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Hudelist B, Prebot J, Lecarpentier E, Apra C. A realistic aneurysm clipping simulation combining 3D-printed and placenta-based models-how I do it. Acta Neurochir (Wien) 2024; 166:172. [PMID: 38592539 DOI: 10.1007/s00701-024-06068-0] [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: 01/31/2024] [Accepted: 03/28/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Neurovascular surgery, particularly aneurysm clipping, is a critical skill for aspiring neurosurgeons. However, hands-on training opportunities are limited, especially with the growing popularity of endovascular techniques. To address this challenge, we present a novel neurovascular surgical training station that combines synthetic 3D-printed models with placental vascular structures to create a semi-realistic surgical field. METHODS Our model consists of three components: a 3D-printed skull replica with anatomical landmarks, a malleable silicone parenchyma with a Sylvian fissure, and vascular layers (placenta). The placental vascular layer is catheterized and perfused to replicate pulsatile flow, offering a realistic aneurysm simulation. This innovative training station provides a cost-effective solution (approximately 200 USD once) without ethical constraints. Surgeons can practice essential skills such as Sylvian fissure dissection, managing anatomical constraints like bone, and achieving proximal vascular control. The model's realism allows for training in various scenarios, including clipping with different hand orientations and handling ruptures realistically. CONCLUSION Our neurovascular surgical station bridges the gap between existing training models, offering affordability, ecological considerations, and minimal ethical concerns. It empowers neurosurgery residents to refine their skills in handling both emergencies and elective cases under close-to-real surgical conditions, with the potential for independent practice and senior supervision.
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Affiliation(s)
- Benoit Hudelist
- Neurosurgery Department, UMR 955, Université Paris Est Créteil (UPEC)AP-HP, Henri Mondor HospitalUnitéIMRB, INSERM 15, 94000, Créteil, France.
- Department of Neurosurgery, GHU Paris - Psychiatry and Neuroscience, Sainte-Anne Hospital, Paris, France.
| | - Juliette Prebot
- Service de modélisation et d'impression 3D de l'Assistance Publique - Hopitaux de Paris (PRIM3D), Paris, France
| | - Edouard Lecarpentier
- Department of Obstetrics Gynecology and Reproductive Medicine, Centre Hospitalier Inter-Communal de Créteil, Creteil, France
- Faculté de Santé, Univ Paris Est Créteil, Créteil, France
- INSERM, Institut Cochin, Paris, France
| | - Caroline Apra
- Neurosurgery Department, UMR 955, Université Paris Est Créteil (UPEC)AP-HP, Henri Mondor HospitalUnitéIMRB, INSERM 15, 94000, Créteil, France
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Casella A, Bano S, Vasconcelos F, David AL, Paladini D, Deprest J, De Momi E, Mattos LS, Moccia S, Stoyanov D. Learning-based keypoint registration for fetoscopic mosaicking. Int J Comput Assist Radiol Surg 2024; 19:481-492. [PMID: 38066354 PMCID: PMC10881678 DOI: 10.1007/s11548-023-03025-7] [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: 12/30/2022] [Accepted: 09/20/2023] [Indexed: 02/22/2024]
Abstract
PURPOSE In twin-to-twin transfusion syndrome (TTTS), abnormal vascular anastomoses in the monochorionic placenta can produce uneven blood flow between the two fetuses. In the current practice, TTTS is treated surgically by closing abnormal anastomoses using laser ablation. This surgery is minimally invasive and relies on fetoscopy. Limited field of view makes anastomosis identification a challenging task for the surgeon. METHODS To tackle this challenge, we propose a learning-based framework for in vivo fetoscopy frame registration for field-of-view expansion. The novelties of this framework rely on a learning-based keypoint proposal network and an encoding strategy to filter (i) irrelevant keypoints based on fetoscopic semantic image segmentation and (ii) inconsistent homographies. RESULTS We validate our framework on a dataset of six intraoperative sequences from six TTTS surgeries from six different women against the most recent state-of-the-art algorithm, which relies on the segmentation of placenta vessels. CONCLUSION The proposed framework achieves higher performance compared to the state of the art, paving the way for robust mosaicking to provide surgeons with context awareness during TTTS surgery.
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Affiliation(s)
- Alessandro Casella
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Italy
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
| | - Sophia Bano
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK.
| | - Francisco Vasconcelos
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
| | - Anna L David
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, UK
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
- Department of Development and Regeneration, University Hospital Leuven, Leuven, Belgium
| | - Dario Paladini
- Department of Fetal and Perinatal Medicine, Istituto Giannina Gaslini, Genoa, Italy
| | - Jan Deprest
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
- Department of Development and Regeneration, University Hospital Leuven, Leuven, Belgium
| | - Elena De Momi
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Leonardo S Mattos
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy
| | - Sara Moccia
- The BioRobotics Institute and Department of Excellence in Robotics and AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
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Andrioli Peralta CF, Jorge Rodrigues da Costa K, Peneluppi Horak AC, Pinheiro do Carmo Gomes S, Sousa Santos E, Galvão Barbante L, Hideo Nakagawa Santos R. Predictors of fetal death, neonatal survival and neurological outcomes in severe twin-twin transfusion syndrome treated by laser ablation of placental vessels. Prenat Diagn 2024; 44:325-335. [PMID: 38243614 DOI: 10.1002/pd.6523] [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: 08/10/2023] [Revised: 11/06/2023] [Accepted: 11/17/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVES To identify predictors of outcomes in severe twin oligo-polyhydramnios sequence (TOPS) with or without twin anemia-polycythemia sequence (TAPS) and/or selective fetal growth restriction (SFGR) treated by laser ablation of placental vessels (LAPV). METHODS Analysis of cases treated from 2011 to 2022. Variables evaluated Prenatal predictors: stages of TOPS, presence of TAPS and/or SFGR; pre-LAPV fetal ultrasound parameters; peri-LAPV variables. Perinatal predictors: GA at birth; birthweight; Apgar scores; transfontanellar ultrasonography (TFUS). OUTCOME VARIABLES fetal death, neonatal survival, infant's neurodevelopment. Binary logistic regression analyses were performed to detect predictors of outcomes. RESULTS 265 cases were included. Predictors of post-LAPV donor fetus' death were delta EFW (p:0.045) and absent/reverse end-diastolic flow in the umbilical artery (AREDF-UA) (p < 0.001). The predictor of post-LAPV recipient fetus' death was hydrops (p:0.009). Predictors of neonatal survival were GA at birth and Apgar scores. Predictors of infant's neurodevelopment were TFUS and pre-LAPV middle cerebral artery Doppler (MCAD) for the donor twin; and pre-LAPV ductus venosus' flow and MCAD for the recipient twin. CONCLUSIONS Prediction of fetal death, neonatal survival and infant's neurodevelopment is possible in cases of TOPS associated or not with SFGR and/or TAPS that were treated by LAPV.
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Affiliation(s)
- Cleisson Fábio Andrioli Peralta
- Fetal Medicine Unit, Heart Hospital (HCor), São Paulo, São Paulo, Brazil
- Fetal Medicine and Surgery Center (Gestar), São Paulo, São Paulo, Brazil
- Research Institute (HCor), São Paulo, São Paulo, Brazil
| | - Karina Jorge Rodrigues da Costa
- Fetal Medicine Unit, Heart Hospital (HCor), São Paulo, São Paulo, Brazil
- Fetal Medicine and Surgery Center (Gestar), São Paulo, São Paulo, Brazil
- Research Institute (HCor), São Paulo, São Paulo, Brazil
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Mallapragda S, Gupta R, Gupta S, Sharma H, Srivastava S, Raj A. Evaluation of Regenerative Efficacy of Amnion and Chorion Membrane in Treatment of Mandibular Molar Furcation Defects: A Clinico-radiographic Study. J Contemp Dent Pract 2024; 25:160-167. [PMID: 38514414 DOI: 10.5005/jp-journals-10024-3640] [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: 03/23/2024]
Abstract
AIM Amnion and chorion membranes possess unique inherited biological properties that enhance wound healing and may accelerate periodontal regeneration. The present study aims to evaluate and compare the efficacy of amnion and chorion membranes in the treatment of furcation defects. MATERIALS AND METHODS A total of 20 patients were selected and were randomly allocated to group I and group II with 10 subjects in each group. Amnion and chorion membranes are placental-derived membranes that accelerate regeneration by having natural growth factors with their antimicrobial and inflammation reduction properties. Group I was treated using bone grafting with decalcified freeze-dried bone allograft (DFDBA) and placement of amnion as a membrane for guided tissue regeneration (GTR) whereas group II was treated using bone grafting with DFDBA and placement of chorion as a membrane for GTR. The patients were followed for clinical and radiographic parameters and were evaluated between 3 and 6 months after surgery. RESULT In intragroup comparison, a significant difference was evident in both the groups for all the clinical and radiographic parameters within the groups. (p = 0.01) This means both amnion and chorion membranes showed statistically significant regenerative efficacy. In intergroup comparison, the results show that all the clinical parameters and radiographic parameters show no significant difference between the groups. CONCLUSION The amnion and chorion membranes had similar regenerative efficacy in combination with DFDBA in patients with buccal degree II furcation defects in mandibular molars. CLINICAL SIGNIFICANCE The amnion and chorion membranes have shown significant improvement in clinical and radiographic parameters when used for the treatment of buccal degree II furcation defects in mandibular molars. How to cite this article: Mallapragda S, Gupta R, Gupta S, et al. Evaluation of Regenerative Efficacy of Amnion and Chorion Membrane in Treatment of Mandibular Molar Furcation Defects: A Clinico-radiographic Study. J Contemp Dent Pract 2024;25(2):160-167.
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Affiliation(s)
- Siddharth Mallapragda
- Department of Periodontology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India, Orcid: https://orcid.org/0000-0001-5233-7092
| | - Radhika Gupta
- Department of Periodontology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India, Phone: +91 9818150018, e-mail: , Orcid: https://orcid.org/0000-0001-9686-4476
| | - Stuti Gupta
- Department of Periodontology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India, Orcid: https://orcid.org/0000-0001-8495-8723
| | - Himani Sharma
- Department of Periodontology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India, Orcid: https://orcid.org/0000-0002-5243-7007
| | - Saransh Srivastava
- Department of Periodontology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India, Orcid: https://orcid.org/0000-0001-7708-4749
| | - Anusha Raj
- Department of Periodontology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India, Orcid: https://orcid.org/0000-0002-6026-5030
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Han L, Zhang B, Xu H, Yin H, Pang Y, Zhang X, Zhai Q, Liu X, Wang Y, Zhang C, Xu Y, Liu Y, Chen X. A new step-wise surgical technique of knapsack-like uterine compression sutures for intractable postpartum hemorrhage in cesarean section. BMC Pregnancy Childbirth 2024; 24:9. [PMID: 38166803 PMCID: PMC10759382 DOI: 10.1186/s12884-023-06208-x] [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: 06/16/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Intractable postpartum hemorrhage (PPH) during cesarean section has been a significant concern for obstetricians. We aimed to explore the effectiveness and safety of a new type of uterine compression suture, the step-wise surgical technique of knapsack-like sutures for treating intractable PPH caused by uterine atony and placenta factors in cesarean section. METHODS The step-wise surgical technique of knapsack-like sutures was established on the basis of the artful combination of vertical strap-like sutures and an annular suture-ligation technique. This novel surgical technique was applied to 34 patients diagnosed with PPH during cesarean section due to severe uterine atony and placental factors in our department. The hemostatic effects, clinical outcomes and follow-up visit results were all reviewed and analyzed. RESULTS This new uterine compression suture successfully stopped bleeding in 33 patients, and the effective rate was 97.06%. Only 1 patient failed and was changed to use bilateral uterine arterial embolization and internal iliac artery embolization. The follow-up visits indicated that 33 patients restored menstruation except for 1 who was diagnosed with amenorrhea. The gynecological ultrasound tests of all the patients suggested good uterine involutions, and they had no obvious complaints such as hypogastralgia. CONCLUSIONS This step-wise surgical technique of knapsack-like uterine compression sutures can compress the uterus completely. It is a technique that can conserve the uterus and fertility function without special equipment in caesarean section for PPH, with the characteristics of being safe, simple and stable (3 S) with rapid surgery, reliable hemostasis and resident doctor to operation (3R).
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Affiliation(s)
- Lei Han
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China.
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China.
| | - Baolin Zhang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
- Department of Obstetrics and Gynecology, Binzhou Central Hospital, Binzhou City, 251700, Shandong Province, P. R. China
| | - Huishu Xu
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Hongmei Yin
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Yiwei Pang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Xianghui Zhang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Qingliang Zhai
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Xiaofeng Liu
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Yanlin Wang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Caiying Zhang
- Department of Postgraduate Student Office, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Yingjiang Xu
- Department of Interventional Vascular Surgery, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Yanni Liu
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China.
| | - Xuemei Chen
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China.
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Windrim C, Ryan G, Rojas D, Montero D, Higgins M, Windrim R. Remote hands-on training with a novel "video-game" simulator for teaching fetoscopic laser techniques for ablation of placental anastomoses in twin-to-twin syndrome. Prenat Diagn 2024; 44:108-110. [PMID: 38112307 DOI: 10.1002/pd.6490] [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: 09/15/2023] [Revised: 11/01/2023] [Accepted: 12/03/2023] [Indexed: 12/21/2023]
Abstract
Key pointsWhat's already known about this topic?
Twin to twin syndrome (TTTS) is a serious complication of monochorionic twin pregnancy
The treatment of choice is fetoscopic laser ablation of placental anastamoses
Simulation plays an important role in teaching this high‐acuity procedure
What does this study add?
