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David AL. Improving motor function in fetal surgery for open spina bifida. BJOG 2024; 131:768. [PMID: 38037518 DOI: 10.1111/1471-0528.17730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/17/2023] [Indexed: 12/02/2023]
Abstract
Linked article: This is a mini commentary on Athiel et al, pp. 759‐767 in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17624.
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Affiliation(s)
- Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
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2
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Okpaise OO, Tonni G, Werner H, Araujo Júnior E, Lopes J, Ruano R. Three-dimensional real and virtual models in fetal surgery: a real vision. Ultrasound Obstet Gynecol 2024; 63:303-311. [PMID: 36565438 DOI: 10.1002/uog.26148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/30/2022] [Accepted: 12/14/2022] [Indexed: 06/17/2023]
Affiliation(s)
- O O Okpaise
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - G Tonni
- Prenatal Diagnostic Centre, Department of Obstetrics and Neonatology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), AUSL Reggio Emilia, Reggio Emilia, Italy
| | - H Werner
- Biodesign Lab DASA/PUC-Rio, Rio de Janeiro, Brazil
| | - E Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
- Medical School, Municipal University of São Caetano do Sul (USCS), Bela Vista Campus, São Paulo, Brazil
| | - J Lopes
- Biodesign Lab DASA/PUC-Rio, Rio de Janeiro, Brazil
- Institute for Pure and Applied Mathematics, Rio de Janeiro, Brazil
| | - R Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Miami, Miller School of Medicine, Miami, FL, USA
- Maternal-Fetal-Children Service of Excellence, Americas Group, United Health Care Brazil, São Paulo, Brazil
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Hendriks S, Althaus J, Atkinson MA, Baschat AA, Berkman BE, Grady C, Wasserman D, Wendler D, Miller JL. Precarious hope: Ethical considerations for offering experimental fetal therapies outside of research after initial studies in humans. Prenat Diagn 2024; 44:180-186. [PMID: 38069681 DOI: 10.1002/pd.6474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/24/2023] [Accepted: 11/20/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE Risks and benefits of experimental fetal therapies can remain uncertain after initial clinical studies, especially long-term effects. Nevertheless, pregnant individuals may request them, hoping to benefit their future child. Guidance about offering experimental fetal therapies outside research (as "innovative therapy") is limited, despite their ethical complexity. We propose points for clinicians and reviewers to consider when deciding whether and how to offer experimental fetal therapies as innovative therapies after initial clinical studies. METHOD We used conceptual analysis and a current case to develop points for consideration, grounded in broader debates on innovative therapy and the unique challenges associated with experimental fetal therapies. RESULTS Clinicians should evaluate whether offering experimental fetal therapies as innovative therapy is appropriate for a pregnant individual and their fetus. The anticipated risk-benefit ratio for the fetus should be favorable. For the pregnant individual, risks may outweigh benefits, within reasonable limits. Medical resources should be sufficient to ensure appropriate care. Clinicians should support pregnant individuals in making informed choices. Clinicians offering innovative therapies with more than minimal risk should collect and report data on outcomes. Independent review should take place. CONCLUSION Considering these points may advance the interests of fetuses, future children, and their families.
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Affiliation(s)
- Saskia Hendriks
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
| | - Janyne Althaus
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, Baltimore, Maryland, USA
| | - Meredith A Atkinson
- Department of Pediatrics, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Benjamin E Berkman
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
- National Human Genome Research Institute, Bethesda, Maryland, USA
| | - Christine Grady
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
| | - David Wasserman
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
| | - Jena L Miller
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, Johns Hopkins University, Baltimore, Maryland, USA
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Waddington SN, Peranteau WH, Rahim AA, Boyle AK, Kurian MA, Gissen P, Chan JKY, David AL. Fetal gene therapy. J Inherit Metab Dis 2024; 47:192-210. [PMID: 37470194 PMCID: PMC10799196 DOI: 10.1002/jimd.12659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/21/2023]
Abstract
Fetal gene therapy was first proposed toward the end of the 1990s when the field of gene therapy was, to quote the Gartner hype cycle, at its "peak of inflated expectations." Gene therapy was still an immature field but over the ensuing decade, it matured and is now a clinical and market reality. The trajectory of treatment for several genetic diseases is toward earlier intervention. The ability, capacity, and the will to diagnose genetic disease early-in utero-improves day by day. A confluence of clinical trials now signposts a trajectory toward fetal gene therapy. In this review, we recount the history of fetal gene therapy in the context of the broader field, discuss advances in fetal surgery and diagnosis, and explore the full ambit of preclinical gene therapy for inherited metabolic disease.
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Affiliation(s)
- Simon N Waddington
- EGA Institute for Women's Health, University College London, London, UK
- Faculty of Health Sciences, Wits/SAMRC Antiviral Gene Therapy Research Unit, Johannesburg, South Africa
| | - William H Peranteau
- The Center for Fetal Research, Division of General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ahad A Rahim
- UCL School of Pharmacy, University College London, London, UK
| | - Ashley K Boyle
- EGA Institute for Women's Health, University College London, London, UK
| | - Manju A Kurian
- Developmental Neurosciences, Zayed Centre for Research into Rare Disease in Children, GOS-Institute of Child Health, University College London, London, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Paul Gissen
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- National Institute of Health Research Great Ormond Street Biomedical Research Centre, London, UK
| | - Jerry K Y Chan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore, Singapore
- Academic Clinical Program in Obstetrics and Gynaecology, Duke-NUS Medical School, Singapore, Singapore
- Experimental Fetal Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Anna L David
- EGA Institute for Women's Health, University College London, London, UK
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Affiliation(s)
- Jan Deprest
- Academic Department Development and Regeneration, Woman and Child and Clinical Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
| | - Tim Van Mieghem
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
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Bowman RM, Lee JY, Yang J, Kim KH, Wang KC. Myelomeningocele: the evolution of care over the last 50 years. Childs Nerv Syst 2023; 39:2829-2845. [PMID: 37417984 DOI: 10.1007/s00381-023-06057-1] [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: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE Myelomeningocele (MMC) is one of the representative anomalies in the field of pediatric neurosurgery. During the 50 years of ISPN history, MMC had a tremendous changes in its incidence, clinical management and outcome with advanced understanding of its pathogenesis. We reviewed the changes in MMC during the period. METHODS We reviewed the literature review and collected our experiences. RESULTS During the 50 years, major changes happened in many aspects of MMC including incidence, pathoembryogenesis, folate deficiency, prevention, prenatal diagnosis, mode of delivery, treatment policy with ethical considerations, clinical treatment including fetal surgery, latex allergy, retethering, management outcome, multidisciplinary team approach, and socioeconomic and family issues. CONCLUSIONS There was a great advance in the management and research of MMC during the 50 years. It is a monumental achievement of pediatric neurosurgeons and colleagues of the related fields.
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Affiliation(s)
- Robin M Bowman
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Neurosurgery Department, Northwestern University, Chicago, IL, USA
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
- Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul, Korea
| | - Jeyul Yang
- Department of Neurosurgery, Myongji Hospital, Goyang, Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Kyu-Chang Wang
- Center for Rare Cancers, Neuro-oncology Clinic, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, Kyounggi-do, 10408, Republic of Korea.
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Farmer DL. The Joy of Discovery: The Birth of Fetal Surgery and the Path to In Utero Stem Cell Therapy. Ann Surg 2023; 278:301-309. [PMID: 37325918 DOI: 10.1097/sla.0000000000005967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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Forde B, Oria M, Lampe K, Martin S, Peiro JL. Creation of a novel synthetic amniotic fluid for use in fetal therapy with in vitro testing on human amniotic membranes. Am J Obstet Gynecol MFM 2023; 5:101055. [PMID: 37328032 DOI: 10.1016/j.ajogmf.2023.101055] [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: 05/16/2023] [Accepted: 06/11/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Normal saline or lactated Ringer's solutions are usually infused at the time of fetal interventions; however, the effect of these fluids on the amniotic membranes has never been assessed. Given both the significant differences between the composition of normal saline solution, lactated Ringer's solution, and amniotic fluid and the significant risk of prematurity after fetal interventions, an investigation is warranted. OBJECTIVE This study aimed to evaluate the effect of current amnioinfusion fluids on the human amnion compared with a novel synthetic amniotic fluid. STUDY DESIGN Amniotic epithelial cells from term placentas were isolated and cultured per protocol. A synthetic amniotic fluid was created with similar electrolyte, pH, albumin, and glucose concentrations to human amniotic fluid, termed "Amnio-well." The cultured human amniotic epithelium was exposed to normal saline solution, lactated Ringer's solution, and Amnio-well. As a control, 1 group of cells remained in culture media. Cells were evaluated for apoptosis and necrosis. A second analysis to examine if cells could be "rescued" was performed, wherein the cells were allowed to remain in the culture media for an additional 48 hours after amnioinfusion. Subsequently, tissue testing with human amniotic membrane explants was evaluated similarly. Immunofluorescent intensity studies were undertaken to evaluate reactive oxygen species-mediated cell damage. Real-time quantitative polymerase chain reaction was used to evaluate gene expression in apoptotic pathways. RESULTS With simulated amnioinfusion, 44%, 52%, and 89% of amniotic epithelial cells were alive after exposure to normal saline solution, lactated Ringer's solution, and Amnio-well, respectively, compared with 85% in control (P<.001). After amnioinfusion and attempted cell rescue, 21%, 44%, 94%, and 88% of cells were alive after exposure to normal saline solution, lactated Ringer's solution, Amnio-well, and control, respectively (P<.001). In simulated amnioinfusion with full-thickness tissue explants, 68%, 80%, 93%, and 96% of cells were viable in normal saline solution, lactated Ringer's solution, Amnio-well, and control, respectively (P<.001). In culture, reactive oxygen species production was higher in normal saline solution, lactated Ringer's solution, and Amnio-well than in control (4.9-, 6.6-, and 1.8-fold higher, respectively, P<.001); however, this could be mitigated in Amnio-well by adding ulin-A-statin and ascorbic acid. Gene expression data revealed abnormal signaling in the p21 and BCL2/BAX pathways with normal saline solution compared with control (P=.006 and P=.041); changes were not seen with Amnio-well. CONCLUSION In vitro, normal saline and lactated Ringer's solutions caused increased amniotic membrane reactive oxygen species and cell death. The use of a novel fluid similar to human amniotic fluid led to the normalization of cellular signaling and less cell death.
