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Fetoscopic surgery using CO 2. (A) Views of the fetoscopic procedure demonstrating the partial amnionectomy and (B) the amniotic band around the left ankle and the depth that the amniotic band had cut into the soft tissue of the ankle.
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Introduction Fetoscopic release of amniotic bands has proved its life- and limb-saving potential. Rupture of the amnion and separation of chorion from the amnion and uterine wall can however preclude the standard fetoscopic approach to release the amniotic bands using a single port.
Methods and Materials A 28-year-old G1P0 woman was referred to our...
Citations
... En las imágenes de RMN ponderadas en T2, las bandas amnióticas se pueden ver como hebras delgadas(11) .La visualización del amnios antes de las 16 semanas de gestación sin anomalías estructurales fetales no debe confundirse con bandas amnióticas, ya que el amnios no se fusiona con el corion hasta aproximadamente las 16 semanas de edad gestacional(12) .El diagnóstico diferencial del síndrome de banda amniótica es principalmente con sinequias uterinas. Las sinequias uterinas son más gruesas que las bandas, a menudo tienen una amplia base triangular a lo largo de la pared uterina, pueden extenderse a la pared contralateral, y en la historia materna existe por lo general el antecedente de legrado uterino(13) .La separación corioamniótica puede confundirse con una banda amniótica, pero la curvatura del amnios es a menudo en forma de medialuna y refleja el contorno del corion(14) .Una vez hecho el diagnóstico de SBA, el estudio Doppler prenatal de la estructura afectada, comparándolo con el flujo del miembro contralateral, representa un recurso indispensable en el seguimiento de dicho hallazgo(15) , ya que la evolución natural de la extremidad afectada por SBA se caracteriza por la progresión del edema distal a la amputación del miembro secundaria a insuficiencia vascular(16) . ...
El síndrome de banda amniótica (SBA) o complejo de disrupción de banda amniótica es aquella malformación congénita que ocurre como consecuencia de bridas amnióticas de etiología heterogénea, patogénesis que involucra una serie de manifestaciones clínicas fetales, tales como constricción, amputación y múltiples defectos craneofaciales, viscerales y de la pared del cuerpo. La prevalencia estimada de SBA oscila entre 1:15,000 y 1:1,200 nacidos vivos. Afecta a ambos sexos por igual. El diagnóstico prenatal puede sospecharse tan pronto como el primer trimestre tardío, cuando las imágenes por ultrasonido detectan anillos de constricción, amputaciones de extremidades y/o defectos craneofaciales. La terapia prenatal puede ofrecer una alternativa de tratamiento con la liberación de anillos de constricción bajo fetoscopia en aquellos fetos que se verían beneficiados con el procedimiento.
... 6 band is not feasible owing to difficult membrane separation, use of gas (CO 2 ) can provide distension of the uterus to facilitate the more complex surgical procedures. 31 Umbilical cord involvement places the fetus at a much higher risk for intrauterine fetal death (IUFD). Therefore, fetoscopic release for umbilical cord involvement should be considered in appropriate candidates without other contraindications to a fetal procedure. ...
Amniotic band syndrome (ABS) is a rare, but serious congenital syndrome complex. It is associated with a wide range of fetal structural anomalies, notably craniofacial and limb anomalies. Early prenatal diagnosis is important to provide accurate information to the parents, predict the prognosis and in some cases perform in-utero lysis of the bands to restore the blood flow to the affected limb. A postnatal multidisciplinary approach involving vascular decompression, reconstructive surgery, prosthesis, and physiotherapy are some of the therapeutic options. It is necessary to consider ABS in prenatal screening with a high index of suspicion as early screening can allow a timely therapeutic strategy and reduce the severity of the associated defects.
... La terapia fetal es uno de los más grandes desafíos de la medicina contemporánea, ya que acceder al ambiente intrauterino permite entregar una oportunidad al feto de preservar con cierto grado de funcionalidad la extremidad afectada (51) . El primer reporte de tratamiento vía fetoscopía en humanos fue realizado por Quintero et al. (49) en 1997, éste fue aplicado en dos pacientes a las 23 semanas de gestación con constricciones en las extremidades. ...