We report the development of a high‐fidelity digital simulation system for teaching TTTS fetoscopic lasers
Remote teaching has been demonstrated to work well with this system
This simulator is robust, easy to store and assemble and relatively inexpensive.
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Affiliation(s)
- Catherine Windrim
- Maternal Fetal Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Greg Ryan
- Maternal Fetal Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - David Rojas
- Maternal Fetal Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Daniel Montero
- Maternal Fetal Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Mary Higgins
- UCD Perinatal Research Centre, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Rory Windrim
- Maternal Fetal Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
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Höbner LM, Staartjes VE, Colombo E, Sebök M, Regli L, Esposito G. How we do it: the Zurich Microsurgery Lab technique for placenta preparation. Acta Neurochir (Wien) 2023; 165:3821-3824. [PMID: 37993631 PMCID: PMC10739554 DOI: 10.1007/s00701-023-05847-5] [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: 09/17/2023] [Accepted: 10/14/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Perfused placentas provide an excellent and accessible model for microvascular dissection, microsuturing and microanastomosis training - particularly in the early microsurgical learning curve. This way, a significant amount of live animals can be spared. METHOD We present the Zurich Microsurgery Lab protocol, detailing steps for obtaining, selecting, cleaning, flushing, cannulating, and preserving human placentas - as well as microsurgical training examples - in a tried-and-true, safe, cost-effective, and high-yield fashion. CONCLUSION Our technique enables highly realistic microsurgical training (microdissection, microvascular repair, microanastomosis) based on readily available materials. Proper handling, preparation, and preservation of the perfused placenta models is key.
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Affiliation(s)
- Lara Maria Höbner
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Victor E Staartjes
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| | - Elisa Colombo
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Martina Sebök
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Luca Regli
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Giuseppe Esposito
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
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Casella A, Lena C, Moccia S, Paladini D, De Momi E, Mattos LS. Toward a navigation framework for fetoscopy. Int J Comput Assist Radiol Surg 2023; 18:2349-2356. [PMID: 37587389 PMCID: PMC10632301 DOI: 10.1007/s11548-023-02974-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 05/23/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE Fetoscopic laser photocoagulation of placental anastomoses is the most effective treatment for twin-to-twin transfusion syndrome (TTTS). A robust mosaic of placenta and its vascular network could support surgeons' exploration of the placenta by enlarging the fetoscope field-of-view. In this work, we propose a learning-based framework for field-of-view expansion from intra-operative video frames. METHODS While current state of the art for fetoscopic mosaicking builds upon the registration of anatomical landmarks which may not always be visible, our framework relies on learning-based features and keypoints, as well as robust transformer-based image-feature matching, without requiring any anatomical priors. We further address the problem of occlusion recovery and frame relocalization, relying on the computed features and their descriptors. RESULTS Experiments were conducted on 10 in-vivo TTTS videos from two different fetal surgery centers. The proposed framework was compared with several state-of-the-art approaches, achieving higher [Formula: see text] on 7 out of 10 videos and a success rate of [Formula: see text] in occlusion recovery. CONCLUSION This work introduces a learning-based framework for placental mosaicking with occlusion recovery from intra-operative videos using a keypoint-based strategy and features. The proposed framework can compute the placental panorama and recover even in case of camera tracking loss where other methods fail. The results suggest that the proposed framework has large potential to pave the way to creating a surgical navigation system for TTTS by providing robust field-of-view expansion.
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Affiliation(s)
- Alessandro Casella
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy.
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Italy.
| | - Chiara Lena
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Sara Moccia
- Department of Excellence in Robotics and AI, The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Dario Paladini
- Department of Fetal and Perinatal Medicine, Istituto Giannina Gaslini, Genoa, Italy
| | - Elena De Momi
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Leonardo S Mattos
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy
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Agarwal N, Papanna R, Bergh EP, Hernandez-Andrade E, Backley S, Salazar A, Johnson A, Espinoza J. Management of large placental chorioangioma: two-port laser approach for fetal intervention. Ultrasound Obstet Gynecol 2023; 62:882-890. [PMID: 37448172 DOI: 10.1002/uog.26307] [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: 04/04/2023] [Revised: 06/09/2023] [Accepted: 05/12/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES There is a paucity of literature providing evidence-based guidelines for the management of large placental chorioangioma (≥ 4 cm in diameter). The objectives of this study were to compare outcomes between patients managed expectantly and those undergoing in-utero intervention and to describe the different in-utero techniques used for cessation of blood flow to the tumor and the associated outcome. METHODS This was a retrospective cohort study of 34 patients referred for the management of large placental chorioangioma in a single center between January 2011 and December 2022, who were managed expectantly or underwent in-utero intervention. In-utero intervention was performed when the fetus developed any signs of impending compromise, including high combined cardiac output (CCO), worsening polyhydramnios or abnormal fetal Doppler velocimetry findings. Interventions included radiofrequency ablation (RFA), interstitial laser ablation (ILA) and single-port or two-port fetoscopic laser photocoagulation (FLP). Treatment selection was dependent on the proximity of the tumor to the umbilical cord insertion (UCI) and placental location. The two-port technique was performed in patients with a chorioangioma with large feeding vessels (≥ 3 mm) located in the posterior placenta, in which one port was used for occlusion using bipolar forceps and the other port was used for laser photocoagulation of the feeding vessels downstream. The single-port technique was used for chorioangioma with small feeding vessels (< 3 mm) located in the posterior placenta. ILA or RFA was performed in cases with an anterior placenta. Supportive treatments, including amnioreduction and intrauterine transfusion (IUT), were performed for worsening polyhydramnios and suspected fetal anemia based on middle cerebral artery Doppler flow studies, respectively. Comparative statistical analysis between cases undergoing expectant management vs in-utero intervention was performed. Descriptive details were provided for patients who underwent in-utero intervention. RESULTS Thirty-four cases of large chorioangioma were evaluated, of which 25 (73.5%) were managed expectantly and nine (26.5%) underwent intervention. The frequency of polyhydramnios was significantly higher in the intervention group compared with the expectant-management group (66.7% vs 8.0%, P < 0.001). The live-birth rate among expectantly managed cases with large chorioangioma was significantly higher compared with that in cases that underwent in-utero intervention (96.0% vs 62.5%, P = 0.01). In the intervention group, preoperative CCO was elevated in all cases with available information and preoperative hydrops was present in 33.3% (3/9) of cases. One patient experienced fetal demise following IUT prior to planned FLP. Among the remaining eight patients, four underwent two-port FLP, two underwent single-port FLP, one underwent ILA and one underwent both ILA and RFA. All three cases in which hydrops was present at the time of intervention resulted in fetal demise. CONCLUSIONS In-utero interventions aimed at cessation of blood flow in the feeding vessels are a therapeutic option for the management of cases with large chorioangioma. The two-port percutaneous technique appears to improve the efficiency of FLP when a large chorioangioma with large feeding vessels is located in the posterior placenta. We propose that in-utero interventions for large chorioangioma should be initiated prior to the development of fetal hydrops. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- N Agarwal
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - R Papanna
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - E P Bergh
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - E Hernandez-Andrade
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - S Backley
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - A Salazar
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - A Johnson
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - J Espinoza
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
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Ceccato GHW, Foltran RS, Franke K, Lovato RM, Nicolato AA, Gusmão SNS, Oliveira MMR, Borba LAB. Two-Stage Pulsatile Human Placenta Model for Microvascular Anastomosis Training in Neurosurgery. World Neurosurg 2023; 179:185-196.e1. [PMID: 37690578 DOI: 10.1016/j.wneu.2023.08.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/27/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE The development of microsurgical skills is crucial for neurosurgical education. The human placenta is a promising model for practicing vascular anastomosis due to its similarities with brain vessels. We propose a 2-stage model for training in extracranial-to-intracranial anastomosis using the placenta. METHODS Initially, we propose practicing anastomosis in 2 adjacent placentas. Once successful, the procedure advances to a more challenging configuration that employs a 3-dimensionally printed skull with a window simulating a pterional craniotomy. It is positioned an intracranial placenta and an extracranial one, and the latter has a prominent vessel exposed toward the side of the craniotomy. Both placentas have one artery and vein cannulated in the umbilical cord, and we present an artificial placental circulation system for microvascular training that regulates pulsation and hydrodynamic pressure while keeping veins engorged with a pressurized bag. To verify anastomosis patency, we utilize sodium fluorescein and iodine contrast. RESULTS The 2-stage model simulated several aspects of microvascular anastomosis. Our perfusion system allowed for intraoperative adjustments of hydrodynamic pressure and pulsation. Using iodine contrast and fluorescein enabled proper evaluation of anastomosis patency and hydrodynamic features. CONCLUSIONS Training in the laboratory is essential for developing microsurgical skills. We have presented a model for microvascular anastomosis with artificial circulation and postoperative imaging evaluation, which is highly beneficial for enhancing the learning curve in microvascular procedures.
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Affiliation(s)
- Guilherme H W Ceccato
- Department of Neurosurgery, Mackenzie Evangelical University Hospital, Curitiba, PR, Brazil; Department of Neurosurgery, Rehabilitation Hospital Center Ana Carolina Moura Xavier, Curitiba, PR, Brazil
| | - Rodrigo S Foltran
- Department of Neurosurgery, Mackenzie Evangelical University Hospital, Curitiba, PR, Brazil; Department of Neurosurgery, Rehabilitation Hospital Center Ana Carolina Moura Xavier, Curitiba, PR, Brazil
| | - Kauê Franke
- Department of Neurosurgery, Mackenzie Evangelical University Hospital, Curitiba, PR, Brazil; Department of Neurosurgery, Rehabilitation Hospital Center Ana Carolina Moura Xavier, Curitiba, PR, Brazil
| | - Renan M Lovato
- Department of Neurosurgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil; Department of Neurosurgery, Regional University Hospital of North of Paraná, Londrina, PR, Brazil
| | - Arthur A Nicolato
- Department of Anatomy, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Sebastiao N S Gusmão
- Department of Surgery, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Marcelo M R Oliveira
- Department of Surgery, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Luis A B Borba
- Department of Neurosurgery, Mackenzie Evangelical University Hospital, Curitiba, PR, Brazil; Department of Neurosurgery, Rehabilitation Hospital Center Ana Carolina Moura Xavier, Curitiba, PR, Brazil; Department of Neurosurgery, Federal University of Paraná, Curitiba, PR, Brazil.
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11
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Guzys A, Reid SM, Bolch C, Reddihough DS, Teoh M, Palma-Dias R, Fung A, Cole S, Hodges R, Fahey M, Walker SP. Developmental outcomes for survivors of placental laser photocoagulation for the management of twin-to-twin transfusion syndrome. BMC Pregnancy Childbirth 2023; 23:699. [PMID: 37770827 PMCID: PMC10540356 DOI: 10.1186/s12884-023-05997-5] [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: 03/17/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Fetoscopic laser coagulation of placental anastomoses reverses the pathological process in twin-to-twin transfusion syndrome, thereby increasing survival, but there are a paucity of studies addressing long-term neurodevelopmental outcome of survivors. This study aimed to ascertain the presence of neurodevelopmental disabilities in child survivors of monochorionic pregnancies managed by placental laser photocoagulation in the Australian state of Victoria. METHODS All pregnancies undergoing placental laser photocoagulation with the Victorian Fetal Therapy Service between 2006-2017 were included. Information on each surviving child, including demographics, perinatal course, and developmental progress was collected from parents, and consent was sought to complete the Child Behaviour Checklist. Interviewers evaluated whether this information was consistent with a diagnosis of any of 14 neurodevelopmental conditions. A three-tiered outcome measure was allocated for each child: (1) unimpaired or developmentally normal, (2) mild or moderate neurological impairment, or (3) severe neurological impairment. Clinical predictors for adverse outcome were identified. RESULTS Of 116 pregnancies (113 twin, 3 triplet), 96 (83%) resulted in 1 + surviving fetuses. 57/113 (50%) twin pregnancies resulted in 2 survivors, 36 (32%) in 1 survivor, and 20 (18%) in no survivors. Of the 235 fetuses, 154 (65.5%) survived to follow-up. Survival increased from 59% in 2006-2008 to 73% in 2015-2017. 90/154 (58%) survivors were followed up at a mean age of 7.5 [SD 3.0] years. Based on parental interview and Child Behaviour Checklist data, 28/90 (31%) participants were assessed as having neurodevelopmental impairment, 27 of mild-moderate severity and 1 severe. Speech/language disorders, attention deficit (hyperactivity) disorders, and fine motor impairment were most common. Neonatal length of stay conferred the highest risk of impairment. CONCLUSION Substantial variation exists between fetal therapy services in the type and length of neonatal follow-up following fetoscopic laser coagulation, contributing to a lack of data on long-term outcomes. The findings from this study support increasingly urgent calls to undertake systematic and sustained follow-up of fetoscopic laser coagulation survivors until school age. Information from this study may assist parents in their decision-making when offered fetal surgery. Importantly, it highlights a group for targeted surveillance and early intervention.
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Affiliation(s)
- Angela Guzys
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
| | - Susan M Reid
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia
| | - Christie Bolch
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
| | - Dinah S Reddihough
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia
| | - Mark Teoh
- Fetal Diagnostics Unit, Monash Health, Melbourne, Australia
- Victorian Fetal Therapy Service, Monash Health, Melbourne, Australia
| | - Ricardo Palma-Dias
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
- Ultrasound Services, The Royal Women's Hospital, Melbourne, Australia
| | - Alison Fung
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Stephen Cole
- Division of Maternity Services, The Royal Women's Hospital, Melbourne, Australia
| | - Ryan Hodges
- Women's and Newborn Program, Monash Health, Melbourne, Australia
| | - Michael Fahey
- Paediatric Neurology Unit, Monash Children's Hospital, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia.
