RESUMO
INTRODUCTION: Identification of intertwin anastomosis may be challenging during fetoscopy in cases with complete anterior placenta. The aim of this study was to describe the technique, feasibility, and outcomes of flexible video fetoscopy for laser coagulation in monochorionic (MC) twin pregnancies with twin-to-twin transfusion syndrome (TTTS) presenting with inaccessible anterior placenta. METHODS: From April 2021 to March 2022, a prospective cohort of consecutive MC twin pregnancies complicated with TTTS presenting with anterior placenta after 20 weeks was recruited. Cases with inaccessible anterior placenta during standard technique were converted into flexible video fetoscopy for completion of laser coagulation of placental anastomoses using a 270° flexible video endoscope through the same uterine port. Descriptive analysis includes feasibility, remaining anastomoses requiring laser photocoagulation, and perinatal outcomes. RESULTS: A total of 45 pregnancies with TTTS were treated with fetoscopic laser therapy during the 1-year study period. Twenty-one pregnancies presented with anterior placenta after 20 weeks, in which an inaccessible vascular equator was observed in 33.3% (7/21). Flexible video fetoscopy was successfully performed in all 7 cases at a median gestational age of 22+2 (20+0-27+1) weeks+days. Visualization of the entire placental surface, coagulation of selected vessels, and exploration of the entire vascular equator were achieved in all cases. Six cases (85.7%) required additional laser coagulation due to either vascular patency despite initial coagulation with conventional fetoscopy (1/6, 16.7%) and/or remaining noncoagulated anastomoses (5/6, 83.3%). Perinatal survival of at least one twin and both twins was achieved in 85.7% and 57.1%, respectively. DISCUSSION: Flexible video fetoscopy for completion of laser coagulation of placental anastomoses is feasible and represents a good option for TTTS cases presenting after 20 weeks with inaccessible anterior placenta.
Assuntos
Transfusão Feto-Fetal , Terapia a Laser , Gravidez , Feminino , Humanos , Lactente , Transfusão Feto-Fetal/diagnóstico por imagem , Transfusão Feto-Fetal/cirurgia , Placenta/cirurgia , Placenta/irrigação sanguínea , Fetoscopia/métodos , Estudos Prospectivos , Estudos de Viabilidade , Fotocoagulação a Laser/métodos , Idade GestacionalRESUMO
OBJECTIVE: To describe the characteristics of amniotic fluid sludge obtained from patients in term and preterm gestations. METHODS: This cross-sectional study included patients with dense aggregates of particulate matter detected in amniotic fluid, observed with transvaginal sonography. All patients were in labor and had an impending delivery, either preterm or at term. Echogenic material contained within amniotic fluid was retrieved transvaginally by needle amniotomy under direct visualization. The amniotic fluid analysis consisted of a Gram stain, cultures for aerobic/anaerobic bacteria and genital mycoplasmas, and a white blood cell count. RESULTS: Twenty-five patients ranging from 18 to 41 weeks of gestation were included in the study. We observed the following: (1) the appearance of amniotic fluid was consistent with pus-like material, vernix, or meconium by naked eye examination; (2) samples collected before 33 weeks of gestation (n = 13) had a pus-like appearance; however, after this gestational age, most of the samples [83% (10/12)] appeared to be consistent with vernix; (3) amniotic fluid cultures were positive for microorganisms in 13 patients, of which 10 were preterm gestations before 33 weeks; (4) the most frequent microorganisms retrieved by culture were genital mycoplasmas (Ureaplasma urealyticum [46% (6/13)]), followed by Mycoplasma hominis [31% (4/13)] and Candida albicans [15% (2/13)]; and (5) patients with sonographic particulate matter in preterm gestations frequently presented acute histologic chorioamnionitis and funisitis, but these conditions were rare in patients at term. CONCLUSION: The nature of amniotic fluid particulate material varies as a function of gestational age. The material obtained in preterm gestations is frequently related to an inflammatory process, while that obtained at term is often consistent with vernix and appears to represent a maturational process.
Assuntos
Corioamnionite , Complicações Infecciosas na Gravidez , Gravidez , Recém-Nascido , Feminino , Humanos , Líquido Amniótico/diagnóstico por imagem , Líquido Amniótico/microbiologia , Esgotos , Amniocentese , Estudos Transversais , Complicações Infecciosas na Gravidez/diagnóstico , Corioamnionite/diagnóstico , Corioamnionite/microbiologia , Material Particulado , SupuraçãoRESUMO
Fetal lymphangioma is an uncommon congenital malformation that is mainly comprised of the subcutaneous tissue of the neck. This malformation can develop in other areas like the thoracic and axillary regions, though rarely. We report 6 consecutive cases of lymphatic malformation in a fetal center in Dominican Republic. In our case series fetal chest lymphangiomas were present in 2 fetuses. In addition, 2 cases of axillary lymphangiomas also involved the thoracic region. Adequate management by a multidiciplinary team is necessary to provide a better approach to delivery.