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Affiliation(s)
- Braxton Forde
- Division of Maternal-Fetal Medicine, University of Cincinnati Medical Center, Cincinnati, OH (Dr Forde); Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Drs Forde and Oria, Ms Lampe, Mr Martin, and Dr Peiro); University of Cincinnati Medical College, Cincinnati, OH (Drs Forde, Oria, and Peiro).
| | - Marc Oria
- Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Drs Forde and Oria, Ms Lampe, Mr Martin, and Dr Peiro); Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Drs Oria and Peiro); University of Cincinnati Medical College, Cincinnati, OH (Drs Forde, Oria, and Peiro)
| | - Kristin Lampe
- Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Drs Forde and Oria, Ms Lampe, Mr Martin, and Dr Peiro)
| | - Samuel Martin
- Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Drs Forde and Oria, Ms Lampe, Mr Martin, and Dr Peiro)
| | - Jose L Peiro
- Center for Fetal and Placental Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Drs Forde and Oria, Ms Lampe, Mr Martin, and Dr Peiro); Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Drs Oria and Peiro); University of Cincinnati Medical College, Cincinnati, OH (Drs Forde, Oria, and Peiro)
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9
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Joshi D, Stellon M, Antony K, Beninati M, Luks FI, Puricelli M, Lobeck IN. Indications, Resource Allocation, and Outcomes Associated with Ex-Utero Intrapartum Treatment Procedures: A North American Fetal Therapy Network Survey. Fetal Diagn Ther 2023; 50:376-386. [PMID: 37339615 PMCID: PMC10614236 DOI: 10.1159/000531615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/13/2023] [Indexed: 06/22/2023]
Abstract
INTRODUCTION Neonates with cardiorespiratory compromise at delivery are at substantial risk of hypoxic neurologic injury and death. Though mitigation strategies such as ex-utero intrapartum treatment (EXIT) exist, the competing interests of neonatal beneficence, maternal non-maleficence, and just distribution of resources require consideration. Due to the rarity of these entities, there are few systematic data to guide evidence-based standards. This multi-institutional, interdisciplinary approach aims to elucidate the current scope of diagnoses that might be considered for such treatments and examine if treatment allocation and/or outcomes could be improved. METHODS After IRB approval, a survey investigating diagnoses appropriate for EXIT consultation and procedure, variables within each diagnosis, occurrence of maternal and neonatal adverse outcomes, and instances of suboptimal resource allocation in the last decade was sent to all North American Fetal Treatment Network center representatives. One response was recorded per center. RESULTS We received a 91% response rate and all but one center offer EXIT. Most centers (34/40, 85%) performed 1-5 EXIT consultations per year and 17/40 (42.5%) centers performed 1-5 EXIT procedures in the last 10 years. The diagnoses with the highest degree of agreement between centers surveyed to justify consultation for EXIT are head and neck mass (100%), congenital high airway obstruction (90%), and craniofacial skeletal conditions (82.5%). Maternal adverse outcomes were noted in 7.5% of centers while neonatal adverse outcomes in 27.5%. A large percentage of centers report cases of suboptimal selection for risk mitigation procedures and several centers experienced adverse neonatal and maternal outcomes. CONCLUSION This study captures the scope of EXIT indications and is the first to demonstrate the mismatch in resource allocation for this population. Further, it reports on attributable adverse outcomes. Given suboptimal allocation and adverse outcomes, further examination of indications, outcomes, and resource use is justified to drive evidence-based protocols.
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Affiliation(s)
- Devashish Joshi
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA,
| | - Michael Stellon
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kathleen Antony
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Michael Beninati
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Francois I Luks
- Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Michael Puricelli
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Inna Neyman Lobeck
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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De Bie FR, Tate T, Antiel RM. Maternal-fetal surgery as part of pediatric palliative care. Semin Fetal Neonatal Med 2023; 28:101440. [PMID: 37173213 DOI: 10.1016/j.siny.2023.101440] [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] [Indexed: 05/15/2023]
Abstract
Maternal-fetal surgical interventions have become a more common part of prenatal care. This third option, beside termination or post-natal interventions, complicates prenatal decision-making: while interventions may be lifesaving, survivors may face a life with disability. Pediatric palliative care (PPC) is more than end of life or hospice care, it aims at helping patients with complex medical conditions live well. In this paper, we briefly discuss maternal-fetal surgery, challenges regarding counseling and benefit-risk evaluation, argue that PPC should be a routine part of prenatal consultation, discuss the pivotal role of the maternal-fetal surgeon in the PCC-team, and finally discuss some of the ethical considerations of maternal-fetal surgery. We illustrate this with a case example of an infant diagnosed with congenital diaphragmatic hernia (CDH).
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Affiliation(s)
- Felix R De Bie
- Department of General Surgery, KU Leuven University Hospital, Leuven, Belgium
| | - Tyler Tate
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Ryan M Antiel
- Division of Pediatric Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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Scheinerman N, Callahan KP. Legal Discrepancies and Expectations of Women: Abortion, Fetal Therapy, and NICU Care. Hastings Cent Rep 2023; 53:36-43. [PMID: 37092649 PMCID: PMC10352933 DOI: 10.1002/hast.1472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Over the past several decades in which access to abortion has become increasingly restricted, parents' autonomy in medical decision-making in the realms of fetal care and neonatal intensive care has expanded. Today, parents can decide against invasive medical interventions at gestational ages where abortions are forbidden, even in cases where neonates are expected to be seriously ill. Although a declared state interest in protecting the lives of fetuses and newborns contributes to justifications for restricting women's autonomy with regards to abortion, it does not fully explain this discrepancy. We believe that social portrayals of women as complying with or shirking their reproductive function play a major role in explaining it. The growing divide between a woman's rights as a reproductive being and as a parent suggest that abortion restriction is rooted in a historical societal desire for women to serve as reproducers and in the corresponding fear of them abandoning this allotted role in pursuit of social equality. The Dobbs v. Jackson (2022) decision is not based in a view of abortion as a medical act occurring between a doctor and patient, as Roe v. Wade (1973) did, but decision-making about fetal therapy or NICU care is still viewed as occurring between a doctor and patient or surrogate because in this act a woman is seen as fulfilling her role as mother.
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Affiliation(s)
- Naomi Scheinerman
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
| | - Katharine Press Callahan
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
- Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania
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Thompson DNP, De Vloo P, Deprest J. Fetal Surgery for Myelomeningocele: Neurosurgical Perspectives. Adv Tech Stand Neurosurg 2023; 47:25-48. [PMID: 37640871 DOI: 10.1007/978-3-031-34981-2_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
More than 30 years have elapsed since it was recognised that folic acid supplementation could substantially reduce the risk of open neural tube defects (ONTDs). During that time, many countries have adopted policies of food fortification with demonstrable reduction in the incidence of both cranial and spinal ONTDs. Improved prenatal detection and termination has also resulted in a reduction in the number of affected live births. Nonetheless, in the USA about 1500 children, and in the UK around 500 children are born each year with myelomeningocele (MMC) and so the management of MMC and its complications continues to constitute a significant clinical workload for many paediatric neurosurgical units around the world.Until recently, the options available following antenatal diagnosis of MMC were termination of pregnancy or postnatal repair. As a result of the MOMS trial, prenatal repair has become an additional option in selected cases (Adzick et al., N Engl J Med 364(11):993-1004, 2011). Fetal surgery for myelomeningocele is now offered in more than 30 centres worldwide. The aim of this chapter is to review the experimental basis of prenatal repair of MMC, to critically evaluate the neurosurgical implications of this intervention and to describe the technique of 'open' repair, comparing this with emerging minimally invasive alternatives.
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Affiliation(s)
- Dominic N P Thompson
- Department of Pediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK.
| | | | - Jan Deprest
- Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
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Moise KJ, Vlastos EJ, Papanna R, Chmait RH, Baschat AA, Lim FY. Current Status of the Workforce and Training at Fetal Therapy Centers in the North America. Fetal Diagn Ther 2022; 49:333-339. [PMID: 36041413 DOI: 10.1159/000525529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022]
Abstract
An anonymous electronic survey was developed to query the 34 centers in the North American Fetal Treatment Network (NAFTNet) regarding the demographics and training of their faculty. Telephone surveys were conducted with directors of known fetal intervention fellowships. More than 50% of Maternal-Fetal Medicine (MFM) faculty at fetal centers were female; more than two thirds of pediatric surgical faculty were male. Most of the training of faculty was undertaken by visiting more experienced centers or having new faculty work with more experienced ones at the same center. Current fetal intervention fellowships appear to achieve levels of competency for intrauterine transfusions and laser therapy for twin-twin transfusion syndrome. Two thirds of centers stated that they would be able to offer a position to an MFM who completed a formal fellowship in fetal intervention.
