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PubMed1975

The "fetoscope"--a new clinical tool for prenatal genetic diagnosis.

Our experience in 65 patients using a "fetoscope" and local anesthesia prior to saline abortion is described. Visualization of the intrauterine contents improved with experience, was optimum at 16 to 18 weeks' gestation, and was superior to the quality of photographic records. Four fetal skin biopsies and 6 amnion biopsies were done. Six blood samples were taken from the fetal surface of the placenta. The limitations of this instrument are described. No significant complications have occurred. Current and probable future indications for fetoscopy are reviewed. Until both the safety of the procedure is proved and problems of visualization due to limitation of visual field are solved, extreme caution is urged in the employment of this instrument in genetic high-risk pregnancy.

Abortion, Therapeutic↗
PubMed1984

The management of severe rhesus isoimmunization by fetoscopic intravascular transfusions.

Twenty-five severely rhesus-isoimmunized fetuses, including 15 with hydrops fetalis, underwent a total of 77 intrauterine transfusions between 19 and 32 weeks' gestation. Fifty-eight of the procedures were fetoscopically directed intravascular transfusions, nine were ultrasound-guided intraperitoneal transfusions, and 10 were a combination of intravascular transfusion, fetal paracentesis, and intraperitoneal transfusion. The average number of antenatal procedures per patient was three (range, one to five). The survival rate for the 19 fetuses that received their initial intrauterine transfusion at or before 25 weeks' gestation was 84%; 11 of the 13 hydropic fetuses and five of the six fetuses without antenatal evidence of hydrops survived. In six cases hydrops fetalis was reversed in utero. The outcome in patients referred after 25 weeks' gestation was poor; neither of the two hydropic fetuses and only two of the four nonhydropic ones survived, which suggests the importance of early referral to a team experienced in the management of this problem. However, most of these fetal losses occurred early in the series. Seven of the 20 neonates were hydropic, and nine had severe thrombocytopenia (platelet count, less than 50,000 X 10(6)/L). The mean cord blood hematocrit and bilirubin of the neonates were 25.1% and 82 mumol/L, respectively. The babies required a total of 69 exchange transfusions (range, 0 to 9) and 68 simple transfusions (range, 0 to 25). One newborn infant who had had ultrasound evidence of hydrops fetalis at 22 weeks' gestation did not require any exchange transfusions. Nine patients required intermittent positive pressure ventilation (eight had respiratory distress syndrome and one had apnea) for a range of 1 to 86 days. The neonatal survival rate was 90% (18/20).

Blood Transfusion, Intrauterine↗
PubMed2005

Neonatal outcome in twin-to-twin transfusion syndrome treated with fetoscopic laser occlusion of vascular anastomoses.

OBJECTIVE: To determine neonatal mortality and morbidity rates in monochorionic twins with chronic twin-to-twin transfusion syndrome (TTTS) treated with fetoscopic laser occlusion of vascular anastomoses. STUDY DESIGN: In a prospective study of monochorionic twins delivered at our center between June 2002 and December 2004, neonatal outcome was assessed in 40 monochorionic twin pairs with TTTS treated with laser compared with 46 monochorionic twin pairs without TTTS. RESULTS: The neonatal mortality rate in the TTTS and no-TTTS group was 8% (6/76) and 3% (3/90), respectively. The rate of severe cerebral lesions on ultrasound scanning in the TTTS and no-TTTS group was 14% (10/72) and 6% (5/82), respectively. The incidence of adverse neonatal outcome (neonatal death, major neonatal morbidity, or severe cerebral lesions) in the TTTS and no-TTTS group was, respectively, 26% (20/76) and 13% (12/90) (RR = 1.97, 95% CI = 1.03 to 3.77). CONCLUSIONS: Although perinatal outcome in TTTS has improved after laser therapy, neonatal mortality and morbidity rates remain high. Relative risk for adverse neonatal outcome is increased 2-fold in TTTS treated with laser relative to monochorionic twins without TTTS.

Case-Control Studies↗
PubMed2000

Successful sealing of fetoscopic access sites with collagen plugs in the rabbit model.

OBJECTIVE: The aim of this study was to evaluate the efficacies of various plugging techniques in sealing the membrane defect created by fetoscopy in the rabbit at midgestation. STUDY DESIGN: Fetoscopy was performed in pregnant rabbits at 23 days' gestation (term, 32 days' gestation). In group 1 fetal sacs were left unclosed (positive control group, n = 24). In group 2 injection with commercially available extracellular matrix (Matrigel; BD Labware, Bedford, Mass) was performed and a myometrial suture was inserted (n = 23). In group 3 the entry site was plugged with collagen (Colgen; Inter-Phar, Paris, France) combined with a myometrial suture (n = 22). At 30 days' gestation the membrane integrity, amniotic fluid presence, and fetal lung/body weight ratios were assessed. The plugging site was examined histologically. RESULTS: The use of suture and collagen plugs (group 3) resulted in functional restoration of membrane integrity with preservation of amniotic fluid and normal fetal lung/body weight ratio at term in 82% of cases, compared with 42% in the positive control group (group 1; P <.05). Histologic examination revealed entrapment of membranes between the plug and the myometrium but no anatomic repair of the membranes. The use of suture and extracellular matrix (group 2) did not achieve better results than those seen in group 1 (positive control group). CONCLUSION: Collagen plugs achieved functional sealing of fetoscopic access sites in a rabbit model and prevented oligohydramnios and pulmonary hypoplasia.

