts the technical aspects and pregnancy outcomes in women treated with selective laser photocoagulation of placental communicating vessels for twin-twin transfusion syndrome (TTTS). METHODS Retrospective review of women undergoing laser for TTTS from January 2010 - December 2021. Outcomes were stratified based on maternal BMI < 30, 30-34.9 and > 35. Data obtained included maternal age, parity, ethnicity, gestational age at laser, placental location, Quintero stage and CHOP cardiovascular score, operative and anesthesia times, procedure to delivery interval, gestational age at delivery, survival to birth, survival to discharge, and presence of residual anastomoses. Statistical analysis included chi-square or Fisher's exact test for categorical variables and Mann Whitney U test for continuous variables with p<.05 being significant. RESULTS A total of 434 women underwent laser for TTTS during the study period. Of those, 274 (63%) had a BMI of < 30, 92 (21.2%) had a BMI between 30-34.9, and 68 (15.7%) had a BMI > 35. There were no differences in maternal age, parity or ethnicity, Quintero stage, CHOP cardiovascular score, placental location, operative time, laser to delivery interval, gestational age at delivery, survival outcomes, or presence of residual anastomoses between the three groups. Patients with BMI of 30-34.9 were operated on at a slightly later gestational age and those with BMI > 35 had longer operative and anesthesia times. There were no technical failures as a result of BMI > 30 or 35. DISCUSSION/CONCLUSION Using appropriate technical adjustments, outcomes for obese women undergoing laser for TTTS are similar to non-obese women although patients with BMI > 35 have longer operative and anesthesia times.
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Affiliation(s)
- Juliana S Gebb
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kendra Miller
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rosa Hwang
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christina Paidas Teefey
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shelly Soni
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kha Manh Tran
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- Richard D. Wood Jr Center for Fetal Diagnosis & Treatment, Department of General, Thoracic & Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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18
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Gebb J, Hwang R, Paidas Teefey C, Soni S, Coleman BG, Zarnow DM, Moldenhauer JS, Khalek N. Magnetic resonance neuroimaging after laser for twin-twin transfusion syndrome with single fetal demise. Am J Obstet Gynecol 2022; 226:728.e1-728.e8. [PMID: 35257667 DOI: 10.1016/j.ajog.2022.02.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/03/2022] [Accepted: 02/26/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Neurologic injury in the surviving twin is a risk after single fetal demise in a monochorionic pregnancy. OBJECTIVE This study aimed to describe fetal magnetic resonance neuroimaging findings in pregnancies complicated by single fetal demise after laser photocoagulation for twin-twin transfusion syndrome. STUDY DESIGN This was a single-center retrospective analysis of a cohort of prospectively collected patients in a monochorionic twin registry who had fetoscopic laser photocoagulation for twin-twin transfusion syndrome with single fetal demise at follow-up. Magnetic resonance neuroimaging was offered 3 to 4 weeks after the demise to assess for potential neurologic sequelae. Magnetic resonance images were interpreted by 2 board-certified neuroradiologists and classified as normal, mildly abnormal, or severely abnormal. The groups were compared on the basis of recipient vs donor demise using the Fisher exact test and Mann-Whitney U test. Multivariate logistic regression was performed to determine risk factors for abnormal magnetic resonance neuroimaging. RESULTS In 378 laser photocoagulation procedures, 64 cases (16.9%) of single demise were identified (36 in the donor group and 28 in the recipient group). Of note, 6 patients had rupture of membranes with nonviable delivery (3 from each group). Moreover, 40 patients (69%) underwent magnetic resonance imaging. Of those patients, 12 (30%) had abnormal findings: 10 (83%) were associated with mild changes, and 2 (17%) were associated with severe findings. Abnormal magnetic resonance neuroimaging was seen in 3 of 22 patients (14%) after donor demise and 9 of 18 patients (50%) after recipient demise (P=.02). Logistic regression revealed that recipient vs donor demise was an independent risk factor for abnormal magnetic resonance imaging. In addition, 2 pregnancies with severe magnetic resonance imaging findings had complicated courses. CONCLUSION Mildly abnormal magnetic resonance neuroimaging findings were common after laser photocoagulation for twin-twin transfusion syndrome complicated by single fetal demise and were more common in cases of recipient demise than donor demise. Severe magnetic resonance neuroimaging findings in this series were limited to patients with complicated peri- or postoperative courses.
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Affiliation(s)
- Juliana Gebb
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Rosa Hwang
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christina Paidas Teefey
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Shelly Soni
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Beverly G Coleman
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Deborah M Zarnow
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julie S Moldenhauer
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nahla Khalek
- Department of General, Thoracic, and Fetal Surgery, Richard D. Wood Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Burrill N, Khalek N, Oliver E, Victoria T, Linn R, Moldenhauer J. eP447: Family history helps solve the case: Prenatal case report of Lowe syndrome. Genet Med 2022. [DOI: 10.1016/j.gim.2022.01.480] [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] Open
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Burrill N, Schindwolf E, Pilchman L, Khalek N, Gebb J, Teefey CP, Coleman B, Oliver E, Horii S, Strong A, Medne L, Bedoukian E, Rintoul N, Maschhoff K, Moldenhauer J. eP449: Expansion of the prenatal phenotype of PIEZO1 variants. Genet Med 2022. [DOI: 10.1016/j.gim.2022.01.482] [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] Open
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Gebb JS, Hwang R, Teefey CP, Soni S, Oliver ER, Moldenhauer JS, Khalek N. Donor growth restriction does not increase demise risk after laser for Twin-Twin Transfusion Syndrome. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.1135] [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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22
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Khalek N, Gebb JS, Soni S, Hwang R, Teefey CP, Didier RA, Moldenhauer JS. Optimal timing for selective cord occlusion in monochorionic pregnancies complicated by selective fetal growth restriction. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.552] [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: 11/28/2022]
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Moldenhauer JS, Teefey CP, Budney A, Soni S, Gebb JS, Khalek N, Schindewolf EM, Cole J. Perinatal depressive risk in pregnancies complicated by fetal anomalies. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.413] [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: 11/01/2022]
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Gebb JS, Hwang R, Soni S, Teefey CP, Rychik JR, Didier RA, Moldenhauer JS, Khalek N. Recipient cardiac dysfunction does not increase risk for demise after laser for Twin-Twin Transfusion Syndrome. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.611] [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: 11/01/2022]
