Fetal laser therapy: applications in the management of fetal pathologies

Le traitement au laser par foetoscopie est utilisé pour la coagulation d'anastomoses artério-veineuses dans le cadre de syndrome transfuseur-transfusé. Actuellement, certaines malformations peuvent être une indication à ce traitement comme le syndrome des bandes amniotiques, le choriangiome, l'obstruction de l'urètre, le kyste sacro-coccygien et les masses pulmonaires. Ces pathologies peuvent être létales sans intervention et ce traitement, encore expérimental, pourrait être proposé dans ces cas. Il s'agit d'une méta-analyse et revue systématique de la littérature à l'aide de « PubMed », « Medline » et « Web of Science » dans laquelle nous avons recensé tous les cas publiés de traitement par laser durant la période foetale depuis 1980. Cinq groupes de pathologie peuvent bénéficier de ce traitement et sont décrits séparément. Le syndrome des bandes amniotiques peut engendrer une amputation du membre atteint par compression induisant une ischémie ou un décès foetal si cette bande atteint le cordon ombilical. De larges choriangiomes, tératomes sacrococcygiens ou masses pulmonaires peuvent mener à un hydrops foetal par compression ou « vol vasculaire » menant dans les cas les plus sévères à la perte foetale. Des valves de l'urètre postérieur créent une obstruction induisant une mégavessie avec des répercussions rénales ainsi qu'une hypoplasie pulmonaire. Le pronostic de ces différentes pathologies peut être fatal et les options thérapeutiques sont limitées. Dans certains cas, la thérapie au laser par foetoscopie peut changer ce pronostic. Encore expérimentale, cette technique montre des résultats prometteurs. Le taux de réussite et le taux de survie dans les différentes catégories est encore perfectible. L'amélioration devra se faire aussi bien au niveau de l'indication opératoire et de la sélection des cas, de la technique et du matériel que de l'expérience des opérateurs. Cette technique peut offrir un espoir de survie pour des foetus très certainement condamnés. Cette étude est basée essentiellement sur des petites séries de cas ou de cas unique, les résultats doivent donc être analysés avec prudence car des biais de report ou au niveau des investigateurs ne peuvent pas être exclus. La prise en charge de tels cas doit se faire dans un centre de référence, la dé ision d'intervenir devrait être multidisciplinaire et les parents bien informés du pronostic. -- Fetoscopic coagulation of placental anastomoses is the treatment of choice for severe twin-to-twin transfusion syndrome. In the present day, fetal laser therapy is also used to treat amniotic bands, chorioangiomas, sacrococcygeal teratomas, lower urinary tract obstructions and chest masses, all of which will be reviewed in this article. Amniotic band syndrome can cause limb amputation by impairing downstream blood flow. Large chorioangiomas (>4 cm), sacrococcygeal teratomas or fetal hyperechoic lung lesions can lead to fetal compromise and hydrops by vascular steal phenomenon or compression. Renal damage, bladder dysfunction and lastly death because of pulmonary hypolasia may be the result of megacystis caused by a posterior urethral valve. The prognosis of these pathologies can be dismal, and therapy options are limited, which has brought fetal laser therapy to the forefront. Management options discussed here are laser release of amniotic bands, laser coagulation of the placental or fetal tumor feeding vessels and laser therapy by fetal cystoscopy. This review, largely based on case reports, does not intend to provide a level of evidence supporting laser therapy over other treatment options. Centralized evaluation by specialists using strict selection criteria and long-term follow-up of these rare cases are now needed to prove the value of endoscopic or ultrasound-guided laser therapy

Ultrasound guided balloon catheterisation: a new method of fetal lower urinary tract obstruction management

