Ramesha Papanna

Prenatal diagnosis and outcome of fetal lung masses

AIM The purpose of this study is to evaluate the accuracy of prenatal diagnostic features, particularly congenital cystic adenomatoid malformation volume ratio (CVR), in predicting outcomes for fetuses with lung masses. METHODS The records and imaging features of all fetuses referred to the Texas Childrens Fetal Center with a fetal lung mass between July 2001 and May 2010 were reviewed retrospectively. Data collected included gestational age (GA) at diagnosis, fetal magnetic resonance imaging findings, CVR, mass size, nature of fetal treatment, surgical findings, pathology, and outcome. Data were analyzed for predicting development of hydrops or the need for fetal therapy using receiver operating characteristic curves. RESULTS Of 82 fetuses (41 male) evaluated for a lung mass, 53 (65%) were left-sided (1 bilateral), and the mean (SD) GA at diagnosis was 21.5 (4.3) weeks. Seventy-three fetuses underwent fetal magnetic resonance imaging at a mean (SD) GA of 26.1 (4.6) weeks. Thirteen fetuses (16%) had fetal treatment. Four fetuses with hydrops underwent open fetal surgical resection, and 3 survived. Six fetuses with large lung masses and persistent mediastinal compression near term underwent ex-utero intrapartum therapy-to-resection procedures, and 3 fetuses with hydrops underwent serial thoracentesis. Congenital cystic adenomatoid malformation volume ratio correlated strongly with the development of hydrops and the need for fetal therapy with an area under the receiver operating characteristic curve of 0.96 (P < .0001) and 0.88 (P < .0001), respectively. Of 18 fetuses with a CVR greater than 2.0 compared with 2 (3%) of 60 with a CVR of 2.0 or less, 10 (56%) required fetal intervention (P < .0001). CONCLUSION Congenital cystic adenomatoid malformation volume ratio correlates strongly with the development of fetal hydrops and the need for fetal intervention. A threshold value of 2.0 yields the most powerful statistical results.

Selective reduction in complicated monochorionic pregnancies: radiofrequency ablation vs. bipolar cord coagulation

To compare radiofrequency ablation (RFA) and bipolar cord coagulation (BPC) methods for selective fetal reduction in the treatment of complicated monochorionic (MC) multifetal gestations.

Use of the Learning Curve-Cumulative Summation test for quantitative and individualized assessment of competency of a surgical procedure in obstetrics and gynecology: fetoscopic laser ablation as a model

OBJECTIVE We sought to determine the learning curve (LC) for fetoscopic laser photocoagulation (FLP) as a model for the evaluation of training in surgical procedures. STUDY DESIGN A retrospective review of consecutive case series of FLP from 2 centers with 3 operators (operator I [O-I], observer trained; operator II [O-II], hands-on trained; and operator III [O-III], clinical fellow) was performed and the LC-cumulative summation (CUSUM) test was plotted. RESULTS The acceptable and unacceptable success rates for at least 1 fetus survival after FLP were set at 82% and 70%, respectively, from a systematic review. A total of 171 consecutive cases were performed by the 3 operators (O-I, 91; O-II, 49; and O-III, 31). From LC-CUSUM test O-I needed 60 procedures, O-II needed 20 procedures, and O-III needed 20 procedures to reach an acceptable performance rate for at least 1 survivor. CONCLUSION The LC-CUSUM test can be used to accurately assess the LC in a surgical procedure in obstetrics and gynecology. Hands-on trained operators exhibit a shorter LC.

The use of combined ultrasound and magnetic resonance imaging in the detection of fetal anomalies.

To compare the referral diagnosis based on prenatal ultrasound to diagnoses made following combined ultrasound (US) and magnetic resonance imaging (MRI) evaluation at the Texas Childrens Fetal Center (TCFC) and postnatal diagnosis.

Chorioamnion separation as a risk for preterm premature rupture of membranes after laser therapy for twin-twin transfusion syndrome.

OBJECTIVE: To compare the outcomes in chorioamnion membrane separation with nonchorioamnion membrane separation cases after fetoscopic laser photocoagulation of placental anastomoses for the treatment of twin to twin transfusion syndrome. METHODS: We performed a retrospective cohort study of twin to twin transfusion syndrome cases that underwent laser ablation at the Texas Childrens Fetal Center from October 2007 to March 2009. The cases were identified from our database. We excluded triplet pregnancies. Chorioamnion membrane separation was identified by ultrasound examination performed within 24 hours of intervention. Preterm premature rupture of membranes (PROM) was defined as rupture of the membranes before 34 weeks of gestation. RESULTS: Ninety-seven cases were included in the analysis; 19 (19.6%) had chorioamnion membrane separation. There were no significant differences in preoperative and intraoperative variables, except for a lower recipient maximum vertical pocket (10.3±2.1 compared with 12.6±3.4; P<.01), and higher rate of iatrogenic septostomy (21% compared with 2.5%; P=.01) in the chorioamnion membrane separation group. Postoperatively, the incidence of preterm PROM was 74% in chorioamnion membrane separation group compared with 23% in the nonchorioamnion membrane separation group (relative risk 3.2, 95% confidence interval 1.9–4.4). The procedure-to-delivery interval was reduced by 20 days in the chorioamnion membrane separation group (P<.01). The neonatal survival rate was 63.2% in the chorioamnion membrane separation group compared with 84% in the nonchorioamnion membrane separation group (P=.016). CONCLUSION: A low preoperative recipient maximum vertical pocket is associated with increased risk of chorioamnion membrane separation. Postoperative chorioamnion membrane separation after laser surgery for twin to twin transfusion syndrome is a major risk factor for preterm PROM, early delivery, and an increase in perinatal mortality. LEVEL OF EVIDENCE: II

