Rubén A. Quintero

Staging of twin-twin transfusion syndrome

OBJECTIVE:The purpose of this study was to evaluate the prognostic value of sonographic and clinical parameters to develop a staging classification of twin-twin transfusion syndrome (TTTS).STUDY DESIGN:Severe TTTS was defined as the presence of polyhydramnios (maximum vertical pocket of ≥8 cm) and oligohydramnios (maximum vertical pocket of ≤2 cm). Nonvisualization of the bladder in the donor twin (−BDT) and absence of presence of hydrops was also noted. The middle cerebral artery, umbilical artery, ductus venosus, and umbilical vein in both fetuses were assessed with pulsed Doppler. Critically abnormal Doppler studies (CADs) were defined as absent/reverse end-diastolic velocity in the umbilical artery, reverse flow in the ductus venosus, or pulsatile flow in the umbilical vein. TTTS was staged as follows: stage I, BDT still visible; stage II, BDT no longer visible, no CADs; stage III, CADs; stage IV, hydrops; stage V, demise of one or both twins. Laser photocoagulation of communicating vessels (LPCV) or umbilical cord ligation was performed depending on the severity of the condition. The study was approved by the Institutional Review Board of St. Joseph’s Hospital in Tampa and by the Fetal Therapy Board at Hutzel Hospital, Detroit, and all patients gave informed consent.RESULTS:A total of 80 of 108 referred patients met criteria for surgery, but only 65 were treated surgically: 48 with LPCV and 17 with umbilical cord ligation. Complete Doppler data were obtainable in 41 of 48 LPCV patients. Survival rates by stage for one or two fetuses were statistically different (χ-squared analysis = 12.9, df = 6, p = 0.044). Neither percent size discordance nor gestational age at diagnosis were predictive of outcome.CONCLUSION: Staging of TTTS using the proposed criteria has prognostic significance. This staging system may allow comparison of outcome data of TTTS with different treatment modalities.

Amniotic fluid white blood cell count: A rapid and simple test to diagnose microbial invasion of the amniotic cavity and predict preterm delivery

The purpose of this study was to determine the value of amniotic fluid white blood cell count in the diagnosis of microbial invasion of the amniotic cavity. Amniotic fluid was retrieved by amniocentesis from 195 patients with preterm labor and intact membranes. Fluid was cultured for aerobic and anaerobic bacteria, as well as for mycoplasmas. The prevalence of a positive amniotic fluid culture was 12.8% (25/195). Patients with a positive amniotic fluid culture had a significantly higher median amniotic fluid white blood cell count than did patients with a negative amniotic fluid culture (median, 6 cells/mm3; range, 0 to 11,000 cells/mm3 vs median, 320 cells/mm3; range, 1 to 4480 cells/mm3; p less than 0.0001). An amniotic fluid white blood cell count greater than or equal to 50 cells/mm3 had a sensitivity of 80% (20/25), a specificity of 87.64% (149/170), a positive predictive value of 48.78% (20/41), and a negative predictive value of 96.75% (149/154) in the detection of a positive amniotic fluid culture for microorganisms. Although the sensitivity of an amniotic fluid white blood cell count (greater than or equal to 50 cells/mm3) in the detection of microbial invasion of the amniotic cavity was greater than that of the Gram stain of amniotic fluid (80% [20/25] vs 48% [12/25]; p less than 0.05), the specificity was lower (87.64% [149/170] vs 98.8% [168/170]; p less than 0.05). However, 88% (15/17) of all patients with an amniotic fluid white blood cell count greater than or equal to 50 cells/mm3 and a negative amniotic fluid culture had a spontaneous preterm delivery. We conclude that the amniotic fluid white blood cell count is a sensitive, simple, and inexpensive test for the detection of microbial invasion of the amniotic cavity. An elevated amniotic fluid white blood cell count is a risk factor for preterm delivery.

Percutaneous fetal cystoscopy and endoscopic fulguration of posterior urethral valves

Percutaneous fetal cystoscopy was performed in a male fetus with ultrasonographic evidence of lower urinary tract obstruction at 19 weeks of gestation. The diagnosis of posterior urethral valves was confirmed. Percutaneous endoscopic fulguration of the valves was successfully performed at 22 weeks of gestation, and urethral patency was established. This case illustrates the feasibility of performing diagnostic and therapeutic endoscopic procedures within the human fetus for the management of a congenital anomaly. While we believe that fetal cystoscopy may improve our diagnostic, prognostic, and therapeutic capabilities in the management of fetuses with lower obstructive uropathy, studies are needed to establish the actual value, risks, and limitations of this new approach in fetal medicine.

