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PubMed1988

A fetoscopic method for enucleation in developmental studies of the visual system.

Prenatal enucleation is accomplished by fetoscopy using an arthroscope and a needle for the delivery of electric current into the uterus of anesthetized, pregnant cats. Under direct vision, the eye(s) of the fetus are easily discerned and can readily be lesioned by the application of an electrical current delivered through the needle. The procedure is relatively simple to perform, minimizes uterine trauma and therefore postsurgical recovery times for the mother cat, enhances the prolongation of pregnancy and allows a shorter operating time for accomplishing the enucleation than does normal surgical invasion. It should be possible to make other uses of the approach, such as prenatal ocular injection of dyes or of tracer substances in place of the enucleation.

Animals↗
PubMed2006

Intertwin anastomoses in monochorionic placentas after fetoscopic laser coagulation for twin-to-twin transfusion syndrome: is there more than meets the eye?

OBJECTIVE: This study was undertaken to detect missed anastomoses on the chorionic surface as well as hidden connections in the depth of the cotyledons in placentas after laser coagulation for twin-to-twin transfusion syndrome (TTTS) and to correlate these findings to clinical outcome. STUDY DESIGN: All cord vessels were injected with dyed barium sulphate. A digital photograph of the chorionic surface angioarchitecture and single-shot digital X-ray (Rx) angiograms were made. The presence and diameter of any missed anastomoses on the chorionic surface and of any hidden angiographic connections were determined. RESULTS: Fifty placentas were analyzed, 7 of double intrauterine fetal death (IUFD) and 43 of double survivors. In 9 of 43 (21%) cases with double survival and in all 7 cases of double IUFD, missed anastomoses were identified that should have been ablated by laser coagulation (P < .001). There appeared to be a correlation between the type and diameter of missed anastomoses on the chorionic surface and the clinical outcome. Placentas with missed large arteriovenous/venoarterial anastomoses (AV/VA) (N = 8) were from cases with recurrent TTTS or double IUFD (unless compensated by a large arterioarterial anastomosis [AA]). Next, missed small AV/VA (N = 4) without AA resulted in isolated (ie, without TTTS) discordant hemoglobin levels requiring intrauterine transfusion. Finally, when there were no missed anastomoses (N = 34), TTTS had resolved in all cases and outcome was good, although 1 case had discordant hemoglobin values treated with a single intrauterine transfusion and 4 others had discordant hemoglobin at birth. On Rx angiography, potential hidden connections were present, all but 1 case. CONCLUSION: Coagulation of all anastomoses visible on the chorionic surface seems adequate to treat TTTS. However, hidden connections in the depth of the cotyledon could not be excluded and may be involved in lesser degrees of intertwin transfusion.

Chorion↗
PubMed2000

Current experience with fetoscopy and the Eurofoetus registry for fetoscopic procedures.

Fetoscopy has consolidated its position in fetal medicine, thanks to a combination of insight into the pathophysiology of selected conditions that are amenable to fetal surgery and the technical innovations in endoscopic equipment. In clinical practice, two types of fetoscopy can be discerned: Obstetrical Endoscopy and Endoscopic Fetal Surgery. The first involves surgical interventions on the placenta, umbilical cord and fetal membranes. Nd:YAG laser coagulation of placental vessels in case of feto-fetal transfusion syndrome and cord occlusion in monochorionic pregnancy are the most typical procedures. The second type addresses some rare fetal conditions requiring in utero surgery; most experience has been gathered with congenital diaphragmatic hernia. Endoscopic fetal surgery has a different historical and experimental background than obstetrical endoscopy, but they both share technical aspects as well as potential side effects. In this review, we aimed at bringing together currently available experience. We suggest that future developments of fetal endoscopic operations will involve a mixture of concepts from both fetoscopy types to reduce maternal invasiveness and complications, eventually improving acceptance by parents and doctors. We encourage the registration of all experience in a yet available open registry for prospective data collection, supported by the European Commission, with as primary target the assessment of maternal and fetal safety.

