Perinatal Outcomes after Fetal Endoscopic Tracheal Occlusion for Isolated Congenital Diaphragmatic Hernia: Rapid Review / Resultados perinatais após oclusão traqueal endoscópica fetal por hérnia diafragmática congênita isolada: Revisão rápida

Abstract Objective To compare the perinatal outcomes of fetuses with isolated congenital diaphragmatic hernia after fetal endoscopic tracheal occlusion (FETO) and antenatal expectant management. Data sources In this rapid review, searches were conducted in the MEDLINE, PMC, EMBASE and CENTRAL databases between August 10th and September 4th, 2020. Randomized controlled trials (RCTs), quasi-RCTs or cluster-RCTs published in English in the past ten years were included. Study selection We retrieved 203 publications; 180 studies were screened by abstract. Full-text selection was performed for eight studies, and 1 single center RCTmet the inclusion criteria (41 randomized women; 20 in the FETO group, and 21 in the control group). Data collection Data collection was performed independently, by both authors, in two steps (title and abstract and full-text reading). Data synthesis There were no cases of maternal mortality. The mean gestational age at delivery was of 35.6±2.4 weeks in the intervention group, and of 37.4±1.9 weeks among the controls (p<0.01). Survival until 6 months of age was reported in 50% of the intervention group, and in 5.8% of the controls (p<0.01; relative risk: 10.5; 95% confidence interval [95%CI]: 1.5-74.7). Severe postnatal pulmonary hypertension was found in 50% of the infants in the intervention group, and in 85.7% of controls (p=0.02; relative risk: 0.6; 95%CI: 0.4-0.9). An analysis of the study indicated some concerns of risk of bias. The quality of evidence was considered moderate to low. Conclusion Current evidence is limited but suggests that FETO may be an effective intervention to improve perinatal outcomes.

Resumo Objetivo Comparar os resultados perinatais de fetos com hérnia diafragmática congênita após oclusão traqueal endoscópica fetal (OTEF) e conduta expectante pré-natal. Fontes dos dados Nesta revisão rápida, pesquisas foram conduzidas nas bases de dados MEDLINE, PMC, EMBASE e CENTRAL entre 10 de agosto de 2020 e 4 de setembro de 2020. Ensaios clínicos randomizados (ECRs), quase-ECRs e ECRs em cluster publicados em inglês nos últimos dez anos foram incluídos. Seleção dos estudos Foram recuperadas 203 publicações; 180 destas foram triadas pelo resumo. Fez-se a leitura do texto completo de 8 estudos, e 1 ECR cumpriu os critérios de inclusão (41 mulheres aleatorizadas; 20 no grupo OTEF e 21 no grupo de controle). Coleta de dados A coleta de dados realizada independentemente pelos dois autores, em duas etapas (título e resumo, e leitura do texto completo). Síntese dos dados Não houve casos de mortematerna. A idade gestacionalmédia no parto foi de 35,6±2,4 semanas no grupo de intervenção, e de 37,4±1,9 semanas entre os controles (p<0,01). A sobrevida até 6 meses de idade foi relatada em 50% do grupo de intervenção, e em 5,8% dos controles (p<0,01; risco relativo: 10,5; intervalo de confiança de 95% [IC95%]: 1,5-74,7). Hipertensão pulmonar grave ocorreu em 50% dos lactentes do grupo de intervenção, e em 85,7% dos controles (p = 0.02; risco relativo: 0,6; IC95%: 0,4-0,9). Uma análise do estudo indicou algumas preocupações quanto ao risco de viés. A qualidade da evidência foi considerada de moderada a baixa. Conclusão As evidências atuais são limitadas,mas sugeremque a OTEF pode ser uma intervenção eficaz para melhorar resultados perinatais.

