Adult ; Female ; Fetofetal Transfusion ; surgery ; Fetoscopy ; Humans ; Laser Coagulation ; Pregnancy

Certain congenital heart defects, which present at birth as complex morphologic defects, are actually the result of a relatively simple primary lesion and the subsequent acquired development of a complex secondary lesion during gestation. Moreover, fetal heart approach during gestation can prevent simple cardiac lesions from such development. Specific structural lesions can be diagnosed before 12 weeks of gestation by transvaginal fetal echocardiography, and animal experiments have shown that direct or indirect fetal cardiac approach and fetal cardiac bypass are technically feasible. A number of fetal bypass models have resulted in long-term survivors, with for example, the delivery of normal lambs at full-term gestation. Also, successful full-term delivery has been obtained after fetal cardiac intervention. The success of fetal cardiac bypass was accomplished by the use of total spinal anesthesia and the administration of indomethacin. Moreover, a 42 % long-term survival after fetal cardiopulmonary bypass in a fetal lamb model has been reported. Maternal risk related to fetal bypass should be considered carefully alongside fetal risks and benefits. Most fetal malformations do not directly threaten maternal health, yet the procedures required to address fetal malformations can produce significant maternal risk and discomfort and subsequent pregnancies may be jeopardized. Further investigation of maternal outcome is required. Deep exploration of fetal and maternal pathophysiologic responses to intervention and comprehensive investigation is required to overcome current limitations, and should precede clinical trials as many problems remain to be solved before these techniques can be applied to human beings.
Animal ; Cardiac Surgical Procedures ; Female ; Fetoscopy ; Fetus/*surgery ; Heart Defects, Congenital/*surgery ; Human ; Pediatrics/methods ; Pregnancy

Fetal endoscopic surgery (FETENDO) involves many techniques that allow surgical procedures to be performed inside the uterus without an hysterotomy. The impetus for developing these minimal access techniques for fetal surgery is the unusual occurrence with an open hysterotomy of preterm labor, premature rupture of membranes, and maternal complications resulting from tocolytic therapy. The unique requirements of this approach necessitated a modification of existing endoscopic techniques, the development of novel fetoscopic instruments, and the inclusion of a wide variety of specialists. Technical expertise in the field and a natural evolution of techniques have given rise to innovative repairs previously not envisioned. Severe congenital diaphragmatic hernia, diseases of monochorionic twins, and obstructive uropathy have already been successfully treated using fetoscopic surgical techniques. Fetoscopic correction of many other non-life threatening anomalies continues to evolve. The future of fetoscopic surgical intervention depends on the continual evolution of novel approaches to disease, the elucidation of the pathophysiology and treatment of other fetal disorders, and a better understanding of treatment of complications of such intervention.
Anesthesia ; Endoscopes ; Female ; Fetal Diseases/*surgery ; Fetoscopy/*methods ; Human ; Intraoperative Period ; Operating Rooms ; Pregnancy ; Tocolysis ; Ultrasonography, Prenatal

Advances in prenatal diagnosis have led to the prenatal management of a variety of congenital diseases. Fetal surgery was born of clinical necessity. Observations by pediatric surgeons and neonatologists of neonates that were born with irreversible organ damage led to the conclusion that one possible approach to prevent this alteration of developmental physiology, was fetal surgical intervention. The demonstration in animal models that the correction of an anatomical defect could reverse the associated pathophysiology led to the first systematic application of fetal surgery at the University of California, San Francisco, in the early 1980s . There has been a dramatic improvement in our ability to diagnose, select and safely operate on an expanding number of fetal anomalies. Many fetal interventions remain investigational but for a number of conditions randomized trials have established the role of in utero surgery, making fetal surgery a clinical reality in a number of fetal therapy programs. Although prenatal stem cell and gene therapy await clinical application, they offer tremendous potential for the treatment of many genetic disorders. Here we review the prenatal evaluation, current status and future potential of various prenatal operative approaches, such as open hysterotomy, fetoscopy, and percutaneous, including tissue engineering, and prenatal cellular and genetic therapy.
California ; Fetal Therapies ; Fetoscopy ; Genetic Therapy ; Humans ; Hysterotomy ; Infant, Newborn ; Models, Animal ; Prenatal Diagnosis ; San Francisco ; Stem Cells ; Tissue Engineering