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12
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Nassr AA, Hessami K, Corroenne R, Sanz Cortes M, Donepudi R, Espinoza J, Yamamoto R, Stirnemann J, Ishii K, Belfort MA, Chmait RH, Shamshirsaz AA. Outcome of laser photocoagulation in monochorionic diamniotic twin pregnancy complicated by Type-II selective fetal growth restriction. Ultrasound Obstet Gynecol 2023; 62:369-373. [PMID: 36704956 DOI: 10.1002/uog.26165] [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: 10/04/2022] [Revised: 12/05/2022] [Accepted: 01/09/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES To evaluate the outcome of monochorionic diamniotic (MCDA) twins complicated by Type-II selective fetal growth restriction (sFGR) who underwent fetoscopic laser photocoagulation and to validate a previously proposed subclassification system for Type-II sFGR in a large multicenter cohort. METHODS This retrospective multicenter cohort study included all MCDA twins complicated by Type-II sFGR who underwent laser photocoagulation of placental anastomoses at four large tertiary fetal-care centers between 2006 and 2020. Cases were subclassified according to a recently proposed system based on Doppler evaluation of the ductus venosus (DV) and middle cerebral artery (MCA) into Type-IIA (normal DV flow and MCA peak systolic velocity (PSV) of the growth-restricted fetus) or Type-IIB (absent or reversed flow in the DV during atrial contraction and/or MCA-PSV ≥ 1.5 multiples of the median of the growth-restricted fetus). Demographic characteristics and pregnancy outcomes were compared between the groups. Data are presented as mean ± SD or n (%) as appropriate. P-values < 0.05 were considered statistically significant. RESULTS A total of 98 patients with MCDA twins met our inclusion criteria, with 56 subclassified as Type IIA and 42 as Type IIB. Demographic characteristics were similar between the groups; however, Type-IIB cases had a significantly earlier gestational age at diagnosis and at laser surgery, as well as larger intertwin estimated fetal weight discordance, which may be a reflection of disease severity. Postnatal survival of the growth-restricted fetus to 30 days of age was significantly lower in Type-IIB compared to Type-IIA cases (23.8% vs 46.4%; P = 0.034). CONCLUSIONS In MCDA twins complicated by Type-II sFGR and treated with laser photocoagulation of placental anastomoses, preoperative Doppler assessment of the DV and MCA helped identify a subset of patients at increased risk of demise of the growth-restricted fetus following intervention. This study provides valuable information for guiding surgical management and patient counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - K Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R Corroenne
- Department of Obstetrics and Gynecology, University Paris Descartes, Hopital Necker-Enfants Malades, Paris, France
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R Yamamoto
- Department of Maternal-Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - J Stirnemann
- Department of Obstetrics and Gynecology, University Paris Descartes, Hopital Necker-Enfants Malades, Paris, France
| | - K Ishii
- Department of Maternal-Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R H Chmait
- Department of Obstetrics and Gynecology, Los Angeles Fetal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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13
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Avelar TM, Lovato RM, Barbosa TG, Xander PAW, Rodrigues LHDAS, Campos AJB, Riechelmann RS, Flores JAC, Aguiar GBDE, Oliveira JGDE, Veiga JCE. Evaluation of konjac noodle as a microsurgery training model: learning curve analysis. Rev Col Bras Cir 2023; 50:e20233528. [PMID: 37436283 PMCID: PMC10508674 DOI: 10.1590/0100-6991e-20233528-en] [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: 01/18/2023] [Accepted: 04/11/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND classical models of microsurgical anastomosis training are expensive and have ethical implications. Some alternatives join low cost and easiness to store. However, the translation of knowledge acquired by training in these methods into the traditional ones is not clear. This project aims to assess the feasibility of konjac noodles as a reliable microsurgery-training model. METHODS 10 neurosurgery residents performed an end-to-end anastomosis in a 2-3mm placenta artery. The anastomoses were evaluated quantitatively, recording time; and qualitatively, applying a validated score (Anastomosis Lapse Index - ALI) by three experienced neurosurgeons and verifying the presence of gross leakage through the infusion of fluorescein. Subsequently, they performed 10 non-consecutive sessions of anastomosis training in the konjac noodle. Eventually, a final anastomosis in the placenta model was performed and the same parameters were scored. RESULTS we observed a 17min reduction in the mean time to perform the anastomosis in the placenta model after the training in the konjac (p<0.05). There was a non-significant 20% reduction in gross leakage, but the training sessions were not able to consistently improve the ALI score. CONCLUSIONS we demonstrate a reduction in anastomosis performing time in placental arteries after training sessions in the konjac noodle model, which can be regarded as a feasible low-cost method, particularly useful in centers with surgical microscopes only in the operation room.
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Affiliation(s)
- Tiago Marques Avelar
- -Faculdade de Ciências Médicas, Santa Casa de São Paulo, Departamento de Cirurgia, Divisão de Neurocirurgia - São Paulo - SP - Brasil
| | - Renan Maximilian Lovato
- -Faculdade de Ciências Médicas, Santa Casa de São Paulo, Departamento de Cirurgia, Divisão de Neurocirurgia - São Paulo - SP - Brasil
| | - Thiago Gomes Barbosa
- -Faculdade de Ciências Médicas, Santa Casa de São Paulo, Departamento de Cirurgia, Divisão de Neurocirurgia - São Paulo - SP - Brasil
| | - Paulo Adolfo Wessel Xander
- -Faculdade de Ciências Médicas, Santa Casa de São Paulo, Departamento de Cirurgia, Divisão de Neurocirurgia - São Paulo - SP - Brasil
| | | | - Adriana Jose Brito Campos
- -Faculdade de Ciências Médicas, Santa Casa de São Paulo, Departamento de Cirurgia, Divisão de Neurocirurgia - São Paulo - SP - Brasil
| | - Ricardo Salemi Riechelmann
- -Faculdade de Ciências Médicas, Santa Casa de São Paulo, Departamento de Cirurgia, Divisão de Neurocirurgia - São Paulo - SP - Brasil
| | - Juan Antonio Castro Flores
- -Faculdade de Ciências Médicas, Santa Casa de São Paulo, Departamento de Cirurgia, Divisão de Neurocirurgia - São Paulo - SP - Brasil
| | - Guilherme Brasileiro DE Aguiar
- -Faculdade de Ciências Médicas, Santa Casa de São Paulo, Departamento de Cirurgia, Divisão de Neurocirurgia - São Paulo - SP - Brasil
| | - Jean Gonçalves DE Oliveira
- -Faculdade de Ciências Médicas, Santa Casa de São Paulo, Departamento de Cirurgia, Divisão de Neurocirurgia - São Paulo - SP - Brasil
| | - José Carlos Esteves Veiga
- -Faculdade de Ciências Médicas, Santa Casa de São Paulo, Departamento de Cirurgia, Divisão de Neurocirurgia - São Paulo - SP - Brasil
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Bagheri K, Anastasio AT, Dmytruk M, Chase NF, Adams SB. Contemporary Review: The Use of Human Placental Tissues in Foot and Ankle Surgery. Foot Ankle Int 2023; 44:675-686. [PMID: 37191405 DOI: 10.1177/10711007231171075] [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] [Indexed: 05/17/2023]
Abstract
The use of fetal tissues in regenerative medicine has long been a source of both promise and controversy. Since the turn of the century, their utilization has expanded because of antiinflammatory and analgesic properties, which have been theorized to act as an avenue for treating various orthopaedic conditions. With increased recognition and use, it is essential to understand the potential risks, efficacy, and long-term effects of these materials. Given the substantial body of literature published since 2015 (the date of the most recent review of fetal tissues in foot and ankle surgery), this manuscript provides an updated reference on the topic. Specifically, we evaluate the recent literature regarding the role of fetal tissues in wound healing, hallux rigidus, total ankle arthroplasty, osteochondral defects of the talus, Achilles tendinopathy, and plantar fasciitis.
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Affiliation(s)
- Kian Bagheri
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
- Campbell University School of Osteopathic Medicine, Lillington, NC, USA
| | - Albert T Anastasio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Michael Dmytruk
- Campbell University School of Osteopathic Medicine, Lillington, NC, USA
| | - Nicholas F Chase
- Campbell University School of Osteopathic Medicine, Lillington, NC, USA
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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15
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Wilmas KM, Patel J, Silapunt S, Doan HQ, Migden MR. The Use of a Dehydrated Complete Human Placental Membrane Allograft for Mohs Surgical Defects of the Nose. Dermatol Surg 2023; 49:343-347. [PMID: 36799879 DOI: 10.1097/dss.0000000000003711] [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] [Indexed: 02/18/2023]
Abstract
BACKGROUND Repair options for Mohs surgical defects include primary closure, flap or graft, or healing by second intention. These options may not be optimal in all cases. A dehydrated complete human placental membrane (dCHPM) allograft may serve as an alternative repair option. OBJECTIVE To assess the aesthetic and functional outcomes of an alternative repair technique for Mohs surgical defects of the nose. METHODS Twenty patients with Mohs surgical defects of the nose repaired with a dCHPM allograft were retrospectively identified. Photographs were used to demonstrate surgical technique and outcomes. Two blinded observers evaluated final outcomes using the Patient and Observer Scar Assessment Scale. RESULTS Observers rated the scar outcome a combined mean score of 8.4 ± 3.2 (scale 5-50). Patients rated their outcomes a mean of 12.6 ± 7.4 (scale 6-60). The mean "Overall Opinion score" was 2.5 ± 1.8 by patients and 1.9 ± 1.3 by observers (scale 1-10). LIMITATIONS This was a single institution study with a small sample size. CONCLUSION Our study demonstrates that dCHPM allografts are a viable alternative repair option for Mohs surgical defects of the nose.
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Affiliation(s)
- Kelly M Wilmas
- Department of Dermatology, The University of California San Francisco, San Francisco, California
| | - Jigar Patel
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sirunya Silapunt
- Department of Dermatology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
| | - Hung Q Doan
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael R Migden
- Departments of Dermatology and Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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Adamec A, Vargová M, Kotríková D, McCullough L, Kanásová D, Daniš J, Gabal R, Krištúfková A, Nižňanská Z, Korbeľ M. Morbidly adherent placenta as a cause of peripartum hysterectomy in the Slovak Republic in the years 2012-2020. Ceska Gynekol 2023; 88:321-327. [PMID: 37932048 DOI: 10.48095/cccg2023321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
OBJECTIVE The main aim of this study was to analyze the cases of peripartum hysterectomy associated with morbidly adherent placenta in the Slovak Republic. MATERIALS AND METHODS Cases of morbidly adherent placenta managed by peripartum hysterectomy in the Slovak Republic between January 2012 and December 2020 were retrospectively analyzed. Data were obtained from the standardized anonymous questionnaires. RESULTS The incidence of morbidly adherent placenta was 0.39 per 1,000 births. A total of 151 (89.9%) women with morbidly adherent placenta were managed by peripartum hysterectomy (38.0% of all peripartum hysterectomies). Placenta accreta, increta and percreta were present in 56.3%, 28.5% and 15.2%, respectively. Placenta previa was present in 60 (39.7%) cases. Up to 112 (74.2%) cases of morbidly adherent placenta were diagnosed at the time of delivery. Hysterectomy was preceded by unsuccessful uterus-saving procedure in 23 (15.2%) of cases. The median of estimated blood loss was 1,500 mL. A packed red blood cells transfusion was used in 138 (91.4%), fresh frozen plasma in 118 (78.2%), fibrinogen concentrate in 39 (25.8%) and tranexamic acid in 25 (16.6%) women. A total of 58 (38.4%) women required admission to an intensive care unit. The mortality rate was 1.3%. CONCLUSION In recent years, there was an increase in the incidence of morbidly adherent placenta, peripartum hysterectomy in the Slovak Republic, along with an increase in caesarean section rates, too. Case analysis highlights the need to improve the prenatal diagnosis and management of morbidly adherent placenta.