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Soni S, Gebb JS, Moldenhauer JS, Hwang R, Teefey CP, Oliver ER, Khalek N. Predictors for dual demise after selective cord occlusion for complex monochorionic pregnancies. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.336] [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: 11/01/2022]
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Didier RA, Oliver ER, Rungsiprakarn P, Debari SE, Adams SE, Hedrick HL, Adzick NS, Khalek N, Howell LJ, Coleman BG. Decreased neonatal morbidity in 'stomach-down' left congenital diaphragmatic hernia: implications of prenatal ultrasound diagnosis for counseling and postnatal management. Ultrasound Obstet Gynecol 2021; 58:744-749. [PMID: 33724570 DOI: 10.1002/uog.23630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/15/2021] [Accepted: 03/03/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the influence of stomach position on postnatal outcome in cases of left congenital diaphragmatic hernia (CDH) without liver herniation, diagnosed and characterized on prenatal ultrasound (US), by comparing those with ('stomach-up' CDH) to those without ('stomach-down' CDH) intrathoracic stomach herniation. METHODS Infants with left CDH who underwent prenatal US and postnatal repair at our institution between January 2008 and March 2017 were eligible for inclusion in this retrospective study. Detailed prenatal US examinations, fetal magnetic resonance imaging (MRI) studies, operative reports and medical records of infants enrolled in the pulmonary hypoplasia program at our institution were reviewed. Cases with liver herniation and those with an additional anomaly were excluded. Cases in which bowel loops were identified within the fetal chest on US while the stomach was intra-abdominal were categorized as having stomach-down CDH. Cases in which bowel loops and the stomach were visualized within the fetal chest on US were categorized as having stomach-up CDH. Prenatal imaging findings and postnatal outcomes were compared between the two groups. RESULTS In total, 152 patients with left CDH were initially eligible for inclusion. Seventy-eight patients had surgically confirmed liver herniation and were excluded. Of the 74 included CDH cases without liver herniation, 28 (37.8%) had stomach-down CDH and 46 (62.2%) had stomach-up CDH. Of the 28 stomach-down CDH cases, 10 (35.7%) were referred for a suspected lung lesion. Sixty-eight (91.9%) cases had postnatal outcome data available for analysis. There was no significant difference in median observed-to-expected (o/e) lung-area-to-head-circumference ratio (LHR) between cases with stomach-down CDH and those with stomach-up CDH (41.5% vs 38.4%; P = 0.41). Furthermore, there was no difference in median MRI o/e total lung volume (TLV) between the two groups (49.5% vs 44.0%; P = 0.22). Compared with stomach-up CDH patients, stomach-down CDH patients demonstrated lower median duration of intubation (18 days vs 9.5 days; P < 0.01), median duration of extracorporeal membrane oxygenation (495 h vs 223.5 h; P < 0.05), rate of supplemental oxygen requirement at 30 days of age (20/42 (47.6%) vs 3/26 (11.5%); P < 0.01) and rate of pulmonary hypertension at initial postnatal echocardiography (28/42 (66.7%) vs 9/26 (34.6%); P = 0.01). No neonatal death occurred in stomach-down CDH patients and one neonatal death was seen in a patient with intrathoracic stomach herniation. CONCLUSIONS In infants with left CDH without liver herniation, despite similar o/e-LHR and o/e-TLV, those with stomach-down CDH have decreased neonatal morbidity compared to those with stomach herniation. Progressive or variable physiological distension of the stomach over the course of gestation may explain these findings. Stomach-down left CDH is mistaken for a lung mass in a substantial proportion of cases. Accurate prenatal US characterization of CDH is crucial for appropriate prenatal counseling and patient management. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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MESH Headings
- Adult
- Cephalometry
- Female
- Fetus/diagnostic imaging
- Fetus/pathology
- Head/diagnostic imaging
- Head/pathology
- Hernias, Diaphragmatic, Congenital/diagnostic imaging
- Hernias, Diaphragmatic, Congenital/embryology
- Hernias, Diaphragmatic, Congenital/pathology
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnostic imaging
- Infant, Newborn, Diseases/embryology
- Infant, Newborn, Diseases/pathology
- Lung/diagnostic imaging
- Lung/embryology
- Lung/pathology
- Magnetic Resonance Imaging
- Male
- Morbidity
- Pregnancy
- Retrospective Studies
- Stomach/diagnostic imaging
- Stomach/embryology
- Stomach/pathology
- Ultrasonography, Prenatal
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Affiliation(s)
- R A Didier
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E R Oliver
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - P Rungsiprakarn
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - S E Debari
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - S E Adams
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - H L Hedrick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N S Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Khalek
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - L J Howell
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B G Coleman
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Soni S, Moldenhauer JS, Kallan MJ, Rintoul N, Adzick NS, Hedrick HL, Khalek N. Influence of Gestational Age and Mode of Delivery on Neonatal Outcomes in Prenatally Diagnosed Isolated Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2021; 48:372-380. [PMID: 33951652 DOI: 10.1159/000515252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 02/15/2021] [Indexed: 11/19/2022]
Abstract
AIM The optimal gestational age (GA) at delivery and mode of delivery (MoD) for pregnancies with fetal congenital diaphragmatic hernia (CDH) is undetermined. The impact of early term (37-38 weeks 6 days) versus full term (39-40 weeks 6 days) and MoD on immediate neonatal outcomes in prenatally diagnosed isolated CDH cases was evaluated. MATERIAL AND METHODS A retrospective chart review of pregnancies evaluated and delivered with the prenatal diagnosis of CDH between July 1, 2008, and December 31, 2018. The primary outcome was survival to hospital discharge. Secondary outcomes included neonatal intensive care unit (NICU) length of stay (LOS), extracorporeal membrane oxygenation (ECMO) requirement and need for supplemental oxygen at day 30 of life. RESULTS A total of 296 patients were prenatally evaluated for CDH and delivered in a single center during the study period. After applying exclusion criteria, data were available on 113 women who delivered early term and 72 women who delivered full term. Survival to hospital discharge was comparable between the 2 groups - 83.2% in the early term versus 93.1% in the full term (p = 0.07; 95% CI of 0.13-1.04). No difference was observed in any other secondary outcomes. MoD was stratified into spontaneous vaginal, induced vaginal, unplanned cesarean and scheduled cesarean delivery with associated neonatal survival rates of 74.2, 90.6, 89.7 and 88.2%, respectively, p = 0.13. The 5-min Apgar score was higher in the elective cesarean group (7.94) followed by the induced vaginal delivery group (7.8) compared to 7.17 and 7.18 in the spontaneous vaginal and unplanned cesarean groups, respectively (p = 0.03). The GA and MoD did not influence survival to hospital discharge nor NICU LOS in multivariate analysis. CONCLUSIONS Though there were no significant differences in neonatal outcomes for early term compared to full term deliveries of CDH neonates, a trend toward improved survival rates and lower ECMO requirements in the full term group may suggest an underlying importance GA at delivery. Further studies are warranted to validate these findings.