Our aim was to demonstrate the potential of first-trimester embryofetoscopy for prenatal diagnosis in a continuing pregnancy. A patient at risk for giving birth to an infant with short rib-polydactyly syndrome, type II (Majewski), presented for prenatal diagnosis at 9 weeks of gestation. A 1 mm semirigid fiberoptic endoscope with an 18 gauge examination sheath and a single-chip digital camera were used for transabdominal embryofetoscopy. Transabdominal embryofetoscopy was performed at 13 weeks of gestation. Direct visualization of the fetus was achieved and no gross limb or facial abnormalities were seen. This case shows that embryofetoscopy is a useful tool for early diagnosis in high-risk patients in the first trimester for continuing pregnancies.
Adult ; Female ; Fetal Diseases/*diagnosis ; Fetoscopy/*methods ; Humans ; Infant, Newborn ; Pregnancy ; Pregnancy Outcome ; Pregnancy Trimester, First ; Short Rib-Polydactyly Syndrome/*diagnosis

PURPOSE: Fetoscopic laser surgery (FLS) is considered an optimal therapeutic strategy for twin-to-twin transfusion syndrome (TTTS). We aimed to determine the clinical outcomes of TTTS patients since the introduction of FLS. METHODS: A retrospective study of TTTS patients born between January 2005 and December 2015 was conducted. Mortality and morbidity were compared in the FLS and non-FLS groups. The FLS group was divided into selective FLS and Solomon technique group, and subgroup analysis was performed. RESULTS: Of 70 pregnancies diagnosed with TTTS during the study period, FLS was performed for 35 (50%). Survival of at least one infant at discharge was achieved in 100% (35/35) of pregnancies in the FLS group and 91.4% (32/35) in the non-FLS group (P=0.028). Subgroup analysis revealed that the Solomon technique group had a higher dual survival rate than the selective FLS group (81.3% vs. 57.9%, P=0.036). Neonatal mortality was significantly lower in the FLS group than in the non-FLS group (1.7% vs. 16.4%, P=0.005). Severe intraventricular hemorrhage more than grade 3 was less frequent in the FLS group than in the non-FLS group (0% vs. 18.2%, P= 0.001). The FLS group showed smaller inter-twin differences in birth weight (24.4% vs. 33.7%, P= 0.032) and lower incidence of twin anemia-polycythemia sequence (0% vs. 43.8%, P<0.001). CONCLUSION: Since the introduction of FLS, the survival rate of TTTS patients has improved. The Solomon technique resulted in better dual survival rates than selective FLS.
Birth Weight ; Female ; Fetofetal Transfusion* ; Fetoscopy ; Hemorrhage ; Humans ; Incidence ; Infant ; Infant Mortality ; Infant, Newborn ; Laser Therapy* ; Mortality ; Pregnancy ; Retrospective Studies ; Survival Rate ; Twins

Adult ; Female ; Fetofetal Transfusion ; surgery ; Fetoscopy ; methods ; Humans ; Pregnancy ; Pregnancy Complications ; surgery ; Pregnancy Reduction, Multifetal ; methods ; Pregnancy, Multiple ; Treatment Outcome ; Young Adult