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17
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D'Antonio F, Herrera M, Oronzii L, Khalil A. Solomon technique vs selective fetoscopic laser photocoagulation for twin-twin transfusion syndrome: systematic review and meta-analysis of maternal and perinatal outcomes. Ultrasound Obstet Gynecol 2022; 60:731-738. [PMID: 36240516 DOI: 10.1002/uog.26095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To ascertain maternal and perinatal outcomes of monochorionic twin pregnancies complicated by twin-twin transfusion syndrome (TTTS) treated with the Solomon technique compared with selective fetoscopic laser photocoagulation (SFLP) of placental anastomoses. METHODS MEDLINE, EMBASE and The Cochrane Library were searched to identify relevant studies. The outcomes observed were perinatal loss and survival, preterm prelabor rupture of membranes (PPROM), preterm birth (PTB), gestational age (GA) at delivery, interval between laser treatment and delivery, maternal bleeding, septostomy or chorioamniotic separation, placental abruption, twin anemia-polycythemia sequence (TAPS), recurrence of TTTS, neonatal morbidity and neurological morbidity. Random-effects head-to-head meta-analyses were used to analyze the data. Pooled odds ratios (OR) and mean differences (MD) and their 95% CIs were calculated. RESULTS Nine studies were included in the systematic review. There was generally no difference in the main maternal and pregnancy characteristics between pregnancies treated using the Solomon technique and those treated using SFLP of placental anastomoses. The risks of fetal loss (pooled OR, 0.69 (95% CI, 0.50-0.95); P = 0.023), neonatal death (pooled OR, 0.37 (95% CI, 0.16-0.84); P = 0.018) and perinatal loss (pooled OR, 0.56 (95% CI, 0.38-0.83); P = 0.004) were significantly lower in pregnancies treated using the Solomon technique than in those treated with SFLP. Likewise, pregnancies treated using the Solomon technique had a significantly higher chance of survival of at least one twin (pooled OR, 2.31 (95% CI, 1.03-5.19); P = 0.004) and double survival (pooled OR, 2.18 (95% CI, 1.29-3.70); P = 0.001). There was no difference in the risk of PPROM (P = 0.603), PPROM within 10 days from laser surgery (P = 0.982), PTB (P = 0.207), maternal bleeding (P = 0.219), septostomy or chorioamniotic separation (P = 0.224) or chorioamnionitis (P = 0.135) between the two groups, while the risk of placental abruption was higher in pregnancies treated using the Solomon technique (pooled OR, 2.90 (95% CI, 1.55-5.44); P = 0.001). In the Solomon technique group, pregnancies delivered at a significantly earlier GA than did those treated with SFLP (pooled MD, -0.625 weeks (95% CI, -0.90 to -0.35 weeks); P < 0.001), while there was no difference in the interval between laser treatment and delivery (P = 0.589). The rate of recurrence of TTTS was significantly lower in pregnancies undergoing the Solomon technique (pooled OR, 0.43 (95% CI, 0.22-0.81); P < 0.001), while there was no difference in the risk of TAPS between the two groups (P = 0.792). Finally, there was no difference in the overall risk of neonatal morbidity (P = 0.382) or neurological morbidity (P = 0.247) between the two groups. CONCLUSIONS Monochorionic twin pregnancies complicated by TTTS undergoing laser treatment using the Solomon technique had a significantly higher survival rate and lower recurrence rate of TTTS but were associated with an increased risk of placental abruption and earlier GA at delivery compared to those treated with SFLP. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - M Herrera
- Maternal Fetal Medicine Department, Colsanitas Clinic, Colombian University Clinic - Pediatric Clinic, Bogota, Colombia
- Maternal Fetal Medicine Foundation, Fetal Health Foundation, Bogota, Colombia
| | - L Oronzii
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
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18
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Damiani GR, Xuamin H, Vimercati A, DI Gennaro D, Loizzi V, Gaetani M, Trojano G, Cicinelli E. Management of a rare case of placenta trophotropism. Minerva Obstet Gynecol 2022; 74:462-465. [PMID: 35107241 DOI: 10.23736/s2724-606x.22.05015-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
There are several variations of placental shape or implantation. Multilobed placentas are thought to arise due to implantation in areas of decreased uterine perfusion. An example is represented by lateral implantation in between the anterior and posterior walls of the uterus. Other local factors leading to multilobation are implantation over leiomyomas, in areas of previous surgery, in the cornu, or over the cervical os. After implantation, there is preferential growth in areas of superior perfusion and atrophy in areas of poor perfusion. This is called trophotropism. We described a singular case of uterine synechia, where is laid the succenturiate lobe from the anterior to the posterior wall, obstacles fetal head descent in the pelvis. Due of that synechia, a cesarean section is necessary for fetal transverse situation with reverse breech extraction.
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Affiliation(s)
- Gianluca R Damiani
- Department of Biomedical Sciences and Human Oncology, Gynecologic and Obstetrics Clinic, University of Bari Aldo Moro, Bari, Italy -
| | - He Xuamin
- Department of Biomedical Sciences and Human Oncology, Gynecologic and Obstetrics Clinic, University of Bari Aldo Moro, Bari, Italy
| | - Antonella Vimercati
- Department of Biomedical Sciences and Human Oncology, Gynecologic and Obstetrics Clinic, University of Bari Aldo Moro, Bari, Italy
| | - Daniele DI Gennaro
- Department of Biomedical Sciences and Human Oncology, Gynecologic and Obstetrics Clinic, University of Bari Aldo Moro, Bari, Italy
| | - Vera Loizzi
- Department of Biomedical Sciences and Human Oncology, Gynecologic and Obstetrics Clinic, University of Bari Aldo Moro, Bari, Italy
| | - Maria Gaetani
- Department of Biomedical Sciences and Human Oncology, Gynecologic and Obstetrics Clinic, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Trojano
- Department of Biomedical Sciences and Human Oncology, Gynecologic and Obstetrics Clinic, University of Bari Aldo Moro, Bari, Italy
| | - Ettore Cicinelli
- Department of Biomedical Sciences and Human Oncology, Gynecologic and Obstetrics Clinic, University of Bari Aldo Moro, Bari, Italy
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Alabi O, Bano S, Vasconcelos F, David AL, Deprest J, Stoyanov D. Robust fetoscopic mosaicking from deep learned flow fields. Int J Comput Assist Radiol Surg 2022; 17:1125-1134. [PMID: 35503395 PMCID: PMC9124660 DOI: 10.1007/s11548-022-02623-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 10/13/2021] [Accepted: 03/23/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Fetoscopic laser photocoagulation is a minimally invasive procedure to treat twin-to-twin transfusion syndrome during pregnancy by stopping irregular blood flow in the placenta. Building an image mosaic of the placenta and its network of vessels could assist surgeons to navigate in the challenging fetoscopic environment during the procedure. METHODOLOGY We propose a fetoscopic mosaicking approach by combining deep learning-based optical flow with robust estimation for filtering inconsistent motions that occurs due to floating particles and specularities. While the current state of the art for fetoscopic mosaicking relies on clearly visible vessels for registration, our approach overcomes this limitation by considering the motion of all consistent pixels within consecutive frames. We also overcome the challenges in applying off-the-shelf optical flow to fetoscopic mosaicking through the use of robust estimation and local refinement. RESULTS We compare our proposed method against the state-of-the-art vessel-based and optical flow-based image registration methods, and robust estimation alternatives. We also compare our proposed pipeline using different optical flow and robust estimation alternatives. CONCLUSIONS Through analysis of our results, we show that our method outperforms both the vessel-based state of the art and LK, noticeably when vessels are either poorly visible or too thin to be reliably identified. Our approach is thus able to build consistent placental vessel mosaics in challenging cases where currently available alternatives fail.
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Affiliation(s)
| | - Sophia Bano
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK.
| | - Francisco Vasconcelos
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Jan Deprest
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Department of Development and Regeneration, University Hospital KU Leuven, Leuven, Belgium
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
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Mustafa HJ, Tadbiri H, Pedersen N, Harman C, Turan OM. Proximate Cord Insertion in Twin-to-Twin Transfusion Syndrome: Case Series and PRISMA compliant Systematic Review and Meta-analysis. Fetal Diagn Ther 2022; 49:180-189. [PMID: 35378537 DOI: 10.1159/000524162] [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: 09/07/2021] [Accepted: 03/17/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We aimed to investigate the prevalence and clinical outcomes of twin-to-twin transfusion syndrome (TTTS) with proximate cord insertions. METHODS Retrospective cohort study of TTTS cases managed at single fetal center between 2012 and 2020. Presence of proximate cord insertions defined as a distance of equal or less than four centimeters between placental cord insertions that was recorded based on sonographic and fetoscopic examinations. Clinical outcomes were investigated compared to unmatched cohort and to 1:2 matched controls using pre-operative variables including: Quintero staging, selective fetal growth restriction (sFGR), anterior placenta, pre-operative cervical length (CL), and gestational age (GA) at fetal intervention. Systematic review and meta-analysis were conducted following PRSMA guidelines through searching PubMed, Scopus, CINAHL, and Medline databases from inception until January 2021. RESULTS The prevalence of proximate cord insertions in monochorionic placentas with TTTS was 2% (5/246). All five cases were managed by fetoscopic laser surgery (FLS). Procedure time was significantly longer (mean: 61.4 minutes in proximate cord vs 37.5 minutes in non-proximate cord, p<0.001), and amnioinfusion was significantly more common (100% in proximate cord vs 43% in non-proximate cord, p=0.01). Perinatal survival, and neonatal outcomes were not different between groups. Similar findings were seen following 1:2 control matching. Systematic review yielded total of 19 case reports of which different management options were applied including FLS (n=13), amniodrainage (n=3), and selective reduction (n=3). Clinical outcomes results were mixed and inconsistent. FLS was described as technically challenging and residual anastomosis were common. Overall fetal and neonatal survival following FLS was 85% and 80% respectively. CONCLUSION Presence of proximate cords in TTTS cases pose serious technical challenges even for highly experienced surgeons. Feasibility should be only determined by fetoscopic examination. .
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Affiliation(s)
- Hiba J Mustafa
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA,
| | - Hooman Tadbiri
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nicole Pedersen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
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21
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Lillegard JB, Eyerly-Webb SA, Watson DA, Bahtiyar MO, Bennett KA, Emery SP, Fisher AJ, Goldstein RB, Goodnight WH, Lim FY, McCullough LB, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Treadwell MC, Tsao K, Wagner AJ, Zaretsky MV. Placental Location in Maternal-Fetal Surgery for Myelomeningocele. Fetal Diagn Ther 2021; 49:117-124. [PMID: 34915495 DOI: 10.1159/000521379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Uterine incision based on placental location in open maternal-fetal surgery (OMFS) has never been evaluated in regards to maternal or fetal outcomes. OBJECTIVE To investigate whether an anterior placenta was associated with increased rates of intraoperative, perioperative, antepartum, obstetric, or neonatal complications in mothers and babies who underwent OMFS for myelomeningocele (fMMC) closure. METHODS Data from the international multi-center prospective registry of patients who underwent OMFS for fMMC closure (fMMC Consortium Registry, 12/15/2010-7/31/2019) was used to compare fetal and maternal outcomes between anterior and posterior placental locations. RESULTS Placental location for 623 patients was evenly distributed between anterior (51%) or posterior (49%). Intraoperative fetal bradycardia (8.3% vs 3.0%, p=0.005) and performance of fetal resuscitation (3.6% vs 1.0%, p=0.034) occurred more frequently in cases with an anterior placenta when compared to those with a posterior placenta. Obstetric outcomes including membrane separation, placental abruption, and spontaneous rupture of membranes were not different among the two groups. However, thinning of the hysterotomy site (27.7% vs 17.7%, p=0.008) occurred more frequently in cases of anterior placenta. Gestational age at delivery (p=0.583) and length of stay in the neonatal intensive care unit (p=0.655) were similar between the two groups. Fetal incision dehiscence and wound revision were not significantly different between groups. Critical clinical outcomes including fetal demise, perinatal death, and neonatal death were all infrequent occurrences and not associated with placental location. CONCLUSIONS Anterior placental location is associated with increased risk of intraoperative fetal resuscitation and increased thinning at the hysterotomy closure site. Individual institutional experiences may have varied but the aggregate data from the fMMC Consortium did not show a significant impact on the gestational age at delivery or maternal or fetal clinical outcomes.
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Affiliation(s)
- Joseph B Lillegard
- Midwest Fetal Care Center, Children's Minnesota, Minneapolis, Minnesota, USA
- Division of General Surgery Research, Mayo Clinic, Rochester, Minnesota, USA
- Pediatric Surgical Associates, Minneapolis, Minnesota, USA
| | | | - David A Watson
- Research Design and Analytics, Children's Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | | | - Ruth B Goldstein
- University of California San Francisco, San Francisco, California, USA
| | - William H Goodnight
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Foong-Yen Lim
- Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | | | | | | | - Rodrigo Ruano
- University of Texas Health Science Center, Houston, Texas, USA
| | | | | | - KuoJen Tsao
- University of Texas Health Science Center, Houston, Texas, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin Fetal Concerns Center, Milwaukee, Wisconsin, USA
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22
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Hou JH, Lee TH, Wang SY, Lai HC, Mao SP. Spontaneous uterine rupture at a non-cesarean section scar site caused by placenta percreta in the early second trimester of gestation: A case report. Taiwan J Obstet Gynecol 2021; 60:784-786. [PMID: 34247827 DOI: 10.1016/j.tjog.2021.05.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Risk factors for placenta percreta are placenta previa and prior cesarean delivery. Placenta percreta-induced ruptures at non-cesarean sites are very rare, particularly in the early second trimester. CASE REPORT A 30-year-old woman with a prior cesarean delivery was brought to our emergency department at 17 weeks' gestation for sudden-onset consciousness loss and generalized convulsions. Hypovolemic shock was identified. Computed tomography scans suggested uterine rupture and massive ascites, r/o hemoperitoneum. Emergency exploratory laparotomy revealed a ruptured hole over the left uterine fundus with protruding placental tissue; placenta percreta was impressed. An intact intrauterine sac was dissected and removed. The placenta was removed and hysterorrhaphy was completed. CONCLUSION Placenta percreta is dangerous and is rarely seen in the early second trimester. Uterine rupture should always be kept in mind in pregnant woman with acute abdomen associated with hypovolemic shock, even in those of early pregnancy without scarred uterus. Routine sonographic examination of placentation, even in early second trimester, should be emphasized.