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Affiliation(s)
- Shelly Soni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael J Kallan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalie Rintoul
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Stirnemann J, Slaghekke F, Khalek N, Winer N, Johnson A, Lewi L, Massoud M, Bussieres L, Aegerter P, Hecher K, Senat MV, Ville Y. Intrauterine fetoscopic laser surgery versus expectant management in stage 1 twin-to-twin transfusion syndrome: an international randomized trial. Am J Obstet Gynecol 2021; 224:528.e1-528.e12. [PMID: 33248135 DOI: 10.1016/j.ajog.2020.11.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Selective fetoscopic laser coagulation of the intertwin anastomotic chorionic vessels is the first-line treatment for twin-twin transfusion syndrome. However, in stage 1 twin-twin transfusion syndrome, the risks of intrauterine surgery may be higher than those of the natural progression of the condition. OBJECTIVE This study aimed to compare immediate surgery and expectant follow-up in stage 1 twin-twin transfusion syndrome. STUDY DESIGN We conducted a multicentric randomized trial, which recruited from 2011 to 2018 with a 6-month postnatal follow-up. The study was conducted in 9 fetal medicine centers in Europe and the Unites States. Asymptomatic women with stage 1 twin-twin transfusion syndrome between 16 and 26 weeks' gestation, a cervix of >15 mm, and access to a surgical center within 48 hours of diagnosis were randomized between expectant management and immediate surgery. In patients allocated to immediate laser treatment, percutaneous laser coagulation of anastomotic vessels was performed within 72 hours. In patients allocated to expectant management, a weekly ultrasound follow-up was planned. Rescue fetoscopic coagulation of anastomoses was offered if the syndrome worsened as seen during a follow-up, either because of progression to a higher Quintero stage or because of the maternal complications of polyhydramnios. The primary outcome was survival at 6 months without severe neurologic morbidity. Severe complications of prematurity and maternal morbidity were secondary outcomes. RESULTS The trial was stopped at 117 of 200 planned inclusions for slow accrual rate over 7 years: 58 women were allocated to expectant management and 59 to immediate laser treatment. Intact survival was seen in 84 of 109 (77%) expectant cases and in 89 of 114 (78%) (P=.88) immediate surgery cases, and severe neurologic morbidity occurred in 5 of 109 (4.6%) and 3 of 114 (2.6%) (P=.49) cases in the expectant and immediate surgery groups, respectively. In patients followed expectantly, 24 of 58 (41%) cases remained stable with dual intact survival in 36 of 44 (86%) cases at 6 months. Intact survival was lower following surgery than for the nonprogressive cases, although nonsignificantly (78% and 71% following immediate and rescue surgery, respectively). CONCLUSION It is unlikely that early fetal surgery is of benefit for stage 1 twin-twin transfusion syndrome in asymptomatic pregnant women with a long cervix. Although expectant management is reasonable for these cases, 60% of the cases will progress and require rapid transfer to a surgical center.
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Affiliation(s)
- Julien Stirnemann
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, AP-HP and EA7328, Université de Paris, Paris, France.
| | - Femke Slaghekke
- Department of Obstetrics and Fetal Therapy, Leiden University Medical Center, Leiden, the Netherlands
| | - Nahla Khalek
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Norbert Winer
- Department of Obstetrics and Gynecology, NUN, INRAE, UMR 1280, PhAN, University Hospital of Nantes, Nantes, France
| | - Anthony Johnson
- The Fetal Center, University of Texas Health Science Center, Houston, TX
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven and Department of Development and Regeneration, Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Mona Massoud
- Fetal Medicine Unit, Hôpital Femme Mère Enfants, Hospices Civils de Lyon, Lyon, France
| | - Laurence Bussieres
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, AP-HP and EA7328, Université de Paris, Paris, France
| | - Philippe Aegerter
- Department of Public Health, UMR 1168, UVSQ INSERM, GIRCI IdF-UFR Médecine Paris-Ile-de-France-Ouest, Université de Versailles St-Quentin-en-Yvelines, Versailles, France
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Marie-Victoire Senat
- Department of Gynecology-Obstetrics, Hôpital Bicêtre AP-HP and Université Paris-Sud, Paris-Saclay Medical School and CESP Centre for Research in Epidemiology and Population Health, Université Paris-Saclay, Université Paris-Sud, UVSQ, INSERM, Villejuif, France
| | - Yves Ville
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, AP-HP and EA7328, Université de Paris, Paris, France
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29
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Moldenhauer JS, Soni S, Jatres J, Gebb J, Khalek N, Paidas Teefey C, Johnson MP, Flake AW, Hedrick HL, Peranteau WH, Heuer GG, Adzick NS. Open Fetal Surgical Outcomes for Myelomeningocele Closure Stratified by Maternal Body Mass Index in a Large Single-Center Cohort. Fetal Diagn Ther 2020; 47:889-893. [PMID: 33166958 DOI: 10.1159/000511781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 09/22/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Open maternal-fetal surgery for in utero closure of myelomeningocele (MMC) has become an accepted treatment option for prenatally diagnosed open neural tube defects. Historically, this option has been limited to women with BMI < 35 due to concern for increasing complications in patients with obesity. OBJECTIVE The aim of this study was to evaluate maternal, obstetric, and fetal/neonatal outcomes stratified by maternal BMI classification in women who undergo open maternal-fetal surgery for fetal myelomeningocele (fMMC) closure. METHODS A single-center fMMC closure registry was queried for maternal demographics, preoperative factors, fetal surgery outcomes, delivery outcomes, and neonatal outcomes. Data were stratified based on maternal BMI: <30, 30-34.99, and ≥35-40, corresponding to normal weight/overweight, obesity class I, and obesity class II. Statistical analysis was performed using statistical software SAS v.9.4 (SAS Institute Inc., Cary, NC, USA). RESULTS A total of 264 patients were analyzed, including 196 (74.2%) with BMI <30, 54 (20.5%) with BMI 30-34.99, and 14 (5.3%) with BMI ≥ 35-40. Maternal demographics and preoperative characteristics were similar among the groups. Operative time increased with increasing BMI; otherwise, perioperative outcomes were similar among the groups. Obstetric and neonatal outcomes were similar among the groups. CONCLUSION Increasing maternal BMI did not result in a negative impact on maternal, obstetric, and fetal/neonatal outcomes in a large cohort of patients undergoing open maternal-fetal surgery for fMMC closure. Further study is warranted to determine the generalizability of these results.