... Para esto, se buscó en MEDLINE con los siguientes términos MeSH (Medical Subject Headings): «Fetoscopy» y "Amniotic Band Syndrome"; además se consideró como criterio de exclusión aquellos casos con gestaciones múltiples. En suma, se obtuvieron 28 registros de los cuales seleccionamos 22. La tabla 3 presenta los casos reportados de manejo de síndrome banda amniótica desde 1997 a la fecha (45,47,49,50,51,(55)(56)(57)(58)(59)(60)(61)(62)64,65) . El promedio de edad materna en la gestación afectada es de 30,7 años, con un rango etario entre 18 a 44 años. ...
... Pedersen et al. (52) reportó un caso anecdótico ocurrido durante una amniocentesis diagnóstica, en la que no había intención alguna de causar disrupción del tejido lo que se logró satisfactoriamente; con un resultado perinatal óptimo. Cabe destacar que dos casos se asocian a la presencia de separación de banda amniótica, lo que da origen a la presencia de bandas amnióticas que comprometen además de la extremidad, también al cordón umbilical (51,64) . ...
The amniotic band syndrome is defined as a group of congenital malformations of sporadic
character caused by early ruptures in the amniotic membrane, which allow strands of membrane to adhere to fetal body segments, causing a disruption in the development of the involved segment. Clinically the syndrome manifests as a broad spectrum of malformations associated to the effects of the amniotic bands, ranging from isolated single defects to multiple malformations which result in important fetal deformities. Its pathogenesis is not yet clear, and diverse theories have been proposed to explain this syndrome. Technological progress allows fetal therapy to be considered as a viable option of prenatal treatment. We have performed a review of the most important pathogenesis theories, clinical manifestations, prenatal and postnatal treatment and discussion of cases reported in the literature which have been managed through fetoscopy.
... Once these differential diagnoses are ruled out, further investigation must be taken to identify other fetal or placental abnormalities. To date, there are no known biochemical markers or genes to definitively diagnose the syndrome, however, there is an association with chromosomal abnormalities, and therefore the work-up often includes amniocentesis for karyotype as well as single nucleotide polymorphism (SNP) microarray [6][7][8][9][10][11][12]. As the presentation and complica- tions are diverse, management depends on individual cases and ranges from expectant management with intervention in the neonatal/pediatric period, to fetoscopic band transection (fetal surgery), and even termination of preg- nancy. ...
A detailed discussion of normal placental development and physiology is
beyond the scope of this chapter and is discussed in other chapters. Instead, this chapter will focus on an overview of congenital placental abnormalities and the obstetrical complications that can arise. The goal of this chapter is to delineate the real-world implications of placental abnormalities and provide the reader with a basis for understanding the other chapters that will delve into microbiology, genom- ics, immunohistochemistry, and biochemistry of the placenta. The focus of this chapter will be on the developmental anomalies and this chapter will not discuss acquired anomalies (e.g., chorioamnionitis, amnion nodosum, metastatic tumors, and umbilical cord true knots). As the intention of this chapter is to focus on the etiopathogenesis of abnormal placentation, it is not intended to instruct the medical management of the described conditions, and therefore the discussions of manage- ment will be brief. The information provided is intended for general knowledge only and is not intended for use in diagnosing or treating a health problem or disease without consultation with a qualified healthcare provider. This chapter is not a sub- stitute for professional medical advice, or treatment for specific medical conditions.
... técnIcas La liberación fetoscópica de las bandas amnióticas a través de técnicas de cirugía mínimamente invasiva puede permitir la preservación de la vida, así como la función de los miembros en los casos de fetos con diagnóstico de SBA. En revisiones de diferentes literaturas se concluye que la liberación fetoscópica de bandas amnióticas ha permitido la preservación de la función de la extremidad en 50% de los casos (14) . ...
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.
... These procedures can be performed either percutaneously or in some cases after exposing the uterus via a laparotomy. The latter approach (one championed by the team at Texas Children's Hospital for minimally invasive fetal interventional procedures) allows for successful completion of procedure in cases of complete anterior placenta, protects the membranes by allowing anchoring of the membranes in complex fetal surgical procedures, and promotes enhanced visualization by enabling a low pressure CO 2 in-utero environment [8,9]. In addition, we feel that an exposed uterus leads to easier fetal manipulation to change and maintain fetal positioning in difficult cases. ...