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Affiliation(s)
- Jung-Hsiu Hou
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Tung-Heng Lee
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Sheng-Yuan Wang
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Hung-Chung Lai
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shih-Peng Mao
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
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Yu F, Li Z, Wang Y, Yue Z, Zhong Y, Zeng L. Hysteroscopic morcellation for removal of persistent placental remnants in the uterine cornu: Two case reports. Medicine (Baltimore) 2021; 100:e24097. [PMID: 33879654 PMCID: PMC8078303 DOI: 10.1097/md.0000000000024097] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/27/2020] [Accepted: 12/08/2020] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Hysteroscopic morcellation is an alternative approach for the removal of placental remnants, given its advantages of safety, efficiency and good reproductive outcomes. This superiority can be even more obvious for removing persistent placental remnants in the lateral angle of the uterine cavity after repeated dilation and curettage (D&C) of an angular pregnancy, which is rarely reported. PATIENT CONCERNS Two patients who were both initially misdiagnosed as having missed intrauterine miscarriages underwent repeated suction-assisted D&C procedures and were found to have persistent placental remnants in the lateral angles of the uterine cavity. DIAGNOSES Ultrasound and hysteroscopy evaluations showed that placental remnants in both cases were in the lateral uterine angles and protruding to the interstitial myometrium around the fallopian tube. We corrected the diagnosis to that of angular pregnancy according to a comprehensive consideration of the ultrasound, hysteroscopy and pathology results. INTERVENTIONS We performed MyoSure hysteroscopic morcellation for both patients and the placental remnants were removed completely without any complication. OUTCOMES The patients were both scheduled for a second-look hysteroscopy 1 to 3 months after surgery, which revealed normal morphology of the uterine cavities and tubal ostia. The patients both achieved normal intrauterine pregnancies several months after surgery. LESSONS Hysteroscopic morcellation is a good alternative approach for the removal of placental remnants and should be considered in cases in which there might be a high risk of incomplete evacuation or a high risk of uterine perforation, especially in cases of angular pregnancy.
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Affiliation(s)
- Fan Yu
- Department of Gynecology, Guangdong Women and Children Hospital, Guangzhou, Guangdong Province
- Department of Obstetrics and Gynecology, Linzhi People's Hospital, Linzhi, Tibet Autonomous Region, China
| | - Zhimin Li
- Department of Gynecology, Guangdong Women and Children Hospital, Guangzhou, Guangdong Province
| | - Yi Wang
- Department of Gynecology, Guangdong Women and Children Hospital, Guangzhou, Guangdong Province
| | - Zhen Yue
- Department of Gynecology, Guangdong Women and Children Hospital, Guangzhou, Guangdong Province
| | - Yuanyue Zhong
- Department of Gynecology, Guangdong Women and Children Hospital, Guangzhou, Guangdong Province
| | - Liqin Zeng
- Department of Gynecology, Guangdong Women and Children Hospital, Guangzhou, Guangdong Province
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Corroenne R, Yepez M, Barth J, Pan E, Whitehead WE, Espinoza J, Shamshirsaz AA, Nassr AA, Belfort MA, Sanz Cortes M. Chorioamniotic membrane separation following fetal myelomeningocele repair: incidence, risk factors and impact on perinatal outcome. Ultrasound Obstet Gynecol 2020; 56:684-693. [PMID: 31841246 DOI: 10.1002/uog.21947] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Prenatal myelomeningocele (MMC) repair has been shown to provide significant benefits to the infant, decreasing the postnatal need for ventriculoperitoneal shunt and improving motor outcome. Chorioamniotic membrane separation (CAS) is a potential complication following prenatal MMC repair and may increase the risk of preterm prelabor rupture of membranes (PPROM) and preterm birth. The objectives of this study were: (1) to evaluate the incidence of CAS after prenatal MMC repair; (2) to determine risk factors associated with its occurrence; and (3) to assess its association with adverse perinatal outcomes. METHODS This was a retrospective cohort study of patients who underwent fetal MMC repair between November 2011 and December 2018. Surgery was performed using either a fetoscopic (laparotomy or exteriorized uterus) approach or an open-hysterotomy approach. Eligibility criteria were those reported in the Management of Myelomeningocele Study. If CAS was detected on ultrasound (US), its severity was graded as 'mild' if amnion detachment involved < 25% of the uterine cavity, 'moderate' if it involved 25-50% and 'severe' if it involved > 50%. Evolution of CAS was classified as stable, increasing or decreasing based on the difference in severity grading between the time at first diagnosis and the last US scan before delivery. Logistic regression analysis was performed to identify pre- or perisurgical factors associated with the development of CAS and to determine the risk of adverse perinatal outcome associated with CAS. RESULTS In total, 91 cases were included. Fetoscopic or open-hysterotomy repair of MMC was performed in 52/91 (57.1%) and 39/91 (42.9%) cases, at a median gestational age (GA) of 25.0 weeks (range, 22.9-26.0 weeks) and 25.0 weeks (range, 21.3-25.9 weeks), respectively. CAS was diagnosed in 31/91 (34.1%) patients, at a median GA of 28.1 weeks (range, 24.4-37.6 weeks). Anterior placenta was identified as a risk factor for the postoperative development of CAS (odds ratio (OR), 3.72 (95% CI, 1.46-9.5); P < 0.01). This risk was dependent on the repair technique. An anterior placenta significantly increased the risk of CAS after fetoscopic repair (OR, 3.94 (95% CI, 1.14-13.6); P = 0.03) but not after open repair (OR, 2.8 (95% CI, 0.6-12.5); P = 0.16). There was no significant difference in the rate of CAS after fetoscopic repair (21/52 (40.4%)) vs open-hysterotomy repair (10/39 (25.6%)) (P = 0.14), nor were there any differences in GA at diagnosis of CAS, interval between surgery and diagnosis, distribution of CAS severity or progression of CAS between the two groups. CAS increased the risk of PPROM (50% in those with vs 12% in those without CAS) (OR, 7.6 (95% CI, 2.5-21.9); P < 0.01) and preterm delivery (70% vs 38%) (OR, 3.2 (95% CI, 1.3-8.1); P < 0.01). Fetoscopically repaired cases with CAS had a higher rate of PPROM (12/20 (60.0%) vs 2/31 (6.5%); P < 0.01) and preterm delivery (13/20 (65.0%) vs 5/31 (16.1%); P < 0.01) than those that did not develop CAS, while the differences were not significant in cases with open-hysterotomy repair. Early detection of CAS (before 30 weeks' gestation) was a risk factor for preterm delivery (90% before 30 weeks vs 36% at or after 30 weeks) (OR, 15.7 (95% CI, 2.3-106.3); P < 0.01). There was no association between PPROM or preterm delivery and the severity or progression of CAS. CONCLUSIONS The presence of an anterior placenta was the only factor that increased the risk for CAS after fetoscopic MMC repair. Detection of CAS after fetoscopic MMC repair significantly increases the risk for PPROM and preterm delivery. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Corroenne
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Yepez
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - J Barth
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - E Pan
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - W E Whitehead
- Department of Neurosurgery, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
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Ahmad MA, Ourak M, Gruijthuijsen C, Deprest J, Vercauteren T, Vander Poorten E. Deep learning-based monocular placental pose estimation: towards collaborative robotics in fetoscopy. Int J Comput Assist Radiol Surg 2020; 15:1561-1571. [PMID: 32350788 PMCID: PMC7419456 DOI: 10.1007/s11548-020-02166-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 11/22/2019] [Accepted: 04/06/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Twin-to-twin transfusion syndrome (TTTS) is a placental defect occurring in monochorionic twin pregnancies. It is associated with high risks of fetal loss and perinatal death. Fetoscopic elective laser ablation (ELA) of placental anastomoses has been established as the most effective therapy for TTTS. Current tools and techniques face limitations in case of more complex ELA cases. Visualization of the entire placental surface and vascular equator; maintaining an adequate distance and a close to perpendicular angle between laser fiber and placental surface are central for the effectiveness of laser ablation and procedural success. Robot-assisted technology could address these challenges, offer enhanced dexterity and ultimately improve the safety and effectiveness of the therapeutic procedures. METHODS This work proposes a 'minimal' robotic TTTS approach whereby rather than deploying a massive and expensive robotic system, a compact instrument is 'robotised' and endowed with 'robotic' skills so that operators can quickly and efficiently use it. The work reports on automatic placental pose estimation in fetoscopic images. This estimator forms a key building block of a proposed shared-control approach for semi-autonomous fetoscopy. A convolutional neural network (CNN) is trained to predict the relative orientation of the placental surface from a single monocular fetoscope camera image. To overcome the absence of real-life ground-truth placenta pose data, similar to other works in literature (Handa et al. in: Proceedings of the IEEE conference on computer vision and pattern recognition, 2016; Gaidon et al. in: Proceedings of the IEEE conference on computer vision and pattern recognition, 2016; Vercauteren et al. in: Proceedings of the IEEE, 2019) the network is trained with data generated in a simulated environment and an in-silico phantom model. A limited set of coarsely manually labeled samples from real interventions are added to the training dataset to improve domain adaptation. RESULTS The trained network shows promising results on unseen samples from synthetic, phantom and in vivo patient data. The performance of the network for collaborative control purposes was evaluated in a virtual reality simulator in which the virtual flexible distal tip was autonomously controlled by the neural network. CONCLUSION Improved alignment was established compared to manual operation for this setting, demonstrating the feasibility to incorporate a CNN-based estimator in a real-time shared control scheme for fetoscopic applications.
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Affiliation(s)
| | - Mouloud Ourak
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | | | - Jan Deprest
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
| | - Tom Vercauteren
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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Bano S, Vasconcelos F, Tella-Amo M, Dwyer G, Gruijthuijsen C, Vander Poorten E, Vercauteren T, Ourselin S, Deprest J, Stoyanov D. Deep learning-based fetoscopic mosaicking for field-of-view expansion. Int J Comput Assist Radiol Surg 2020; 15:1807-1816. [PMID: 32808148 PMCID: PMC7603466 DOI: 10.1007/s11548-020-02242-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/30/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Fetoscopic laser photocoagulation is a minimally invasive surgical procedure used to treat twin-to-twin transfusion syndrome (TTTS), which involves localization and ablation of abnormal vascular connections on the placenta to regulate the blood flow in both fetuses. This procedure is particularly challenging due to the limited field of view, poor visibility, occasional bleeding, and poor image quality. Fetoscopic mosaicking can help in creating an image with the expanded field of view which could facilitate the clinicians during the TTTS procedure. METHODS We propose a deep learning-based mosaicking framework for diverse fetoscopic videos captured from different settings such as simulation, phantoms, ex vivo, and in vivo environments. The proposed mosaicking framework extends an existing deep image homography model to handle video data by introducing the controlled data generation and consistent homography estimation modules. Training is performed on a small subset of fetoscopic images which are independent of the testing videos. RESULTS We perform both quantitative and qualitative evaluations on 5 diverse fetoscopic videos (2400 frames) that captured different environments. To demonstrate the robustness of the proposed framework, a comparison is performed with the existing feature-based and deep image homography methods. CONCLUSION The proposed mosaicking framework outperformed existing methods and generated meaningful mosaic, while reducing the accumulated drift, even in the presence of visual challenges such as specular highlights, reflection, texture paucity, and low video resolution.
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Affiliation(s)
- Sophia Bano
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
| | - Francisco Vasconcelos
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
| | - Marcel Tella-Amo
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
| | - George Dwyer
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
| | | | | | - Tom Vercauteren
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Sebastien Ourselin
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Jan Deprest
- Department of Development and Regeneration, University Hospital Leuven, Leuven, Belgium
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, London, UK
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Miyadahira MY, Brizot MDL, de Carvalho MHB, Biancolin SE, Machado RDCA, Krebs VLJ, Francisco RPV, Peralta CFA. Type II and III Selective Fetal Growth Restriction: Perinatal Outcomes of Expectant Management and Laser Ablation of Placental Vessels. Clinics (Sao Paulo) 2018; 73:e210. [PMID: 29723347 PMCID: PMC5902759 DOI: 10.6061/clinics/2018/e210] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/30/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To describe the perinatal outcomes of type II and III selective fetal growth restriction (sFGR) in monochorionic-diamniotic (MCDA) twin pregnancies treated with expectant management or laser ablation of placental vessels (LAPV). METHODS Retrospective analysis of cases of sFGR that received expectant management (type II, n=6; type III, n=22) or LAPV (type II, n=30; type III, n=9). The main outcomes were gestational age at delivery and survival rate. RESULTS The smaller fetus presented an absent/reversed "a" wave in the ductus venosus (arAWDV) in all LAPV cases, while none of the expectant management cases presented arAWDV. The median gestational age at delivery was within the 32nd week for expectant management (type II and III) and for type II LAPV, and the 30th week for type III LAPV. The rate of at least one twin alive at hospital discharge was 83.3% and 90.9% for expectant management type II and III, respectively, and 90% and 77.8% for LAPV type II and III, respectively. CONCLUSION LAPV in type II and III sFGR twins with arAWDV in the smaller fetus seems to yield outcomes similar to those of less severe cases that received expectant management.
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Affiliation(s)
- Mariana Yumi Miyadahira
- Departamento de Ginecologia e Obstetricia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria de Lourdes Brizot
- Departamento de Ginecologia e Obstetricia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | | | - Sckarlet Ernandes Biancolin
- Departamento de Ginecologia e Obstetricia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rita de Cássia Alam Machado
- Departamento de Ginecologia e Obstetricia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vera Lúcia Jornada Krebs
- Departamento de Pediatria, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Cleisson Fábio Andrioli Peralta
- Departamento de Ginecologia e Obstetricia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
- Gestar Medicina e Cirurgia Fetal, Sao Paulo, SP, BR
- Hospital do Coracao, Sao Paulo, SP, BR
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Lafitte AS, Verspyck E, Jeanne Pasquier C, Dolley P, Dreyfus M, Benoist G. Pseudoamniotic Band Syndrome After Fetoscopic Laser Ablation of Placental Anastomoses for Twin-Twin Transfusion Syndrome: Two Case Reports and Systematic Review. J Ultrasound Med 2017; 36:2373-2377. [PMID: 28736902 DOI: 10.1002/jum.14295] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 11/28/2016] [Revised: 03/06/2017] [Accepted: 03/11/2017] [Indexed: 06/07/2023]
Abstract
Pseudoamniotic band syndrome is a rare complication that occurs after invasive procedures for complicated monochorionic twins. We report 2 cases of intrauterine recipient fetal death after laser therapy for twin-twin transfusion syndrome due to umbilical cord constriction by the amniotic band.