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Affiliation(s)
- Julie S Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA, .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,
| | - Shelly Soni
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jillian Jatres
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Juliana Gebb
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christina Paidas Teefey
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark P Johnson
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alan W Flake
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William H Peranteau
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory G Heuer
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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30
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Oliver ER, DeBari SE, Didier RA, Johnson AM, Khalek N, Peranteau WH, Howell LJ, Adzick NS, Coleman BG. Two's Company: Multiple Thoracic Lesions on Prenatal US and MRI. Fetal Diagn Ther 2020; 47:642-652. [PMID: 32599594 DOI: 10.1159/000507783] [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: 12/31/2019] [Accepted: 03/25/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Congenital pulmonary airway malformations (CPAM), bronchopulmonary sequestrations (BPS), and CPAM-BPS hybrid lesions are most commonly solitary; however, >1 lung congenital lung lesion may occur. OBJECTIVES To assess the frequency of multiple congenital thoracic anomalies at a high-volume referral center; determine prenatal ultrasound (US) and magnetic resonance imaging (MRI) features of these multifocal congenital lung lesions that may allow prenatal detection; and determine the most common distribution or site of origin. METHODS Database searches were performed from August 2008 to May 2019 for prenatally evaluated cases that had a final postnatal surgical diagnosis of >1 congenital lung lesion or a lung lesion associated with foregut duplication cyst (FDC). Lesion location, size, echotexture, and signal characteristics were assessed on prenatal imaging and correlated with postnatal computed tomographic angiography and surgical pathology. -Results: Of 539 neonates that underwent surgery for a thoracic lesion, 35 (6.5%) had >1 thoracic abnormality. Multiple discrete lung lesions were present in 19 cases, and a lung lesion associated with an FDC was present in 16. Multifocal lung lesions were bilateral in 3 cases; unilateral, multilobar in 12; and, unilobar multisegmental in 4. Median total CPAM volume/head circumference ratio for multifocal lung lesions on US was 0.66 (range, 0.16-1.80). Prenatal recognition of multifocal lung lesions occurred in 7/19 cases (36.8%). Lesion combinations were CPAM-CPAM in 10 cases, CPAM-BPS in 5, CPAM-hybrid in 2, hybrid-hybrid in 1, and hybrid-BPS in 1. Of 5 unilateral, multifocal lung lesions, multifocality was prenatally established through identification of a band of normal intervening lung or intrinsic differences in lesion imaging features. CONCLUSIONS Although less common, multiple thoracic abnormalities can be detected prenatally. Of multifocal lung lesions, the most common combination was CPAM-CPAM, with a unilateral, multilobar distribution. Prenatal recognition is important for pregnancy counseling and postnatal surgical management.
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Affiliation(s)
- Edward R Oliver
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA, .,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA, .,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,
| | - Suzanne E DeBari
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ryne A Didier
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ann M Johnson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - William H Peranteau
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Beverly G Coleman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Feygin T, Khalek N, Moldenhauer JS. Fetal brain, head, and neck tumors: Prenatal imaging and management. Prenat Diagn 2020; 40:1203-1219. [PMID: 32350893 DOI: 10.1002/pd.5722] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 02/06/2020] [Accepted: 04/03/2020] [Indexed: 12/21/2022]
Abstract
Fetal tumors represent an infrequent pathology when compared to congenital malformations, although their true incidence may be underestimated. A variety of benign and malignant neoplasms may occur anywhere in the neural axis. Imaging plays an important role in the fetal tumor diagnosis and evaluation of their resultant complications. Discovery of a fetal mass on obstetric ultrasound necessitates further evaluation with prenatal magnetic resonance imaging (MRI). New MR sequences and new applications of existing techniques have been successfully implemented in prenatal imaging. A detailed assessment may be performed using a variety of MR. Fetal tumors may be histologically benign or malignant, but their prognosis generally remains poor, especially for intracranial lesions. Unfavorable tumor location or heightened metabolic demands on a developing fetus may result in severe complications and a fatal outcome, even in cases of benign lesions. Nowadays, prenatal treatment focuses mainly on alleviation of secondary complications caused by the tumors. In this article we review congenital tumors of the brain, face, and neck encountered in prenatal life, and discuss diagnostic clues for appropriate diagnosis.
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Affiliation(s)
- Tamara Feygin
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- The Center for fetal diagnosis and treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- The Center for fetal diagnosis and treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Soni S, Moldenhauer JS, Rintoul N, Adzick NS, Hedrick HL, Khalek N. Perinatal Outcomes in Fetuses Prenatally Diagnosed with Congenital Diaphragmatic Hernia and Concomitant Lung Lesions: A 10-Year Review. Fetal Diagn Ther 2020; 47:630-635. [PMID: 32380499 DOI: 10.1159/000507481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/16/2020] [Accepted: 03/23/2020] [Indexed: 11/19/2022]
Abstract
AIM To describe perinatal outcomes of fetuses with a prenatal diagnosis of a concomitant lung lesion in the setting of congenital diaphragmatic hernia (CDH) and to compare outcomes with an isolated CDH control group without a lung lesion, matched by ultrasound-based prognostic markers including presence of liver herniation and lung measurements. MATERIAL AND METHODS This was a retrospective case-control study, wherein all pregnancies diagnosed with CDH and concomitant lung lesions were identified between July 1, 2008, and December 31, 2018. For each case, 2 controls with isolated CDH from the same study period were selected after matching for the presence of liver herniation into the thoracic cavity and ultrasound-based lung measurements either observed over expected lung-to-head ratio (LHR) or absolute LHR with their corresponding gestational age. The outcomes analyzed in the 2 groups included survival to hospital discharge, neonatal intensive care unit (NICU) length of stay (LOS), extracorporeal membrane oxygenation (ECMO) requirement and need for supplemental oxygen (O2) at day 30 of life. RESULTS A total of 21 pregnancies were identified with CDH and a concomitant lung lesion in the study period. All the lung lesions were stratified into a "low-risk category" with a congenital cystic adenomatoid malformation volume ratio of less than 1.0 at the time of presentation. None of these fetuses developed hydrops or required in utero intervention. Overall survival in the group was 80.7% (17/21) and rate of ECMO was 38.1%. Causes of mortality included pulmonary insufficiency, sepsis, renal failure, and bowel infarction. Upon comparison between the cases and controls, the 2 groups were similar with respect to pregnancy demographics. There were no fetal demises in either group. Outcomes including survival rate, NICU LOS, ECMO requirements and need for supplemental O2 at day 30 of life, were comparable among the 2 groups. CONCLUSIONS In our descriptive series, the presence of a concomitant, low-risk lung lesion in the setting of fetal CDH did not have a significant impact on the natural course of the disease, nor was it associated with a worse prognosis.