Objectives: Fetal lower urinary tract obstruction (LUTO), most often associated with presence of posterior urethral valves, poses high risk of perinatal mortality or postnatal renal failure. Looking for a method of causative treatment we have devel­oped a technique of fetal urethroplasty with a coronary angioplasty balloon catheter inserted under an ultrasonographic guidance via an 18-gauge needle introduced transabdominally to fetal bladder. Material and methods: We have used this procedure in three women with singleton pregnancies (two primiparas and one multipara, 32–35 years of age), diagnosed with fetal megacystis at 12–16 weeks of gestation. Urethral catheterization was carried out at 16–18 weeks and an unobstructed urine flow was achieved in all three cases immediately after the procedure, followed by a resolution of megacystis and normalization of amniotic fluid volume. Results: In all three cases, the post-procedure period was uneventful. In the first two fetuses, amniotic fluid volume re­mained normal until 30 weeks of gestation when a gradual development of oligohydramnios and some signs of renal cystic dysplasia were observed. Nevertheless, both pregnancies were continued till term (37 and 39 weeks, respectively) and two boys without signs of pulmonary hypoplasia were delivered. The third patient is currently 25 weeks pregnant; volume of amniotic fluid in her fetus is normal and no signs of urinary flow obstruction or renal dysplasia have been recorded thus far. Conclusions: Although some technical aspects of the procedure still need to be established, it seems worth consideration as a form of potentially least traumatic intrauterine intervention in fetuses with lower urinary tract obstruction

Neonatal survival and kidney function after prenatal interventions for obstructive uropathies

Objectives: Prenatal interventions in LUTO (lower urinary tract obstruction) usually are still question of a debate between gynaecologist and paediatric nephrologist. We aimed the study to assess the early survival rate and renal outcome in LUTO foetuses. Material and methods: The study was a prospective data analysis of 39 foetuses from singleton pregnancies. All pregnant women with LUTO in the foetus were qualified for VAS based on a local practice. The mean time of first urine analysis ranged between 13–30 weeks of pregnancy. Primary end-point analysis included live birth, 28d-survival, pulmonary and renal function assessment in neonatal period. Results: From initial number of 39, six patients miscarried before the procedure was performed. Overall, 33 VAS were performer at the mean 21 week of pregnancy (range 14–30 weeks). 25/39 foetuses survived until delivery. Three neonates died in first 3 days of life. In the first month 3 children required peritoneal dialysis, but at 28 day all children were dialysis-free. Overall survival rate at 28 day was 56%. Renal function preservation of the initial group (39) turned out to be low — 18% (7/39). Conclusions: Our study showed average survival curves and complications. LUTO in the foetus had mostly unfavourable outcome in the neonatal period. The prenatal intervention did not increase it significantly and did not guarantee the preservation of normal kidney function

Early vesico-amniotic shunting — does it change the prognosis in fetal lower urinary tract obstruction diagnosed in the first trimester?

Objectives: The aim of the study was to assess the outcome of vesico-amniotic shunting performed before 16 weeks of pregnancy in fetuses with severe megacystis diagnosed in the first trimester of pregnancy. Material and methods: Between January 2008 and October 2012 severe megacystis with the bladder length > 15 mm was diagnosed in 17 fetuses. The procedure of early vesico-amniotic shunting (VAS) was offered to 8 patients with presumably isolated LUTO. The procedure of VAS was performed in 6 fetuses. Before the intervention one or two procedures of vesicocentesis and urine analysis were performed. Results: In all treated cases shunts provided urinary tract decompression. All babies were born prematurely, 2 of them died due to premaurity, 3 of them survived and have normal renal function at the age of 5–6 years. In 4/5 children accompanying malformations were later diagnosed, in 1 born prematurely neonate necropsy was not performed. Conclusions: Our results suggest that early vesico-amniotic shunting in fetal LUTO is feasible and may potentially prevent not only pulmonary hypoplasia but also renal insufficiency. However, the rationale of the procedure needs further investigation due to a high risk of long-term morbidity and co-existing malformations in children Before offering the therapy detailed counseling of the parents about the possible pros and cons of the therapy is necessary

Congenital anomalies of the kidney and urinary tract: antenatal diagnosis, management and counselling of families

Congenital anomalies of the kidney and urinary tract are collectively one of the most commonly diagnosed antenatal conditions. Clinicians have several tools available to diagnose anomalies, including imaging, biomarkers, family history and genetic studies. In certain cases, antenatal interventions such as vesico-amniotic shunting may be considered to improve postnatal outcomes. Congenital kidney anomalies detected antenatally can vary in clinical significance from almost no impact postnatally to significant morbidity and perinatal mortality. Prognosis broadly depends on kidney size, structure and amount of amniotic fluid, alongside genetics and family history, and progression on subsequent scans. It is important to counsel parents appropriately using a parent-focused and personalised approach. The use of a multidisciplinary team should always be considered

Induced labour in pregnancy with congenital abnormalities: clinical indications or patient demand