Chorioamnion plugging and the risk of preterm premature rupture of membranes after laser surgery in twin-twin transfusion syndrome

To examine the incidence of preterm premature rupture of membranes (PPROM) in pregnancies affected by twin–twin transfusion syndrome (TTTS) treated with laser photocoagulation where an absorbable gelatin sponge was used as a chorioamnion sealant of the fetoscopic access port.

Fetal pulmonary response after fetoscopic tracheal occlusion for severe isolated congenital diaphragmatic hernia

OBJECTIVE: To estimate the response in lung growth and vascularity after fetal endoscopic tracheal occlusion for severe congenital diaphragmatic hernia in the prediction of neonatal survival. METHODS: Between January 2006 and December 2010, fetal lung parameters (observed-to-expected lung-to-head ratio; observed-to-expected lung volume; and contralateral lung vascularization index) were evaluated before fetal tracheal occlusion and were evaluated longitudinally every 2 weeks in 72 fetuses with severe isolated congenital diaphragmatic hernia. Thirty-five fetuses underwent fetal endoscopic tracheal occlusion and 37 cases did not. RESULTS: Survival rate was significantly higher in the fetal endoscopic tracheal occlusion group (54.3%) than in the no fetal endoscopic tracheal occlusion group (5.4%, P<.01). Fetal endoscopic tracheal occlusion resulted in a significant improvement in fetal lung size and pulmonary vascularity when compared with fetuses that did not go to the fetal intervention (increase of the observed-to-expected lung-to-head ratio, observed-to-expected total lung volume, and contralateral pulmonary vascularization index 56.2% compared with 0.3%, 37.9% compared with 0.1%, and 98.6% compared with 0.0%, respectively; P<.01). Receiver operating characteristic curves indicated that the observed-to-expected total fetal lung volume was the single best predictor of neonatal survival before fetal endoscopic tracheal occlusion (cutoff 0.23, area under the curve [AUC] 0.88, relative risk 5.3, 95% confidence interval [CI] 1.4–19.7). However, the contralateral lung vascularization index at 4 weeks after fetal endoscopic tracheal occlusion was more accurate in the prediction of neonatal outcome (cutoff 24.0%, AUC 0.98, relative risk 9.9, 95% CI 1.5–66.9) with the combination of observed-to-expected lung volumes and contralateral lung vascularization index at 4 weeks being the best predictor of outcome (AUC 0.98, relative risk 16.6, 95% CI 2.5–112.3). CONCLUSION: Fetal endoscopic tracheal occlusion improves survival rate by increasing the lung size and pulmonary vascularity in fetuses with severe congenital diaphragmatic hernia. The pulmonary response after fetal endoscopic tracheal occlusion can be used to predict neonatal survival. LEVEL OF EVIDENCE: II

Changes in the recipient fetal Tei index in the peri‐operative period after laser photocoagulation of placental anastomoses for twin–twin transfusion syndrome

To assess serial changes in the Tei index of the recipient fetus secondary to fetoscopic laser photocoagulation of placental anastomoses (FLP) for twin‐twin transfusion syndrome (TTTS) during the peri‐operative period.

Fetal membrane patch and biomimetic adhesive coacervates as a sealant for fetoscopic defects

Iatrogenic preterm premature rupture of membranes after fetoscopic procedures affects 10-47% of patients, secondary to the non-healing nature of membranes and the separation of layers during the entry. In this study we developed an in vitro model to mimic the uterine wall-fetal membrane interface using a water column with one end sealed with human fetal membranes and poultry breast, and a defect was created with an 11 French trocar. Further, a fetal membrane patch in conjunction with multiphase adhesive coacervates modeled after the sandcastle worm bioadhesive was tested for sealing of an iatrogenic defect. The sealant withstood an additional traction of 12 g for 30-60 min and turbulence of the water column without leakage of fluid or slippage. The adhesive is non-toxic when in direct contact with human fetal membranes in an organ culture setting. A fetal membrane patch with multiphase adhesive complex coacervates may help to seal the defect and prevent iatrogenic preterm premature rupture of the membranes.

Laparoscopy‐assisted fetoscopy for laser surgery in twin–twin transfusion syndrome with anterior placentation

To compare a laparoscopy‐assisted fetoscopic approach with an ultrasound‐directed percutaneous approach for laser photocoagulation of placental anastomoses in cases of twin–twin transfusion syndrome (TTTS) with anterior placentation.