Treatment of iatrogenic previable premature rupture of membranes with intra-amniotic injection of platelets and cryoprecipitate (amniopatch): Preliminary experience

OBJECTIVE Our aim was to describe the treatment of iatrogenic previable premature rupture of membranes with the intra-amniotic injection of platelets and cryoprecipitate (amniopatch). STUDY DESIGN Patients with iatrogenic previable premature rupture of membranes and without evidence of intra-amniotic infection underwent transabdominal intra-amniotic injection of platelets and cryoprecipitate through a 22-gauge needle. The study was approved by the Institutional Review Board of St Josephs Hospital in Tampa, Florida, and all patients gave written informed consent. RESULTS Seven patients with iatrogenic preterm premature rupture of membranes underwent placement of an amniopatch. Membrane sealing was verifiable in 6 of 7 patients. Three patients had iatrogenic preterm premature rupture of membranes after operative fetoscopy, 3 cases were after genetic amniocentesis, and 1 was after diagnostic fetoscopy. Three pregnancies progressed well, with restoration of the amniotic fluid volume and no further leakage. Two patients had unexplained fetal death despite successful sealing. One case of bladder outlet obstruction had no further leakage, but oligohydramnios persisted and did not allow unequivocal documentation of sealing. One patient miscarried from twin-twin transfusion, but the amniotic cavity was sealed. CONCLUSIONS Iatrogenic preterm premature rupture of membranes can be treated effectively with an amniopatch. The technique is simple and does not require knowledge of the exact location of the defect. Unexpected fetal death from the procedure may be attributable to vasoactive effects of platelets or indigo carmine. Although the appropriate dose of platelets and cryoprecipitate needs to be established, the amniopatch may mean that iatrogenic preterm premature rupture of membranes no longer needs to be considered a devastating complication of pregnancy.

Sequential selective laser photocoagulation of communicating vessels in twin–twin transfusion syndrome

Objective. We have previously described the selective laser photocoagulation of communicating vessels (SLPCV) technique for the treatment of twin–twin transfusion syndrome (TTTS). Because TTTS is thought to result from a net transfer of blood from the donor twin to the recipient twin, we hypothesized that lasering the arteriovenous anastomoses from the donor to the recipient (AVDRs) first (sequential SLPCV or SQLPCV) would result in an improved hemodynamic status and decreased likelihood of intrauterine fetal demise of the donor twin (IUFD-D). Materials and methods. The diagnosis of TTTS was made by ultrasound showing the combined presence of a maximum vertical pocket ≥ 8 cm in one sac and ≤2 cm in the other in a monochorionic/diamniotic twin pregnancy. Triplet pregnancies and monoamniotic pregnancies were excluded. Severity of TTTS was assessed using the Quintero staging system. All vascular anastomoses were endoscopically identified and classified as AVDR (AV from donor to recipient), AVRD (AV from recipient to donor), arterio-arterial (AA), or veno-venous (VV). The surgical procedure was coded as SQLPCV if all AVDRs were lasered first. Outcome measures included intrauterine fetal demise and perinatal survival. Results. One hundred and ninety-three TTTS patients (137 SQLPCV, 56 SLPCV) underwent surgery from May 2003 to August 2005. Gestational age at surgery or at delivery, Stage, patent anastomoses, or persistent/reverse TTTS were not different between the groups. IUFD-D was significantly lower in the SQLPCV than in the SLPCV group (7.3% vs 21.4%, respectively, p = 0.005). Dual perinatal survival was significantly higher in the SQLPCV than in the SLPCV group (73.7% vs 57.1%, respectively, p = 0.02), although the incidence of at least one survivor was not different between the groups (90.5% vs 87.5%, respectively). Logistic regression showed SQLPCV, but not placental location, operating time or number of anastomoses to be significantly associated with a decreased likelihood of IUFD-D (p = 0.007). Conclusion. SQLPCV is associated with a decreased likelihood of IUFD-D and an increased rate of dual survivors compared to SLPCV. SQLPCV represents both an anatomical and functional surgical approach to the laser treatment of twin–twin transfusion syndrome.

Selective laser photocoagulation of communicating vessels in severe twin-twin transfusion syndrome in women with an anterior placenta.

