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BACKGROUND: Invasive fetal cardiac intervention (FCI) has been reported in single-institution series, promoting technical and physiologic success. OBJECTIVES: This study describes the creation of an international registry of cases presenting for FCI, intended to compile technical and outcome data from a multicenter cohort. METHODS: For this initial analysis, the entire database of the International Fetal Cardiac Intervention Registry (IFCIR) was queried for details of diagnoses, procedures, and outcomes. Maternal-fetal dyads from January 2001 through June 2014 were included.RESULTS:Eighteen institutions submitted data by data harvest. Of 370 cases entered, 245 underwent FCI: 100 aortic valvuloplasties from a previous single-center report (excluded from additional reporting here), an additional 86 aortic and 16 pulmonary valvuloplasties, 37 atrial septal cases, and 6 unclassified cases. FCI did not appear to affect overall survival to hospital discharge. Among live-born infants with a fetal diagnosis of aortic stenosis/evolving hypoplastic left heart syndrome, more than twice as many were discharged with biventricular circulation after successful FCI versus those meeting institutional criteria but without any or successful FCI (42.8% vs. 19.4%, respectively). When fetal deaths were counted as treatment failures, the percentages were similar: biventricular circulation at discharge was 31.3% versus 18.5% for those discharged with univentricular palliation. Survival to discharge for live-born fetuses with atrial restriction was similar to that of those undergoing technically successful versus unsuccessful FCI (63.6% vs. 46.7%, respectively), although criteria for diagnosis were nonuniform. CONCLUSIONS: We describe the contents of the IFCIR and present post-natal data to suggest potential benefit to fetal therapy among pregnancies considered for possible intervention and support proposals for additional work.

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OBJECTIVE: To report our preliminary clinical experience in the antenatal correction of open spina bifida (OSB) using a fetoscopic approach and a simplified closure technique. METHODS: Four fetuses with lumbar-sacral defects were operated in utero from 25 to 27 weeks. Surgeries were performed percutaneously under general anesthesia using three trocars and partial carbon dioxide insufflation. After dissection of the neural placode, the surrounding skin was closed over a cellulose patch using a single continuous stitch. RESULTS: Surgical closure was successful in three of the four cases. All successful cases showed improvement of the hindbrain herniation and no neonatal neurosurgical repair was required in two cases. Delivery occurred between 31 and 33 weeks, and no fetal or neonatal deaths occurred. Ventriculoperitoneal shunting was not needed in two out of the 3 successful cases. CONCLUSIONS: Our preliminary experience suggests that definitive fetoscopic repair of OSB is feasible using our innovative surgical technique. A phase I trial for the fetoscopic correction of OSB with this technique is currently being conducted.

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OBJECTIVE: To evaluate pulmonary growth and development after fetoscopic intraluminal tracheal occlusion (FITO) using a modified 8-mm Z-stent in an ovine model of congenital left-sided diaphragmatic hernia (CDH). METHODS: Thirty-three time-dated ewes were studied: Group I: healthy controls; Group II: CDH controls (untreated); Group III: CDH treated with FITO. CDH was created in Groups II and III at 70-80 days' gestation. FITO was performed at 100-110 days. Left lung histological, morphometric, immunohistochemical and biochemical studies were conducted after delivery and euthanasia at 138 days. RESULTS: Fifteen (45%) animals (Group I: 3; Group II: 5; Group III: 7) were available for analysis. The left lung parenchymal volume to fetal weight ratios were similar between Groups I and III (p = 0.24), and higher than Group II (p < 0.05III (79 versus 75%, p = 0.26), compared to 41% in Group II (p < 0.05). Pulmonary hypoplasia occurred in 1/7 (16%) in the FITO group, compared to 100% in Group II and 0% in Group I (p = .003). DNA and protein were significantly increased in Group III (p < 0.001). The concentration of type II pneumocytes was similar between healthy controls and the FITO group, and was paradoxically increased in untreated hernia fetuses. There was no histological evidence of tracheal injury. CONCLUSION: FITO with a modified 8-mm Z-stent is associated with lung growth and maturation similar to controls without obvious deleterious effects. A phase I clinical trial of FITO with the modified 8-mm Z-stent in severe CDH patients seems warranted.

