RESUMO
OBJECTIVES: A recent European randomized trial - Tracheal Occlusion To Accelerate Lung Growth - demonstrated that fetoscopic endoluminal tracheal occlusion (FETO) is associated with increased postnatal survival among infants with severe congenital diaphragmatic hernia (CDH). However, this differs in middle-income countries such as Brazil, where abortion is illegal and neonatal intensive care is inadequate. This study evaluated the effects of FETO on improving the survival of infants with moderate-to-severe CDH in isolated and non-isolated cases. METHODS: This retrospective cohort study selected 49 fetuses with CDH, a normal karyotype, and a lung-to-head ratio (LHR) of <1 from a single national referral center for fetal surgery in São Paulo, Brazil, between January 2016 and November 2019. FETO was performed between 26 and 29 weeks of gestation. The primary outcomes were infant survival until discharge from the neonatal intensive care unit and survival until six months of age. RESULTS: Forty-six women with singleton fetuses having severe CDH underwent prenatal intervention with FETO. Infant survival rates until discharge and at six months of age were both 38â¯%. The observed-to-expected LHR increased by 25â¯% after FETO in neonates who survived until discharge. Spontaneous intrauterine death occurred in four growth-restricted fetuses after FETO. Preterm birth in <37 weeks and preterm rupture of membranes in <34 weeks occurred in 56.5â¯% (26) and 26â¯% (12) cases, respectively. CONCLUSIONS: FETO may increase neonatal survival in fetuses with severe CDH, particularly in countries with limited neonatal intensive care.
Assuntos
Fetoscopia , Hérnias Diafragmáticas Congênitas , Traqueia , Hérnias Diafragmáticas Congênitas/cirurgia , Hérnias Diafragmáticas Congênitas/terapia , Hérnias Diafragmáticas Congênitas/mortalidade , Humanos , Feminino , Fetoscopia/métodos , Fetoscopia/estatística & dados numéricos , Estudos Retrospectivos , Gravidez , Traqueia/cirurgia , Recém-Nascido , Brasil/epidemiologia , Adulto , Lactente , Resultado do Tratamento , Masculino , Taxa de SobrevidaRESUMO
OBJECTIVE: A trial comparing prenatal with postnatal open spina bifida (OSB) repair established that prenatal surgery was associated with better postnatal outcome. However, in the trial, fetal surgery was carried out through hysterotomy. Minimally invasive approaches are being developed to mitigate the risks of open maternal-fetal surgery. The objective of this study was to investigate the impact of a novel neurosurgical technique for percutaneous fetoscopic repair of fetal OSB, the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique, on long-term postnatal outcome. METHODS: This study examined descriptive data for all patients undergoing fetoscopic OSB repair who had available 12- and 30-month follow-up data for assessment of need for cerebrospinal fluid (CSF) diversion and need for bladder catheterization and ambulation, respectively, from eight centers that perform prenatal OSB repair via percutaneous fetoscopy using a biocellulose patch between the neural placode and skin/myofascial flap, without suture of the dura mater (SAFER technique). Univariate and multivariate logistic regression analyses were used to examine the effect of different factors on need for CSF diversion at 12 months and ambulation and need for bladder catheterization at 30 months. Potential cofactors included gestational age at fetal surgery and delivery, preoperative ultrasound findings of anatomical level of the lesion, cerebral lateral ventricular diameter, lesion type and presence of bilateral talipes, as well as postnatal findings of CSF leakage at birth, motor level, presence of bilateral talipes and reversal of hindbrain herniation. RESULTS: A total of 170 consecutive patients with fetal OSB were treated prenatally using the SAFER technique. Among these, 103 babies had follow-up at 12 months of age and 59 had follow-up at 30 months of age. At 12 months of age, 53.4% (55/103) of babies did not require ventriculoperitoneal shunt or third ventriculostomy. At 30 months of age, 54.2% (32/59) of children were ambulating independently and 61.0% (36/59) did not require chronic intermittent catheterization of the bladder. Multivariate logistic regression analysis demonstrated that significant prediction of need for CSF diversion was provided by lateral ventricular size and type of lesion (myeloschisis). Significant predictors of ambulatory status were prenatal bilateral talipes and anatomical and functional motor levels of the lesion. There were no significant predictors of need for bladder catheterization. CONCLUSION: Children who underwent prenatal OSB repair via the percutaneous fetoscopic SAFER technique achieved long-term neurological outcomes similar to those reported in the literature after hysterotomy-assisted OSB repair. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Assuntos