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Affiliation(s)
- Kenneth Joseph Moise
- Department of Women's Health, Dell Medical School, UT Health Austin, Comprehensive Fetal Care Center, Dell Children's Medical Center, Austin, Texas, USA
| | - Emanuel Joseph Vlastos
- Obstetrics and Gynecology, University of Missouri-Kansas School of Medicine, Kansas City, Missouri, USA
- Fetal Therapy Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology and Reproductive Medicine, McGovern School of Medicine - UT Health Houston, Houston, Texas, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Keck School of Medicine at the Medical University of Southern California, Los Angeles, California, USA
- Los Angeles Fetal Surgery, CHLA-USC Fetal-Maternal Center, Los Angeles, California, USA
| | - Ahmet A Baschat
- Department of Obstetrics and Gynecology, John Hopkins School of Medicine, Baltimore, Maryland, USA
- Center for Fetal Therapy, Baltimore, Maryland, USA
| | - Foong-Yen Lim
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
- Fetal Care Center, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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Michie M. Beyond Abortion Clinics: How Overturning Roe Will Obstruct Life-Saving Research and Fetal Therapy. Am J Bioeth 2022; 22:62-64. [PMID: 35917428 PMCID: PMC9721389 DOI: 10.1080/15265161.2022.2089278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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15
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Hoagland MA, Fleming J, Foley C, Fernandez P, Wood CL. Avoiding the use of halogenated anesthetic agents for uterine relaxation in open mid-gestation fetal surgery: A case report. Fetal Diagn Ther 2022; 49:190-195. [PMID: 35609531 DOI: 10.1159/000524899] [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: 11/23/2021] [Accepted: 04/05/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Profound uterine relaxation is required for open fetal surgery. This is typically achieved by the administration of high-dose halogenated anesthetic agents. However, this anesthetic technique is associated with adverse cardiovascular effects in the fetus and may have long-term neurocognitive effects as well. CASE PRESENTATION We present reports for two patients in whom uterine relaxation was maintained with nitroglycerin and magnesium infusions without any exposures to halogenated anesthetic agents. There were no adverse fetal or maternal effects from this technique. DISCUSSION/CONCLUSION To the best of our knowledge, these are the first reports of open fetal surgery being performed without the use of halogenated anesthetic agents. This has potential short- and long-term benefits for the fetus, particularly as more complex and longer duration minimally invasive procedures are developed.
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Affiliation(s)
- Monica A Hoagland
- Section of Pediatric Anesthesiology, Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jamie Fleming
- Division of Pediatric Anesthesia, Department of Anesthesiology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Carolyn Foley
- Section of Pediatric Anesthesiology, Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Patrick Fernandez
- Section of Pediatric Anesthesiology, Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cristina L Wood
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Crombag N, Pizzolato D, Deprest J, Dierickx K. Maternal-Fetal Therapy: The (Psycho)Social Dilemma. Am J Bioeth 2022; 22:63-65. [PMID: 35258422 DOI: 10.1080/15265161.2022.2027561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
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Hendriks S, Grady C, Wasserman D, Wendler D, Bianchi DW, Berkman B. A New Ethical Framework for Assessing the Unique Challenges of Fetal Therapy Trials. Am J Bioeth 2022; 22:45-61. [PMID: 33455521 PMCID: PMC8530458 DOI: 10.1080/15265161.2020.1867932] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
New fetal therapies offer important prospects for improving health. However, having to consider both the fetus and the pregnant woman makes the risk-benefit analysis of fetal therapy trials challenging. Regulatory guidance is limited, and proposed ethical frameworks are overly restrictive or permissive. We propose a new ethical framework for fetal therapy research. First, we argue that considering only biomedical benefits fails to capture all relevant interests. Thus, we endorse expanding the considered benefits to include evidence-based psychosocial effects of fetal therapies. Second, we reject the commonly proposed categorical risk and/or benefit thresholds for assessing fetal therapy research (e.g., only for life-threatening conditions). Instead, we propose that the individual risks for the pregnant woman and the fetus should be justified by the benefits for them and the study's social value. Studies that meet this overall proportionality criterion but have mildly unfavorable risk-benefit ratios for pregnant women and/or fetuses may be acceptable.
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Affiliation(s)
- Saskia Hendriks
- Department of Bioethics, Clinical Center, National
Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, MD 20892, USA
| | - Christine Grady
- Department of Bioethics, Clinical Center, National
Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, MD 20892, USA
| | - David Wasserman
- Department of Bioethics, Clinical Center, National
Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, MD 20892, USA
| | - David Wendler
- Department of Bioethics, Clinical Center, National
Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, MD 20892, USA
| | - Diana W. Bianchi
- National Human Genome Research Institute, National
Institutes of Health, 31 Center Dr, Room 2A03, Bethesda, MD 20894, USA
| | - Benjamin Berkman
- Department of Bioethics, Clinical Center, National
Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, MD 20892, USA
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Lyerly AD, Verite A, Marshall MF. Restrictions on Abortion, Social Justice and the Ethics of Research in Maternal-Fetal Therapy Trials. Am J Bioeth 2022; 22:78-81. [PMID: 35258420 DOI: 10.1080/15265161.2022.2030588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
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Farrell RM, Michie M. Considering Reprogenomics in the Ethical Future of Fetal Therapy Trials. Am J Bioeth 2022; 22:71-73. [PMID: 35258428 PMCID: PMC9912160 DOI: 10.1080/15265161.2022.2027558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Affiliation(s)
- Ruth M. Farrell
- OB/GYN and Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio
- Center for Bioethics, Cleveland Clinic, Cleveland, Ohio
- Center for Genomic Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Marsha Michie
- Department of Bioethics, Case Western Reserve University, Cleveland, Ohio
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Elrod J, Ochsenbein-Kölble N, Mazzone L, Zimmermann R, Berger C, Speck RF, Strübing N, Mohr C, Moehrlen U, Meuli M. Fetal-maternal surgery for spina bifida in a HIV-infected mother. Fetal Diagn Ther 2022; 49:25-28. [PMID: 34991089 DOI: 10.1159/000521788] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/03/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In select cases, in utero surgery for MMC leads to better outcomes than postnatal repair. However, maternal HIV infection constitutes a formal exclusion criterion due to the potential of vertical HIV transmission. Encouraged by a previous case of a successful fetal spina bifida repair in a Hepatitis Bs antigen positive woman, a plan was devised allowing for fetal surgery. CASE REPORT In utero MMC repair was performed although the mother was HIV-infected. To minimize the risk of in utero HIV transmission, the mother was treated by HAART throughout gestation as well as intravenous zidovudine administration during maternal-fetal surgery. The mother tolerated all procedures very well without any sequelae. The currently 20 month-old toddler, is HIV negative and has significantly benefitted from fetal surgery. DISCUSSION/CONCLUSION This case shows that maternal HIV is not a priori a diagnosis that excludes fetal surgery. Rather, it might be a surrogate for moving towards personalized medicine and away from applying too rigorous exclusion criteria in the selection of candidates for maternal-fetal surgery.
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Affiliation(s)
- Julia Elrod
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Children's Research Center (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Luca Mazzone
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Children's Research Center (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Roland Zimmermann
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Berger
- Children's Research Center (CRC), University Children's Hospital Zurich, Zurich, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Roberto F Speck
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Nele Strübing
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Mohr
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Children's Research Center (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Meuli
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Children's Research Center (CRC), University Children's Hospital Zurich, Zurich, Switzerland
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21
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Schwab ME, Braun HJ, Padilla BE. Imaging modalities and management of prenatally diagnosed suprarenal masses: an updated literature review and the experience at a high volume Fetal Treatment Center. J Matern Fetal Neonatal Med 2022; 35:308-315. [PMID: 31984817 PMCID: PMC9125789 DOI: 10.1080/14767058.2020.1716719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/20/2019] [Accepted: 01/13/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE The differential diagnosis for prenatal suprarenal masses (SRMs) is broad and includes neuroblastoma, adrenal hemorrhage, and subdiaphragmatic extralobar pulmonary sequestration (SEPS). We sought to elucidate the appropriate postnatal management for fetuses found to have an SRM. METHODS We conducted a retrospective review of patients prenatally diagnosed with SRM at our institution between 1998 and 2018. Prenatal characteristics, imaging, and neonatal outcomes were collected. We also performed a PubMed literature search and pooled analysis of all patients with a prenatally diagnosed SRM previously described in the literature. RESULTS The literature review yielded 32 studies, of which 19 were single case reports. In our case series, 12 patients were included. Seven patients were delivered vaginally, one was terminated. Postnatal diagnoses included: SEPS (n = 5), adrenal hemorrhage (n = 3), polycystic kidney (n = 2), splenic cyst (n = 1), and unknown for one patient. All but two of the final diagnoses had been on the initial diagnostic differential. With the exception of the terminated fetus, all remain alive today. On pooled analysis, patients who underwent operative management were diagnosed later 32 versus 24 weeks and had a significant predominance of left-sided lesions (59.5 versus 39.2%). The published literature demonstrates a trend toward observation versus resection over the past 30 years. CONCLUSIONS Patients prenatally diagnosed with an SRM have an excellent prognosis. Our series demonstrates a high incidence of SEPS, which were all resected, and adrenal hemorrhage, which were observed with repeat imaging. These patients can be followed with serial postnatal ultrasounds to determine the diagnosis prior to deciding the appropriate treatment.