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OBJECTIVE: To assess the ability of a three-layer graft in the closuse of large fetal skin defects. METHODS: Ovine fetuses underwent a large (4 × 3 cm) full-thickness skin defect over the lumbar region at 105 days' gestation (term = 140 days). A bilaminar artificial skin was placed over a cellulose interface to cover the defect (3-layer graft). The skin was partially reapproximated with a continuous nylon suture. Pregnancy was allowed to continue and the surgical site was submitted to histopathological analysis at different post-operative intervals. RESULTS: Seven fetuses underwent surgery. One maternal/fetal death occurred, and the remaining 6 fetuses were analyzed. Artificial skin adherence to the wound edges was observed in cases that remained in utero for at least 15 days. Neoskin was present beneath the silicone layer of the bilaminar artificial skin. CONCLUSIONS: Our study shows that neoskin can develop in the fetus using a 3-layer graft, including epidermal growth beneath the silicone layer of the bilaminar skin graft. These findings suggest that the fetus is able to reepithelialise even large skin defects. Further experience is necessary to assess the quality of this repair.

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Objetivo: se presenta el caso de una paciente primigestante con embarazo monocorial biamniótico y síndrome de transfusión intergemelar estadio III, diagnosticado en la semana 23 de gestación. El manejo se llevó a cabo con foto-coagulación láser selectiva y secuencial de vasos comunicantes. Se presentó complicación con síndrome de Ballantyne y RCIU selectivo del feto donante. Desembarazada en la semana 35 con buen resultado perinatal. El objetivo es realizar una revisión actualizada de la literatura del síndrome de Ballantyne. Materiales y métodos: se revisaron las bases de datos PubMed, Cochrane, MEDLINE y libros de la especialidad, relativos al término “síndrome de Ballantyne”, sin restricción en la fecha de publicación. Conclusión: la fotocoagulación láser selectiva y secuencial de vasos comunicantes es el manejo de elección para el síndrome de transfusión fetofetal. La restricción de crecimiento selectivo del feto donante en estadio III se puede presentar en el 40 a 70% de los casos. El síndrome de Ballantyne puede ser secundario a edema placentario sin hidrops fetal; su sospecha puede ayudar a identificar cuáles pacientes se podrían beneficiar de un manejo activo de esta patología.

Objective: a 21 years old primigravid patient with biamniotic monochorial twin pregnancy and stage III twin-to -twin transfusion syndrome, diagnosed during week 23 of gestation is presented. She was managed with selective, sequential laser photocoagulation of the communicating blood vessels which was complicated by Ballantyne’s syndrome (mirror syndrome) and selective intrauterine growth restriction (IUGR) of the donor fetus. She delivered during week 35 with good perinatal result. The object was to make an updated review of the literature about Ballantyne’s syndrome. Materials and methods: the PubMed/ MEDLINE, Cochrane databases were searched as well as books on the specialization, related to the term “Ballantyne’s syndrome”, with no restriction regarding publication date. Conclusion: selective, sequential laser photocoagulation of the communicating blood vessels is the management of choice for twintwin fetus transfusion syndrome. Selective growth restriction of the donor fetus in stage III could be presented in 40% to 70% of cases. Ballantyne’s syndrome could be secondary to placental edema without fetal hydrops; suspecting it, helps to identify which patients could benefit from active management of this pathology.

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OBJECTIVES: Congenital cystic adenomatoid malformation (CCAM) is a rare lesion of the developing fetal lung consisting of increased cell proliferation in the bronchial structures with lack of differentiation of the alveoli. Pregnancies may be at an increased risk for perinatal loss with type III CCAM. The purpose of this paper is to present our experience with the management of complicated types II and III CCAM with a novel technique: percutaneous ultrasound-guided fetal sclerotherapy (FST). METHODS: Three patients were referred with type II-III CCAM. Poor prognostic factors included hydrops, severe mediastinal shift, polyhydramnios and early gestational age (<26 weeks). Patients signed an informed consent. FST was performed with percutaneous injection of Ethamolin (ethanolamine oleate) or Polidocanol (aethoxysklerol) under ultrasound guidance using a 22-gauge needle. RESULTS: Resolution of hydrops and of the mass effect was observed in all cases without any complications. All patients were delivered at term. CONCLUSIONS: Fetal sclerotherapy is a novel approach to the management of complicated type II-III CCAM. Further studies are indicated to assess the risks and benefits of this innovative technique.

