A. Shamshirsaz

Unusual pleuroamniotic shunt complication managed using a two‐port in‐CO2 fetoscopic technique: technical and ethical considerations

We report a case of fetal upper arm constriction by a pleuroamniotic shunt, treated fetoscopically using a two-port, in-CO2 gas technique. A 35-year-old, gravida six, para four woman presented at 21 + 4 weeks’ gestation with a fetus with bilateral pleural effusions and non-immune hydrops, which resolved after bilateral double pigtail catheters were inserted. At 28 weeks, one of the shunts was seen encircling the fetal left upper arm. Over 2 weeks this progressed to a deep indentation with distal arm edema (Figure 1). A plastic surgeon recommended release of the constriction to prevent superficial nerve damage and possible vascular consequences. An extensive anterior placenta prevented percutaneous access to the amniotic cavity. At 30 + 2 weeks’ gestation, after extensive counseling regarding her options, a laparotomy under deep general anesthesia was performed and the uterus was exteriorized. Vecuronium and fentanyl were given into the fetal left arm intramuscularly as an anesthetic. A 12 F vascular cannula was then inserted into the amniotic space using the Seldinger technique and sutured in place, and a pediatric cystoscope (Storz, Tuttlingen, Germany) with a 1-mm Storz grasper was used to attempt to unwind the shunt (which exited the fetal chest in the left armpit). There was a film of tissue growing over the shunt making it impossible to unwind the device. Approximately 60 mL of amniotic fluid was then removed and replaced with 200 mL CO2 gas (0.5 L/min, 12 mmHg). A second 12 F port was placed under direct vision and sutured in place. The CO2 allowed excellent visualization of the fetal upper body and area of interest. A 3-mm laparoscopic grasper introduced via the second 12 F port was used to slowly unwind the shunt from the fetal arm (Videoclip S1). Using the 1-mm hysteroscopic grasper we stabilized the shunt and cut it 1 cm from the chest wall with 3-mm laparoscopic scissors, placed through the second port (Figure 2). A pediatric cardiologist continuously monitored the fetal heart rate and cardiac function, which remained normal. There were no signs of maternal hypercarbia or fetal acidosis. At completion of the surgery, the gas was slowly removed and replaced with warmed saline and the ports were closed with 2/0 vicryl sutures. Operative time was 42 min. Repeat ultrasound on a weekly basis revealed resolution of the left arm swelling and minimal residual indentation. At 38 + 2 weeks’ gestation the patient presented with spontaneous rupture of membranes, and following pitocin augmentation she had an uncomplicated spontaneous vaginal delivery. The right shunt was removed without Figure 1 Preoperative ultrasound image showing constriction of fetal left arm by shunt (double pigtail catheter).

Fetal laryngoscopy to evaluate vocal folds in a fetus with congenital high airway obstruction syndrome (CHAOS)

Congenital high airway obstruction syndrome (CHAOS) is a rare fetal condition in which an intrinsic obstruction of the upper airway is present, ranging from a simple airway stenosis to complete agenesis with fused vocal cords1. The general level of obstruction can be readily identified by fetal ultrasound and magnetic resonance imaging (MRI), but determining specific causes and severity of obstruction (e.g. long-segment laryngeal atresia vs a thin membrane) has been a challenge2. We report here the feasibility of using fetal laryngoscopy to evaluate the vocal cords of a fetus with CHAOS. A 46-year-old woman, gravida 3 para 0, was referred at 19 weeks’ gestation with a fetus showing sonographic features of CHAOS. These included a dilated trachea and bronchial tree, as well as bilaterally hyperechoic lungs with significant ascites and inverted diaphragm. There was no hydrops nor associated anomalies. There was no sign of Fraser syndrome. A fetal echocardiogram demonstrated normal anatomy and function with mildly increased cardiac output but no evidence of fetal heart failure. Fetal ultrasound and MRI revealed obstruction at the level of the larynx, with a probable obstructing membrane at the level of the subglottic airway, just below the vocal folds (Figure 1a). The karyotype was normal. The patient and her husband requested information about the condition of the fetal vocal cords and the severity of obstruction. Following multidisciplinary counseling, they elected to undergo fetoscopic diagnostic laryngoscopy to evaluate the anatomy of the larynx and trachea. In the event that the vocal cords were intact and that the obstruction could be relieved, the parents requested that we attempt laser treatment to open the obstructed trachea. The institutional Fetal Therapy Board approved the procedure. At 21 weeks’ gestation, fetoscopic laryngoscopy was performed under maternal sedation with local anesthesia and ultrasound-guided fetal intramuscular anesthesia. Using the same technique as for fetal endoscopic tracheal occlusion, the fetoscope was advanced into the amniotic cavity3. The fetoscope was advanced down the oropharynx until the esophagus was seen. On fetoscopic visualization, the oropharynx, epiglottis, supraglottic structures and esophagus were noted to be normal. However, the vocal cords were fused and no location for laryngeal entry was seen (Figure 1b). An interstitial 400μm laser fiber was advanced until it made contact with the mid-sagittal area of vocal cord fusion, and we attempted to open the obstruction using a diode laser (Multibeam, Dornier Medtech, Kennesaw, GA, USA), in order to evaluate the extent of the atresia. The procedure was abandoned Fused vocal cords Epiglottis