... Brought to you by | Cornell University Library Authenticated Download Date | 6/1/17 4:39 AM 5. In cases where percutaneous access to the fetus is precluded by complete anterior placenta and/or inadequate visualization due to membrane separation, successful release of amniotic bands in a CO 2 environment may be an option [9]. ...
... The experimental technique we are currently evaluating at Texas Children's Hospital entails performing a laparotomy, exteriorizing the uterus and inserting two 12Fr ports into the uterus after removal of most of the amniotic fluid. Through these ports, instruments are introduced to operate on the fetus [9,92,97]. Although fetal acidosis is a theoretical concern, animal studies suggest that maternal hyperventilation may reduce this effect [98] and our own data do not suggest fetal acidosis. ...
The identification of congenital birth defects and fetal malformations continues to increase during the antenatal period with improved imaging techniques. Understanding of how to treat specific fetal conditions continues to improve outcomes from these treatment modalities. In an effort to further improvement in this field, we provide a review that begins with a brief background of fetal surgery including the history of fetal surgery, ethics surrounding fetal surgery, and considerations of how to treat the fetus during intervention. A synopsis of the most commonly encountered disease processes treated by fetal intervention/surgery including definitions, treatment modalities, and outcomes following fetal intervention/surgery is then provided. Within the sections describing each disease process, methodology is described that has helped with efficiency and success of procedures performed at our institution.
Objective:
To determine if the evaluation of the fetal ventricular system and hindbrain herniation (HBH) is associated with motor outcome at birth in prenatally repaired open neural tube defect (NTD).
Methods:
Retrospective cohort study of 47 patients with NTD who underwent prenatal repair (17 fetoscopic; 30 open-hysterotomy). At referral and six weeks postoperatively, the degree of HBH, ventricular atrial widths and ventricular volume were evaluated by MRI. Head circumference and ventricular atrial widths were measured on ultrasound at referral and during the last ultrasound before delivery. Anatomic level of the lesion (LL) was determined based on the upper bony spinal defect detected by ultrasound. We considered the functional level as worse than anatomical level at birth when the motor level was equal or worse than the anatomical LL.
Results:
26% (12/47) of the cases showed worse functional level than anatomical level at birth. Having a HBH below C1 at the time of referral was associated with a worse functional level than anatomical level at birth (OR=9.7, CI95[2.2-42.8], p<0.01. None of the other brain parameters showed a significant association with motor outcomes at birth.
Conclusions:
HBH below C1 before surgery was associated with a worse functional level than anatomical level at birth. This article is protected by copyright. All rights reserved.
This chapter provides insights into the history of fetal surgery, what surgeries are currently in use, ethical considerations that have surfaced, and the future direction of the field. Experimental fetal surgery in animal models first started the 1920s, and over time evolved into the well‐known lamb model popularized by Barcroft in the 1940s. Fundamental to invasive fetal treatment is a risk–benefit assessment that considers the potential benefits to the fetus, newborn, and mother balanced against the risks of the proposed intervention to these same parties. In general, a policy should be adopted to administer fetal anesthesia for any invasive procedure that might cause the fetus to experience pain, regardless of whether the procedure is being performed under local, regional, or general anesthesia. Occasionally, closed fetal interventions are performed using a combination of sonographic and fetoscopic guidance.
Amniotic band syndrome is a rare condition. There have been few cases reported of fetoscopic band dissection. The aim of this case series is to report 3 cases of fetoscopic treatment for amniotic band syndrome, including indication for surgery, technical aspects, complications and outcomes.
Fetoscopic treatment was performed respectively at 23 5/7, 26 5/7 and 18 3/7 weeks' gestation. Two procedures were performed with a laser fiber through a single trocar whereas one surgery was performed with scissors.
In conclusion, fetoscopic release of the amniotic bands in case of amniotic band syndrome is feasible with encouraging results in order to prevent amputation and dysfunction of the extremities.