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Affiliation(s)
- Shelly Soni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA, .,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA, .,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,
| | - Julie S Moldenhauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie Rintoul
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Pritchard AB, Kanai SM, Krock B, Schindewolf E, Oliver-Krasinski J, Khalek N, Okashah N, Lambert NA, Tavares ALP, Zackai E, Clouthier DE. Loss-of-function of Endothelin receptor type A results in Oro-Oto-Cardiac syndrome. Am J Med Genet A 2020; 182:1104-1116. [PMID: 32133772 DOI: 10.1002/ajmg.a.61531] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 06/27/2019] [Revised: 02/06/2020] [Accepted: 02/06/2020] [Indexed: 01/14/2023]
Abstract
Craniofacial morphogenesis is regulated in part by signaling from the Endothelin receptor type A (EDNRA). Pathogenic variants in EDNRA signaling pathway components EDNRA, GNAI3, PCLB4, and EDN1 cause Mandibulofacial Dysostosis with Alopecia (MFDA), Auriculocondylar syndrome (ARCND) 1, 2, and 3, respectively. However, cardiovascular development is normal in MFDA and ARCND individuals, unlike Ednra knockout mice. One explanation may be that partial EDNRA signaling remains in MFDA and ARCND, as mice with reduced, but not absent, EDNRA signaling also lack a cardiovascular phenotype. Here we report an individual with craniofacial and cardiovascular malformations mimicking the Ednra -/- mouse phenotype, including a distinctive micrognathia with microstomia and a hypoplastic aortic arch. Exome sequencing found a novel homozygous missense variant in EDNRA (c.1142A>C; p.Q381P). Bioluminescence resonance energy transfer assays revealed that this amino acid substitution in helix 8 of EDNRA prevents recruitment of G proteins to the receptor, abrogating subsequent receptor activation by its ligand, Endothelin-1. This homozygous variant is thus the first reported loss-of-function EDNRA allele, resulting in a syndrome we have named Oro-Oto-Cardiac Syndrome. Further, our results illustrate that EDNRA signaling is required for both normal human craniofacial and cardiovascular development, and that limited EDNRA signaling is likely retained in ARCND and MFDA individuals. This work illustrates a straightforward approach to identifying the functional consequence of novel genetic variants in signaling molecules associated with malformation syndromes.
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Affiliation(s)
- Amanda Barone Pritchard
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stanley M Kanai
- Department of Craniofacial Biology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Bryan Krock
- Division of Genomic Diagnostics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Erica Schindewolf
- Center for Fetal Diagnosis and Treatment, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Nahla Khalek
- Center for Fetal Diagnosis and Treatment, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Najeah Okashah
- Department of Pharmacology and Toxicology, Medical College of Georgia-Augusta University, Augusta, Georgia, USA
| | - Nevin A Lambert
- Department of Pharmacology and Toxicology, Medical College of Georgia-Augusta University, Augusta, Georgia, USA
| | - Andre L P Tavares
- Department of Craniofacial Biology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Elaine Zackai
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David E Clouthier
- Department of Craniofacial Biology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Khalek N, Villa A, Moldenhauer J, Gebb JS, Johnson M, Hwang R, Ciampaglia A, Szwast A, Tian Z, Rychik J. 901: Cardiovascular manifestations resolve two years following selective laser photocoagulation for twin-twin transfusion syndrome. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.912] [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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35
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Teefey CP, Cole J, Jatres J, Budney A, Kelly S, Soni S, Gebb JS, Khalek N, Adzick NS, Moldenhauer J. 911: Perinatal mood and anxiety disorders in women undergoing open fetal surgery for myelomeningocele closure. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.922] [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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36
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Oliver ER, DeBari SE, Horii SC, Pogoriler JE, Victoria T, Khalek N, Howell LJ, Adzick NS, Coleman BG. Congenital Lobar Overinflation: A Rare Enigmatic Lung Lesion on Prenatal Ultrasound and Magnetic Resonance Imaging. J Ultrasound Med 2019; 38:1229-1239. [PMID: 30208226 DOI: 10.1002/jum.14801] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 04/18/2018] [Revised: 08/01/2018] [Accepted: 08/01/2018] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To report the ultrasound (US) features in prenatal cases of suspected congenital pulmonary airway malformation or unspecified lung lesions with a final surgical pathologic diagnosis of congenital lobar overinflation (CLO). METHODS Institutional Review Board-approved radiology and clinical database searches from 2001 to 2017 were performed for prenatally diagnosed lung lesions with a final diagnosis of CLO. All patients had detailed US examinations in addition to magnetic resonance imaging (MRI). Size, echotexture, and vascularity were assessed with US, and the signal and vascularity were assessed with MRI. Follow-up prenatal US scans, postnatal imaging, and postnatal outcomes were reviewed. RESULTS The study population consisted of 12 patients. The median gestational age was 23.3 weeks. The median congenital pulmonary airway malformation volume-to-head circumference ratio was 0.66. Lesion locations were 6 in the lower lobes (4 right and 2 left), 5 in the upper lobes (3 left and 2 right), and 1 in the right middle lobe. The texture was homogeneously echogenic relative to the normal lung in 100% with no visualized macrocysts. Hypervascularity by color Doppler US was observed in 5 cases (41.7%). A T2 hyperintense lung lesion was identified by MRI in 12 of 12 cases (100%), with elongated vessels identified in 11 of 12 cases (91.7%). All 12 cases had pathologically proven CLO. CONCLUSIONS Congenital lobar overinflation should be considered in cases of prenatal echogenic lung lesions without macrocysts or classic findings of bronchial atresia. Hypervascularity may be an important imaging feature of a subset of CLO. Most cases become less conspicuous, decrease in size without overt hydrops, and are asymptomatic postnatally.