Fetoscopia/estatística & dados numéricos , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Espinha Bífida Cística/cirurgia , Cateterismo Urinário/estatística & dados numéricos , Ventriculostomia/estatística & dados numéricos , Caminhada/estatística & dados numéricos , Feminino , Fetoscopia/métodos , Feto/cirurgia , Seguimentos , Idade Gestacional , Humanos , Histerotomia/métodos , Histerotomia/estatística & dados numéricos , Lactente , Recém-Nascido , Modelos Logísticos , Procedimentos Neurocirúrgicos/métodos , Período Pós-Operatório , Gravidez , Espinha Bífida Cística/complicações , Espinha Bífida Cística/embriologia , Resultado do Tratamento , Bexiga Urinária , Derivação Ventriculoperitoneal/estatística & dados numéricosRESUMO
PURPOSE: To provide a comprehensive overview of the perinatal and maternal outcomes of fetuses undergoing EXIT surgery for the management of fetal airway obstruction secondary to cervical or oral tumors. METHODS: A comprehensive search from inception to September 2018 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported an EXIT surgery in singleton were considered eligible. A descriptive analysis was performed. RESULTS: Out of the 250 full-text study reports, 120 articles reporting 235 cases of EXIT surgery were included. EXIT surgery was performed at 35.1â¯weeks of gestation on average. The most frequent diagnosis was teratoma (46.4%, nâ¯=â¯109/235). There were 13 adverse maternal events, and the most frequent one was postpartum hemorrhage (4.7%, nâ¯=â¯11/235). No maternal death was reported. Fetal and neonatal death occurred in 17% (40/235) of the cases. There were 29 adverse fetal events (12.2%), and the most frequent one was the failure of intubation or tracheostomy (3.4%, nâ¯=â¯8/235). CONCLUSION: EXIT surgery could be considered for the management of an oral or cervical tumor that's highly suspicious of blocking the fetal airway. This systematic review reports that EXIT surgery poses substantial risks of maternal and fetal adverse events, including neonatal death. LEVEL OF EVIDENCE: IV case series with no comparison group.
Assuntos
Obstrução das Vias Respiratórias/cirurgia , Doenças Fetais/cirurgia , Fetoscopia , Feminino , Fetoscopia/efeitos adversos , Fetoscopia/métodos , Fetoscopia/mortalidade , Fetoscopia/estatística & dados numéricos , Feto/cirurgia , Humanos , GravidezRESUMO
BACKGROUND: Fetal aortic stenosis (AoS) may progress to hypoplastic left heart syndrome (HLHS) in utero. There are currently no data, prenatal or postnatal, describing survival of fetuses or neonates with AoS or HLHS in a country with suboptimal postnatal management. STUDY DESIGN: Prospective cohort study performed in Mexico, including cases diagnosed with AoS and HLHS within a 6-year period. AoS patients fulfilling previously published criteria for evolving HLHS (eHLHS) were offered fetal aortic valvuloplasty. Outcome variables were perinatal mortality, postnatal management, type of postnatal circulation, and overall survival. RESULTS: Fifty-four patients were included: 16 AoS and 38 HLHS. Eighteen patients had associated anomalies and/or an abnormal karyotype. Seventy-four percent of HLHS received comfort measures, with only three cases reporting an attempt at surgical palliation, and one survivor of the first stage. Fetal aortic valvuloplasty was performed successfully in nine cases of eHLHS. Overall postnatal survival was 44% in AoS with fetal aortic valvuloplasty, and one case (ongoing) in the HLHS group. CONCLUSIONS: HLHS in Mexico carries more than a 95% risk of postnatal death, with little or no experience at surgical palliation in most centers. Fetal aortic valvuloplasty in AoS may prevent progression to HLHS and in this small cohort was associated with ≈50% survival.