Background We describe two techniques for the laser treatment of twin–twin transfusion syndrome in women with anterior placentas. Technique In the first technique, anastomoses were photocoagulated using a flexible endoscope through a single port. The second technique used a side-firing laser fiber with a rigid angled-view endoscope (two ports). Experience Seventy-two women had surgery between July 1997 and December 1999, 35 (48.6%) of whom had anterior placentas. Survival was similar for fetuses with anterior (80%) and posterior (75.6%) placentas, but operating time was significantly longer for those with anterior placentas (81.1 compared with 64.4 minutes for the anterior and posterior placentas, respectively; P = .02, Student t test). At least one fetus survived in 76% (16 of 21) of women treated with flexible endoscopes and 86% (12 of 14) of those treated with the side-firing lasers. Six of 72 women (8.3%) had patent vascular anastomoses on placental examination, and five of them had anterior placentas (P = .08, Fisher exact test). Conclusion Although anterior placentas are surgically more challenging than posterior placentas, both techniques allow an effective percutaneous approach to the laser treatment of twin–twin transfusion syndrome.

Twin–twin transfusion syndrome

The understanding and management of twin-twin transfusion syndrome has evolved significantly over the past few years. Improved and standardized sonographic diagnostic criteria, understanding of the heterogeneic nature of the syndrome, development of an anatomical and reproducible surgical technique for the identification of vascular anastomoses, and technological advances and developments now allow clinicians to view the disease as a more readily understandable and treatable condition. Many tasks remain, including education of peers, better screening and diagnosis, and further development of surgical instruments. Generalization of treatment outcomes should no longer apply given the varied results with disease stage. Confirmation of our tailored approach to management of the disease according to stage should soon be corroborated with an appropriate clinical trial.

Successful in utero endoscopic ablation of posterior urethral valves: a new dimension in fetal urology

Fetal lower urinary tract obstructive uropathy, when associated with oligohydramnios, is usually associated with a poor outcome. We present a case of successful in utero endoscopic ablation of posterior urethral valves in which the infant survived the neonatal period without evidence of renal dysplasia. The role, indications, and potential benefits of this novel technique are discussed.

Twin-to-twin transfusion syndrome: an antiangiogenic state?

OBJECTIVE An imbalanced chronic blood flow between the donor and recipient twin through placental vascular anastomoses is the accepted pathophysiology of twin-to-twin transfusion syndrome (TTTS). Vascular endothelial growth factor receptor-1 (VEGFR-1) mRNA is overexpressed only in the syncytiotrophoblast of the donor twin in some cases of TTTS. This study was conducted to determine maternal plasma concentrations of placental growth factor (PlGF), soluble VEGFR-1, and soluble endoglin (s-Eng) in monochorionic-diamniotic pregnancies with and without TTTS. STUDY DESIGN This case-control study included monochorionic-diamniotic pregnancies between 16-26 weeks with and without TTTS. Maternal plasma concentrations of PlGF, sVEGFR-1, and s-Eng were determined with ELISA. A P value < .05 was considered statistically significant. RESULTS Patients with TTTS had higher median plasma concentrations of s-Eng (14.8 ng/mL vs 7.8 ng/mL; P < .001) and sVEGFR-1 (6383.1 pg/mL vs 3220.1 pg/mL; P < .001]; and lower median plasma concentrations of PlGF (115.5 pg/mL vs 359.3 pg/mL; P = .002) than those without TTTS. CONCLUSION We propose that an antiangiogenic state may be present in some cases of TTTS.

Transabdominal intra-amniotic endoscopic assessment of previable premature rupture of membranes.

OBJECTIVE Our purpose was to describe the endoscopic characteristics of the site of rupture in vivo in patients with spontaneous premature rupture of membranes. STUDY DESIGN Patients with preterm premature rupture of membranes between 16 and 26 weeks of gestation, without evidence of intra-amniotic infection, and with a normal karyotype underwent transabdominal endoscopic examination of the amniotic cavity. Subsequently, an amniopatch of a combination of platelets and cryoprecipitate to seal the membrane defect was administered. The study was approved by the Institutional Review Board of St. Josephs Hospital in Tampa, Florida, and all patients gave written informed consent. RESULTS Four patients underwent endoscopic examination and amniopatch administration; three had spontaneous preterm premature rupture of membranes, and in the other the membranes ruptured after an early amniocentesis. The location of the site of rupture was over the internal os in the 3 cases with spontaneous preterm premature rupture of membranes. This area was normal in the patient with iatrogenic preterm premature rupture of membranes. The longer the time between preterm premature rupture of membranes and fetoscopy, the larger and less defined was the site of rupture. The amniopatch restored amniotic integrity for a maximum of 72 hours. CONCLUSIONS This is the first in vivo endoscopic visualization of the site of spontaneous rupture of membranes from within the uterine cavity. The defect is located over the internal cervical os in patients with spontaneous preterm premature rupture of membranes. There appear to be time-related changes in the morphologic characteristics of the site of rupture. Endoscopic visualization of the site of rupture has the potential for improving our understanding of spontaneous preterm premature rupture of membranes and in the development of possible therapeutic alternatives.