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Affiliation(s)
- Edward R Oliver
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Suzanne E DeBari
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Steven C Horii
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer E Pogoriler
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Teresa Victoria
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Beverly G Coleman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Laje P, Fraga MV, Peranteau WH, Hedrick HL, Khalek N, Gebb JS, Moldenhauer JS, Johnson MP, Flake AW, Adzick NS. Complex gastroschisis: Clinical spectrum and neonatal outcomes at a referral center. J Pediatr Surg 2018; 53:1904-1907. [PMID: 29628208 DOI: 10.1016/j.jpedsurg.2018.03.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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] [Received: 11/06/2017] [Revised: 02/05/2018] [Accepted: 03/08/2018] [Indexed: 02/07/2023]
Abstract
AIM OF THE STUDY To evaluate the outcomes of neonates with complex gastroschisis (GC), and correlate outcomes with each type of complication. METHODS Retrospective review of patients with complex GC owing to prenatal and/or postnatal abdominal complications; 2008-2016. Primary outcomes: time to discontinue parenteral nutrition (off-PN), length of stay (LOS) and neonatal survival. MAIN RESULTS We treated 58 patients with complex gastroschisis owing to abdominal complications, which were: intestinal necrosis at birth (n=9), intestinal atresia (n=16), medical necrotizing enterocolitis (NEC) (n=15), surgical NEC (n=1), in utero volvulus (n=1), vanishing gastroschisis (n=2), severe intestinal dysmotility (n=1), delayed abdominal closure (n=3), abdominal compartment syndrome (n=2) and hiatal hernia/severe gastroesophageal reflux disease (GERD; n=11). The off-PN time and LOS of the whole group were 92 (35-255) and 119 (42-282) days, significantly longer than those of a demographically equivalent contemporaneous series of 125 patients with uncomplicated gastroschisis (off-PN 32 [12-105] days [p<0.001]; LOS 41 [18-150] days [p<0.001]). Patients with intestinal necrosis at birth or with intestinal atresia had the longest off-PN and LOS times (133 [38-255] / 157 [43-282] and 114 [36-222] / 143 [42-262] days, respectively), followed by patients with complications of the abdominal wall closure (n=5) (69 [43-93] / 89 [58-110] days), patients with hiatal hernias/severe GERD who required fundoplication (63 [35-84] / 89 [57-123] days) and patients who developed medical NEC (67 [35-103] / 76 [50-113] days). Short-bowel syndrome/PN-dependence occurred in 6/58 (10%) patients (2 vanishing gastroschisis, 1 in utero volvulus, 2 intestinal atresias and 1 bowel necrosis at birth). There were no neonatal mortalities. CONCLUSION Gastroschisis can be complicated by a wide variety of prenatal and postnatal events. The most severe outcomes occur in patients with bowel necrosis at birth, intestinal atresias, or vanishing gastroschisis. Complications, however, did not affect neonatal survival in our experience. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Pablo Laje
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Maria V Fraga
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William H Peranteau
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nahla Khalek
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Juliana S Gebb
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie S Moldenhauer
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark P Johnson
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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38
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Schindewolf E, Khalek N, Johnson MP, Gebb J, Coleman B, Crowley TB, Zackai EH, McDonald-McGinn DM, Moldenhauer JS. Expanding the fetal phenotype: Prenatal sonographic findings and perinatal outcomes in a cohort of patients with a confirmed 22q11.2 deletion syndrome. Am J Med Genet A 2018; 176:1735-1741. [PMID: 30055034 DOI: 10.1002/ajmg.a.38665] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 02/14/2018] [Accepted: 02/15/2018] [Indexed: 01/17/2023]
Abstract
22q deletion syndrome (22q11.2DS) is most often correlated prenatally with congenital heart disease and or cleft palate. The extracardiac fetal phenotype associated with 22q11.2DS is not well described. We sought to review both the fetal cardiac and extracardiac findings associated with a cohort of cases ascertained prenatally, confirmed or suspected to have 22q11.2DS, born and cared for in one center. A retrospective chart review was performed on a total of 42 cases with confirmed 22q11.2DS to obtain prenatal findings, perinatal outcomes and diagnostic confirmation. The diagnosis was confirmed prenatally in 67% (28/42) and postnatally in 33% (14/42). The majority (81%) were associated with the standard LCR22A-LCR22D deletion. 95% (40/42) of fetuses were prenatally diagnosed with congenital heart disease. Extracardiac findings were noted in 90% (38/42) of cases. Additional findings involved the central nervous system (38%), gastrointestinal (14%), genitourinary (16.6%), pulmonary (7%), skeletal (19%), facial dysmorphism (21%), small/hypoplastic thymus (26%), and polyhydramnios (30%). One patient was diagnosed prenatally with a bilateral cleft lip and cleft palate. No fetus was diagnosed with intrauterine growth restriction. The average gestational age at delivery was 38 weeks and average birth weight was 3,105 grams. Sixty-two percentage were delivered vaginally and there were no fetal demises. A diagnosis of 22q11.2 deletion syndrome should be considered in all cases of prenatally diagnosed congenital heart disease, particularly when it is not isolated. Microarray is warranted in all cases of structural abnormalities diagnosed prenatally. Prenatal diagnosis of 22q11.2 syndrome can be used to counsel expectant parents regarding pregnancy outcome and guide neonatal management.
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Affiliation(s)
- Erica Schindewolf
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nahla Khalek
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mark P Johnson
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Juliana Gebb
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Beverly Coleman
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Terrence Blaine Crowley
- Division of Human Genetics, Department of Pediatrics, 22q and You Center and Clinical Genetics Center, Children's Hospital of Philadelphia, the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elaine H Zackai
- Division of Human Genetics, Department of Pediatrics, 22q and You Center and Clinical Genetics Center, Children's Hospital of Philadelphia, the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna M McDonald-McGinn
- Division of Human Genetics, Department of Pediatrics, 22q and You Center and Clinical Genetics Center, Children's Hospital of Philadelphia, the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julie S Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Baumgarten HD, Gebb JS, Khalek N, Moldenhauer JS, Johnson MP, Peranteau WH, Hedrick HL, Adzick NS, Flake AW. Preemptive Delivery and Immediate Resection for Fetuses with High-Risk Sacrococcygeal Teratomas. Fetal Diagn Ther 2018; 45:137-144. [PMID: 29734172 DOI: 10.1159/000487542] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/29/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Fetuses with "high-risk" sacrococcygeal teratoma (SCT) have a mortality rate of 40-50%. While fetal surgery may benefit select fetuses prior to 27 weeks' gestation, many fetuses die due to consequences of rapid tumor growth after 27 weeks. Here we report our experience applying "preemptive" delivery to fetuses who manifest signs of decompensation between 27 and 32 weeks. METHODS A retrospective review of SCT fetuses delivered between 2010 and 2016 at ≤32 weeks' gestation was performed. Patients who decompensated prior to 27 weeks and were treated with fetal surgery or neonatal palliation were excluded. RESULTS Forty-two SCT fetuses were evaluated, and 11 were preemptively delivered in response to impending fetal or maternal decompensation. Nine (81.8%) survived. One death was due to pulmonary hypoplasia in a neonate with significant intra-abdominal tumor burden, and the other was due to in utero tumor rupture. There were no deaths related to prematurity in this cohort. CONCLUSIONS Many fetuses with SCT manifest signs of decompensation between 27 and 32 weeks. In the absence of fetal hydrops prior to 27 weeks or tumor rupture in utero, early delivery is associated with favorable outcomes. Our single-center experience supports a management algorithm change to incorporate "preemptive" delivery for selected cases.