Neurological outcomes by mode of delivery for fetuses with open neural tube defects: a systematic review and meta‐analysis

Controversy exists regarding the optimal mode of delivery for fetuses with open neural tube defects.

Fetoscopic laser ablation of vasa previa in pregnancy complicated by giant fetal cervical lymphatic malformation

Vasa previa is a rare complication of pregnancy that is classified as Type 1 if velamentous umbilical cord insertion causes fetal blood vessels to traverse the internal cervical os and Type 2 if the fetal vessels are connected to a bilobed placenta and cover the internal cervical os1. It has been associated with high perinatal mortality due to fetal exsanguination following vessel damage at the time of membrane rupture. Accurate prenatal diagnosis and appropriate timing of Cesarean delivery improve neonatal outcome2. Successful cases of intrauterine laser photocoagulation of Type 2 vasa previa have been reported previously3–5.

Pregnancy after endometrial ablation: a systematic review

Pregnancies have been reported after endometrial ablation but there is little data regarding subsequent pregnancy outcomes.

OP11.06: Do placental and amniotic membrane pathological changes occur following open and fetoscopic neural tube defect (NTD) repair?: Short oral presentation abstracts

one showed a fluctuant colour, between bright red and dark purple (bidirectional flow), which is rare in this type of anastomoses that usually have unidirectional flow. Results: In 9 of the 10 cases, there was intrauterine demise of the sick twin within the next 4 weeks after surgery. The changing colour in the AV anastomosis which is supposed to be unidirectional, was due to the low central blood pressure of the premortem small twin which turns into a low vascular pressure in the chorionic arterial branch too low to overcome the pressure of the chorionic vein branch of the normal twin at the level of the AV anastomosis. Conclusions: MCDA twin pregnancies complicated with a severe sFGR type II with no superimposed TTTS and that showed during Fetoscopic surgery a fluctuant change of colour at the level of an AV anastomosis had a high mortality rate of the small twin.

OP23.08: Longitudinal growth evaluation in fetuses with neural tube defect with and without prenatal-fetoscopic and open-repair

Objectives: An interstitial laser ablation becomes a good candidate for the prenatal treatment of chorioangioma, sacrococcygeal teratoma, selective fetal growth restriction and twin reversed arterial perfusion sequence in early gestation. The aim of this study was to describe the in vitro results of interstitial laser coagulation in different types of laser generator, power and time. Methods: Total 144 placentae were interstitially ablated with PlexoLong 19 gauge needle, 400 micron laser fiber and Nd:YAG or Diode at 12 power-time combinations (5, 10, 15 seconds versus 15, 20, 25, 30 watts). We evaluated the diameter of coagulated zone using ultrasound and histopathology. Results: Mean coagulated placental diameter (ultrasound) was shown in figure 1. Ablated size measurement by ultrasound was slightly larger than microscopy (p<0.001). The average length (histopathology) after 5, 10 and 15 seconds of coagulation were 5.12, 7.00 and 7.85 mm (±0.16), and after using power 15, 20, 25 and 30 watt were 5.20, 6.36, 7.08 and 7.99 mm (±0.21), respectively. In addition, using the Diode was significantly wider than using Nd:YAG in coagulated diameter (p<0.001). Histology of the placental tissue showed gradual change in degree of thermal damage and period of time. Conclusions: Interstitial laser ablation particular Diode, seems to be an effective prenatal treatment when the feeding vessels are smaller than 8 mm in diameter.