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La hernia diafragmática congénita (HDC) está asociada a 40-60 por ciento de mortalidad perinatal, fundamentalmente debido al desarrollo de hipoplasia pulmonar. El fracaso de la corrección in utero de la HDC por cirugía fetal abierta y el descubrimiento de que la oclusión de la tráquea fetal puede evitar hipoplasia pulmonar, ha producido un nuevo enfoque terapéutico. El objetivo de este trabajo era evaluar una técnica mínimamente invasiva de oclusión intratraqueal en un modelo experimental de hernia diafragmática. Se creó una HDC en fetos de ovejas bajo condiciones de antisepsia a los 90 días de gestación. En el grupo experimental se colocó un dispositivo oclusivo intratraqueal por vía endoscópica a los 105 días. Fetos con hernia sin tratamiento (grupo control positivo) y sanos (grupo control negativo) sirvieron de comparación. El embarazo se interrumpió por cesárea a los 135 días de gestación (término 140 días), y los fetos fueron sacrificados. La presencia o ausencia de hipoplasia pulmonar se determinó mediante análisis histológico de los pulmones. La tráquea se examinó para evaluar posibles efectos traumáticos del dispositivo. Veintiocho ovejas fueron intervenidas, pero sólo 13 completaron el protocolo. La oclusión traqueal evitó el desarrollo de hipoplasia pulmonar en 8/11 (72 por ciento) fetos experimentales. No hubo traumatismo traqueal importante en 6 fetos estudiados, excepto una perforación. Conclusión: El desarrollo de hipoplasia pulmonar por hernia diafragmática puede evitarse mediante la colocación de un dispositivo oclusivo intratraqueal. Estos experimentos pueden servir de base para el posible tratamiento de fetos humanos con hernia diafragmática congénita mediante técnicas mínimamente invasivas

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Presentamos el primer caso de cirugía endoscópica fetal realizado en nuestro país en un caso de embarazo gemelar complicado con la denominada secuencia de perfusión arterial reversa (secuencia TRAP) en el que se realizó ligadura del cordón umbilical del feto acardio-acéfalo a las 26 semanas de gestación

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En medicina se escriben aproximadamente 2 millones de artículos nuevos cada año, por lo que permanecen al tanto de los descubrimientos y nuevos conocimientos médicos constituye una real tarea para los profesionales de hoy. El uso de computadoras personales para ganar acceso directo (on-line) a los bancos de datos de la Biblioteca Nacional de Medicina en Washington (NLM) se ha convertido en un método alterno para manejar esta explosión de información. Sin embargo, para los países latinoamericanos, el obstáculo más importante es de carácter económico por lo costoso de la llamada internacional. Desde 1981, instituciones académicas de EE.UU y Europa pueden comunicarse entre sí mediante el uso de correo electrónico a través de una red de telecomunicaciones denominada BITNET. Dicho medio de comunicación, que permite el envío de mensajes, datos, resultados, o archivos completos a un relativo bajo costo, requiere de la instalación de infraestructuras de acceso, o nodos. Un sistema que permite la utilización de los bancos de datos de la NLM mediante correo electrónico, denominado BITNIS, ha sido posible mediante un esfuerzo internacional entre médicos e ingenieros chilenos y el auspicio de la Oficina Panamericana de la Salud, la NLM y el Instituto Nacional de Salud (NIH). Una gestion ante el centro de computación de la Universidad de Yale con el objeto de permitir la utilización del nodo BITNET de esta universidad ha permitido que Venezuela se incorpore a este novedoso sistema de informática médica. Mediante el apoyo de IBM se espera que Venezuela y otros países latinoamericanos cuenten pronto con nodos BITNET propios y redes internas..

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Se evaluó la eficacia clínica y velocidad de respuesta bacteriológica del tinidazol en 21 pacientes adultas (18-33 años) con diagnóstico clínico y bacteriológico de vaginitis por G. vaginalis. Se administró tinidazol en dosis única de 2.0 g por vía oral. Se realizaron las siguientes evaluaciones antes y a las 24 horas, 48 horas y 7 días después del tratamiento con tinidazol: examen ginecológico, test de amines, búsqueda de célula guía (clue-cell) y aislamiento en fresco y cultivo G. vaginalis. Se observó una rápida respuesta clínica y bacteriológica y a las 48 horas la curación clínica y bacteriológica fue del 90% y 71.4% respectivamente. El tinidazol fue bien tolerado. Puede considerarse al tinidazol como una alternativa de elección en el tratamiento de vaginitis por G. vaginalis

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