Databases, Factual↗
PubMed1996

Fetoscopic Nd:YAG Laser Coagulation for Twin-Twin Transfusion Syndrome in Cases of Anterior Placenta

Laser coagulation of anastomosing placental chorionic plate vessels was suggested as a treatment of severe twin-twin transfusion syndrome in midtrimester. An anteriorly located placenta may hamper access and visualization of the vessels involved. We treated six women with completely anterior placenta at 18 to 22 weeks' gestation. Through a 2- to 3-cm minilaparotomy the uterus was accessed after retraction of the viscera. A flexible cannula was inserted through the uterine fundus, and a 35-degree, 0.20-mm minifibroscope and 400-mm fiber were introduced. All vessels crossing the intertwining membrane were coagulated in a continuous mode and a maximum output of 45 W. All fetuses survived the operation. One fetus died in utero 6 weeks postoperatively from cardiac failure, and its receptor twin was born alive. All other pregnancies are either continuing, or the women delivered two healthy babies. Thus far, total fetal survival is 91.6%, compared with results with posterior-sided placentas. Neodymium:yttrium-aluminum-garnet laser coagulation is also possible in case of anterior placenta, but requires a minimal maternal incision and general anesthesia to allow safe cannula placement. A bent scope allows for a larger placental surface to be treated.

Journal Article↗
PubMed2002

Fetoscopic treatment for discordant twins.

BACKGROUND/PURPOSE: In rare instances in monochorionic twin pregnancies, one twin can have a discordant anomaly (eg, cystic hygroma). If this twin dies in utero, neurologic injury and death can occur in the surviving cotwin. To protect the normal twin, the authors developed an approach to separate the circulations and ablate the umbilical cord of the abnormal twin. METHODS: From September 1998 to February 2001, 6 cases of discordant anomalous twins were diagnosed by prenatal ultrasound scan in which the anomaly was lethal or parents desired prenatal termination for this abnormal twin. All underwent surgical intervention with gestational ages varying from 19 to 24 weeks. RESULTS: Depending on cord insertion site and placental anatomy, blood flow was interrupted to the anomalous fetus by either radiofrequency ablation (RFA; 2 cases), cord transection (1 case), or cord transection after laser ablation of communicating vessels (3 cases). Fetal death occurred in one normal twin 4 days postoperatively. Average age at delivery for the 5 surviving fetuses was 34.5 weeks' gestation. On follow-up, all surviving infants are neurologically intact. CONCLUSION: An otherwise normal monochorionic twin threatened by an anomalous cotwin can be salvaged successfully with a strategy tailored to interrupt the vascular connections between the 2 twins.

Abnormalities, Multiple↗
PubMed2001

Fetoscopic temporary tracheal occlusion by means of detachable balloon for congenital diaphragmatic hernia.

Occlusion of the fetal trachea blocks the egress of fetal lung fluid and stimulates the growth of hypoplastic lungs in fetuses with diaphragmatic hernia. Accomplishing temporary and reversible occlusion of the fetal trachea has proven difficult without invasive fetal surgery. Using simultaneous real-time ultrasonography and fetal bronchoscopy through a single uterine port, we placed a detachable balloon in the trachea of 2 fetuses with severe diaphragmatic hernia. In both fetuses the fetal lung subsequently enlarged, allowing survival after birth.

Adult↗
PubMed1997

Assessment of access strategies for fetoscopic urologic surgery: preliminary results.

Attempted endoscopic fetal interventions have been increasingly reported, given the knowledge that minimizing the trauma to the uterus by a small access portal can allow prolonged amnioscopic-guided surgery. Numerous fetal anomalies have been targeted for these interventions, including congential obstructive uropathies. This preliminary investigation explored innovative access strategies utilizing time-dated pregnant ewes, 95 to 100 days' gestation (term 145 days). Two strategies were specifically investigated: percutaneous, ultrasonographically guided microamnisocopy and ultrasonographically aided, laparoscopically guided amnioscopy. Both strategies provided excellent fetal visibility and were facilitated by the use of small trocars and microlaparoscopic instrumentation, which promoted prolonged amnioscopy with minimal access trauma.

Amnion↗
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↗
PubMed2003

Fetoscopic surgery.

Explore the source record for details and available documents.

Diseases in Twins↗
PubMed2004

Fetoscopic placement of a transurethral stent for intrauterine obstructive uropathy.

