Julian E. De Lia

Maternal metabolic abnormalities in twin-to-twin transfusion syndrome at mid-pregnancy.

We report abnormal maternal laboratory parameters in twin-to-twin transfusion syndrome (TTTS) at mid-pregnancy. A retrospective chart review was undertaken of 109 patients with TTTS evaluated for placental laser surgery. Complete blood count (CBC), blood type and Rh factor, urine analysis and serum chemistry panel were obtained preoperatively, with the CBC and serum albumin repeated on the first postoperative day. The mean gestational age was 21.2+/-1.7 weeks. Initial abnormal values included hematocrit (32.1+/-3.0%), hemoglobin (11.0+/-1.03 g/dl), serum magnesium (1.71+/-0.17 mg/dl), total protein (6.08+/-0.55 g/dl) and albumin (3.06+/-0.34 g/dl). Despite minimal blood loss and conservative fluid replacement mean hematocrit, hemoglobin, and albumin were 27.3+/-2.74%, 9.3+/-0.94 g/dl and 2.56+/-0.23 g/dl, respectively on postoperative day one. Weight gain (8.0+/-5.5 lb.) and low urinary output were characteristic peri-operative events. Maternal hypoproteinemia and anemia occur in TTTS at mid-pregnancy. This may contribute independently to amniotic fluid production rates in the fetuses, and explain in part the maternal sensitivity to intravenous fluids in multiple pregnancy.

Placental Laser Surgery for Severe Previable Feto-fetal Transfusion Syndrome in Triplet Gestation

Information on feto-fetal transfusion syndrome (FFTS) in higher-order multifetal gestation is limited. We report outcomes of 10 triplet pregnancies treated by fetoscopic laser occlusion of the chorioangiopagous vessels (FLOC). The study period was August 1992 to August 2008. Inclusion criteria were gestational age < or =25 weeks and ultrasound confirmation of monochorionicity in at least one twin set and FFTS. Treatment included FLOC, exit amnioreduction, and cerclage when indicated. Hospital records, placental pathology, neonatal course, and long term follow-up of the mother and infants were reviewed. There were eight triamnionic dichorionic and two triamnionic monochorionic triplets. Mean maternal age was 29.8 years, and five conceived following in vitro fertilization. FFTS stage at treatment was > or =II in all cases, at a mean gestational age 20.9 +/- 2.2 weeks. Two patients required immediate rescue cerclage, and all 10 had hypoproteinemia and anemia. Mean age at delivery was 31.2 +/- 3.4 weeks, with a mean birth weight 1568.4 +/- 498 g for the live-born fetuses. Twenty-three (77%) fetuses survived, with at least one fetus surviving in 9 (90%) cases. Cerebral ultrasound imaging and neurological examination were normal in all neonates, and clinical follow-up has remained normal at 67.5 +/- 56 months for the group. FLOC is feasible in dichorionic and monochorionic triplet pregnancy complicated by FFTS. Outcomes are comparable to our experience with twins, namely improved perinatal survival and neonatal morbidity when compared with alternative treatments.

Cherney versus midline vertical incision for myomectomy or hysterectomy of a significantly enlarged uterus

Abstract OBJECTIVE: Our purpose was to determine whether a different in clinical outcome could be demonstrated with the choice of Cherney versus vertical incision in patients undergoing surgical treatment of large benign uterine myomas. STUDY DESIGN: Twenty consecutive patients underwent hysterectomy or myomectomy for a large (five or more times normal size) myomatous uterus through a Cherney incision. A pathologist blinded for clinical outcome matched the specimens removed from the Cherney group with 20 others removed through vertical incisions during the corresponding period on the basis of specimen weight alone. A chart review was undertaken to determine significant demographic and outcome variables, with particular attention to clinical course and operative complications. RESULTS: The groups were similar in age, race, parity, body mass index, preoperative hematocrit, associated illnesses, type of anesthesia and anesthetic agents, associated surgical fiindings, and associated surgical procedures. No significant differences were detected in the duration of anesthesia, surgical procedure or hospital stay, volume of perioperative blood loss, narcotic analgesic usage, or the number of minor or major complications. Trends toward greater blood loss, transfusion, and complications in the vertical group may have been related to exposure, whereas longer duration of surgery and greater postoperative analgesic use were seen with Cherney incisions. CONCLUSION: No clinical difference could be demonstrated with incision choice in a group of 40 patients having surgical treatment of large uterine myomas.

Twin-to-twin transfusion syndrome--30 years at the front.

Thirty years ago, twin-to-twin transfusion syndrome (TTTS) was one of the most challenging problems of modern obstetrics. The associated mortality and morbidity was staggering, and a sense of hopelessness prevailed among clinicians and pediatric pathologists. Technical advances in ultrasound, endoscopy, video recording, and medical lasers formed the basis for diagnosis and in utero therapy of placental disorders. We review some historical events which gave rise to a new treatment modality for TTTS, fetoscopic laser occlusion of chorioangiopagous vessels, now the most common operation performed worldwide in behalf of fetuses in peril.