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Affiliation(s)
- Anne Sophie Lafitte
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, Centre Hospitalier Universitaire de Caen, Caen, France
- Universitaire de Caen Normandie, Caen, France
| | - Eric Verspyck
- Service de Gynécologie Obstétrique, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | | | - Patricia Dolley
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Michel Dreyfus
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, Centre Hospitalier Universitaire de Caen, Caen, France
- Universitaire de Caen Normandie, Caen, France
| | - Guillaume Benoist
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, Centre Hospitalier Universitaire de Caen, Caen, France
- Universitaire de Caen Normandie, Caen, France
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Degenhardt J, Reinold M, Enzensberger C, Wolter A, Kawecki A, Kohl T, Graupner O, Willruth A, Gembruch U, Bahlmann F, Steinhard J, Axt-Fliedner R. Short-Time Impact of Laser Ablation of Placental Anastomoses on Myocardial Function in Monochorionic Twins with Twin-to-Twin Transfusion Syndrome. Ultraschall Med 2017; 38:403-410. [PMID: 26331331 DOI: 10.1055/s-0035-1553405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Purpose To evaluate pre- and post-procedure myocardial function in monochorionic twins with TTTS who underwent laser ablation of placental anastomoses using pulsed wave tissue Doppler imaging (pw TDI). Materials and Methods 20 monochorionic twin gestations with TTTS were included and underwent laser ablation at our center between 2011 and 2014. Prior to and after the intervention, cardiac function was assessed by measuring the mitral annular plane systolic excursion (MAPSE), the tricuspid annular plane systolic excursion (TAPSE), Tei index, isovolumetric contraction time (ICT), ejection time (ET), isovolumetric relaxation time (IRT) for the left ventricle in pulsed wave Doppler (pw D) ultrasound as well as ICT, ET, IRT and Tei index in pw TDI for the left and right ventricle. E-, A-, E´- and A´-wave peak velocity and the systolic downward motion (S´) were measured for both ventricles and the E/A, E/E´ and E´/A´ ratios were calculated. In a mean of 1.3 (SD 0.6) days after laser ablation, this measurement protocol was repeated. Results Pre-intervention recipients had longer ICT, ET and IRT in pw D and pw TDI compared to donors not reaching statistical significance for most parameters. Statistically significant were prolonged ICT in pw D (p 0.01) and ET (p 0.01) in pw TDI in recipients. In donor fetuses preoperative myocardial function did not differ significantly from postoperative myocardial function except in increased left ventricular ejection time of the left ventricle in pw TDI (p 0.04) and an increased E´/A´ratio (p 0.01). After laser coagulation, myocardial function was slightly altered in recipients as ICT and IRT shortened and Tei indices decreased but only reaching statistical significance in shortened IRTs in pw TDI for both ventricles. Conclusion Laser ablation of placental anastomoses in TTTS might influence myocardial function in the postoperative period. Shortened IRT intervals may reflect an improvement of diastolic function in recipients.
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Affiliation(s)
- Jan Degenhardt
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, Justus-Liebig-University and UKGM, Giessen, Germany
| | - Meike Reinold
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, Justus-Liebig-University and UKGM, Giessen, Germany
| | - Christian Enzensberger
- Department of Obstetrics and Gynecology, Philipps-University, Marburg, Division of Prenatal Medicine, Marburg, Germany
| | - Aline Wolter
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, Justus-Liebig-University and UKGM, Giessen, Germany
| | - Andrea Kawecki
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, Justus-Liebig-University and UKGM, Giessen, Germany
| | - Thomas Kohl
- German Center for Fetal Surgery & Minimally Invasive Therapy, University of Giessen, Germany
| | - Oliver Graupner
- Department of Obstetrics and Gynecology, Philipps-University, Marburg, Division of Prenatal Medicine, Marburg, Germany
| | - Arne Willruth
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Germany
| | - Franz Bahlmann
- Obstetrics and Gynecology, Bürgerhospital, Frankfurt, Germany
| | | | - Roland Axt-Fliedner
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, Justus-Liebig-University and UKGM, Giessen, Germany
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Gil Guevara E, Bower S, Nicolaides KH. Monochorionic diamniotic twin pregnancy with selective fetal growth restriction Type II: sonographic and fetoscopic findings of poor prognosis. Ultrasound Obstet Gynecol 2017; 50:272-273. [PMID: 27873366 DOI: 10.1002/uog.17369] [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: 09/08/2016] [Revised: 11/07/2016] [Accepted: 11/14/2016] [Indexed: 06/06/2023]
Affiliation(s)
- E Gil Guevara
- The Center for Fetal, Cellular and Molecular Therapy, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - S Bower
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Nakata M, Ishii K, Sumie M, Takano M, Hirata H, Murata S, Takahashi Y, Murakoshi T, Sago H. A prospective pilot study of fetoscopic laser surgery for twin-to-twin transfusion syndrome between 26 and 27 weeks of gestation. Taiwan J Obstet Gynecol 2017; 55:512-4. [PMID: 27590373 DOI: 10.1016/j.tjog.2016.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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] [Accepted: 08/24/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The aim of this study is to clarify the feasibility and efficacy of fetoscopic laser photocoagulation of placental vascular communicating vessels (FLP) on twin-twin transfusion syndrome (TTTS) after 26 weeks of gestation. MATERIALS AND METHODS This is a prospective pilot study investigating all cases of TTTS between 26 weeks and 27 weeks during 2012 and 2013 in Japan. The primary endpoints in this study were the feasibility of FLP and rate of harmful complications for the mother's health. Also, perinatal prognosis was investigated. RESULTS Six cases were enrolled and underwent FLP. Two of the six cases were classified preoperatively as Quintero Stage II and four cases were Stage III. FLP was completely achieved in all six cases. No severe maternal complications were noted during and immediately after the surgery. All but one case continued the pregnancies > 14 days after FLP. The median gestational age at delivery was 33.4 weeks (28.0-36.6 weeks). All 12 fetuses survived at the 28(th) day in the neonatal period. No case was diagnosed with cerebral lesion at the neonatal period. CONCLUSION This prospective pilot study shows that FLP could be a therapeutic option for TTTS between 26 weeks and 27 weeks of gestation.
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Affiliation(s)
- Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan; Perinatal Care Center, Tokuyama Central Hospital, Shunan, Japan.
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Masahiro Sumie
- Fetal Medicine, National Center of Child Health and Development, Tokyo, Japan
| | - Mayumi Takano
- Perinatal Care Center, Tokuyama Central Hospital, Shunan, Japan
| | - Hiroko Hirata
- Perinatal Care Center, Tokuyama Central Hospital, Shunan, Japan
| | - Susumu Murata
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan
| | | | - Takeshi Murakoshi
- Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Haruhiko Sago
- Fetal Medicine, National Center of Child Health and Development, Tokyo, Japan
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Mori M, Iwase A, Osuka S, Kondo M, Nakamura T, Nakahara T, Goto M, Kikkawa F. Choosing the optimal therapeutic strategy for placental polyps using power Doppler color scoring: Transarterial embolization followed by hysteroscopic resection or expectant management? Taiwan J Obstet Gynecol 2017; 55:534-8. [PMID: 27590378 DOI: 10.1016/j.tjog.2014.12.016] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Accepted: 12/05/2014] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate a protocol for selection of placental polyp management, including expectant management and hysteroscopic resection with or without transarterial embolization (TAE), using power Doppler color score (PDCS) as the vascularity parameter. MATERIALS AND METHODS This retrospective case-control study included 25 patients who were diagnosed with placental polyps. We evaluated the vascularity of placental polyps with PDCS measured by transvaginal ultrasonography as follows: PDCS 1, no blood flow; PDCS 2, minimal flow; PDCS 3, moderate flow; and PDCS 4, marked blood flow. We then selected expectant management or hysteroscopic resection with or without TAE. RESULTS Three of 17 patients with PDCS 1 or 2 underwent surgical intervention, and expectant management was successful in 14. Seven of eight patients with PDCS 3 or 4 underwent surgical intervention, while expectant management was successful in only one patient. CONCLUSION PDCS is a simple examination for evaluating the vascularity of placental polyps. PDCS might be useful for selecting the optimal treatment for placental polyps, such as expectant management or surgical intervention, according to their vascularity.
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Affiliation(s)
- Masahiko Mori
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akira Iwase
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Satoko Osuka
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mika Kondo
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoko Nakamura
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tatsuo Nakahara
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Maki Goto
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Oppenheimer A, Saada J, De Laveaucoupet J, Dagher I, Galimard J, Benachi A, Deffieux X. Surgical procedure for a late abdominal pregnancy with complete placenta removal. J Gynecol Obstet Hum Reprod 2017; 46:201. [PMID: 28403979 DOI: 10.1016/j.jogoh.2016.12.003] [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: 11/08/2016] [Accepted: 12/28/2016] [Indexed: 11/18/2022]
Affiliation(s)
- A Oppenheimer
- University Paris-Sud, Department of obstetrics and gynecology, 92140 Clamart, France
| | - J Saada
- University Paris-Sud, Department of obstetrics and gynecology, 92140 Clamart, France
| | - J De Laveaucoupet
- University Paris-Sud, Department of radiology, 92140 Clamart, France
| | - I Dagher
- University Paris-Sud, Department of abdominal surgery, 92140 Clamart, France
| | - J Galimard
- Neuilly Hospital, Department of obstetrics and gynecology, 92200 Neuilly-sur-Seine, France
| | - A Benachi
- University Paris-Sud, Department of obstetrics and gynecology, 92140 Clamart, France
| | - X Deffieux
- University Paris-Sud, Department of obstetrics and gynecology, 92140 Clamart, France.
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Kaya B, Guralp O, Daglar K, Tuten A, Demirol A, Yayci E, Atacag T, Dogan A. Extra-abdominal removal of placenta during cesarean section: a prospective randomized controlled trial of a novel technique. J Perinat Med 2016; 44:557-65. [PMID: 26854288 DOI: 10.1515/jpm-2015-0330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 12/22/2015] [Indexed: 11/15/2022]
Abstract
AIM To evaluate intraoperative and early postoperative outcomes of a novel placenta delivery technique; extra-abdominal removal vs. intra-abdominal removal of the placenta during cesarean section (CS). METHODS A total of 210 women delivering by CS at term in a tertiary university hospital between March 2014 and January 2015 were randomized to extra-abdominal removal vs. intra-abdominal removal of the placenta. The women were randomly allocated to the extra- (group 1) or intra-abdominal removal group (group 2) according to random sampling method, where women with even and odd numbers were allocated to intra- and extra-abdominal groups, respectively. The amount of intra-abdominal hemorrhagic fluid accumulation, the duration of operation and estimated blood loss during operation were the primary outcomes. The secondary outcomes included the mean difference between pre- and post-operative hemoglobin and hematocrit levels, the mean postoperative pain score, any additional need of analgesia, postoperative bowel function, postoperative endometritis and wound infections. RESULTS The amount of aspirated hemorrhagic fluid was significantly higher in the intra-abdominal group compared to the extra-abdominal group (34.6±22.2 mL vs. 9.4±4.8 mL, P<0.001). Mean duration of the operation, intraoperative blood loss, postoperative requirement of additional analgesia, postoperative pain scores, postoperative endometritis or wound infection, and length of hospital stay were not significantly different between the intra- and extra-abdominal placental removal groups. CONCLUSION By extra-abdominal removal of the placenta, the accumulation of bloody fluid in the abdominal cavity is significantly less compared to the intra-abdominal removal method, which, in turn, provides avoidance of excessive mounted-gauze use, intra-abdominal manipulations, or iatrogenic trauma.