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40
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Fraga MV, Laje P, Peranteau WH, Hedrick HL, Khalek N, Gebb JS, Moldenhauer JS, Johnson MP, Flake AW, Adzick NS. The influence of gestational age, mode of delivery and abdominal wall closure method on the surgical outcome of neonates with uncomplicated gastroschisis. Pediatr Surg Int 2018; 34:415-419. [PMID: 29417204 DOI: 10.1007/s00383-018-4233-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 01/25/2018] [Indexed: 11/29/2022]
Abstract
AIM OF THE STUDY To evaluate if gestational age (GA), mode of delivery and abdominal wall closure method influence outcomes in uncomplicated gastroschisis (GTC). METHODS Retrospective review of NICU admissions for gastroschisis, August 2008-July 2016. Primary outcomes were: time to start enteral feeds (on-EF), time to discontinue parenteral nutrition (off-PN), and length of stay (LOS). MAIN RESULTS A total of 200 patients with GTC were admitted to our NICU. Patients initially operated elsewhere (n = 13) were excluded. Patients with medical/surgical complications (n = 62) were analyzed separately. The study included 125 cases of uncomplicated GTC. There were no statistically significant differences in the outcomes of patients born late preterm (34 0/7-36 6/7; n = 70) and term (n = 40): on-EF 19 (5-54) versus 17 (7-34) days (p = 0.29), off-PN 32 (12-101) versus 30 (16-52) days (p = 0.46) and LOS 40 (18-137) versus 37 (21-67) days (p = 0.29), respectively. Patients born before 34 weeks GA (n = 15) had significantly longer on-EF, off-PN and LOS times compared to late preterm patients: 26 (12-50) days (p = 0.01), 41 (20-105) days (p = 0.04) and 62 (34-150) days (p < 0.01), respectively. There were no significant differences in outcomes between patients delivered by C-section (n = 62) and patients delivered vaginally (n = 63): on-EF 20 (5-50) versus 19 (7-54) days (p = 0.72), off-PN 32 (12-78) versus 33 (15-105) days (p = 0.83), LOS 42 (18-150) versus 41 (18-139) days (p = 0.68), respectively. There were significant differences in outcomes between patients who underwent primary reduction (n = 37) and patients who had a silo (88): on-EF 15 (5-37) versus 22 (6-54) days (p < 0.01), off-PN 28 (12-52) versus 34 (15-105) days (p = 0.04), LOS 36 (18-72) versus 44 (21-150) days (p = 0.04), respectively. CONCLUSION In our experience, late preterm delivery did not affect outcomes compared to term delivery in uncomplicated GTC. Outcomes were also not influenced by the mode of delivery. Patients who underwent primary reduction had better outcomes than patients who underwent silo placement.
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Affiliation(s)
- Maria V Fraga
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Pablo Laje
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - William H Peranteau
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Holly L Hedrick
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Nahla Khalek
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Juliana S Gebb
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Julie S Moldenhauer
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Mark P Johnson
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Alan W Flake
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - N Scott Adzick
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Gebb J, Khalek N, Qamar H, Johnson M, Oliver E, Coleman B, Peranteau W, Hedrick H, Flake A, Adzick N, Moldenhauer J. High Tumor Volume to Fetal Weight Ratio Is Associated with Worse Fetal Outcomes and Increased Maternal Risk in Fetuses with Sacrococcygeal Teratoma. Fetal Diagn Ther 2018; 45:94-101. [DOI: 10.1159/000486782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 12/29/2017] [Indexed: 11/19/2022]
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Riley JS, Urwin JW, Oliver ER, Coleman BG, Khalek N, Moldenhauer JS, Spinner SS, Hedrick HL, Adzick NS, Peranteau WH. Prenatal growth characteristics and pre/postnatal management of bronchopulmonary sequestrations. J Pediatr Surg 2018; 53:265-269. [PMID: 29229484 PMCID: PMC5828905 DOI: 10.1016/j.jpedsurg.2017.11.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 11/08/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE The prenatal natural history of intralobar and extralobar bronchopulmonary sequestrations (BPSs), including lesion growth patterns and need for prenatal intervention, have not been fully characterized. We review our series of BPSs to determine their natural history and outcomes in the context of the need for prenatal intervention. METHODS A retrospective review of the pre/postnatal course of 103 fetuses with an intralobar (n=44) or extralobar BPS (n=59) managed at a single institution between 2008 and 2015 was performed. Outcomes included prenatal lesion growth trajectory, presence of hydrops, need for prenatal intervention, survival, and postnatal surgical management. RESULTS Most extralobar (71%) and intralobar BPSs (94%) decreased in size or became isoechoic from initial to final evaluation. Peak lesion size occurred at 26-28weeks gestation. Eight fetuses developed hydrothorax, four of which (all extralobar BPSs) also developed hydrops. All four hydropic fetuses received maternal betamethasone, and three hydropic fetuses underwent thoracentesis and/or thoracoamniotic shunt placement with subsequent hydrops resolution. All fetuses survived. Forty-one intralobar (93%) and 35 extralobar BPSs (59%) were resected after birth. CONCLUSIONS BPSs tend to decrease in size after 26-28weeks gestation and rarely require fetal intervention. Lesions resulting in hydrothorax ± hydrops can be effectively managed with maternal steroids and/or drainage of the hydrothorax. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- John S Riley
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John W Urwin
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward R Oliver
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Beverly G Coleman
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nahla Khalek
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie S Moldenhauer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan S Spinner
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William H Peranteau
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Kim AG, Danzer E, Moldenhauer JS, Khalek N, McClain LE, Waqar LN, Hedrick HL, Johnson MP, Adzick NS, Peranteau WH, Flake AW. Amniotic Fluid Concentrations of Glial Fibrillary Acidic Protein Do Not Correlate with Prenatal Metrics in Fetuses with Myelomeningocele. Fetal Diagn Ther 2017; 43:297-303. [DOI: 10.1159/000478258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 06/06/2017] [Indexed: 11/19/2022]
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Antiel RM, Flake AW, Johnson MP, Khalek N, Rintoul NE, Lantos JD, Curlin FA, Tilburt JC, Feudtner C. Specialty-Based Variation in Applying Maternal-Fetal Surgery Trial Evidence. Fetal Diagn Ther 2017; 42:210-217. [PMID: 28301843 DOI: 10.1159/000455024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 06/29/2016] [Accepted: 11/25/2016] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The Management of Myelomeningocele Study (MOMS) compared prenatal with postnatal surgery for fetal myelomeningocele (MMC). We sought to understand how subspecialists interpreted the trial results and whether their practice has changed. MATERIALS AND METHODS Cross-sectional, mailed survey of 1,200 randomly selected maternal-fetal medicine (MFM) physicians, neonatologists, and pediatric surgeons. RESULTS Of 1,176 eligible physicians, 670 (57%) responded. Compared to postnatal closure, 33% viewed prenatal closure as "very favorable" and 60% as "somewhat favorable." Most physicians reported being more likely to recommend prenatal surgery (69%), while 28% were less likely to recommend pregnancy termination. In multivariable analysis, neonatologists were more likely to report prenatal closure as "very favorable" (OR 1.6; 95% CI: 1.03-2.5). Pediatric surgeons and neonatologists were more likely to recommend prenatal closure (OR 2.1; 95% CI: 1.3-3.3, and OR 2.9; 95% CI: 1.8-4.6) and less likely to recommend termination (OR 3.8; 95% CI: 2.2-6.7, and OR 4.7; 95% CI: 2.7-8.1). In addition, physicians with a higher tolerance for prematurity were more likely to report prenatal closure as "very favorable" (OR 1.02; 95% CI: 1.00-1.05). DISCUSSION In light of the MOMS trial, the vast majority of pediatric subspecialists and MFMs view prenatal MMC closure favorably. These attitudes vary by specialty and risk tolerance.