Cirurgias intrauterinas: alternativa de intervenção para as cardiopatias congênitas / Intrauterine surgeries: intervetion alternative for congenital cardiopathies

As cardiopatias congênitas são anormalidades estruturais ou funcionais do sistema cardiovascular, advindas desde o nascimento, mesmo que diagnosticadas posteriormente. Entre as malformações congênitas, as cardiopatias são as principais causas de mortalidade infantil nos Estados Unidos e em outros países desenvolvidos. Com o intuito de reduzir os efeitos progressivos dessas patologias, a intervenção intrauterina tem se destacado como opção terapêutica diante de resultados iniciais satisfatórios. O presente artigo teve por objetivo demonstrar a evolução da cirurgia intrauterina para correção cardíaca, a partir da avaliação dos benefícios ao feto e visando a riscos mínimos e aceitáveis para a mãe. Foi realizada uma pesquisa na base de dados Publisher Medline (PubMed), Scientific Electronic Library Online (SciELO) e Biblioteca Virtual da Saúde (BVS), incluindo artigos publicados entre 2008 e 2018; além da pesquisa efetuada no Manual de Medicina Fetal da SOGIMIG ­ 2018. Os critérios de elegibilidade são amplos. São necessários equipe multidisciplinar, equipamentos sofisticados e aperfeiçoamento da técnica, dessa forma dificulta-se a realização das cirurgias. Entretanto, diante dos resultados já demonstrados, a cirurgia intrauterina apresenta-se como alternativa terapêutica promissora.(AU)

The congenital cardiopathies are structural or functional abnormalities of the cardiovascular system, originated from birth, even when previously diagnosed. Among the congenic malformations, the cardiopathies are the main causes of infant mortality in the United States and in other developed countries. In order to reduce the progressive effects of these pathologies, intrauterine intervention has been highlighted as a therapeutic option in contempt of satisfactory initial results. This article has as goal to demonstrate the evolution of the intrauterine surgery for cardiac correction, based on the evaluation of the benefits to the fetus and aiming at minimum and acceptable risks to the mother. A research was made based on the Publisher Medline (PubMed) data base, Scientific Electronic Library Online (SciELO) and Biblioteca Virtual da Saúde (BVS), including published articles between 2008 and 2018. Beyond the research made on The fetal medicine manual from SOGIMIG ­ 2018. The eligibility criteria are broad. It is necessary a multidisciplinary team, sophisticated equipments and technique improvement, therefore interfering in the performance of surgeries. However, in contempt of the already demonstrated results the intrauterine surgery presents itself as a therapeutic promising alternative.(AU)

Secuencia de bandas amnióticas, una actualización / An update on amniotic bands sequence

La secuencia de bandas amnióticas es un desorden congénito caracterizado por anomalías craneofaciales, de la pared corporal y de las extremidades que pueden asociarse con bandas fibrosas fetoplacentarias. Su prevalencia ha sido reportada entre 0,19 y 8,1 por 10 000 nacimientos. Diversas teorías han tratado de explicar su etiología, sin embargo, ninguna, en forma individual, sustenta todas y cada una de las anomalías observadas, por lo que se ha considerado una entidad multifactorial. La identificación de anomalías (pre-yposnatalmente) sugestivas de secuencia de bandas amnióticas permite el abordaje diagnóstico para efectuar intervenciones terapéuticas oportunas que posibiliten la liberación de bandas amnióticas mediante fetoscopia con recuperación de la perfusión de la porción distal de la extremidad involucrada o bien la reparación quirúrgica posnatal y para otorgar asesoramiento genético. Este artículo ofrece una actualización sobre aspectos epidemiológicos, teorías etiológicas, factores de riesgo, características clínicas, diagnóstico (que incluye el diagnóstico prenatal), asesoramiento genético, abordaje terapéutico y pronóstico de esta entidad.

Amniotic bands sequence is a congenital disorder characterized by craniofacial, body wall, and limb anomalies that may be associated with fetal-placental fibrous bands. Its prevalence has been reported to range from 0.19 to 8.1 per 10 000births. Different theories have attempted to explain the etiology of amniotic band sequence; however, none has individually been able to support each and every defect observed, so it has been considered to be a multifactorial condition. The (pre- and post-natal) identification of anomalies suggestive of amniotic band sequence is useful for the diagnostic approach and implementation of timely therapeutic interventions favoring the release of the amniotic bands using fetoscopy with recovery of the involved distal limb perfusion, or else the possibility of performing a post-natal surgical repair. It is also helpful to provide genetic counseling. This article offers an update on the epidemiological aspects, etiological theories, risk factors, clinical characteristics, diagnosis (including antenatal diagnosis), genetic counseling, therapeutic approach, and prognosis of amniotic bands sequence.