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Bai Y, Luo X, Li Q, Yin N, Fu X, Zhang H, Qi H. High-intensity focused ultrasound treatment of placenta accreta after vaginal delivery: a preliminary study. Ultrasound Obstet Gynecol 2016; 47:492-498. [PMID: 25846712 DOI: 10.1002/uog.14867] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [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: 10/08/2014] [Revised: 03/23/2015] [Accepted: 03/29/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the safety and efficiency of high-intensity focused ultrasound (HIFU) in the treatment of placenta accreta after vaginal delivery. METHODS Enrolled into this study between September 2011 and September 2013 were 12 patients who had been diagnosed with placenta accreta following vaginal delivery and who had stable vital signs. All patients were treated using an ultrasound-guided HIFU treatment system. As indication of the effectiveness of the treatment we considered decreased vascular index on color Doppler imaging, decrease in size of residual placenta compared with pretreatment size on assessment by three-dimensional ultrasound with Virtual Organ Computer-aided Analysis, reduced signal intensity and degree of enhancement on magnetic resonance imaging and avoidance of hysterectomy following treatment. To assess the safety of HIFU treatment, we recorded side effects, hemorrhage, infection, sex steroid levels, return of menses and subsequent pregnancy. Patients were followed up in this preliminary study until December 2013. RESULTS The 12 patients receiving HIFU treatment had an average postpartum hospital stay of 6.8 days and an average period of residual placental involution of 36.9 days. HIFU treatment did not apparently increase the risk of infection or hemorrhage and no patient required hysterectomy. In all patients menstruation recommenced after an average of 80.2 days, and sex steroid levels during the middle luteal phase of the second menstrual cycle were normal. Two patients became pregnant again during the follow-up period. CONCLUSION This preliminary study suggests that ultrasound-guided HIFU is a safe and effective non-invasive method to treat placenta accreta patients after vaginal delivery who have stable vital signs and desire to preserve fertility. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Y Bai
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - X Luo
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Q Li
- Department of Pathology, Chongqing Medical University, Chongqing, People's Republic of China
| | - N Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - X Fu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - H Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - H Qi
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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Lo TK, Lam CHL, Cheung KW, Ng GHT, Wu AKP. Scalloping of placenta-myometrium interface on ultrasound in case with myomectomy scar. Ultrasound Obstet Gynecol 2016; 47:518-522. [PMID: 26242775 DOI: 10.1002/uog.15666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 07/11/2015] [Accepted: 07/28/2015] [Indexed: 06/04/2023]
Affiliation(s)
- T-K Lo
- Department of Obstetrics and Gynecology, Princess Margaret Hospital, 2-10 Princess Margaret Hospital Road, Lai Chi Kok, Kowloon, Hong Kong
| | - C H-L Lam
- Department of Radiology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - K-W Cheung
- Department of Obstetrics & Gynecology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - G H-T Ng
- Department of Radiology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - A K-P Wu
- Department of Radiology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
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Eschbach SJ, Boons LSTM, Wolterbeek R, Middeldorp JM, Klumper FJCM, Lopriore E, Oepkes D, Haak MC. Prediction of single fetal demise after laser therapy for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2016; 47:356-362. [PMID: 26395988 DOI: 10.1002/uog.15753] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/16/2015] [Accepted: 09/02/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Single fetal demise (SFD) occurs in up to 20% of monochorionic pregnancies treated with laser coagulation for twin-twin transfusion syndrome (TTTS). We aimed to determine the independent factors associated with SFD to improve outcome in the care of TTTS pregnancies in the future. METHODS This was a case-control study on twin pregnancies treated for TTTS between 2007 and 2013. Data on ultrasound, laser surgery and outcome were retrieved from our monochorionic twin database. We analyzed separately cases of SFD in donor and recipient twins, and compared them with treated pregnancies that resulted in two live births. RESULTS Of the 273 TTTS pregnancies treated with laser coagulation, SFD occurred in 30 donors (11.0%) and 27 recipients (9.9%). In 67% of pregnancies with SFD, the death occurred within 1 week after laser treatment. For SFD in donors, absent/reversed end-diastolic flow in the umbilical artery was the strongest predictor (odds ratio (OR), 3.0 (95% CI, 1.1-8.0); P = 0.01), followed by the presence of an arterioarterial anastomosis (OR, 4.2 (95% CI, 1.4-13.1); P = 0.03) and discordance in estimated fetal weight (OR, 1.0 (95% CI, 1.0-1.1); P = 0.04). For SFD in recipients, independent predictors were absent/reversed A-wave in the ductus venosus (OR, 3.6 (95% CI, 1.2-10.5); P = 0.02) and the absence of recipient-to-donor arteriovenous anastomoses (OR, 10.6 (95% CI, 1.8-62.0); P < 0.01). CONCLUSIONS Our findings confirm earlier reports that suggest that abnormal blood flow is associated with SFD after laser treatment for TTTS. The association of SFD with the type of anastomoses is a new finding. We speculate that the type of anastomoses present determines the degree of hemodynamic change during laser therapy. Future strategies should aim at stabilizing fetal circulation before laser therapy to decrease the vulnerability to acute preload and afterload changes. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S J Eschbach
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L S T M Boons
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - R Wolterbeek
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J C M Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Dhillon RK, Hillman SC, Pounds R, Morris RK, Kilby MD. Comparison of Solomon technique with selective laser ablation for twin-twin transfusion syndrome: a systematic review. Ultrasound Obstet Gynecol 2015; 46:526-533. [PMID: 25677883 DOI: 10.1002/uog.14813] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 09/23/2014] [Revised: 01/04/2015] [Accepted: 01/30/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To compare the Solomon and selective techniques for fetoscopic laser ablation (FLA) for the treatment of twin-twin transfusion syndrome (TTTS) in monochorionic-diamniotic twin pregnancies. METHODS This was a systematic review conducted in accordance with the PRISMA statement. Electronic searches were performed for relevant citations published from inception to September 2014. Selected studies included pregnancies undergoing FLA for TTTS that reported on recurrence of TTTS, occurrence of twin anemia-polycythemia sequence (TAPS) or survival. RESULTS From 270 possible citations, three studies were included, two cohort studies and one randomized controlled trial (RCT), which directly compared the Solomon and selective techniques for FLA. The odds ratios (OR) of recurrent TTTS when using the Solomon vs the selective technique in the two cohort studies (n = 249) were 0.30 (95% CI, 0.00-4.46) and 0.45 (95% CI, 0.07-2.20). The RCT (n = 274) demonstrated a statistically significant reduction in risk of recurrent TTTS with the Solomon technique (OR, 0.21 (95% CI, 0.04-0.98); P = 0.03). The ORs for the development of TAPS following the Solomon and the selective techniques were 0.20 (95% CI, 0.00-2.46) and 0.61 (95% CI, 0.05-5.53) in the cohort studies and 0.16 (95% CI, 0.05-0.49) in the RCT, with statistically significant differences for the RCT only (P < 0.001). Observational evidence suggested overall better survival with the Solomon technique, which was statistically significant for survival of at least one twin. The RCT did not demonstrate a significant difference in survival between the two techniques, most probably owing to the small sample size and lack of power. CONCLUSION This systematic review of observational, comparative cohort and RCT data suggests a trend towards a reduction in TAPS and recurrent TTTS and an increase in twin survival, with no increase in the occurrence of complications or adverse events, when using the Solomon compared to the selective technique for the treatment of TTTS. These findings need to be confirmed by an appropriately-powered RCT with long-term neurological follow-up.
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Affiliation(s)
- R K Dhillon
- Centre for Women's & Children's Health, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - S C Hillman
- Centre for Women's & Children's Health, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - R Pounds
- Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Dudley, UK
| | - R K Morris
- Centre for Women's & Children's Health, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Fetal Medicine Centre, Birmingham Women's NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - M D Kilby
- Centre for Women's & Children's Health, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Fetal Medicine Centre, Birmingham Women's NHS Foundation Trust, Edgbaston, Birmingham, UK
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Van den Bosch T, Van Schoubroeck D, Timmerman D. Maximum Peak Systolic Velocity and Management of Highly Vascularized Retained Products of Conception. J Ultrasound Med 2015; 34:1577-1582. [PMID: 26254150 DOI: 10.7863/ultra.15.14.10050] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [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: 10/21/2014] [Accepted: 11/29/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate blood loss and procedure-related complications during and after surgical removal of retained products of conception with high-velocity enhanced myometrial vascularity. METHODS We conducted a prospective study of 18 consecutive women with a diagnosis of retained products of conception and enhanced myometrial vascularity, with a peak systolic velocity (PSV) higher than 60 cm/s. All underwent ultrasound-guided surgical removal of the retained products under general anesthesia. Blood loss during the procedure was collected and recorded. The removed tissue was sent for histologic examination. An ultrasound examination was repeated within 24 hours. RESULTS Five patients had retained products of conception after a term delivery, 1 after a second-trimester termination of pregnancy, 7 after a spontaneous first-trimester miscarriage, and 5 after a first-trimester termination elsewhere. The PSV in the area of enhanced myometrial vascularity at diagnosis ranged from 61.0 to 152.6 cm/s (mean, 104.9 cm/s). The estimated blood loss at surgery ranged from 20 to 1000 mL (mean, 200 mL). After surgery, the PSV in the myometrium dropped dramatically (≤30 cm/s in all but 1 case). In all cases, trophoblastic tissue was confirmed at histologic examination. CONCLUSIONS Although surgical removal of retained products of conception was uneventful in most cases, heavy bleeding has to be anticipated in cases of high-velocity flow in the myometrium underlying residual trophoblastic tissue. Accordingly, in cases of high-velocity enhanced myometrial vascularity, we advocate surgical removal of the residual tissue under ultrasound guidance by an experienced surgeon and in the presence of a fully informed anesthetist.
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Affiliation(s)
- Thierry Van den Bosch
- Department Obstetrics and Gynecology, University Hospitals, Catholic University of Leuven, Leuven, Belgium (T.V.d.B., D.V S., D.T.); and Department of Obstetrics and Gynecology, Tienen Regional Hospital, Tienen, Belgium (T.V.d.B.).
| | - Dominique Van Schoubroeck
- Department Obstetrics and Gynecology, University Hospitals, Catholic University of Leuven, Leuven, Belgium (T.V.d.B., D.V S., D.T.); and Department of Obstetrics and Gynecology, Tienen Regional Hospital, Tienen, Belgium (T.V.d.B.)
| | - Dirk Timmerman
- Department Obstetrics and Gynecology, University Hospitals, Catholic University of Leuven, Leuven, Belgium (T.V.d.B., D.V S., D.T.); and Department of Obstetrics and Gynecology, Tienen Regional Hospital, Tienen, Belgium (T.V.d.B.)
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Nashar SV, Dimitrova V, Zlatkov V, Frandeva B, Dimitrov A. [PROLONGED RETAINED PLACENTA ACCRETA IN THE UTERUS AFTER VAGINAL DELIVERY (A CASE REPORT AND REVIEW OF LITERATURE)]. Akush Ginekol (Sofiia) 2015; 54:34-39. [PMID: 26137778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A case of prolonged retention in the uterus of placenta accreta after vaginal delivery is reported in the paper. The patient was 20 years old G3, P0 with two pregnancy terminations on request. She was admitted to the obstetric department of a regional hospital one day after the EDD with irregular contractions and non reassuring CTG. A few hours later intrauterine fetal demise occurred. Spontaneous labor commenced and a stillborn growth retarded fetus was delivered. Methergin was administered during the third stage of labor, but the placenta was not separated even after repeated Crede maneuvers, the last one under anesthesia. Since cervical spasm was present, the attempts for manual or instrumental separation of the placenta were unsuccessful. There was no genital bleeding, so further conservative approach was followed including continuous IV infusion of uterotonics, combined antibiotic therapy, close observation of the vital signs and the laboratory indicators. Three days after delivery the patient was transferred to a University Hospital because of subfebrile temperature. Her general condition on admission, although subfebrile, was good, there was no genital bleeding, the cervix was closed. The subfebrile temperatrure persisted despite antibiotic treatment; CRP was elevated (51,9 mg/l.). Because of suspicion for endomyometritis, on day 8th after delivery instrumental extraction of the placenta was undertaken with preparedness for hysterectomy in case of need. Although the procedure was difficult, with the placenta being extracted in parts, bleeding was scarce. The post operative period was uneventful and the patient was discharged from hospital five days after the intervention. A review of literature on the obstetric management of cases with retained placenta accreta after vaginal delivery is presented. The existing therapeutic options are discussed including their advantages and complications.
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Dimitrov A, Garnizov T, Frundeva B, Masseva A, Zlatkov V. [MANAGEMENT OF PLACENTA ACCRETA, DIAGNOSED BEFORE BIRTH]. Akush Ginekol (Sofiia) 2015; 54:13-21. [PMID: 27032229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The optimal management of placenta accreta and until now remains unclear. The reasons for this are a rarity of this condition and the considerable heterogeneity of the group under the term "placenta accreta." Total hysterectomy during caesarean section is the most common approach to a known placenta accreta. Planned or emergency perinatal hysterectomy is associated with several complications--damage to the urinary tract, relaparotomiya, massive blood transfusions and stay in ICU. The average blood loss is about 3000 ml. To reduce blood loss in perinatal hysterectomy contribute: preliminary uterine artery occlusion, istmus-coporal longitudinal hysterectomy for extraction of the fetus, placental extraction along with the uterus. To save the woman's uterus at placenta accreta are using the following methods: cutting the uterine wall on which is located the placenta, imposing single stitches covering 2-3 cm in 1 cm, around the placental area; removal of the maximum possible part of the placenta; using longitudinal hysterectomy. So far, there are no comparative studies of the efficacy of different surgical techniques to preserve the uterus cases of placenta accreta. Extraction of the placenta to be done after the administration of uterotonics and devascularization the uterus. To reduce bleeding from the uterus after removal of parts of the placenta and according to the situation can be used: x-back hemostatic sutures from internal side of the uterus, tamponade with gauze roll, balloon catheters or haemostatic mushrooms. Conservative surgical treatment of placenta accreta is not always possible. In hospital Maternity Hospital-Sofia for the period 1986-2000 there were 17 cases of placenta accreta diagnosed only at birth. Maintaining the uterus was successful in 35% of these cases.
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42
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Luo A, Mao P. Late postpartum hemorrhage due to placental and fetal membrane residuals: experience of two cases. CLIN EXP OBSTET GYN 2015; 42:104-105. [PMID: 25864293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To investigate the cause and preventative measures of late postpartum hemorrhage resulted from placental and fetal membrane residuals. MATERIALS AND METHODS Retrospective analysis on 161 cases of late postpartum hemorrhage resulting from residuals of placenta and fetal membrane from 2002 to 2012. RESULTS Among the 161 cases, there were 148 cases of vaginal delivery and 13 cases of cesarean section delivery. One hundred twenty-one cases (4.77%) of placental and fetal membrane residuals were present in 2,535 cases of pregnant women with history of abortion; 40 cases (2.01%) of placental and fetal membrane residuals were found in 1,989 cases of pregnant women without history of abortion. CONCLUSION Placental and fetal membrane residuals are the major cause of late postpartum hemorrhage. Repeated abortion will increase the incidence of late postpartum hemorrhage resulting from placental and fetal membrane residuals.