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Affiliation(s)
- Marisa E. Schwab
- Department of Surgery, University of California, San Francisco, CA
| | - Hillary J. Braun
- Department of Surgery, University of California, San Francisco, CA
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Abstract
Primary immunodeficiencies (PIDs) have become a prime target for gene therapy given the morbidity, mortality, and the single gene etiology. Given that outcomes are better the earlier gene therapy is implemented, it is possible that fetal gene therapy may be an important future direction for the treatment of PIDs. In this chapter, the current treatments available for several PIDs will be reviewed, as well as the history and current status of gene therapy for PIDs. The possibility of in utero gene therapy as a possibility will then be discussed.
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Affiliation(s)
- Anne H Mardy
- Department of Obstetrics, Gynecology, and Reproductive Services, University of California, San Francisco, California
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Abstract
Prenatal gene therapy could provide a cure for many monogenic diseases. Prenatal gene therapy has multiple potential advantages over postnatal therapy, including treating before the onset of disease, the ability to induce tolerance and cross the blood-brain barrier. In this chapter, we will describe in utero gene therapy and its rationale, clinical trials of postnatal gene therapy, preclinical studies of in utero gene therapy, and potential risks to the mother and fetus.
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Affiliation(s)
- Marisa E Schwab
- Center for Maternal-Fetal Precision Medicine
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Tippi C MacKenzie
- Center for Maternal-Fetal Precision Medicine
- Department of Surgery, University of California, San Francisco, San Francisco, California
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Abstract
In utero fetal therapy offers the opportunity to prevent and treat diseases with a cellular or genetic basis. Components of successful fetal treatment include isolation of a replacement cell population, in utero stem cell transplantation, cell engraftment with fetal immune tolerance, and ongoing cell function. Fetal gene therapy with CRISPR-Cas9 represents an exciting potential therapy for genetic diseases not amenable to gene supplementation via adenoviral vector transduction. These fetal therapies have unique ethical and safety considerations. Clinical trials for in utero cell therapy are underway, as additional discoveries in stem cell biology and gene therapy move closer to clinical translation.
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Affiliation(s)
- Matthew A Shear
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Andrew Massa
- Columbia Vagelos College of Physicians and Surgeons, New York, New York
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Sparks TN. The Current State and Future of Fetal Therapies. Clin Obstet Gynecol 2021; 64:926-932. [PMID: 34560766 PMCID: PMC8530888 DOI: 10.1097/grf.0000000000000651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Through next-generation sequencing, we can now detect a myriad of rare genetic diseases in utero that were previously not diagnosed until after birth. Fetal therapies hold strong promise for transforming prenatal management of genetic diseases, preventing adverse effects from organ damage in utero, and improving the grim perinatal outcomes of numerous genetic diseases. Many novel, in utero therapies are under investigation for genetic diseases using hematopoietic stem cells, cellular pathway inhibitors, viral vectors, and other biotechnologies. This article reviews emerging fetal therapies, as well as existing guidance for their development, considerations for their safety, and ethical and societal implications.
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Affiliation(s)
- Teresa N Sparks
- Department of Obstetrics, Gynecology, & Reproductive Sciences
- Institute of Human Genetics, University of California, San Francisco, San Francisco, California
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Affiliation(s)
| | | | - Paul D Losty
- University of Liverpool, Liverpool, United Kingdom
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Buckels EJ, Bloomfield FH, Oliver MH, Spiroski AM, Harding JE, Jaquiery AL. Sexually dimorphic changes in the endocrine pancreas and skeletal muscle in young adulthood following intra-amniotic IGF-I treatment of growth-restricted fetal sheep. Am J Physiol Endocrinol Metab 2021; 321:E530-E542. [PMID: 34459219 DOI: 10.1152/ajpendo.00111.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fetal growth restriction (FGR) is associated with decreased insulin secretory capacity and decreased insulin sensitivity in muscle in adulthood. We investigated whether intra-amniotic IGF-I treatment in late gestation mitigated the adverse effects of FGR on the endocrine pancreas and skeletal muscle at 18 mo of age. Singleton-bearing ewes underwent uterine artery embolization between 103 and 107 days of gestational age, followed by 5 once-weekly intra-amniotic injections of 360-µg IGF-I (FGRI) or saline (FGRS) and were compared with an unmanipulated control group (CON). We measured offspring pancreatic endocrine cell mass and pancreatic and skeletal muscle mRNA expression at 18 mo of age (n = 7-9/sex/group). Total α-cell mass was increased ∼225% in FGRI males versus CON and FGRS males, whereas β-cell mass was not different between groups of either sex. Pancreatic mitochondria-related mRNA expression was increased in FGRS females versus CON (NRF1, MTATP6, UCP2), and FGRS males versus CON (TFAM, NRF1, UCP2) but was largely unchanged in FGRI males versus CON. In skeletal muscle, mitochondria-related mRNA expression was decreased in FGRS females versus CON (PPARGC1A, TFAM, NRF1, UCP2, MTATP6), FGRS males versus CON (NRF1 and UCP2), and FGRI females versus CON (TFAM and UCP2), with only MTATP6 expression decreased in FGRI males versus CON. Although the window during which IGF-I treatment was delivered was limited to the final 5 wk of gestation, IGF-I therapy of FGR altered the endocrine pancreas and skeletal muscle in a sex-specific manner in young adulthood.NEW & NOTEWORTHY Fetal growth restriction (FGR) is associated with compromised metabolic function throughout adulthood. Here, we explored the long-term effects of fetal IGF-I therapy on the adult pancreas and skeletal muscle. This is the first study demonstrating that IGF-I therapy of FGR has sex-specific long-term effects at both the tissue and molecular level on metabolically active tissues in adult sheep.
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Affiliation(s)
- Emma J Buckels
- The Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Mark H Oliver
- The Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Jane E Harding
- The Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Anne L Jaquiery
- The Liggins Institute, University of Auckland, Auckland, New Zealand
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Windrim R, Gregory C, Keunen J, Abbasi N, Ryan G, Van Mieghem T, LeBouthillier F, Seaward G. Letter: Development of a Novel High-Fidelity Simulator for Teaching In Utero Fetal Shunting. J Obstet Gynaecol Can 2021; 42:1318-1319. [PMID: 33189240 DOI: 10.1016/j.jogc.2020.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Rory Windrim
- Ontario Fetal Centre at Mount Sinai Hospital, Toronto.
| | | | | | - Nimrah Abbasi
- Ontario Fetal Centre at Mount Sinai Hospital, Toronto
| | - Greg Ryan
- Ontario Fetal Centre at Mount Sinai Hospital, Toronto
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Palanki R, Peranteau WH, Mitchell MJ. Delivery technologies for in utero gene therapy. Adv Drug Deliv Rev 2021; 169:51-62. [PMID: 33181188 PMCID: PMC7855052 DOI: 10.1016/j.addr.2020.11.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/13/2020] [Accepted: 11/04/2020] [Indexed: 12/19/2022]
Abstract
Advances in prenatal imaging, molecular diagnostic tools, and genetic screening have unlocked the possibility to treat congenital diseases in utero prior to the onset of clinical symptoms. While fetal surgery and in utero stem cell transplantation can be harnessed to treat specific structural birth defects and congenital hematological disorders, respectively, in utero gene therapy allows for phenotype correction of a wide range of genetic disorders within the womb. However, key challenges to realizing the broad potential of in utero gene therapy are biocompatibility and efficiency of intracellular delivery of transgenes. In this review, we outline the unique considerations to delivery of in utero gene therapy components and highlight advances in viral and non-viral delivery platforms that meet these challenges. We also discuss specialized delivery technologies for in utero gene editing and provide future directions to engineer novel delivery modalities for clinical translation of this promising therapeutic approach.
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Affiliation(s)
- Rohan Palanki
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - William H Peranteau
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Fetal Research, Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Michael J Mitchell
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Institute for Regenerative Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Grant MT, Vrecenak JD. In Utero Hematopoietic Cell Transplantation Does Not Alter the Germ Line. J Surg Res 2021; 257:462-467. [PMID: 32896814 DOI: 10.1016/j.jss.2020.07.021] [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: 03/06/2020] [Revised: 06/18/2020] [Accepted: 07/11/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND In utero hematopoietic cell transplantation (IUHCT) has been demonstrated to reliably generate chimeric offspring. This technique introduces transplanted cells into a fetus while the immune system is still developing, allowing for engraftment without the need for myeloablation. However, little is known about the effect of engraftment on the gonadal tissue or within the germ line of the resultant chimeras. MATERIALS AND METHODS BALB/cJ mice pups were injected with B6-green fluorescent protein mononuclear bone marrow (BM) cells at gestational ages E13 or E14. Two female and two male chimeras were then crossbred with untreated mice. The gonadal tissue of the chimeras was evaluated with fluorescent stereomicroscopy and green fluorescent protein histologic staining. The progeny of the cross-bred mice was analyzed using flow cytometric evaluation of both the peripheral blood and BM. RESULTS Although transplanted cells engrafted within the gonads, no evidence of chimerism was found in oocytes or spermatogonia of female and male mice treated with IUHCT, respectively. Crossbreeding chimeric mice with untreated mice generated progeny without evidence of chimerism in peripheral blood and BM. CONCLUSIONS IUHCT yields chimeric mice that have engrafted cells within the gonads but not within the germ line itself. Correspondingly, progeny from the unaltered germ line has no detectable chimerism. This has clinical implications as the offspring of future patients treated with IUHCT would carry the disease for which their parents were treated with IUHCT.