Manejo del síndrome de transfusión feto fetal en gestaciones gemelares monocoriales / Management of twin-twin transfusion syndrome in monochorionic twin gestations

El síndrome de transfusión feto fetal es una complicación grave de las gestaciones gemelares monocoriales. Su etiología se debe a la transfusión crónica de sangre del feto donante, al feto receptor; a través de las anastomosis vasculares entre los territorios placentarios de ambos. El cuadro clínico característico se evidencia en ambos fetos: receptor y donante, lo cual es consecuencia directa de las alteraciones en la volemia que padece cada uno. En el feto receptor, se observa un polihidramnios relacionado con la poliuria derivada de un estado de hipervolemia constante, que evoluciona hacia una insuficiencia cardiaca congestiva. En el feto donante, el cuadro es inverso; caracterizado por oligoamnios, oliguria, crecimiento intrauterino retardado e hipovolemia, con tasas de mortalidad sin tratamiento de entre 80-100 por ciento de los casos, que varían en función del grado de transfusión. El diagnóstico se basa en el estudio ecográfico exhaustivo de ambos fetos, procurando un diagnóstico precoz y un estadiaje correcto, ya que el pronóstico se verá muy influenciado por la actuación temprana. El tratamiento de elección es la coagulación láser de las anastomosis vasculares por fetoscopia, idealmente entre la semana 18 y 26 de embarazo. El pronóstico es variable, en función de la disponibilidad de terapia fetal y de la edad gestacional en el momento del diagnóstico; al ser, en general, de muy mal pronóstico sin tratamiento efectivo(AU)

Twin-twin transfusion syndrome is one of the most serious complications of monochorionic multiple gestations. Its etiology is due to a chronic blood transfusion from de donor twin to the recipient twin through the vascular anastomoses between the placental territories of both fetuses. The characteristic clinical presentation appears in both donor and recipient fetuses, as a direct consequence of altered volemia in each one. Polyhydramnios related to polyuria resulting from a state of constant hypervolemia is observed in the recipient twin, finally evolving into congestive heart failure. The clinical presentation in the donor twin is reversed and characterized by oligoamnios, oliguria, retarded intrauterine growth and hypovolemia, with untreated mortality rates ranging 80-100 percent of all cases, which may vary depending on the severity of the transfusion. The diagnosis is based on exhaustive echographic examination of both fetuses to make an early diagnosis and correct staging, since the prognosis depends very much on early action. The treatment of choice is fetoscopic laser coagulation of vascular anastomoses between 18 and 26 weeks of gestation. The prognosis is variable, depending on the availability of fetal therapy and the gestational age at diagnosis, being prognosis generally very poor without an effective treatment(AU)

Mirror Syndrome after Fetoscopic Laser Treatment - A Case Report / Síndrome do espelho após tratamento laser por fetoscopia - caso clínico

Abstract Mirror syndrome is a rare disease with unknown pathophysiology that can be present in different diseases that can cause fetal hydrops. The prognosis is usually bad with a high perinatal mortality. We report an unusual form of mirror syndrome that manifested itself only after a successful treatment for fetal hydrops (caused by twin-twin transfusion syndrome, in Quinteros stage IV) was performed. This syndrome was controlled by medical treatment, and despite the usually bad prognosis seen in these cases, we could extend the pregnancy from the 23rd to the 34th week of gestation, resulting in the birth of 2 live infants.

Resumo A síndrome do espelho é uma doença rara, de fisiopatologia desconhecida, que se manifesta em situações obstétricas responsáveis pela presença de hidrópsia fetal. Habitualmente o prognóstico é reservado, uma vez que se associa a elevadas taxas de mortalidade perinatal. O presente caso clínico trata de uma situação de síndrome do espelho que se manifestou, atipicamente, após o tratamento eficaz para a hidrópsia fetal associada à síndrome de transfusão feto-fetal. Apesar do mau prognóstico associado a estas situações, conseguiu-se controlar a situação apenas com tratamento médico e, desta forma, prolongar a gravidez durante 12 semanas.