PURPOSE: Fetal urinary obstructive uropathy and consecutive oligohydramnios result in a poor outcome. Usually renal insufficiency and life threatening lung hypoplasia have developed at term. We report a case of in utero fetal cystoscopy and successful placement of a transurethral vesico-amniotic Double-J (Medical Engineering Corp., New York, New York) stent. Indications, results and the potential benefits of different techniques are discussed. MATERIAL AND METHODS: A 36-year-old woman (primipara) was evaluated at week 26 due to a male fetus with bilateral hydronephrosis, massive distended bladder and an open posterior urethra. Using local anesthesia the fetal bladder was punctured, a 2.6 mm endoscope was inserted and a wire was advanced antegrade through the penis. A 2.8Fr Double-J stent was then placed between the bladder and amniotic cavity. RESULTS: The bladder drained into the amnion, hydronephrosis disappeared and the lung developed normally. At week 37 a healthy infant was delivered who voided spontaneously. CONCLUSIONS: After careful selection of candidates for fetal intervention in obstructive uropathy direct vision fetoscopy and transurethral stent placement can be performed in patients with oligohydramnios, favorable urinary electrolytes and normal appearing kidneys.

Adult↗
PubMedDate not supplied

Ontogeny of clenched-hand development in trisomy 18 fetuses: A serial transabdominal fetoscopic observation.

Malpositioning of the fingers is a characteristic anomaly in fetuses with trisomy 18. The defect results in part from muscle variations along the radial margin of forearm and hand, absence of the thenar muscles, anomalous tendons and attachments among the forearm groups, and fusions among the arm flexor group. These variations result in radial or ulnar displacement of the tendons of extensor digitorum and digiti minimi, with overlapping of the fourth and fifth fingers radially and second finger in an ulnar direction. The ontogeny of these changes is unknown. We performed serial transabdominal thin-gauge fetoscopy in a patient with increased nuchal thickening at 12 weeks of pregnancy at the time of genetic testing and again at 14 weeks at the time of termination of pregnancy. Changes in the positioning of the fingers were not apparent at 12 weeks, but were evident at 14 weeks. The findings were beyond the resolution of ultrasound. We conclude that malpositioning of the fingers in trisomy 18 occurs some time between 12 and 14 weeks of gestation. Noninvasive confirmation of these findings may be possible with new and improved ultrasound imaging capabilities or perhaps with three-dimensional ultrasound.

Adult↗
PubMed2005

Remifentanil for fetal immobilization and maternal sedation during fetoscopic surgery: a randomized, double-blind comparison with diazepam.

Obstetric endoscopy procedures are routinely performed at our institution to treat selected complications of monochorionic twin gestation. We perform these procedures under combined spinal epidural anesthesia plus maternal sedation. In the absence of general anesthesia, fetal immobilization is not achieved. We hypothesized that remifentanil would induce adequate maternal sedation and provide fetal immobilization, which is equal or superior to that induced by diazepam. Fifty-four second trimester pregnant women were included in this randomized, double-blind trial. After combined spinal epidural anesthesia, maternal sedation was initiated using either incremental doses of diazepam or a continuous infusion of remifentanil. Maternal sedation, hemodynamics, side effects, and fetal hemodynamics and immobilization were evaluated before, during, and for 60 min after surgery. Remifentanil produced adequate maternal sedation with mild but clinically irrelevant respiratory depression (respiratory rate 13 +/- 4 breaths/min and Pco(2) 38.6 +/- 4 mm Hg at 40 min of surgery), whereas diazepam resulted in a more pronounced maternal sedation but no respiratory depression (respiratory rate 18 +/- 3 breaths/min and Pco(2) 32.7 +/- 3 mm Hg at 40 min of surgery). Compared with diazepam, fetal immobilization with remifentanil occurred faster and was more pronounced, resulting in improved surgical conditions; the number of gross body and limb movements was 12 +/- 4 (diazepam) versus 2 +/- 1 (remifentanil) at 40 min of surgery. Because of this, the mean (range) duration of surgery was significantly shorter in the remifentanil-treated patients, 60 (54-71) min versus 80 (60-90) min in the diazepam group. We conclude that remifentanil produces improved fetal immobilization with good maternal sedation and only minimal effects on maternal respiration.

Adult↗
PubMed2003

Operative fetoscopical management of intrauterine obstructive uropathia by urethral stent.

We report on an innovative therapeutic attempt in a case with obstructive uropathia in a fetus. Placement of an anterograd urethral stent was performed in the 26th gestational week. Transurethral catheterization via the fetal megacystis, the urethra and the orificium externum of the penis was feasible during fetal endoscopy (Fetendo). During serial ultrasound scans from the 27th to the 36th gestational week a normalization of the amniotic fluid volume was observed. The postpartal evaluation demonstrated that the kidney structure, values of kreatinin serum levels and renal clearance were in the normal range. The boy's development after the seventh month is completely normal. Fetendo with urethral stent application for obstructive uropathy should be performed for the carefully selected patient with oligohydramnion and normal kidney appearance.

Adult↗