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Affiliation(s)
- Ryan M Antiel
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
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45
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Peranteau WH, Iyoob SD, Boelig MM, Khalek N, Moldenhauer JS, Johnson MP, Hedrick HL, Flake AW, Coleman BG, Adzick NS. Prenatal growth characteristics of lymphatic malformations. J Pediatr Surg 2017; 52:65-68. [PMID: 27836363 DOI: 10.1016/j.jpedsurg.2016.10.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 10/10/2016] [Accepted: 10/20/2016] [Indexed: 01/08/2023]
Abstract
PURPOSE The natural history of prenatally diagnosed lymphatic malformations (LM) remains unknown. The ability to predict growth of a lesion is important to prenatal counseling and any future prenatal intervention. We describe the prenatal growth patterns of LMs as they relate to gestational age, anatomical location, and postnatal management. METHODS A retrospective review of fetuses prenatally diagnosed with an LM who were followed with serial ultrasounds from 2003 to 2014 was performed with attention to the growth of the lesion as indicated by the lesion volume ratio (LVR). RESULTS Thirty patients with LM had serial ultrasound measurements between 19 and 39weeks gestation. The LVR increased in 53%, decreased in 23%, and remained stable in 23% of fetuses from the initial to the final ultrasound. Unlike other locations that demonstrated both positive and negative growth profiles, axillary lesions only demonstrated increased growth. Lesions with positive growth increased throughout gestation (peak LVR at 35±3weeks). Twenty-four patients had postnatal interventions, including surgical resection, sclerotherapy, and surgery + sclerotherapy. CONCLUSION LMs have variable prenatal growth profiles. The majority of lesions, especially axillary LMs, will continue to grow throughout gestation and will not reach a growth plateau until the end of gestation. LEVEL OF EVIDENCE Level III (Retrospective cohort study).
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Affiliation(s)
- William H Peranteau
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Suzanne D Iyoob
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew M Boelig
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nahla Khalek
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Julie S Moldenhauer
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mark P Johnson
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Beverly G Coleman
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Gebb JS, Khalek N, Qamar H, Ozcan T, Johnson MP, Rendon N, Oliver ER, Coleman BG, Peranteau WH, Hedrick HL, Flake AW, Adzick NS, Moldenhauer JS. 178: Tumor volume to fetal weight ratio > 0.12 is associated with worse perinatal outcomes in fetuses with sacrococcygeal teratoma. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.082] [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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Moldenhauer J, Lim FY, Miller R, Johnson A, Emery SP, Moon-Grady AJ, Wilkins-Haug L, Peterson E, Bahtiyar OM, Villa A, Zarrin H, Khalek N. 180: North American fetal therapy network: selective reduction in complicated monochorionic twins. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.084] [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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Rychik J, Khalek N, Gaynor JW, Johnson MP, Adzick NS, Flake AW, Hedrick HL. Fetal intrapericardial teratoma: natural history and management including successful in utero surgery. Am J Obstet Gynecol 2016; 215:780.e1-780.e7. [PMID: 27530489 DOI: 10.1016/j.ajog.2016.08.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/21/2016] [Accepted: 08/08/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intrapericardial teratoma is a rare, lethal tumor often detected in fetal life. Tumor mass and pericardial effusion cause cardiac tamponade that, if relieved, could be life-saving. Optimal timing of intervention and methods for effective fetal treatment are unknown. OBJECTIVE We describe our single-center experience with fetal intrapericardial teratoma including the first report of successful in utero surgical resection with survival to term. STUDY DESIGN We reviewed our database for suspected fetal intrapericardial teratoma. On fetal ultrasound and echocardiography tumor size was estimated by calculation of an ellipse and analyzed in relation to Doppler-derived fetal cardiac output, venous flow patterns, hydrops, and outcome. RESULTS Eight fetuses with suspected intrapericardial teratoma were seen from 2009 through 2015. Gestational age at initial presentation ranged from 21-34 (median 26) weeks. Two cases mimicked the appearance of intrapericardial teratoma, but had no serial change in cardiac output over time and were ultimately determined to be other types of tumor. In 6 cases of true intrapericardial teratoma, tumor growth was extremely rapid and associated with progressive decline in cardiac output (to <400 mL/kg/min) manifesting in hydrops and death if left untreated. One case was treated successfully at 31 weeks through ex utero intrapartum delivery with tumor resection while on placental support. Another case underwent open fetal surgery and resection at 24 weeks, with resumption of gestation until delivery at 37 weeks with excellent outcome. CONCLUSION Fetal intrapericardial teratoma can be successfully managed utilizing serial surveillance and by treatment in a timely manner prior to the predictable onset of hydrops, determined through increasing tumor size and a declining cardiac output. Surgical resection in utero is possible, with good results.
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Affiliation(s)
- Jack Rychik
- Fetal Heart Program, Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Nahla Khalek
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mark P Johnson
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alan W Flake
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Khalek N, Villa A, Getrajdman C, Kennedy D, Moldenhauer JS, Johnson MP. 764: Outcomes in monochorionic twin pregnancies affected by selective intrauterine growth restriction: radiofrequency ablation versus expectant management. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.812] [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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50
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Peranteau WH, Boelig MM, Khalek N, Moldenhauer JS, Martinez-Poyer J, Hedrick HL, Flake AW, Johnson MP, Adzick NS. Effect of single and multiple courses of maternal betamethasone on prenatal congenital lung lesion growth and fetal survival. J Pediatr Surg 2016; 51:28-32. [PMID: 26526208 DOI: 10.1016/j.jpedsurg.2015.10.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [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: 09/16/2015] [Accepted: 10/06/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE Administration of maternal betamethasone (BMZ) is a therapeutic option for fetuses with large microcystic congenital lung lesions at risk for, or causing, hydrops. Not all fetuses respond to a single course of BMZ. We review our experience with the use of single and multiple courses of maternal BMZ for the management of these patients. METHODS A retrospective review of fetuses with congenital lung lesions managed with maternal BMZ from 2003 to 2014 was performed. RESULTS Forty-three patients were managed with prenatal steroids (28 single course, 15 multiple courses). Single course recipients demonstrated a reduction in lesion size and resolution of hydrops in 82% and 88% of patients respectively compared to 47% and 56% in recipients of multiple steroid courses. Survival of multiple course patients (86%) was comparable to that of single course patients (93%) and improved compared to non-treated historical controls. Multiple course recipients demonstrated an increased need for open fetal surgery and postnatal surgery at a younger age. CONCLUSION Fetuses who fail to respond to a single course of BMZ may benefit, as indicated by hydrops resolution and improved survival, from additional courses. However, failure to respond is indicative of a lesion which may require fetal or immediate neonatal resection.
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Affiliation(s)
- William H Peranteau
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
| | - Matthew M Boelig
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Nahla Khalek
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Julie S Moldenhauer
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Juan Martinez-Poyer
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Mark P Johnson
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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