Twin-twin transfusion syndrome: neurodevelopment of infants treated with laser surgery / Síndrome de transfusão feto-fetal: neurodesenvolvimento de lactentes tratados com cirurgia a laser

ABSTRACT Objective To assess the neurodevelopmental functions of survivors of twin-twin transfusion syndrome (TTTS) treated by fetoscopic laser coagulation (FLC), during the first year of life, comparing them to a control group; and to verify the influence of specific variables on neurodevelopment. Method This was a prospective, longitudinal study. The sample comprised 33 monochorionic diamniotic twins who underwent FLC for treatment of TTTS and 22 full-term infants of single-fetus pregnancies. Bayley Scales of Infant and Toddler Development Screening Test were used for evaluation. Prenatal, perinatal and postnatal information were obtained. Results There was an increased frequency of infants in the TTTS group with inadequate performance compared to the control group. The identified variables (fetal donor, low economic income and cardiorespiratory disease) negatively impacted expressive communication and fine motor skills. Conclusion Although through follow-up is recommended in all TTTS survivors, particular attention is required for the high-risk group as defined in this study.

RESUMO Objetivo Avaliar o desenvolvimento neurológico de sobreviventes da sindrome de transfusão feto-fetal (STFF) submetidos à coagulação a laser por fetoscopia (CLF), durante o primeiro ano de vida, comparando estes ao grupo controle; e verificar a influência de variáveis específicas no desenvolvimento. Método Tratou-se de estudo prospectivo, longitudinal. A amostra foi composta por 33 gêmeos diamnióticos monocoriônicos submetidos à CLF para tratamento da STFF e 22 lactentes a termo de gestação única. Bayley Scales of Infant and Toddler Development Screening Test foram utilizadas para avaliação. Informações pré-natal, perinatal e pós-natal foram coletadas. Resultados Houve maior número de lactentes com desempenho inadequado no grupo STFF do que no controle. As variáveis identificadas (feto doador, baixa renda econômica e doença cárdio-respiratória) influenciaram negativamente a comunicação expressiva e as habilidades motoras finas. Conclusão Embora o acompanhamento seja recomendado para todos lactentes com STFF, especial atenção deve ser dada àqueles que apresentam fatores de risco.

Comparison between two surgical techniques for prenatal correction of meningomyelocele in sheep / Comparação entre duas técnicas cirúrgicas de correção intrauterina da mielomeningocele em fetos de ovelha

OBJECTIVE: To compare the classical neurosurgical technique with a new simplified technique for prenatal repair of a myelomeningocelelike defect in sheep. METHODS: A myelomeningocele-like defect (laminectomy and dural excision) was created in the lumbar region on day 90 of gestation in 9 pregnant sheep. Correction technique was randomized. In Group 1 the defect was corrected using the classic neurosurgical technique of three-layer suture (dura mater, muscle and skin closure) performed by a neurosurgeon. In Group 2, a fetal medicine specialist used a biosynthetic cellulose patch to protect the spinal cord and only the skin was sutured above it. Near term (day 132 of gestation) fetuses were sacrificed for pathological analysis. RESULTS: There were two miscarriages and one maternal death. In total, six cases were available for pathological analysis, three in each group. In Group 1, there were adherence of the spinal cord to the scar (meningo-neural adhesion) and spinal cord architecture loss with posterior funiculus destruction and no visualization of grey matter. In Group 2, we observed in all cases formation of a neo-dura mater, separating the nervous tissue from adjacent muscles, and preserving the posterior funiculus and grey matter. CONCLUSION: The new simplified technique was better than the classic neurosurgical technique. It preserved the nervous tissue and prevented the adherence of the spinal cord to the scar. This suggests the current technique used for the correction of spina bifida in humans may need to be reassessed.