Amnion↗
PubMed1997

The pregnant ewe: an animal model for fetoscopic surgery.

OBJECTIVE: To develop an animal model for fetal endoscopic surgery which could be feasible and reproducible. The aim of this work was to perform a fetoscopy without the need of a laparotomy. METHODS: Pregnant ewes underwent under general anesthesia laparoscopy with the creation of a maternal pneumoperitoneum. After localizing the placenta by transillumination, we carried out fetoscopy through a 5 mm trocar using a perfusion of Ringer's solution. RESULTS: Five video-assisted procedures have been performed. None of the cases has shown any bleeding from myometrial wounds and no suture was necessary. There was no leakage of amniotic fluid. Intrauterine space was large enough to manipulate instruments without producing any fetal damage. Sharp visualization and anatomical description of the fetus were precise without the use CO2. There were no miscarriages and postnatal examinations of the lambs were normal. CONCLUSION: Fetoscopic surgery can be performed in the pregnant sheep without any complications but preterm labor which is the main problem in human fetal surgery, is infrequent in the sheep. Our model is reproducible and simulates the surgical endoscopic procedures which will occur in a close future in the human species.

Animals↗
PubMed2006

Fetoscopic laser therapy for twin-twin transfusion syndrome.

Twin-twin transfusion syndrome (TTTS) complicates approximately 1 in 5 of all monochorionic, diamniotic twin pregnancies. If of early onset and untreated, severe TTTS is associated with a dismal prognosis, with perinatal mortality rates exceeding 90%. The most controversial issue regarding the optimal treatment of TTTS has centered on the use of amniocentesis or laser until the first and only randomized trial on interventions for TTTS was published a couple of years ago, comparing laser to amnioreduction. That report confirmed that the laser group had a higher likelihood of the survival of at least one twin to 28 days of age and to 6 months of age. Infants in the laser group also had a lower incidence of cystic periventricular leukomalacia and were more likely to be free of neurologic complications at 6 months of age (52% vs. 31%, p = 0.003). Although not every case of TTTS is an eligible candidate for fetoscopic-guided laser therapy, it is recommended that obstetricians who have the chance to manage TTTS in their daily practice be familiar with the rationale behind this laser treatment for TTTS.

Arteriovenous Anastomosis↗
PubMed2002

Transient hydropic signs in the donor fetus after fetoscopic laser coagulation in severe twin-twin transfusion syndrome: incidence and clinical relevance.

OBJECTIVE: To evaluate the incidence, characteristics, and impact on perinatal outcome of the development of hydropic signs in the donor fetus after laser coagulation for severe twin-twin transfusion syndrome in the second trimester. METHODS: Forty cases of second-trimester severe twin-twin transfusion underwent fetoscopic laser coagulation of placental anastomoses and were followed up with serial ultrasound up to 14 days after therapy. Ultrasound scans were performed just before, and on days 1, 3, 5 and 14 after therapy, and fetuses were monitored for the presence of hydropic signs (skin edema, pleural effusion, ascites and pericardial effusion). Response to therapy and perinatal outcome in terms of neonatal survival were recorded for all cases. RESULTS: Four recipients (10%) and three donors (7.5%) died over the first 72 h after therapy. During the study period, two recipients (5.5%) developed frank hydrops fetalis, and eventually died in utero. Ten donors (27.0%) developed one or more hydropic signs. In nine (90%), signs were mild or moderate and transient (mean, 3.2 days), while in one case hydrops worsened and the fetus eventually died. No donors with transient hydrops died in utero, and two died postnatally due to extreme prematurity. Gestational age at procedure and deepest amniotic fluid vertical pocket were similar between hydropic and non-hydropic donors. Discrepancy in estimated fetal weight at procedure was significantly lower in donors developing hydrops (9.6 (SD, 6.4) vs. 17.8 (14.4)%,P = 0.018). In pregnancies with hydropic donors, gestational age at delivery (33.1 (3.4) vs. 29.7 (3.5) weeks,P = 0.015) and birth weight for recipient (2392 (423) vs. 1631 (576) g, P < 0.001) and donor (1908 (774) vs. 1281 (583) g,P = 0.021) were significantly higher. The development of transient hydrops had no influence on neonatal survival at 28 days nor on the rate of clinical resolution of intertwin transfusion. CONCLUSIONS: Transient hydropic signs may develop in a proportion of donor fetuses after laser coagulation for severe twin-twin transfusion syndrome. This phenomenon is normally not associated with a poor prognosis, and possibly indicates an hemodynamic adaptation response following interruption of the transfusion process.