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Ruano R, Rodo C, Peiro JL, Shamshirsaz AA, Haeri S, Nomura ML, Salustiano EMA, de Andrade KK, Sangi-Haghpeykar H, Carreras E, Belfort MA. Fetoscopic laser ablation of placental anastomoses in twin-twin transfusion syndrome using 'Solomon technique'. Ultrasound Obstet Gynecol 2013; 42:434-439. [PMID: 23616360 DOI: 10.1002/uog.12492] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 04/12/2013] [Accepted: 04/17/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To document perinatal outcomes following use of the 'Solomon technique' in the selective photocoagulation of placental anastomoses for severe twin-twin transfusion syndrome (TTTS). METHODS Between January 2010 and July 2012, data were collected from 102 consecutive monochorionic twin pregnancies complicated by severe TTTS that underwent fetoscopic laser ablation at four different centers. We compared outcomes between subjects that underwent selective laser coagulation using the Solomon technique (cases) and those that underwent selective laser coagulation without this procedure (controls). RESULTS Of the 102 pregnancies examined, 26 (25.5%) underwent the Solomon technique and 76 (74.5%) did not. Of the 204 fetuses, 139 (68.1%) survived up to 30 days of age. At least one twin survived in 82 (80.4%) pregnancies and both twins survived in 57 (55.9%) pregnancies. When compared with the control group, the Solomon-technique group had a significantly higher survival rate for both twins (84.6 vs 46.1%; P < 0.01) and a higher overall neonatal survival rate (45/52 (86.5%) vs 94/152 (61.8%); P < 0.01). Use of the Solomon technique remained independently associated with dual twin survival (adjusted odds ratio (aOR), 11.35 (95% CI, 3.11-53.14); P = 0.0007) and overall neonatal survival rate (aOR, 4.65 (95% CI, 1.59-13.62); P = 0.005) on multivariable analysis. There were no cases of recurrent TTTS or twin anemia-polycythemia sequence (TAPS) in the Solomon-technique group. CONCLUSIONS Use of the Solomon technique following selective laser coagulation of placental anastomoses appears to improve twin survival and may reduce the risk of recurrent TTTS and TAPS. Our data support the idea of performing a randomized controlled trial to evaluate the effectiveness of the Solomon technique.
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Affiliation(s)
- R Ruano
- Baylor College of Medicine and Texas Children's Hospital, Department of Obstetics and Gynecology, Division of Maternal-Fetal Medicine, Houston, TX, USA; Faculdade de Medicina da Universidade de Sao Paulo, Department of Obstetrics and Gynecology, Sao Paulo, SP, Brazil
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Van Mieghem T, Martin AM, Weber R, Barrea C, Windrim R, Hornberger LK, Jaeggi E, Ryan G. Fetal cardiac function in recipient twins undergoing fetoscopic laser ablation of placental anastomoses for Stage IV twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2013; 42:64-69. [PMID: 23495173 DOI: 10.1002/uog.12454] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/27/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE Cardiac dysfunction is common in the recipient fetus of twin-twin transfusion syndrome (TTTS). In this study, we aimed to document the severity of fetal cardiac dysfunction in Stage IV TTTS (fetal hydrops) and assess evolution of cardiac function longitudinally after fetoscopic laser surgery. METHODS We reviewed obstetric ultrasound examination data, pre- and postoperative echocardiograms and neonatal outcomes for 22 cases of Stage IV TTTS undergoing fetoscopic laser ablation of placental anastomoses between 1998 and 2011. Myocardial performance index, atrioventricular valve flow patterns, ventricular shortening fraction, ventricular hypertrophy, outflow tract obstruction and venous Doppler waveforms were assessed. RESULTS Nineteen fetuses (86.4%) had ascites, eight (36.4%) had pleural effusions, nine (40.9%) had a pericardial effusion and 12 (54.5%) had subcutaneous edema at presentation. Preoperatively, cardiac function was grossly abnormal in all. Eight fetuses (36.4%) had functional pulmonary atresia and one (4.5%) had functional aortic atresia. Seventy-seven percent of recipient fetuses survived until birth. Postoperative echocardiographic follow-up (mean, 26 days) showed that indices of fetal cardiac function improved considerably, but never completely normalized. Six of the eight fetuses with functional pulmonary atresia (75.0%), as well as the fetus with functional aortic atresia, survived to birth. In all cases, the functional atresia resolved within 48 h of laser ablation therapy and none had structural valve anomalies at birth. All fetal effusions resolved after the laser. CONCLUSIONS Fetoscopic laser ablation of placental anastomoses reverses cardiac dysfunction and valvulopathy, even in the most severe cases of TTTS. However, recovery takes longer than in early stage disease.
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Affiliation(s)
- T Van Mieghem
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Tsankova M, Marinov B, Bozhilov D, Pirnareva E. [Placenta accreta--prenatal diagnosis, treatment]. Akush Ginekol (Sofiia) 2013; 52:48-53. [PMID: 23807980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Placenta accreta is a potentially life threatening obstetric condition that requires a multidisciplinary management. Placenta praevia and previous Cesarean section are the two most important known risk factors for placenta accreta. This study presents two patients having both of the foremention risk factors diagnosed ultrasonographically with placenta accreta in the second trimester. Ultrasound findings considered suggestive of placenta accreta are: presence of placental lacunae (vascular spaces), loss of the hyperehoic uterine serosa-bladder wall interface, loss of the retroplacental hypoechoic clear space, hypervascularity of the interface between the uterine wall and the bladder wall/isthmico-cervical zone, presence of placenta praevia, either anterior or posterior, overlying the uterine scar. Both of the cases with suspected placenta accreta ended successfully by planned preterm Cesarean hysterectomy with the placenta left in situ. Placenta accreta is a significant cause of maternal morbidity and mortality and the most common reason for urgent postpartum hysterectomy.
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Roberts VHJ, Räsänen JP, Novy MJ, Frias A, Louey S, Morgan TK, Thornburg KL, Spindel ER, Grigsby PL. Restriction of placental vasculature in a non-human primate: a unique model to study placental plasticity. Placenta 2011; 33:73-6. [PMID: 22030304 DOI: 10.1016/j.placenta.2011.10.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 09/30/2011] [Accepted: 10/04/2011] [Indexed: 11/18/2022]
Abstract
The limits of placental plasticity, i.e., the ability of the placenta to adapt and alter its growth trajectory in response to altered fetal requirements, are not known. We report fetal and placental hemodynamic adaptations in a novel non-human primate model in which the fetal inter-placental bridging vessels were surgically ligated. Doppler ultrasound studies showed that the rhesus placenta compensates for an approximate 40% reduction in functional capacity by increased growth and maintenance of umbilical volume blood flow. This unique experimental animal model has applications for mechanistic studies of placental plasticity and the impact on fetal development.
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Affiliation(s)
- V H J Roberts
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center (ONPRC), Oregon Health & Science University, 505 NW 185th Ave, Beaverton, OR 97006, USA.
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Zlotnik A, Gruenbaum SE, Gruenbaum BF, Koifman A, Rusabrov E. Awake fiberoptic intubation and general anesthesia in a parturient with mirror syndrome and a predicted difficult airway. Isr Med Assoc J 2011; 13:640-642. [PMID: 22097238] [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] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Alexander Zlotnik
- Departments of Anesthesiology and Critical Care, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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Abstract
BACKGROUND Cord drainage in the third stage of labour involves unclamping the previously clamped and divided umbilical cord and allowing the blood from the placenta to drain freely into an appropriate receptacle. OBJECTIVES The objective of this review was to assess the specific effects of placental cord drainage on the third stage of labour following vaginal birth, with or without prophylactic use of uterotonics in the management of the third stage of labour. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2010). SELECTION CRITERIA Randomised controlled trials comparing placental cord draining with no placental cord drainage as part of the management of the third stage of labour. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the quality of trials and extracted data. This was then verified by the third review author who then entered the agreed outcomes to the review. MAIN RESULTS Three studies involving 1257 women met our inclusion criteria. Cord drainage reduced the length of the third stage of labour (mean difference (MD) -2.85 minutes, 95% confidence interval (CI) -4.04 to -1.66; three trials, 1257 women (heterogeneity: T² = 0.87; Chi²P=17.19, I² = 88%)) and reduced the average amount of blood loss (MD -77.00 ml, 95% CI -113.73 to -40.27; one trial, 200 women).No incidence of retained placenta at 30 minutes after birth was observed in the included studies, therefore, it was not possible to compare this outcome. The differences between the cord drainage and the control group were not statistically significant for postpartum haemorrhage or manual removal of the placenta. None of the included studies reported fetomaternal transfusion outcomes and there were no data relating to maternal pain or discomfort during the third stage of labour. AUTHORS' CONCLUSIONS There was a small reduction in the length of the third stage of labour and also in the amount of blood loss when cord drainage was applied compared with no cord drainage. The clinical importance of such observed statistically significant reductions, is open to debate. There is no clear difference in the need for manual removal of placenta, blood transfusion or the risk of postpartum haemorrhage. Due to small trials with medium risk of bias, the results should be interpreted with caution.
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Affiliation(s)
- Hora Soltani
- Sheffield Hallam UniversityFaculty of Health and Wellbeing32 Collegiate CrescentSheffieldUKS10 2BP
| | - Thomas A Poulose
- Sheffield Teaching Hospital NHS TrustDepartment of Obstetrics and Gynaecology10 Beech Hill RoadSheffieldYorkshireUKS10 2SB
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Hernández-Andrade E, Guzmán-Huerta M, Benavides-Serralde JA, Páez-Serralde F, Camargo-Marín L, Acevedo-Gallegos S, Moreno-Alvarez O, Mancilla-Ramírez J. [Laser ablation of the placental vascular anastomoses for the treatment of twin-to-twin transfusion syndrome]. Rev Invest Clin 2011; 63:46-52. [PMID: 21585010] [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: 05/30/2023]
Abstract
AIM To report the experience of the intrauterine treatment of monochorionic biamnotic (MC/BA) twin pregnancies complicated with twin-to-twin transfusion syndrome (TTTS) applying laser ablation of the placental vascular anastomoses (LAPVA). MATERIAL AND METHODS During 18 months period 35 MC/BA twin pregnancies were treated. TTTS was diagnosed based on the discrepancies in amniotic fluid and bladder size between both twins. Severity of TTTS was classified according to the hemodynamic changes in both twins. LAPVA was performed between 16-26 weeks of gestation using a rigid straight fetoscope and a YAG (neodymium: yttrium aluminium garnet) laser equipment. Survival was considered when the neonate was home discharged. RESULTS Overall survival was 62.8% (44/70 fetuses). In 77% of pregnancies (27/35) at least one twin survived, and in 48.5% (17/35) of cases both twins survived. Bleed was the most frequent complication (12/35; 34%). In 5 cases there was severe bleeding leading to late premature rupture of membranes and death of both twins. Median time stay in the neonatal intensive care unit was 20 days (range, 7-120). There were no signs of brain damage at the time of discharge. CONCLUSION These results are similar to those already published. Bleeding was the most frequent complication, however as the experience improved it was less frequent. Overall success is highly associated with a good neonatal care support.
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Affiliation(s)
- Edgar Hernández-Andrade
- Subdirección de Investigación Clínica, Institute Nacional de Perinatología Isidro Espinosa de los Reyes, México, DF.
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Baschat AA, Gungor S, Glosemeyer P, Huber A, Hecher K. Changes in umbilical venous volume flow after fetoscopic laser occlusion of placental vascular anastomoses in twin-to-twin transfusion syndrome. Am J Obstet Gynecol 2010; 203:479.e1-6. [PMID: 20864074 DOI: 10.1016/j.ajog.2009.11.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2009] [Revised: 08/26/2009] [Accepted: 11/05/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To examine effects of fetoscopic laser occlusion of placental vascular anastomoses on umbilical venous volume flow in twin-to-twin transfusion syndrome. STUDY DESIGN Absolute umbilical venous volume flow, measured preoperatively and 48 hours after fetoscopic laser occlusion was related to Doppler studies, bladder filling in donors, and anastomoses. RESULTS Among 45 patients, recipients had decreased ductus venosus pulsatility index (ductus venosus-pulsatility index for veins, 1.16 vs 1.01; P < .001) and unchanged umbilical venous volume flow after fetoscopic laser occlusion (74.7 vs 74.5 mL; P = .407). Donors had decreased umbilical artery pulsatility (1.34 vs 1.11; P = .008), increased ductus venous-pulsatility index for veins (0.75 vs 0.91; P < .014), and significantly increased umbilical venous volume flow per kilogram by 52.3% (136.6 vs 208.0 mL/Kg/min; P < .001). Donor bladder filling occurred at higher umbilical venous volume flow per kilogram (142.7 vs 221.4 mL/Kg/min; P < .012). Increase in umbilical venous volume flow per kilogram correlated with the net difference in arteriovenous anastomoses (Pearson r = 0.403, P = .006). CONCLUSION Fetoscopic laser occlusion in twin-to-twin transfusion syndrome corrects intertwin differences in umbilical venous volume flow by predominant effects in the donor. Reappearance of donor bladder filling correlates with correction of volume flow.
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Affiliation(s)
- Ahmet Alexander Baschat
- Center for Advanced Fetal Care, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland, Baltimore, MD, USA
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