Assuntos
Valvuloplastia com Balão , Coração Fetal/cirurgia , Fetoscopia , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Cuidado Pós-Natal/estatística & dados numéricos , Resultado da Gravidez/epidemiologia , Adulto , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/patologia , Estenose da Valva Aórtica/cirurgia , Valvuloplastia com Balão/métodos , Valvuloplastia com Balão/estatística & dados numéricos , Estudos de Coortes , Circulação Coronária/fisiologia , Feminino , Coração Fetal/patologia , Fetoscopia/efeitos adversos , Fetoscopia/reabilitação , Fetoscopia/estatística & dados numéricos , Idade Gestacional , Humanos , Síndrome do Coração Esquerdo Hipoplásico/diagnóstico , Síndrome do Coração Esquerdo Hipoplásico/epidemiologia , Recém-Nascido , Masculino , México/epidemiologia , Mortalidade Perinatal , Cuidado Pós-Natal/normas , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Gravidez , Cuidado Pré-Natal/métodos , Cuidado Pré-Natal/estatística & dados numéricos , Estudos Retrospectivos , Análise de Sobrevida , Adulto JovemRESUMO
AIM: To establish the provision of fetal surgery for myelomeningocele (MMC) worldwide. METHODS: Through the International Society for Prenatal Diagnosis (ISPD) Fetal Therapy Special Interest Group and the North American Fetal Therapy Network (NAFTNet), fetal therapy centres were surveyed (September 2017-June 2018) regarding availability of fetal MMC surgical repair, patient inclusion criteria, repair techniques, number of cases, and outcome reporting. Responses were summarised on an interactive map on the ISPD website. RESULTS: Forty-four of 59 centres responded (74.6%) of which 34 centres (77.1%) currently offered fetal surgery for MMC and seven centres (15.9%) were awaiting a first case after service set up. Patient inclusion criteria were similar and based on the Management of Myelomeningocele (MOMS) trial. Five centres (14.7%) operated beyond 26 weeks' gestational age, outside the MOMS criteria. Open fetal surgery was provided in 23 centres (67.6%), fetoscopic surgery only in five (14.7%), and six centres offered both types (17.6%). Neurosurgical closure was similar for open surgery but highly variable in fetoscopy surgery. The median number of cases per centre was 21 (range 1-253). CONCLUSIONS: Fetal surgery for MMC is now offered globally. Two thirds of centres offer open repair via hysterotomy using criteria based on the MOMS trial.
Assuntos
Fetoscopia/estatística & dados numéricos , Feto/cirurgia , Acessibilidade aos Serviços de Saúde , Meningomielocele/cirurgia , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Ásia , Austrália , Europa (Continente) , Feminino , Terapias Fetais , Humanos , América do Norte , Gravidez , América do SulRESUMO
El diagnóstico intrauterino y el tratamiento de las anormalidades, tales como hidrocefalia obstructiva congénita, hidronefrosis y hernia diafragmática, mediante cirugía fetal, han obtenido grandes adelantos desde el punto de vista clínico y continúan en evolución. La anestesia para estos procedimientos tiene como objetivo provocar mínimos riesgos para la madre y el feto. Por esta razón, la ténica anestésica debe incluir un monitoreo materno-fetal exhaustivo, durante y después del procedimiento. Las técnicas percutáneas, frecuentemente, requieren anestesia local con sedación. Sin embargo, ésta no provee anestesia adecuada para procedimientos que requieren histerectomía o fetoscopía. Su empleo proporciona confort materno, pero no produce suficiente relajación uterina ni adecuada anestesia fetal. Con el empleo de anestesia general, la tocolisis se mantiene con agentes halogenados y útero-inhibidores, mientras que la anestesia en el feto se logra con el uso de opioides y relajantes musculares, siendo esta técnica segura para ambos. El uso de fármacos útero-inhibidores debe mantenerse durante y después de la histerotomía, que, junto con la analgesia epidural mediante colocación de un catéter, contribuyen a disminuir el riesgo de parto prematuro, logrando el control eficaz del dolor postoperatorio. (AU)
Assuntos
