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PubMed1987

[Results of fetoscopic examinations at our hospital].

From 1983 to 1985, antenatal diagnosis by fetoscopy under ultrasound guidance has been performed at our institute for 17 pregnant women between 15 and 34 weeks of gestation. Indications for fetoscopy were visualization of the fetus, placenta, and amniotic membrane for morphological anomaly and fetal blood sampling for coagulation disorder. The diagnosis, made by visual observation of the fetus, blood coagulation tests, and karyotyping revealed 12 normal fetuses and 5 abnormal fetuses (one having chromosome abnormality, one amniotic band syndrome, one cephalothracopagus, one Beckwith-Wiedemann syndrome, and one sacral tumor). Courses of pregnancy following fetoscopy resulted in four normal full-term deliveries, six premature deliveries due to four hydramnions and two spontaneous ruptures of the membrane more than 14 weeks after fetoscopy. Three other pregnancies were interrupted due to intrauterine fetal death 11 weeks after fetoscopy in one case and to therapeutic abortion for maternal complications such as toxemia of pregnancy in two cases. The outcome of one case was unknown because the mother had moved away. The other pregnancy is still under observation at the third trimester. Although no complications in the fetuses were seen following fetoscopy, complications in the mothers included two cases of genital bleeding, one case of amniotic fluid leakage, and one cases of abruption of the fetal membrane. Symptoms in all four cases disappeared during several days of bed rest. These results demonstrate the importance of fetoscopy in prenatal diagnosis.

Amniotic Band Syndrome↗
PubMed1999

Closure techniques for fetoscopic access sites in the rabbit at mid-gestation.

Operative fetoscopy may be limited by its relatively high associated risk of preterm prelabour rupture of membranes. The objective of this study was to study closure techniques of the access site for fetoscopy in the mid-gestational rabbit. A total of 32 does (288 amniotic sacs) at 22 days gestational age (GA; term = 32 days) underwent 14 gauge needle fetoscopy, by puncture through surgically exposed amnion. Entry site was randomly allocated to four closure technique groups: myometrial suture (n = 14), fibrin sealant (n = 15), autologous maternal blood plug (n = 13), collagen plug (n = 14); 16 sacs were left unclosed (positive controls), and the unmanipulated 216 sacs were negative controls. Membrane integrity, presence of amniotic fluid and fetal lung to body weight ratio (FLBWR) were evaluated at 31 days GA. Following fetoscopy without an attempt to close the membranes, amniotic integrity was restored in 41% of cases (amniotic integrity in controls 94%; P = 0.00001). When the access site was surgically closed, the amnion resealed in 20-44% of cases, but none of the tested techniques was significantly better than the others or than positive controls. Permanent amniotic disruption was associated with a significantly lower FLBWR in all groups. In conclusion, the rate of fetoscopy-induced permanent membrane defects in this model did not improve by using any of the closure techniques tested here.

Animals↗
PubMed1985

Prenatal diagnosis of classic hemophilia (hemophilia A) by immunoradiometric assays.

During the period from 1978 to 1983, 92 pregnancies have been evaluated by fetoscopy for the prenatal diagnosis of hemophilia A. Satisfactory fetal plasma samples were obtained in 80 instances and the diagnosis--or exclusion--of hemophilia was made by immunoradiometric assay of the factor VIII coagulant protein (VIII:CAg). The accuracy of the diagnosis established by fetoscopy has been verified after delivery or termination, and there have been no misdiagnoses resulting from laboratory error. Additional evidence for the accuracy of the analysis was the observation that the frequency of hemophilia in pregnancies of obligate carriers of the hemophilia gene, and of women whose plasma assays were indicative of the carrier state, was 29 of 59 fetuses at risk. In one case of cross-reacting material-positive hemophilia, samples obtained at fetoscopy and from the newborn infant had normal VIII:CAg levels but the infant had decreased factor VIII procoagulant activity. There were five fetal deaths resulting from fetoscopy in 55 pregnancies not intentionally terminated. Although only a small percentage of pregnant hemophilia carriers in the United States have elected to undergo fetoscopy for prenatal diagnosis, this procedure has allowed a number of pregnancies to go to term with delivery of normal males in families that were not willing to accept the risk of a hemophilic child. In eight instances, fetoscopic evaluation was sought for two successive pregnancies.

Antigens↗
PubMed1999

Obstetrical endoscopy.

Fetoscopy has been reintroduced in fetal diagnosis and therapy, as a result of instrumental innovations. It has been suggested that fetoscopy be used to guide endoscopic operations on the fetus, but this application is still in the experimental phase. Its use for surgical interventions on the placenta, umbilical cord, and to a lesser extent the fetal membranes, could be called 'obstetrical' endoscopy. Nd:YAG laser coagulation of chorionic plate vessels for feto-fetal transfusion syndrome is the most common operation carried out today. Survival rates of 60% or more have recently been reported on both sides of the Atlantic Ocean. Neurological morbidity does not exceed 6%, which compares favorably with serial amnioreductions and may become the most important incentive for performing the operation. A randomized trial comparing both therapies as a next step is being proposed. Fetoscopy has also been used for cord ligation, but because of the complexity of the operation and the high risk for preterm prelabor rupture of the membranes, other alternatives have been investigated. Most experience has been gathered with bipolar cord occlusion, a procedure which can be performed under ultrasound guidance. The instrumental considerations and potential complications of fetoscopy are discussed.