Assuntos
Linfangioma , Anormalidades Linfáticas , Feminino , Feto , Humanos , Linfangioma/diagnóstico por imagem , Gravidez , Diagnóstico Pré-Natal , Ultrassonografia Pré-NatalRESUMO
The amniotic band syndrome (ABS) is characterized by accumulation of fibrous tissue bands or strings that adhere to the fetus and may produce compression in different sites. Most cases present multiple congenital anomalies incompatible with life. A small group of fetuses have isolated constrictions of the limb that may cause severe limb dysfunction or limb amputation if not treated during pregnancy. This rare condition occurs in approximately 1:1 200 to 1:15 000 live births. The exact cause of ABS remains uncertain; however, theories of intrinsic, extrinsic and iatrogenic reasons have been proposed. The evolution of the limb affected by ABS is characterized by progression of distal edema due to venous obstruction, and intrauterine amputation of the limb from vascular insufficiency. Fetoscopic release of the amniotic bands through minimally invasive surgery techniques may allow life preservation as well as limb function. Literature review suggests that fetoscopic release of amniotic bands allows preservation of limb function in 50% of cases.
El síndrome de bandas amnióticas (SBA) se caracteriza por un acúmulo de bandas o cuerdas de tejido fibroso que se adhieren al feto y pueden producir compresión en diferentes partes del mismo. La gran mayoría de los casos presentan múltiples anomalías congénitas incompatibles con la vida. En un pequeño grupo de fetos se evidencian constricciones aisladas de la extremidad, las cuales pueden causar disfunción severa de la extremidad o amputación del miembro si no son tratadas mientras el feto está todavía en el útero. Esta rara condición ocurre en aproximadamente 1:1 200 a 1:15 000 nacidos vivos. La causa exacta de SBA permanece incierta; sin embargo, se plantean teorías de origen intrínseco, extrínseco y iatrogénico. La evolución de la extremidad afectada por SBA se caracteriza por la progresión de edema distal debido a obstrucción venosa, con amputación intrauterina del miembro secundaria a insuficiencia vascular. La liberación fetoscópica de las bandas amnióticas a través de técnicas de cirugía mínimamente invasivas, puede permitir la preservación de la vida, así como la función de los miembros en los casos de fetos con diagnóstico de SBA. Al revisar la literatura se concluye que la liberación fetoscópica de bandas amnióticas permite la preservación de la función de la extremidad en 50% de los casos.
RESUMO
Microcystic fetal lung tumors or masses such as the congenital cystic adenomatoid malformation (CCAM) and bronchopulmonary sequestration (SBP) are rare congenital pathologies, diagnosed by ultrasound during prenatal assessment, with a high mortality rate of 95% as a consequence of prenatal complications due to hydrops and postnatal death from pulmonary hypoplasia. Minimally invasive therapies using sclerosing agents are positioned among the low cost and highly effective techniques for such pathologies. Methodology: We conducted a prospective, randomized, blind clinical study in 17 pregnant women with diagnosis of fetal microcystic CCAM or hybrid lesion (CCAM + SBP), who were treated with betamethasone or polidocanol. Alternative therapy was employed in case of failure of the initial procedure. Results: In four (44.4%) of the nine cases treated with betamethasone, the alternative therapy of sclerosis with polidocanol was required for treatment due to fetal compromise. Involution of the lung lesion and the hydropic condition was faster and progressive with percutaneous sclerotherapy compared to the maternal steroid effect. Perinatal results were also more satisfactory in the group with polidocanol (91.7%) than in the group with the steroid (60%). Conclusions: Percutaneous sclerotherapy with polidocanol was found efficacious for CCAM and hybrid lesion treatment, with faster and more efficient resolution of the pathology in cases resistant to previously administered steroid therapy.
Las tumoraciones o masas pulmonares fetales microquísticas, tales como la malformación adenomatoidea quística congénita (CCAM, por sus siglas en inglés) y el secuestro bronco pulmonar (SBP), representan patologías congénitas poco frecuentes, diagnosticadas por ultrasonido durante la evaluación prenatal, con un alto índice de mortalidad de 95% como consecuencia de las complicaciones prenatales por hidropesía y fallecimiento posnatal debido a hipoplasia pulmonar. Las terapias de mínima invasión usando agentes esclerosantes han tomado posicionamiento entre las técnicas de bajo costo y alta efectividad para dichas patologías. Metodología. Se realizó un estudio clínico prospectivo, aleatorio, ciego, en 17 embarazadas con diagnóstico de CCAM microquística o de lesión híbrida (CCAM +SBP) tratadas con betametasona o con polidocanol, optando por la terapia alternativa en caso de fallar la técnica inicial. Resultados. En 4/9 (44,4%) de los 9 casos tratados con betametasona se requirió la terapia alternativa de esclerosis con polidocanol para la resolución del cuadro, que comprometía el estado fetal. La involución de la lesión pulmonar y del cuadro hidrópico fue más rápida y progresiva con la escleroterapia percutánea en comparación con el efecto esteroideo materno. Los resultados perinatales fueron asimismo más satisfactorios en el grupo con polidocanol (91,7%) que en el grupo con el esteroide (60%). Conclusiones. Se comprobó la eficacia de la escleroterapia percutánea con polidocanol para el tratamiento de la CCAM y de lesión híbrida, con resolución más rápida y eficaz de la patología en los casos donde existía resistencia a la terapia esteroidea previamente administrada.