Humanos , Gravidez , Feminino , Doenças Fetais/cirurgia , Doenças Fetais/diagnóstico , Anestesia Geral , Entorpecentes/administração & dosagem , Relaxantes Musculares Centrais/administração & dosagem , Hidrocefalia/cirurgia , Hérnia Diafragmática/cirurgia , Fetoscopia/estatística & dados numéricos , Fetoscopia/métodos , Gravidez/fisiologia , Fatores de Risco , Tocólise , Diagnóstico Pré-Natal , Consentimento Livre e Esclarecido , Fentanila/administração & dosagem , Pancurônio/administração & dosagem , Cuidados Pós-Operatórios , Monitorização Fetal , Medição de Risco , Ética Médica , Dor/prevenção & controleAssuntos
Animais , Cobaias , Âmnio , Fetoscopia/estatística & dados numéricos , Injeções , Surfactantes Pulmonares/administração & dosagem , Síndrome do Desconforto Respiratório do Recém-Nascido/mortalidade , Síndrome do Desconforto Respiratório do Recém-Nascido/prevenção & controle , Síndrome do Desconforto Respiratório do Recém-Nascido/terapiaAssuntos
Animais , Cobaias , Surfactantes Pulmonares/administração & dosagem , Injeções , Fetoscopia/estatística & dados numéricos , Âmnio , Síndrome do Desconforto Respiratório do Recém-Nascido/prevenção & controle , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Síndrome do Desconforto Respiratório do Recém-Nascido/mortalidadeRESUMO
In 1989 at the Hospital Civil of Guadalajara we make a study with 100 patients with a term pregnancy, initial labor and alive fetus. At all women we practiced interrogatory about subjective intensity of fetal movements, amnioscopy and cardiotocographic registry and we compare results with Apgar score of the newborns at minute and five minutes. The fetal movements were normal in 91% of which 95.7% had Apgar score > or = 7 at minute and 98.9% Apgar score > or = 8 at five minutes; clear amniotic fluid in 75% of which 94.6% had Apgar score > or = 7 at minute and 100% had Apgar > or = 8 at five minutes and 94% with normal cardiotocographic registry of which 95.7% had Apgar score > or = 7 at minute and 100% had Apgar score > or = 8 at five minutes. In the distress fetal prediction, the best method was the cardiotocography and the worse was the meconial amniotic fluid. We conclude that the subjective intensity of fetal movements are similar in the well-being fetal prediction to the amnioscopy and cardiotocography and the physicians must use it in the obstetric care.
Assuntos
Cardiotocografia , Monitorização Fetal/métodos , Movimento Fetal , Fetoscopia , Adolescente , Adulto , Índice de Apgar , Cardiotocografia/estatística & dados numéricos , Estudos de Avaliação como Assunto , Feminino , Monitorização Fetal/estatística & dados numéricos , Fetoscopia/estatística & dados numéricos , Humanos , Recém-Nascido , Masculino , México/epidemiologia , Gravidez , Resultado da Gravidez/epidemiologia , Estudos ProspectivosRESUMO
En 1989 en el Hospital Civil de Guadalajara realizamos un estudio con 100 pacientes con embarazo a término, inicio de trabajo de parto y feto vivo. A todas las mujeres se les realizó interrogatorios sobre la intensidad subjetiva de los movimientos fetales, se les practicó aqmnioscopia y registro carditocográfico comparandose los resultados obtenidos con el Apgar de los recién nacidos al minuto y 5 minutos. Los movimientos fetales fueron normales en 91 por ciento de los cuales 95.7 por ciento tuvieron Apgar * al minuto y 98.9 por ciento Apgar * 8 a los 5 minutos; líquido amiótico claro en 75 por ciento de los cuales 94.6 por ciento tuvieron Apgar * 7 al minuto y 100 por ciento Apgar * 8 a los 5 minutos y 94 por ciento con cardiotocografía normal de los cuales 95.7 por ciento tuvieron Apgar * 7 al minuto y 100 por ciento Apgar * 8 a los 5 minutos. En la predicción de fetos con sufrimiento fetal el manejo método fue la cardiotocografía y el menos útil fue la presencia de líquido amniótico meconial. Se concluye que la predicción del bienestar fetal es similar con la evaluación de la intensidad de los movimientos fetales que con la amnioscopia y cardiotocografía y que es un método que debería utilizarse en todos los servicios de atención obstétrica.