Female↗
PubMedDate not supplied

Effects on the maternofetal unit of the rabbit model after substitution of the amniotic fluid with perfluorocarbons.

OBJECTIVES: Exchanging amniotic fluid (AF) with perfluorocarbon (PFC) may serve as a medium for fetoscopic surgery. This study evaluates the distribution and physiologic effects of intraamniotic PFC as a medium for fetoscopy. METHODS: Fetuses of 17 pregnant rabbits underwent either exchange of the AF with PFC, electrolyte solution (ES), or control. The quality of vision during fetoscopy was assessed in AF and PFC. After 6 h, we determined the distribution of PFC in the maternofetal unit. RESULTS: Quality of vision during fetoscopy was better in PFC than with AF. There was no difference in fetal survival between the study groups. PFC was demonstrated on X-ray in the pharynx of 4 fetuses, and the esophagus in 1. CONCLUSIONS: PFC provided an ideal medium for fetoscopy without fetal compromise.

Amniotic Fluid↗
PubMed1989

Fetal tissue sampling. The San Francisco experience with 190 pregnancies.

Prenatal diagnosis of genetic defects was done using fetal blood sampling in 167 at-risk pregnancies, by fetal skin biopsy in 15 pregnancies, and by fetal liver biopsy in 8 pregnancies. Fetal blood sampling was done by fetoscopy through January 1985 and by sonographically directed percutaneous umbilical blood sampling since then. In our series, cytogenetics has become the major indication for fetal blood sampling, increasing from 6% of the cases with fetoscopy to 48% with umbilical blood sampling. Fetoscopy provided pure fetal blood in 61% of cases while umbilical blood sampling provided pure fetal blood 97% of the time. The corrected risk of fetal demise after percutaneous umbilical fetal blood sampling was 2% and after fetoscopy was 4%.

Biopsy↗
PubMed1982

[Development of a fetoscope and its clinical application].

One of the major goals in modern obstetrics is to provide more detailed informations of prenatal fetal physiology. Since 1972, more than 200 amniocentesis were performed in our hospital and the importance of prenatal genetic diagnosis has been recognized. But amniocentesis has the limitations which are 1) the lack of expression of many single gene hereditary disorders in amniotic fluid and its cells, 2) the large percentage (90%) of nonviable fetal cells in any given sample, 3) the length of time required to culture fetal cells. Accordingly the necessity of development of other methods to obtain further direct data on the fetus from the uterine cavity has been indicated. Among gynecological endoscopies, fetoscopy which is direct visualization of the fetus by introduction of an endoscope into the amniotic cavity is expected to obtain direct information from the uterine environment in pregnant women. By our newly developed fetoscope, we investigated clinical indications and contraindications of fetoscopy as well as future possibilities of this endoscope. Our present study indicates that further developments and future benefits of fetoscopy entirely depend on the progress of laboratory techniques which can provide more accurate data through specimens obtained fetoscopy.

Adult↗
PubMedDate not supplied

Changes in maternal serum alpha-fetoprotein levels associated with intrauterine genetic diagnostic procedures.

The amount of fetal-maternal transfusion during invasive intrauterine diagnostic instrumentation was determined by measuring the increase in maternal serum alpha-fetoprotein (delta AFP) caused by the procedure. Fetal liver biopsy or fetoscopy for purposes other than blood sampling caused a mean delta AFP of 11.4 ng/ml and 34.2 ng/ml, respectively. Fetoscopy with fetal blood sampling produced a mean delta AFP of 211.8 ng/ml, while fetoscopy followed by placentesis caused a mean delta AFP of 462.8 ng/ml (representing a 1.07 ml fetal-maternal transfusion). Although this magnitude of fetal-maternal transfusion is an acceptable risk for the fetus, it is a sufficient transfusion to cause blood cell antigen sensitization.

Biopsy, Needle↗
PubMed2003

Increased polymorphonuclear infiltration and iatrogenic amniotic band after closure of fetoscopic access sites with a bioactive membrane in the rabbit at midgestation.