OBJECTIVE: Approximately 15-20% of all clinically recognized pregnancies result in spontaneous abortion and 60-70% of these are attributable to detectable chromosome abnormalities. Although the incidence of first trimester losses is high, spontaneous abortion material is often poorly described from a development perspective. The purpose of this study was to determine the usefulness of transcervical embryoscopy in diagnosing localized and generalized defects in the embryonic morphogenesis of missed abortions. The embryoscopic findings are supplemented by the results of cytogenetic analysis in all cases. METHODS: In this study, consisted of 26 women with the final diagnosis of missed abortion between August 1, 2003 and October 31, 2003 in Samsung Cheil Hospital. Prior to the instrumental evacuation of the uterus a rigid hysteroscope was passed transcervically into the amniotic cavity to obtain a detail view of the embryo. Karyotyping was done in all cases included in this study. RESULTS: Visualization of embryo or early fetus was successful in 24 cases. Among 24 examined cases, 21 cases had successful karyotype and as a result 11 (11/21, 52.4%) had abnormal karyotype. Among 21 cases which had successful karyope, 4 (4/21, 19.0%) had normal external features, 10 (10/21, 47.6%) had classified as growth-disorganized and 7 (7/21, 33.3%) had either isolated or multiple defects, including facial dysplasia, delayed limb development, facial fusion to chest, umbilical cyst, brownish discoloration of ventral part and increased nuchal thickness. Of the morphologically normal and growth-disorganized embryo in embryoscopic examination, only 1 and 4 (1/4, 25.0% and 4/10, 40.0%) had a abnormal karyotype. In contrast, of the morphologically abnormal embryo in embryoscopic examination, 5 (5/7, 71.4%) had a abnormal karyotype. CONCLUSION: Transcervical embryoscopy permits visualization of the embryo in utero, unaffected by the damage usually caused by its instrumental evacuation or spontaneous passage. This technique can be a helpful tool for understanding human embryonic malformations and genetic counseling for parents. Futhermore, correlation of morphological and cytogenetic findings in spontaneous abortion specimens could provide the need of further evaluation for future pregnancies in couples which had fear of repeated abortions. But, more larger scaled controlled study is needed for widely use of transcervical embryoscopy in missed abortion.
Abnormal Karyotype ; Abortion, Missed* ; Abortion, Spontaneous ; Chromosome Aberrations ; Cytogenetic Analysis ; Cytogenetics ; Diagnosis ; Embryonic Structures ; Extremities ; Family Characteristics ; Female ; Fetoscopy* ; Fetus ; Genetic Counseling ; Humans ; Hysteroscopes ; Incidence ; Karyotype ; Karyotyping ; Morphogenesis ; Parents ; Pregnancy ; Pregnancy Trimester, First ; Thorax ; Urachal Cyst ; Uterus

OBJECTIVE: To evaluate the initial maternal and perinatal outcomes of fetoscopic laser photocoagulation for the treatment of twin-to-twin transfusion syndrome (TTTS) in a referral center in Brazil. METHODS: This prospective observational study analyzed 24 fetoscopic laser photocoagulation procedures at 18–26 weeks of gestation. TTTS severity was determined using the Quintero classification. Blood vessels that crossed the interamniotic membrane were nonselectively photocoagulated. The χ2 test and Mann-Whitney U test were used for the statistical analysis. RESULTS: The mean (±standard deviation) age of pregnant women, gestational age at surgery, surgical time, gestational age at birth, and newborn weight were 32.2±4.1 years, 20.7±2.9 weeks, 51.8±16.7 minutes, 30.5±4.1 weeks, and 1,531.0±773.1 g, respectively. Using the Quintero classification, there was a higher percentage of cases in stage III (54.2%), followed by stages IV (20.8%), II (16.7%), and I (8.3%). Ten (41.7%) donor fetuses died and 14 (58.3%) donor fetuses survived until the end of gestation. Placental insertion location (anterior vs. posterior) did not affect the incidence of iatrogenic septostomy, surface bleeding, and premature rupture of membranes until the end of gestation. The death rate of donor and recipient fetuses before 24th gestational week increased with severity of TTTS. CONCLUSION: The maternal and perinatal outcomes resulting from the implementation of a new minimally invasive surgical technique are in line with those obtained in major centers worldwide, considering the learning curves and infrastructures.
Blood Vessels ; Brazil* ; Classification ; Female ; Fetofetal Transfusion* ; Fetoscopy ; Fetus ; Gestational Age ; Hemorrhage ; Humans ; Incidence ; Infant, Newborn ; Learning Curve ; Light Coagulation* ; Membranes ; Mortality ; Observational Study ; Operative Time ; Parturition ; Perinatal Mortality ; Pregnancy ; Pregnant Women ; Prospective Studies ; Referral and Consultation ; Rupture ; Tissue Donors