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Affiliation(s)
- Matthew T Grant
- Division of Pediatric Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St Louis, Missouri
| | - Jesse D Vrecenak
- Division of Pediatric Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St Louis, Missouri.
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Belfort MA, Shamshirsaz AA, Cassady CI, Donepudi R, Espinoza J, Sanz Cortes M, King A, Nassr AA. Repair of a large uterine dehiscence during the second trimester leading to successful prolongation of the pregnancy. Am J Obstet Gynecol 2020; 223:929-932. [PMID: 32712004 DOI: 10.1016/j.ajog.2020.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/14/2020] [Accepted: 07/22/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Michael A Belfort
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Neurosurgery, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Surgery, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Anesthesiology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX.
| | - Alireza A Shamshirsaz
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Surgery, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Christopher I Cassady
- Radiology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Roopali Donepudi
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Jimmy Espinoza
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Magdalena Sanz Cortes
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Alice King
- Surgery, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Ahmed A Nassr
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
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Kiani AK, Paolacci S, Scanzano P, Michelini S, Capodicasa N, D'Agruma L, Notarangelo A, Tonini G, Piccinelli D, Farshid KR, Petralia P, Fulcheri E, Buffelli F, Chiurazzi P, Terranova C, Plotti F, Angioli R, Castori M, Pös O, Szemes T, Bertelli M. Prenatal genetic diagnosis: Fetal therapy as a possible solution to a positive test. Acta Biomed 2020; 91:e2020021. [PMID: 33170180 PMCID: PMC8023142 DOI: 10.23750/abm.v91i13-s.10534] [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] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/17/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Fetal abnormalities cause 20% of perinatal deaths. Advances in prenatal genetic and other types of screening offer great opportunities for identifying high risk pregnancies. METHODS Through a literature search, here we summarise what are the prenatal diagnostic technique that are being used and how those techniques may allow for prenatal interventions. RESULTS Next generation sequencing and non-invasive prenatal testing are fundamental for clinical diagnostics because of their sensitivity and accuracy in identifying point mutations, aneuploidies, and microdeletions, respectively. Timely identification of genetic disorders and other fetal abnormalities enables early intervention, such as in-utero gene therapy, fetal drug therapy and prenatal surgery. CONCLUSION Prenatal intervention is mainly focused on conditions that may cause death or lifelong disabilities, like spina bifida, congenital diaphragm hernia and sacrococcygeal teratoma; and may be an alternative therapeutic option to termination of pregnancy. However, it is not yet widely available, due to lack of specialized centers.
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Affiliation(s)
| | | | | | - Sandro Michelini
- Department of Rehabilitation, San Giovanni Battista Hospital, Rome, Italy.
| | | | - Leonardo D'Agruma
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy.
| | - Angelantonio Notarangelo
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy.
| | - Gerolamo Tonini
- Surgical Department, Unit of Urology, Poliambulanza Foundation, Brescia, Italy.
| | - Daniela Piccinelli
- Department of Mother and Child Health, Unit of Obstetrics and Gynecology, Poliambulanza Foundation, Brescia, Italy.
| | | | | | - Ezio Fulcheri
- UOSD Fetal and Perinatal Pathology, Department of Translational Research, Laboratory Medicine, Diagnostics and Services, IRCCS Giannina Gaslini Institute, Genoa, Italy.
| | - Francesca Buffelli
- UOSD Fetal and Perinatal Pathology, Department of Translational Research, Laboratory Medicine, Diagnostics and Services, IRCCS Giannina Gaslini Institute, Genoa, Italy.
| | - Pietro Chiurazzi
- Istituto di Medicina Genomica, Università Cattolica del Sacro Cuore, Rome, Italy; UOC Genetica Medica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome Italy.
| | - Corrado Terranova
- University Campus Bio Medico of Rome, Department of Obstetrics and Gynecology, Rome, Italy.
| | - Francesco Plotti
- University Campus Bio Medico of Rome, Department of Obstetrics and Gynecology, Rome, Italy.
| | - Roberto Angioli
- University Campus Bio Medico of Rome, Department of Obstetrics and Gynecology, Rome, Italy.
| | - Marco Castori
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy.
| | - Ondrej Pös
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Bratislava, Slovakia; Geneton Ltd., Bratislava, Slovakia.
| | - Tomas Szemes
- 14 Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Bratislava, Slovakia; Geneton Ltd., Bratislava, Slovakia; Comenius University Science Park, Bratislava, Slovakia.
| | - Matteo Bertelli
- MAGI EUREGIO, Bolzano, Italy; MAGI'S LAB, Rovereto (TN), Italy; EBTNA-LAB, Rovereto (TN), Italy.
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Ville Y. Should we offer fetal surgery for severe congenital diaphragmatic hernia or bring these cases to trial? Difference between chance and hazard. Ultrasound Obstet Gynecol 2020; 56:491-492. [PMID: 33001494 DOI: 10.1002/uog.22103] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/17/2020] [Accepted: 04/21/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Y Ville
- Fetal Medicine and Surgery Centre, MICADO Consortium (Multidisciplinary Initiative for Congenital and Developmental Anomalies), Université de Paris, Hôpital Necker-Enfants Malades, Paris, France
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Ben Miled S, Loeuillet L, Duong Van Huyen JP, Bessières B, Sekour A, Leroy B, Tantau J, Adle-Biassette H, Salhi H, Bonnière-Darcy M, Tessier A, Martinovic J, Causeret F, Bruneau J, Saillour Y, James S, Ville Y, Attie-Bitach T, Encha-Razavi F, Stirnemann J. Severe and progressive neuronal loss in myelomeningocele begins before 16 weeks of pregnancy. Am J Obstet Gynecol 2020; 223:256.e1-256.e9. [PMID: 32283072 DOI: 10.1016/j.ajog.2020.02.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 10/13/2019] [Revised: 01/31/2020] [Accepted: 02/10/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite undisputable benefits, midtrimester prenatal surgery is not a cure for myelomeningocele (MMC): residual intracranial and motor deficits leading to lifelong handicap question the timing of prenatal surgery. Indeed, the timing and intensity of intrauterine spinal cord injury remains ill defined. OBJECTIVE We aimed to describe the natural history of neuronal loss in MMC in utero based on postmortem pathology. STUDY DESIGN Pathology findings were analyzed in 186 cases of myelomeningocele with lesion level between S1 and T1. Using a case-control, cross-sectional design, we investigated the timewise progression and topographic extension of neuronal loss between 13 and 39 weeks. Motor neurons were counted on histology at several spinal levels in 54 isolated MMC meeting quality criteria for cell counting. These were expressed as observed-to-expected ratios, after matching for gestational age and spinal level with 41 controls. RESULTS Chiari II malformation increased from 30.7% to 91.6% after 16 weeks. The exposed spinal cord displayed early, severe, and progressive neuronal loss: the observed-to-expected count dropped from 17% to ≤2% after 16 weeks. Neuronal loss extended beyond the lesion to the upper levels: in cases <16 weeks, the observed-to-expected motor neuron count was 60% in the adjacent spinal cord, decreasing at a rate of 16% per week. Progressive loss was also found in the upper thoracic cord, but in much smaller proportions. The observed-over-expected ratio of motor neurons was not correlated with the level of myelomeningocele. CONCLUSIONS Significant neuronal loss is present ≤16 weeks in the exposed cord and progressively extends cranially. Earlier prenatal repair (<16 weeks) could prevent Chiari II malformation in 69.3% of cases, rescue the 17% remaining motor neurons in the exposed cord, and prevent the extension to the upper spinal cord.
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Affiliation(s)
- Selima Ben Miled
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University; Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University; EHU FETUS, Université de Paris and IMAGINE Institute
| | - Laurence Loeuillet
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | | | - Bettina Bessières
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Amel Sekour
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Brigitte Leroy
- Department of Pathology, Poissy Saint Germain-en-Laye Hospital, Versailles Saint-Quentin-en-Yvelines University
| | - Julia Tantau
- Department of Pathology, Poissy Saint Germain-en-Laye Hospital, Versailles Saint-Quentin-en-Yvelines University
| | - Homa Adle-Biassette
- Department of Neuropathology, Lariboisière Hospital, AP-HP and Paris Diderot University
| | - Houria Salhi
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Maryse Bonnière-Darcy
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Aude Tessier
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Jelena Martinovic
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Frédéric Causeret
- Institute of Psychiatry and Neuroscience of Paris, INSERM U1266, & IMAGINE Institute
| | - Julie Bruneau
- Department of Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Yoann Saillour
- Institute of Psychiatry and Neuroscience of Paris, INSERM U1266, & IMAGINE Institute
| | - Syril James
- Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Yves Ville
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University; EHU FETUS, Université de Paris and IMAGINE Institute
| | - Tania Attie-Bitach
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University; INSERM UMR 1163, IMAGINE Institute
| | - Ferechte Encha-Razavi
- Department of Histology-Embryology and Cytogenetics, Unit of Embryo & Fetal Pathology, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University
| | - Julien Stirnemann
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University; EHU FETUS, Université de Paris and IMAGINE Institute.