Female↗
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↗
PubMedDate not supplied

Limb constriction as a complication of intra-uterine vesico-amniotic shunt: fetoscopic release.

Complete fetal bladder outlet obstruction was first diagnosed in a fetus at 13.5 weeks. After sequential vesicocentesis had shown good renal function, a vesico-amniotic shunt was inserted at 17 weeks with a Rodeck catheter. The procedure was successful and amniotic fluid volume re-accumulated to normal levels. A detailed scan at 20 weeks showed that the distal free end of the catheter was wound round the left fetal thigh. As the fetus grew, there was progressive constriction of the fetal thigh by the catheter. By 29 weeks, Doppler blood flow changes to the left leg were apparent. Fetoscopic surgery was performed at 30 weeks to release the constriction. The catheter was divided successfully, but the divided end of the shunt subsequently retracted into the fetal abdomen, producing urinary ascites, bilateral hydroureter and hydronephrosis. The baby was delivered at 31.5 weeks in good condition. Endoscopic resection of anterior and posterior urethral valves was performed at 6 months of age. At 2 years, the child has normal renal function, growth parameters and developmental milestones. Mild indentation of the left thigh was still apparent, although there was no functional impairment.

Amniotic Fluid↗
PubMed2006

Manifestation of mirror syndrome after fetoscopic laser photocoagulation in severe twin-twin transfusion syndrome.

Mirror syndrome is a preeclampsia-like disease first described in a case of severe hydrops fetalis caused by rhesus isoimmunization, later reported in some cases of nonimmunological fetal hydrops. Twin-twin transfusion syndrome (TTTS) is a severe complication associated with monochorionic pregnancies, in particular, severe TTTS with one hydropic fetus leading to a poor prognosis. We report here a case of mirror syndrome that occurred after selective fetoscopic laser photocoagulation in severe TTTS at 24 weeks' gestation.

Adult↗
PubMed1951

A new fetoscope.

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Fetoscopes↗
PubMed1982

Prenatal fetoscopic diagnosis of the Apert syndrome.

We report the prenatal diagnosis of the Apert syndrome by fetoscopy. The patient was a 22-year-old college student with this autosomal dominant form of acrocephalosyndactyly whose first pregnancy had resulted in a stillborn, affected infant. Fetoscopy at 17 weeks showed that she was carrying another affected fetus, and the pregnancy was terminated.

Acrocephalosyndactylia↗
PubMed1982

Selective feticide of the affected twin by fetoscopic air embolism.

Three twin pregnancies, each with one affected fetus (by microcephaly, haemophilia A and spina bifida respectively) were encountered. Selective feticide was performed at the patient's request by injection of filtered air into an umbilical vessel by fetoscopy. The method was successful in all three pregnancies two of which resulted in a live, healthy baby.

Abortion, Induced↗
PubMedDate not supplied

Immunoreactive trypsin level in fetoscopically-obtained cord sera of second trimester fetuses.

Immunoreactive trypsin (IRT) has been assayed in cord blood collection by fetoscopy from fetuses with estimated gestational ages of between 16-24 weeks. Eighty per cent of the specimens contained more than 5 ng/ml of IRT indicating pancreatic synthesis of trypsin by mid-term. A prenatal test for cystic fibrosis based on IRT estimation might be valid if the onset of pancreatic dysfunction associated with the disease also occurs at mid-trimester.

Cystic Fibrosis↗
PubMed2003

The lung-to-head ratio and fetoscopic temporary tracheal occlusion: prediction of survival in severe left congenital diaphragmatic hernia.

OBJECTIVES: To evaluate the reliability of sonographic lung-to-head ratio (LHR) measurement as a predictor of survival in fetuses with congenital diaphragmatic hernia (CDH) and to compare the probability of survival in those with temporary tracheal occlusion (TO) or standard care with respect to the LHR. METHODS: Fifty-six fetuses with left CDH with liver herniated into the thorax at complete prenatal evaluation were included in logistic regression analyses of antenatal predictors of survival to hospital discharge. Sixteen subjects underwent TO and 40 received standard care. RESULTS: LHR was a significant predictor of survival, with probability of survival increasing with increasing LHR (odds ratio (OR) 8.5, P = 0.04). When subjects with anomalies were excluded, the LHR effect was similar after adjustment for TO (OR 7.1, P = 0.11). Linear spline models suggested a plateau in survival at an LHR of 1.0 and all models suggested increased odds of survival with TO. Minimum LHR measurements had a high degree of inter- and intraobserver agreement (intraclass correlation coefficients of 0.70 and 0.80, respectively). CONCLUSIONS: Calculation of the LHR in fetuses with CDH is a reliable and powerful predictor of survival to hospital discharge, although improving odds of survival may plateau at an LHR of 1.0. TO may have an independent benefit on survival to hospital discharge.

Balloon Occlusion↗