Congenital abnormalities are a nightmare for a pregnant woman. However, congenital abnormalities are divided into several conditions. The state of major disability is the worst situation, with the possibility of disability and even postpartum death. The disability is still a pregnancy that can cause complications that have a bad effect on the mother, so the pregnancy is often induced labor for fear of endangering the mother even though the complications have not yet appeared. In addition, it often happens because the family refuses the presence of a child with a disability. Criteria and references for intrauterine anomalies have been made by various countries and organizations, with the treatment taking into account clinical, psychosocial, religious, and legal aspects. However, this reference is not always easy to implement due to various factors, so that the decision to induced labor or induced abortion is always based on the advice of the medical team and family approval without leaving the legal aspect. Parental consent is important because not all pregnant women agree to induced labor of pregnancy even though it is a major disability and threatens postpartum death. On the other hand, if the defect can be corrected, then a clinician must be able to maintain the pregnancy and refuse unnecessary attempts to terminate the pregnancy

1st International Conference on Advances in Obstetrics & Gynaecology Oral Presentations - Selected abstracts Sultan Qaboos University, 4–6 December 2013

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Fetal Interventions: A Closer Look at Fetoscopic Laser Surgery: A Literature Review

Over the past decades, due to the advances in imaging methods, prenatal diagnosis of congenital malformations has become widely available. Simultaneously with the improvement of surgical techniques and the development of instrumentation technology, fetal treatment of these pathologies became possible, arising as an alternative to the standard postnatal therapy, aiming to improve fetal outcomes and optimize the transition into neonatal life. Thus, fetal surgery emerges, comprising open interventions and minimally invasive procedures, such as fetoscopy. Fetoscopic surgery, or fetal endoscopic surgery, is a technique that uses endoscopic technology to correct structural and/or functional fetal anomalies in utero, under continuous ultrasound guidance. Fetoscopy is mainly performed percutaneously and allows direct visualization of the fetus and adjacent structures. Nowadays, fetal surgery is most commonly indicated in the treatment of twinto-twin transfusion syndrome, a complication of monochorionic twin pregnancies, using laser coagulation. However, fetoscopic laser surgery can also be performed for the management of other conditions affecting monochorionic pregnancies, such as twin anemia polycythemia sequence and twin reversed arterial perfusion sequence, as well as several other pathologies including amniotic band syndrome, lower urinary tract obstruction, congenital high airway obstruction syndrome, chorioangiomas, and sacrococcygeal teratomas. The aim of this literature review is to provide a brief overview of the most common fetal interventions and to describe fetoscopic laser surgery, covering its indications, techniques, and outcomes following fetal treatment.Nas últimas décadas, a evolução da técnica imagiológica permitiu o diagnóstico pré-natal de um maior número de malformações congénitas. Simultaneamente com os avanços da técnica cirúrgica e dos próprios instrumentos utilizados, o tratamento fetal destas patologias surge como uma alternativa às opções terapêuticas pós-natais, de modo a melhorar o prognóstico neonatal e otimizar a transição do feto à vida extrauterina. Deste modo, a cirurgia fetal torna-se uma realidade, abrangendo procedimentos por via aberta e intervenções minimamente invasivas, como a fetoscopia. A cirurgia fetoscópica, ou cirurgia endoscópica fetal, consiste na utilização de técnicas de endoscopia para a correção de anomalias estruturais e/ou funcionais do feto, com o auxílio de monitorização ecográfica contínua. A fetoscopia é uma intervenção realizada maioritariamente por abordagem percutânea, permitindo a visualização direta do feto e estruturas adjacentes. Atualmente, a cirurgia fetal mais frequentemente realizada tem como indicação a síndrome de transfusão feto-fetal, complicação da gravidez gemelar monocoriónica, recorrendo à fetoscopia com coagulação a laser. A cirurgia fetal a laser pode também ser uma opção terapêutica noutras complicações das gestações gemelares monocoriónicas, como na sequência anemia-policitemia gemelar e na sequência de perfusão arterial reversa gemelar. Além destas patologias, o tratamento fetoscópico a laser foi também descrito na síndrome da banda amniótica, uropatia obstrutiva, síndrome de obstrução congénita das vias aéreas superiores, corioangioma e teratoma sacrococcígeo. Esta revisão bibliográfica pretende explorar os diferentes tipos de cirurgia fetal, focando-se na descrição da técnica da cirurgia fetoscópica a laser, bem como nas suas indicações e diferentes prognósticos após a intervenção fetal