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Abstract
PURPOSE OF REVIEW Osteogenesis imperfecta (OI) is a chronic disease with few treatment options available. The purpose of this review is to provide an overview on treating OI with mesenchymal stem cells (MSC). RECENT FINDINGS Off-the-shelf MSC have a good safety profile and exhibit multilineage differentiation potential and a low immunogenic profile and are easy to manufacture. Their ability to migrate, engraft, and differentiate into bone cells, and also to act via paracrine effects on the recipient's tissues, makes MSC candidates as a clinical therapy for OI. Due to their high osteogenic potency, fetal MSC offer an even higher therapeutic potential in OI compared with MSC derived from adult sources. Preclinical and initial clinical data support the use of MSC in treating OI. The characteristics of MSC make them of great interest in treating OI. MSC may be safely transplanted via intravenous administration and show potential positive clinical effects.
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Affiliation(s)
- Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, ANA Futura, floor 8, Alfred Nobels Allé 8, 141 52 Huddinge, Stockholm, Sweden.
| | - Lilian Walther-Jallow
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet, ANA Futura, floor 8, Alfred Nobels Allé 8, 141 52 Huddinge, Stockholm, Sweden
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Ebner M, Wang G, Li W, Aertsen M, Patel PA, Aughwane R, Melbourne A, Doel T, Dymarkowski S, De Coppi P, David AL, Deprest J, Ourselin S, Vercauteren T. An automated framework for localization, segmentation and super-resolution reconstruction of fetal brain MRI. Neuroimage 2020; 206:116324. [PMID: 31704293 PMCID: PMC7103783 DOI: 10.1016/j.neuroimage.2019.116324] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/26/2019] [Accepted: 10/29/2019] [Indexed: 12/17/2022] Open
Abstract
High-resolution volume reconstruction from multiple motion-corrupted stacks of 2D slices plays an increasing role for fetal brain Magnetic Resonance Imaging (MRI) studies. Currently existing reconstruction methods are time-consuming and often require user interactions to localize and extract the brain from several stacks of 2D slices. We propose a fully automatic framework for fetal brain reconstruction that consists of four stages: 1) fetal brain localization based on a coarse segmentation by a Convolutional Neural Network (CNN), 2) fine segmentation by another CNN trained with a multi-scale loss function, 3) novel, single-parameter outlier-robust super-resolution reconstruction, and 4) fast and automatic high-resolution visualization in standard anatomical space suitable for pathological brains. We validated our framework with images from fetuses with normal brains and with variable degrees of ventriculomegaly associated with open spina bifida, a congenital malformation affecting also the brain. Experiments show that each step of our proposed pipeline outperforms state-of-the-art methods in both segmentation and reconstruction comparisons including expert-reader quality assessments. The reconstruction results of our proposed method compare favorably with those obtained by manual, labor-intensive brain segmentation, which unlocks the potential use of automatic fetal brain reconstruction studies in clinical practice.
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Affiliation(s)
- Michael Ebner
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK; School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
| | - Guotai Wang
- School of Mechanical and Electrical Engineering, University of Electronic Science and Technology of China, Chengdu, China; Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK; School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
| | - Wenqi Li
- Nvidia, Cambridge, UK; School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Michael Aertsen
- Department of Radiology, University Hospitals KU Leuven, Leuven, Belgium
| | - Premal A Patel
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK; Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Rosalind Aughwane
- Institute for Women's Health, University College London, London, UK; Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Andrew Melbourne
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Tom Doel
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Steven Dymarkowski
- Department of Radiology, University Hospitals KU Leuven, Leuven, Belgium
| | - Paolo De Coppi
- Institute of Child Health, University College London, London, UK
| | - Anna L David
- Institute for Women's Health, University College London, London, UK; Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK; Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium; Institute for Women's Health, University College London, London, UK; Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Sébastien Ourselin
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Tom Vercauteren
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK; Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
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Aughwane R, Ingram E, Johnstone ED, Salomon LJ, David AL, Melbourne A. Placental MRI and its application to fetal intervention. Prenat Diagn 2020; 40:38-48. [PMID: 31306507 PMCID: PMC7027916 DOI: 10.1002/pd.5526] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/18/2019] [Accepted: 07/08/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Magnetic resonance imaging (MRI) of placental invasion has been part of clinical practice for many years. The possibility of being better able to assess placental vascularization and function using MRI has multiple potential applications. This review summarises up-to-date research on placental function using different MRI modalities. METHOD We discuss how combinations of these MRI techniques have much to contribute to fetal conditions amenable for therapy such as singletons at high risk for fetal growth restriction (FGR) and monochorionic twin pregnancies for planning surgery and counselling for selective growth restriction and transfusion conditions. RESULTS The whole placenta can easily be visualized on MRI, with a clear boundary against the amniotic fluid, and a less clear placental-uterine boundary. Contrasts such as diffusion weighted imaging, relaxometry, blood oxygenation level dependent MRI and flow and metabolite measurement by dynamic contrast enhanced MRI, arterial spin labeling, or spectroscopic techniques are contributing to our wider understanding of placental function. CONCLUSION The future of placental MRI is exciting, with the increasing availability of multiple contrasts and new models that will boost the capability of MRI to measure oxygen saturation and placental exchange, enabling examination of placental function in complicated pregnancies.
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Affiliation(s)
| | - Emma Ingram
- Division of Developmental Biology & MedicineUniversity of ManchesterManchesterUK
| | - Edward D. Johnstone
- Division of Developmental Biology & MedicineUniversity of ManchesterManchesterUK
| | - Laurent J. Salomon
- Hôpital Necker‐Enfants Malades, AP‐HP, EHU PACT and LUMIERE PlatformUniversité Paris DescartesParisFrance
| | - Anna L. David
- Institute for Women's HealthUniversity College LondonLondonUK
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Andrew Melbourne
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Medical Physics and Biomedical EngineeringUniversity College LondonLondonUK
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Affiliation(s)
- Julien Baruteau
- Gene Transfer Technology Group, Institute for Women's Health, University College London, London, UK
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Genetics and Genomic Medicine Programme, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Simon N Waddington
- Gene Transfer Technology Group, Institute for Women's Health, University College London, London, UK
- Wits/SAMRC Antiviral Gene Therapy Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Melhem NZ, Ledermann S, Rees L. Chronic kidney disease following twin-to-twin transfusion syndrome-long-term outcomes. Pediatr Nephrol 2019; 34:883-888. [PMID: 30560449 DOI: 10.1007/s00467-018-4176-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 11/17/2018] [Accepted: 12/11/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Amongst other sequelae, acute kidney injury (AKI) is a well-recognised post-natal complication of twin-to-twin transfusion syndrome (TTTS). Despite this, there has been a lack of data reporting long-term renal outcomes. Our aim was to report the long-term renal outcomes of infants born with TTTS. METHODS We performed a retrospective case note review of all infants referred to our centre between 1998 and 2018 with a primary diagnosis of TTTS. Subjects with confirmed TTTS were divided into a chronic kidney disease (CKD) group and a non-CKD group for comparison. RESULTS Twenty-six infants with TTTS were included for analysis. Eight (31%) subjects developed CKD. Within the CKD group, 50% went on to require long-term renal replacement therapy (RRT) of whom all underwent renal transplantation. For subjects who had neonatal AKI, cumulative survival rate before RRT at 5 and 10 years was 79% and 70%, respectively. Subjects with CKD had a significantly higher incidence of AKI in the neonatal period and were more likely to be the donor twin. Gestational age at birth, gender, antenatal interventions and comorbidities did not affect long-term renal outcome between the two groups. CONCLUSION This is the first long-term follow-up study demonstrating that CKD progressing to the need for RRT can develop after TTTS. Donor-twin status and neonatal AKI associated with adverse long-term outcomes warranting long-term surveillance in this group.
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Affiliation(s)
- Nabil Ziad Melhem
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Sarah Ledermann
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Lesley Rees
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
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SPIEGEL ALLENM. THE JEREMIAH METZGER LECTURE: A BRIEF HISTORY OF EUGENICS IN AMERICA: IMPLICATIONS FOR MEDICINE IN THE 21 ST CENTURY. Trans Am Clin Climatol Assoc 2019; 130:216-234. [PMID: 31516187 PMCID: PMC6736015] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In the first half of the 20th century, the US was swept up in a multifaceted movement to enhance the genetic makeup of the country's population. This eugenics movement, based on flawed scientific principles promulgated by Galton in the UK and Davenport in the US included legally mandated compulsory sterilization in 27 states in the US and sharply restricted immigration from many parts of the world. Compulsory sterilization legislation was upheld by the Supreme Court in 1927. The American eugenics movement was a model for the compulsory sterilization implemented by the Nazis after they took power in Germany in 1933. The movement waned in America only following World War II when the US public became aware of the full extent of the Nazi Aryan racial superiority program. With the advent of major advances in molecular and cellular biology that are already being applied to clinical medicine in the 21st century, we have entered a new eugenics era. It is critical that we learn the lessons of our earlier eugenics movement if we are to avoid making the same flawed decisions now.