OBJECTIVE: This study was undertaken to evaluate the efficacy and safety of closing the fetoscopy access site in a midgestational rabbit model by using a commercially available bioactive membrane. STUDY DESIGN: Fetoscopy was performed in a total of 100 gestational sacs in 20 does at midgestation (23 days, term = 31 days). In 50 cases (group 1), the fetoscopic access port was closed with a 5-mm patch of biocompatible matrix derived from porcine small intestine containing growth factors (transforming growth factor-beta and fibroblast growth factor-beta). Fifty sacs served as positive controls (group 2) and 55 unoperated fetuses were used as negative controls (group 3). At 30 days of gestation, a second-look laparotomy was performed. Outcome parameters were fetal weight, fetal lung weight, fetal lung-to-body weight ratio, and microscopy of the plugging site. RESULTS: Membrane integrity after fetoscopy was restored in 28 of the 40 (70%) of cases in group 1 versus 13 of the 32 (41%) in group 2 (P =.012). Birth weights were comparable (group 1: 30.65 +/- 5.68 g; group 2: 29.70 +/- 5.05 g; group 3: 29.52 +/- 6.25 g; NS), but fetal lung weight (group 1: 0.964 +/- 0.20 g; group 2: 0.798 +/- 0.17 g; P <.01) and fetal lung-to-body weight ratio (group 1: 0.032 +/- 0.0067; group 2: 0.027 +/- 0.0082; P <.05) were significantly higher in the study group. In group 1, cellular proliferation was significantly increased. Polymorphonuclear infiltration was observed in 19 of the 40 (48%) cases in group 1 versus 5 of the 32 (16%) cases in group 2 (P <.05). In one treated sac, a fibrous band joining the two fetal legs without constriction was present. CONCLUSION: The use of a bioactive membrane improved fetal membrane repair rates and decreased incidence of pulmonary hypoplasia in the rabbit but increased polymorphonuclear infiltration. In one amniotic sac, a situation comparable to amniotic band syndrome was documented.

Amniotic Band Syndrome↗
PubMed1999

Feasibility of minimally invasive intrauterine fetal access in a monkey model.

PURPOSE: We evaluated new intervention techniques and surgical instruments in a fetal monkey model to determine improvements that would be useful for early intrauterine intervention. Our findings may be helpful in the future for treating select cases of severe prenatal obstructive uropathology. MATERIALS AND METHODS: In a series of experiments on 18 pregnant rhesus monkeys (Macaca mulatta) at mid trimester we assessed various endoscopic intra-amniotic access techniques as well as morbidity, mortality and possibilities for fetoscopy. RESULTS: In all 18 fetuses adequate fetoscopy was possible with no maternal mortality. Of the 18 pregnancies 14 went to term with no early or late postoperative complications. Technical improvements changed the intrauterine access technique from open placement of trocars to the use of the Seldinger technique, gun introduction of needles with small caliber sheets and small caliber introduction trocars, resulting in minimal amniotic membrane separation. Various rigid and flexible endoscopes were evaluated for fetoscopy and up to 3 cannulas were placed. No change in the fetal growth pattern was observed on postoperative ultrasound. Subsequent pregnancies occurred during this study period, and there were no acceptance problems of the newborns by the mothers. CONCLUSIONS: New techniques have led to improved intrauterine fetal access. Morbidity mainly depends on the disruption of amniotic membranes, which has an important preterm role. Adapted endoscopes and other instruments offer new possibilities for fetal diagnosis and therapy in the future. Our primate model seems to be suitable for evaluating these new techniques before they are used in a clinical setting.

Animals↗
PubMed1983

[Report on 8 years' experience in prenatal diagnosis of genetic defects. I. Indications and methods].

Prenatal diagnostic procedures were done following 1231 transabdominal amniocenteses in 1113 patients of a gestational age of 17.4 +/- 0.5 weeks. Partly parallel the following methods were used: 1218 estimations of alpha-fetoprotein, 903 chromosomal analyses, 89 amniofetographies, 40 fetoscopies and 7 estaminations of hormones, immunoglobulins and enzymes. Amniotic fluid could be obtained in 91.8 per cent with the first insertion of the needle, using the free-hand-needle-technique. In 8 per cent amniotic fluid samples were bloody. The amniocentesis had to be repeated in 7.6 per cent because of no growth of cells (6.3 per cent), or no amniotic fluid could be obtained (1.3 percent). In the average 14.9 +/- 8.1 metaphases were analysed and 2.9 +/- 1.1 karyogram were made. The organisation of prenatal diagnostics was explained. The indication was in 39.6 per cent the age, in 20.3 per cent the repeated risk of the birth of a fetus with trisomy 21. In 13.7 per cent there was an indication to estimate alpha-fetoprotein which was done nearly without exception for exclusion of neural tube defects. The prenatal determination of the fetal sex was necessary in 7.3 per cent in cases of X-chromosomal inheritable diseases. Previous deliveries of infants with malformation-syndrome or chromosomal trisomies like Edwards-or Patau-syndrome and radiation or chemotherapy of one of the parents were summarized under other indications (7.3 per cent). Balanced parental translocations were the indication in 1.7 per cent. Amniofetography was used in 8 per cent of the patients to exclude malformations caused by prevalent multiple factors. It was in 35 per cent the prevailing diagnostic method. The set of problems of its use was discussed. Fetoscopy (3.6 per cent) partly was an additional diagnostic procedure partly a leading method. By means of a catalogue of indications it was referred to the use of fetoscopy to visualization in prenatal diagnostics. The exclusion of genetic metabolic defects was the motive to prenatal biochemic investigations in 0.5 per cent. The prerequisites of devices and technique to prenatal diagnostics were discussed.

Abnormalities, Multiple↗