Interwencyjne zabiegi kardiologiczne u płodów – czy jesteśmy do nich przygotowani?

Objective: The aim of the study was to analyze types and methods of intrauterine fetal cardiac interventions performed between June 2011 and December 2013, and to assess the perinatal management of the neonates. Methods: The program was developed after analysis of the available literature, practical individual training in Linz, Austria, and simulation of the procedure in a dissecting-room. The rules for anesthesia in pregnant women and their fetuses were developed. The interventions were performed in fetuses with critical cardiac defects, in the operating room, under ultrasonographic control. The protocol was approved by the Local Bioethics Committee at the Centre of Postgraduate Medical Education. Material: We included fetuses with critical aortic stenosis (n=29), critical pulmonary stenosis (n=2), and closed or extremely restricted foramen ovale (n=7). Between June 2011 and December 2013, the team comprised of JD, MD and AK conducted 42 interventions in 35 fetuses, including 32 balloon aortic valvuloplasties (in 29 fetuses), 2 pulmonary valvuloplasties, 4 balloon atrial septostomies and 4 atrial septal stent placement. Three fetuses required both, aortic valvuloplasty and fenestration of the atrial septum. Results: Out of the 42 procedures, 41 (97%) were technically successful. We recorded 3 cases of fetal demise associated with the intervention. We modulated the protocol of anesthesia given to pregnant women, switching from general to local anesthesia with intravenous sedation. We always provided additional fetal anesthesia with fentanyl and atracurium via the umbilical vein. Conclusions: Based on our 2.5-year experience, it seems safe to conclude that all types of fetal cardiac interventions may be successfully conducted at Polish centers. The procedures are safe for the pregnant women and improve fetal status. Most of the neonates treatedCel pracy: Analiza rodzajów i sposobu wykonania wewnątrzmacicznych zabiegów kardiologicznych u płodów oraz postępowania w okresie okołoporodowym między czerwcem 2011 i grudniem 2013 roku. Metodyka: Program interwencji kardiologicznych u płodów zaplanowano po przeanalizowaniu dostępnego piśmiennictwa, odbyciu indywidualnego szkolenia praktycznego w Linz w Austrii oraz po przeprowadzeniu symulacji zabiegów w prosektorium. Opracowane zostały zasady znieczulenia pacjentek i płodów. Zabiegi wykonywano w wybranych grupach płodów z krytycznymi wadami serca, w warunkach bloku operacyjnego, pod kontrolą ultrasonograficzną. Uzyskano zgodę komisji bioetycznej CMKP. Materiał: Do zabiegów kwalifikowano płody z krytycznym zwężeniem zastawki aortalnej (29), krytycznym zwężeniem zastawki płucnej (2) oraz z zamkniętym lub skrajnie restrykcyjnym otworem owalnym (7). W okresie od czerwca 2011 do grudnia 2013 roku zespół w składzie: JD, MD, AK przeprowadził 42 zabiegi u 35 płodów, w tym: 32 balonowe plastyki zastawki aortalnej (u 29 płodów), 2 plastyki zastawki płucnej, 4 atrioseptostomie balonowe i 4 założenia stentów do przegrody międzyprzedsionowej. U trzech płodów konieczne było poszerzenie zastawki aortalnej i wytworzenie połączenia na poziomie przegrody międzyprzedsionkowej. Wyniki: Wykonano 41 z 42 zaplanowanych zabiegów (97%). W 3 przypadkach doszło do zgonu płodu związanego z zabiegiem. Zmodyfikowano sposób znieczulenia ciężarnych z ogólnego na miejscowe z dożylną sedacją. Zawsze dodatkowo znieczulano i unieruchamiano płód podaniem fentantylu i atracurium do żyły pępowinowej. Wnioski: Na podstawie 2,5 letnich doświadczeń uważamy, że wszystkie rodzaje prenatalnych interwencji kardiologicznych mogą być skutecznie przeprowadzane w Polsce. Są one bezpieczne dla matek i poprawiają stan płodu. Większość noworodków leczonych prenatalnie została przekazana w dobrym stanie do referencyjnego ośrodka kardiologii i kardiochirurgii dziecięcej

sFlt-1/PlGF Ratio in Prediction of Short-Term Neonatal Outcome of Small for Gestational Age Neonates

Background: Small for gestational age is a pregnancy complication associated with a variety of adverse perinatal outcomes. The aim of the study was to investigate if sFlt-1/PlGF ratio is related to adverse short-term neonatal outcome in neonates small for gestational age in normotensive pregnancy. Methods: A prospective observational study was conducted. Serum sFlt-1/PlGF ratio was measured in women in singleton gestation diagnosed with fetus small for gestational age. Short-term neonatal outcome analyzed in the period between birth and discharge home. Results: Eighty-two women were included. Women with sFlt-1/PlGF ratio ≥33 gave birth to neonates with lower birthweight at lower gestational age. Neonates from high ratio group suffered from respiratory disorders and NEC significantly more often. They were hospitalized at NICU more often and were discharged home significantly later. sFlt-1/PlGF ratio predicted combined neonatal outcome with sensitivity of 73% and specificity of 82.2%. Conclusions: sFlt-1/PlGF ratio is a useful toll in prediction of short-term adverse neonatal outcome in SGA pregnancies

Fetal Cardiac Interventions—Are They Safe for the Mothers?

The aim of fetal cardiac interventions (FCI), as other prenatal therapeutic procedures, is to bring benefit to the fetus. However, the safety of the mother is of utmost importance. The objective of our study was to evaluate the impact of FCI on maternal condition, course of pregnancy, and delivery. 113 mothers underwent intrauterine treatment of their fetuses with critical heart defects. 128 percutaneous ultrasound-guided FCI were performed and analyzed. The patients were divided into four groups according to the type of FCI: balloon aortic valvuloplasty (fBAV), balloon pulmonary valvuloplasty (fBPV), interatrial stent placement (IAS), and balloon atrioseptoplasty (BAS). Various factors: maternal parameters, perioperative data, and pregnancy complications, were analyzed. There was only one major complication—procedure-related placental abruption (without need for blood products transfusion). There were no cases of: procedure-related preterm prelabor rupture of membranes (pPROM), chorioamnionitis, wound infection, and anesthesia associated complications. Tocolysis was only necessary only in two cases, and it was effective in both. None of the patients required intensive care unit admission. The procedure was effective in treating polyhydramnios associated with fetal heart failure in six out of nine cases. Deliveries occurred at term in 89%, 54% were vaginal. The results showed that FCI had a negligible impact on a further course of pregnancy and delivery

Fetal Cardiac Interventions—Polish Experience from “Zero” to the Third World Largest Program

This article presents the technical aspects of the Polish fetal cardiac interventions (FCI) program, including preparation of the team and modifications in the technique of the procedure that aim to increase its safety for the mother and the fetus. Over 9 years, 128 FCI in 113 fetuses have been performed: 94 balloon aortic valvuloplasties (fBAV), 14 balloon atrioseptoplasties (fBAS) with stent (BAS+), 5 balloon atrioseptoplasties without stent placement (BAS−), and 15 fetal pulmonary valvuloplasties (fBPS). The technical success rate ranged from 80% (BAS−) to 89% (fBAV), while the procedure-related death rate (defined as death within 72 hours following the procedure) ranged from 7% (fBAV and fBPV) to 20% (BAS). There were 98 live births after all FCI (3 pregnancies continue). Median gestational age at delivery was 39 weeks in our center and 38 weeks in other centers