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Affiliation(s)
- ALLEN M. SPIEGEL
- Correspondence and reprint requests: Allen M. Spiegel, MD, Albert Einstein College of Medicine,
Belfer 1003, 1300 Morris Park Avenue, Bronx, New York 10461929-246-6738
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Lim YJ, Jo HJ, Chung ML. Omental calcification, necrotizing enterocolitis, and undescended testes after fetal abdomino-amniotic shunting performed for the management of meconium peritonitis: A case report. J Clin Ultrasound 2018; 46:546-548. [PMID: 29574772 DOI: 10.1002/jcu.22589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 02/24/2018] [Indexed: 06/08/2023]
Abstract
Prenatal ultrasonography (US) in a 39 year-old woman revealed massive fetal ascites. A fetal abdomino-amniotic shunting procedure was performed. Subsequently, plain radiographs demonstrated diffuse gaseous distention of the bowel and multiple punctate calcifications in the left upper abdomen. Postnatal US examination showed multiple echogenic foci in the liver and the left upper abdomen, bowel wall thickening in the right-sided abdomen, and undescended testes. There was no intra-abdominal free air or loculated fluid collections. Medical management was instituted secondary to the clinical suspicion of omental calcification, necrotizing enterocolitis, and undescended testes. Follow-up US examination showed resolution of portal vein gas and bowel wall thickening. The neonate recovered fully.
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Affiliation(s)
- Yun-Jung Lim
- Department of Radiology, Haeundae Paik Hospital, Inje University, Haeundae-gu, Busan, Korea
| | - Hyun-Jin Jo
- Department of Obstetrics & Gynecology, Haeundae Paik Hospital, Inje University, Haeundae-gu, Busan, Korea
| | - Mi Lim Chung
- Department of Pediatrics, Haeundae Paik Hospital, Inje University, Haeundae-gu, Busan, Korea
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Cao KX, Booth A, Ourselin S, David AL, Ashcroft R. The legal frameworks that govern fetal surgery in the United Kingdom, European Union, and the United States. Prenat Diagn 2018; 38:475-481. [PMID: 29663461 PMCID: PMC6033164 DOI: 10.1002/pd.5267] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
The specialty of fetal surgery or fetal intervention is one of the most exciting emerging fields of modern medicine. It is made possible by decades of major developments in antenatal imaging, obstetric anaesthesia, fetal medicine, paediatric surgery, and of course by the bold and novel practitioners willing to take new steps to advance the field. Beginning in the 1970s, it has now reached a stage of maturity where there are several established in utero procedures and countless clinical trials and studies to develop more. But what is the legal situation that fetal surgeons find themselves in? What are the rights and legal protections for the fetus and the mother, both of which are arguably the patient? This article will address this question, discussing and summarising the current legal frameworks governing fetal surgery in the jurisdictions of the United Kingdom, European Court of Human Rights, and the United States of America as well as discuss what the future may hold and how researchers and physicians in the specialty can best navigate the legal environment.
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Affiliation(s)
- Kevin X. Cao
- Department of UrologyGreat Ormond Street HospitalLondonUK
| | | | | | - Anna L. David
- UCL Institute for Women's HealthLondonUK
- Department of Development and RegenerationKatholieke Universiteit LeuvenLeuvenBelgium
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Ville Y. [Fetal therapy, state of the art and perspectives]. Rev Prat 2018; 68:31-34. [PMID: 30840383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Yves Ville
- Service de maternité et de médecine foetale EA 7328 GH Necker-Enfants malades Université René Descartes Institut Imagine
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Nakano-Kobayashi A, Awaya T, Kii I, Sumida Y, Okuno Y, Yoshida S, Sumida T, Inoue H, Hosoya T, Hagiwara M. Prenatal neurogenesis induction therapy normalizes brain structure and function in Down syndrome mice. Proc Natl Acad Sci U S A 2017; 114:10268-10273. [PMID: 28874550 PMCID: PMC5617268 DOI: 10.1073/pnas.1704143114] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [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] [Indexed: 12/23/2022] Open
Abstract
Down syndrome (DS) caused by trisomy of chromosome 21 is the most common genetic cause of intellectual disability. Although the prenatal diagnosis of DS has become feasible, there are no therapies available for the rescue of DS-related neurocognitive impairment. A growth inducer newly identified in our screen of neural stem cells (NSCs) has potent inhibitory activity against dual-specificity tyrosine phosphorylation-regulated kinase 1A (DYRK1A) and was found to rescue proliferative deficits in Ts65Dn-derived neurospheres and human NSCs derived from individuals with DS. The oral administration of this compound, named ALGERNON (altered generation of neurons), restored NSC proliferation in murine models of DS and increased the number of newborn neurons. Moreover, administration of ALGERNON to pregnant dams rescued aberrant cortical formation in DS mouse embryos and prevented the development of abnormal behaviors in DS offspring. These data suggest that the neurogenic phenotype of DS can be prevented by ALGERNON prenatal therapy.
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Affiliation(s)
- Akiko Nakano-Kobayashi
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Tomonari Awaya
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Isao Kii
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Yuto Sumida
- Laboratory of Chemical Bioscience, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, Tokyo 101-0062, Japan
| | - Yukiko Okuno
- Medical Research Support Center, Kyoto University Graduate School of Medicine, Kyoto 606-8501, Japan
| | - Suguru Yoshida
- Laboratory of Chemical Bioscience, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, Tokyo 101-0062, Japan
| | - Tomoe Sumida
- Laboratory of Chemical Bioscience, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, Tokyo 101-0062, Japan
| | - Haruhisa Inoue
- Center for iPS Cell Research and Application, Kyoto University, Kyoto 606-8507, Japan
- Drug-Discovery Cellular Basis Development Team, RIKEN BioResource Center, Kyoto 606-8507, Japan
| | - Takamitsu Hosoya
- Laboratory of Chemical Bioscience, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, Tokyo 101-0062, Japan
| | - Masatoshi Hagiwara
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan;
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Mon RA, Treadwell MC, Berman DR, Day L, Kreutzman J, Mychaliska GB, Perrone EE. Outcomes of fetuses with primary hydrothorax that undergo prenatal intervention (prenatal intervention for hydrothorax). J Surg Res 2017; 221:121-127. [PMID: 29229117 DOI: 10.1016/j.jss.2017.08.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 08/08/2017] [Accepted: 08/16/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Primary hydrothorax is a congenital anomaly affecting 1 in 10,000-15,000 pregnancies. The natural history of this condition is variable with some fetuses having spontaneous resolution and others showing progression. The associated pulmonary hypoplasia leads to increased perinatal morbidity and mortality. Optimal prenatal intervention remains controversial. METHODS After obtaining the Institutional Review Board approval, a retrospective review of all patients evaluated for a fetal pleural effusion in the Fetal Diagnosis and Treatment Center at The University of Michigan, between 2006 and 2016 was performed. Cases with secondary etiologies for an effusion or when families decided to pursue elective termination were excluded. RESULTS Pleural effusions were identified in 175 patients. Primary hydrothorax was diagnosed in 15 patients (8%). The effusions were bilateral in 13/15 cases (86%) and 10/15 (66%) had hydrops at presentation. All 15 patients with primary hydrothorax underwent prenatal intervention. Thoracentesis was performed in 14/15 cases (93%). Shunt placement was performed in 10/15 cases (66%). Shunt migration was seen in four patients (40%) and all of these underwent prenatal shunt replacement. Overall survival was 76%. The rates of prematurity and preterm premature rupture of membranes were 69% and 35%, respectively. CONCLUSIONS Fetal intervention for the treatment of primary hydrothorax is effective, and it appears to confer a survival advantage. Both the fetuses and the mothers tolerated the procedures well. Preterm labor and preterm premature rupture of membranes remain an unsolved problem. Further studies are needed to understand the mechanisms behind the development of fetal hydrothorax.
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Affiliation(s)
- Rodrigo A Mon
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - Marjorie C Treadwell
- University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Deborah R Berman
- University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Lori Day
- University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Jeannie Kreutzman
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - Erin E Perrone
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan.
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Nassr AA, Shazly SAM, Abdelmagied AM, Araujo Júnior E, Tonni G, Kilby MD, Ruano R. Effectiveness of vesicoamniotic shunt in fetuses with congenital lower urinary tract obstruction: an updated systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017; 49:696-703. [PMID: 27270578 DOI: 10.1002/uog.15988] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [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: 02/08/2016] [Revised: 05/26/2016] [Accepted: 05/31/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To evaluate the effect on perinatal and postnatal survival of vesicoamniotic shunt (VAS) as treatment for fetal lower urinary tract obstruction (LUTO). METHODS An electronic search of Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews and Scopus using relevant search terms was conducted from inception to June 2015 to identify studies comparing outcomes of VAS vs conservative management for treatment of LUTO. Cohort studies and clinical trials were considered eligible. Single-arm studies and studies that did not report survival were excluded. Sample size and language were not criteria for exclusion. Two reviewers extracted independently data in a standardized form, including study characteristics and results. Primary outcomes were perinatal and postnatal survival. Secondary outcome was postnatal renal function. Data on fetal survival were expressed as odds ratio (OR) and 95% CI. RESULTS Of the 423 abstracts retrieved, nine studies were eligible for inclusion. These studies included 112 fetuses treated with VAS and 134 that were managed conservatively. There was heterogeneity in study design. Although the data demonstrated a difference in effect estimates between the study arms in terms of perinatal survival (OR, 2.54 (95% CI, 1.14-5.67)), there was no difference in 6-12-month survival (OR, 1.77 (95% CI, 0.25-12.71)) or 2-year survival (OR, 1.81 (95% CI, 0.09-38.03)). In addition, there was no difference in effect on postnatal renal function between fetuses that underwent intervention and those that did not (OR, 2.09 (95% CI, 0.74-5.94)). CONCLUSIONS Available data seem to support an advantage for perinatal survival in fetuses treated with VAS compared with conservative management. However, 1-2-year survival and outcome of renal function after VAS procedure remain uncertain. Further studies are necessary to evaluate the effectiveness of fetal intervention for LUTO based on different severity of the disease, due to the very low quality of the studies according to GRADE guidelines. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A A Nassr
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - S A M Shazly
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
| | - A M Abdelmagied
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
- Women's Health Hospital, Assiut University Hospitals, Assiut, Egypt
| | - E Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo, São Paulo, Brazil
| | - G Tonni
- Prenatal Diagnostic Service, Department of Obstetrics and Gynecology, AUSL Reggio Emilia, Reggio Emilia, Italy
| | - M D Kilby
- Centre for Women's and Children's Health, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - R Ruano
- Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic, Rochester, MN, USA
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Cruz-Martinez R, Martínez-Rodríguez M, Bermúdez-Rojas M, Magaña-Abarca C, Narvaez-Dominguez V, Rojas-Macedo A, Bautista-García N, Alcocer-Alcocer M. Fetal laser ablation of feeding artery of cystic lung lesions with systemic arterial blood supply. Ultrasound Obstet Gynecol 2017; 49:744-750. [PMID: 27363854 DOI: 10.1002/uog.16011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 12/30/2015] [Revised: 06/15/2016] [Accepted: 06/17/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the effectiveness of laser surgery in fetuses with a cystic lung lesion with systemic arterial blood supply (hybrid lung lesion) at risk of perinatal death. METHODS A cohort of five consecutive fetuses with a large hybrid lung lesion associated with hydrops and/or pleural effusion with severe lung compression was selected for percutaneous ultrasound-guided fetal laser ablation of the feeding artery (FLAFA) before 32 weeks' gestation in a single tertiary national referral center in Queretaro, Mexico. The primary outcomes were survival and need for postnatal surgery. RESULTS FLAFA was performed successfully in all cases at a median gestational age of 24.9 (range, 24.4-31.7) weeks. After fetal intervention, dimensions in both lungs increased and fluid effusions resolved in all cases. All cases were delivered liveborn at term at a median gestational age of 39.6 (range, 38.0-39.7) weeks, without respiratory morbidity or need for oxygen support, resulting in perinatal survival of 100%. During follow-up, three (60%) cases showed progressive regression of the entire lung mass and did not require postnatal surgery, whereas in two (40%) cases a progressive decrease in size of the mass was observed but a cystic portion of the lung mass persisted and postnatal lobectomy was required. CONCLUSION In fetuses with large hybrid lung lesions at risk of perinatal death, FLAFA is feasible and could improve survival and decrease the need for postnatal surgery. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Cruz-Martinez
- National Fetal Medicine Research Network 'Fetal Medicine Mexico', Queretaro, Mexico
- Fetal Medicine and Surgery Research Unit, Children's and Women's Specialty Hospital of Queretaro, and Unidad de Investigación en Neurodesarrollo, Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM) Campus Juriquilla, Queretaro, Mexico
| | - M Martínez-Rodríguez
- National Fetal Medicine Research Network 'Fetal Medicine Mexico', Queretaro, Mexico
- Fetal Medicine and Surgery Research Unit, Children's and Women's Specialty Hospital of Queretaro, and Unidad de Investigación en Neurodesarrollo, Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM) Campus Juriquilla, Queretaro, Mexico
| | - M Bermúdez-Rojas
- National Fetal Medicine Research Network 'Fetal Medicine Mexico', Queretaro, Mexico
| | - C Magaña-Abarca
- National Fetal Medicine Research Network 'Fetal Medicine Mexico', Queretaro, Mexico
| | - V Narvaez-Dominguez
- Fetal Medicine and Surgery Research Unit, Children's and Women's Specialty Hospital of Queretaro, and Unidad de Investigación en Neurodesarrollo, Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM) Campus Juriquilla, Queretaro, Mexico
| | - A Rojas-Macedo
- Department of Neonatology, Children's and Women's Specialty Hospital of Queretaro, Queretaro, Mexico
| | - N Bautista-García
- Fetal Medicine and Surgery Research Unit, Children's and Women's Specialty Hospital of Queretaro, and Unidad de Investigación en Neurodesarrollo, Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM) Campus Juriquilla, Queretaro, Mexico
| | - M Alcocer-Alcocer
- Fetal Medicine and Surgery Research Unit, Children's and Women's Specialty Hospital of Queretaro, and Unidad de Investigación en Neurodesarrollo, Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM) Campus Juriquilla, Queretaro, Mexico
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Gosavi A, Vijayakumar PD, Ng BSW, Loh MH, Tan LG, Johana N, Tan YW, Sandikin D, Su LL, Wataganara T, Biswas A, Choolani MA, Mattar CNZ. Rapid initiation of fetal therapy services with a system of learner-centred training under proctorship: the National University Hospital (Singapore) experience. Singapore Med J 2017; 58:311-320. [PMID: 27439783 PMCID: PMC5474526 DOI: 10.11622/smedj.2016127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Management of complicated monochorionic twins and certain intrauterine structural anomalies is a pressing challenge in communities that still lack advanced fetal therapy. We describe our efforts to rapidly initiate selective feticide using radiofrequency ablation (RFA) and selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS), and present the latter as a potential model for aspiring fetal therapy units. METHODS Five pregnancies with fetal complications were identified for RFA. Three pregnancies with Stage II TTTS were selected for SFLP. While RFA techniques utilising ultrasonography skills were quickly mastered, SFLP required stepwise technical learning with an overseas-based proctor, who provided real-time hands-off supervision. RESULTS All co-twins were live-born following selective feticide; one singleton pregnancy was lost. Fetoscopy techniques were learned in a stepwise manner and procedures were performed by a novice team of surgeons under proctorship. Dichorionisation was completed in only one patient. Five of six twins were live-born near term. One pregnancy developed twin anaemia-polycythaemia sequence, while another was complicated by co-twin demise. DISCUSSION Proctor-supervised directed learning facilitated the rapid provision of basic fetal therapy services by our unit. While traditional apprenticeship is important for building individual expertise, this system is complementary and may benefit other small units committed to providing these services.
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Affiliation(s)
- Arundhati Gosavi
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Pradip D Vijayakumar
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
| | - Bryan SW Ng
- Department of Anaesthesia, National University Health System, Singapore
| | - May-Han Loh
- Department of Anaesthesia, National University Health System, Singapore
| | - Lay Geok Tan
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nuryanti Johana
- Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Yi Wan Tan
- Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Dedy Sandikin
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lin Lin Su
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tuangsit Wataganara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Arijit Biswas
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mahesh A Choolani
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Citra NZ Mattar
- Department of Obstetrics and Gynaecology, National University Health System, Singapore
- Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Baggot PJ, Baggot RM. Fetal Therapy for Down Syndrome: Report of Three Cases and a Review of the Literature. Issues Law Med 2017; 32:31-41. [PMID: 29108162] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Down syndrome (trisomy 21) is a well-known cause of mental retardation. It can be diagnosed in early pregnancy. Scientists have made great strides in outlining the pathophysiologic mechanisms of mental retardation in Down syndrome. Much less has been published on human therapy. To our knowledge, these are the first published cases of fetal therapy for Down syndrome. METHODOLOGY Reports of three cases. In all cases, treatment was both biochemical (e.g. nutritional) and educational. In all cases, treatment was both before and after birth. RESULTS All children lacked the characteristic faces usually seen in the children with Down syndrome. This suggests a treatment effect before birth. All children had better than expected development. DISCUSSION Enhancement of development is proposed as a new therapeutic principle. Developing neurons exchange neurotrophic factors during development when they give or receive stimulation from other neurons. Neurons which receive neurotrophic stimulation survive, and those, which do not, are lost to apoptosis. The developmental therapeutic principle seeks to optimize brain development. Biochemical inputs (neurotransmitters, drugs, hormones, nutrients) and functional stimulation are integrated to optimize the growth and survival of neurons individually; other cells; subcellular organelles; and the brain as a whole. Treatment may be before and after birth, both biochemical and functional. These principles may be applied to Down syndrome, other conditions, and normal fetuses or children. PREVIOUSLY PUBLISHED Baggot PJ and Baggot RM (2014). Fetal Therapy for Down Syndrome: Report of three cases and review of the literature. J Am Phys Surg 19(1):20-24.
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Thong XY, Lee LY, Chia DA, Wong YC, Biswas A. Management and Outcomes of Fetal Hydrops in a Tertiary Care Centre in Singapore. Ann Acad Med Singap 2017; 46:4-10. [PMID: 28182812] [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] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Introduction: Fetal hydrops is a serious condition which can be caused by immune and non-immune aetiologies. We aimed to review the management of fetal hydrops at our hospital. Materials and Methods: A retrospective review of all cases of fetal hydrops diagnosed in our institution from 2006 to 2013 was carried out. Results: Out of the 30 cases of fetal hydrops diagnosed antenatally, 17 were cases of Bart's hydrops which were all terminated in-utero. Of the remaining 13 cases, 11 cases consisted of non-immune causes of hydrops. Planned antenatal interventions including in-utero blood transfusions (n = 4) and thoracentesis (n = 5) as well as planned caesarean deliveries (n = 11) were performed in the majority of cases. Postnatal neonatal intensive care with interventions including chest drainage and transfusions were also performed. A majority, 92%, of the cases survived the perinatal period following a variable length of hospital stay ranging from a week to 3 months. Conclusion: Management of fetal hydrops is complex. Close coordination between the obstetric and neonatal teams was the key to good short-term survival of neonates with antenatally diagnosed hydrops, as it allows timely antenatal intervention and anticipation of potential perinatal complications.
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Affiliation(s)
- Xin Yi Thong
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
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