OBJETIVO: Comparar a técnica neurocirúrgica clássica a uma nova técnica simplificada, para correção de mielomeningocele, em fetos de ovelhas. MÉTODOS: Em 9 fetos, foi criado um defeito semelhante à mielomeningocele (laminectomia e excisão de dura-máter) no 90º dia de gestação. O tipo de correção foi randomizado. No Grupo 1, o defeito foi corrigido usando a técnica neurocirúrgica clássica, com a sutura de três camadas (dura-máter, músculo e pele), realizada por um neurocirurgião. No Grupo 2, um especialista em Medicina Fetal utilizou a técnica simplificada, colocando um fragmento de celulose biossintética sobre a medula e suturando apenas da pele sobre a celulose. Próximo ao termo da gestação (132 dias), os fetos foram sacrificados para análise anatomopatológica. RESULTADOS: Ocorreram dois casos de aborto e uma morte materna, restando seis casos para avaliação - três em cada grupo. No Grupo 1, todos os casos mostraram aderência da medula à cicatriz (meningoadesão) e perda da arquitetura medular, com destruição do funículo posterior e perda da visualização da substância cinzenta. No Grupo 2, observou-se, em todos os casos, a formação de uma neodura-máter, separando o tecido nervoso do músculo adjacente, sendo que o funículo posterior e a substância cinzenta estavam preservados. CONCLUSÃO: A técnica simplificada foi superior à neurocirúrgica, com maior preservação da medula e evitando as aderências do tecido nervoso. Os presentes achados sugerem que a técnica utilizada atualmente na correção de mielomeningocele em fetos humanos deva ser reavaliada.

Resultados actualizados en el tratamiento por fetoscopía del síndrome de transfusión feto fetal en Clínica Alemana de Santiago / Results in fetoscopy-guided treatment of twin to twin transfusion syndrome in Clinica Alemana

Twin to twin transfusion syndrome diagnosed before 26 weeks has 90 percent mortality and occurs in 15 percent of monochorionic twin pregnancies. Treatment is complex as a screening program, referral, complex surgical procedure and specialized perinatal care are required. The objective is to report the recent results in fetoscopy-guided treatment of TTTS cases in Clínica Alemana. Results: 18 new cases were treated in the latest 2 years, in a series of 36 cases from 2005. Survival of one or both twins was 72.8 percent in the first 18 cases, and 77.8 percent in the latest 18 cases. The number of cases with both survivors increased from 5/18 to 7/18. Conclusions: The outcome was similar to that reported from international series. The results are better in the later cases, according to the increasing experience in our center.

Antecedentes: El Síndrome de Transfusión Feto Fetal (STFF) diagnosticado antes de las 26 semanas tiene una mortalidad de 90 por ciento y se afecta el 15 por ciento de los gemelares monocoriales. El manejo es complejo dado que requiere un proceso de diagnostico en los centros de atención, un proceso de derivación, la cirugía y el manejo perinatal especializado posterior. Objetivo: Actualizar el resultado del tratamiento por fetoscopía en Clínica Alemana de Santiago (CAS) en los casos recientemente tratados. Resultados: Desde 2005 hasta la fecha se han tratado 36 casos con sus embarazos resueltos. La sobrevida de al menos un feto fue 77,8 por ciento en los últimos 18 casos, mostrando una mejora en relación a los primeros (72,8 por ciento). El número de embarazos con ambos fetos vivos aumento de 5 a 7. Conclusiones: El resultado materno-perinatal es similar a las series internacionales y muestran una mejora progresiva en la sobrevida en la serie tratada. Los resultados favorables se mantienen a largo plazo y se consolidan en beneficio de las pacientes.

Metodologia aplicada na avaliação de fetos suínos abortados e natimortos / Methodology used in the evaluation of stillborns and aborted fetuses from swine

Este artigo revisa dados relativos à realização de necropsia em fetos suínos abortados e natimortos. Aspectos descritos incluem coleta de material, procedimentos de necropsia, achados macroscópicos e histopatológicos alguns dos quais de pouco ou nenhum significado patológico são frequentemente observados numa rotina de diagnóstico e geralmente interpretados erroneamente como lesões reais ou de importância.

This paper reviews information on necropsies in stillborn and aborted fetuses from swine. Aspects dealt with include sampling collection, necropsy procedures, gross and histopathological findings, some of which are of little or no pathological significance but often observed in the routine diagnostic work and misinterpreted as real or important lesions.

Tratamiento por fetoscopia del síndrome de transfusión feto fetal en Clínica Alemana de Santiago / Fetoscopy guided laser coagulation for twin to twin transfusion syndrome

Antecedentes: El síndrome de transfusión feto fetal (STFF) afecta el 15 por ciento de los gemelares monocoriales y tiene una mortalidad de 90 por ciento cuando se diagnostica antes de las 26 semanas. Objetivo: Evaluar el resultado perinatal mediante fotocoagulación con láser por fetoscopia, de las anastomosis vasculares placentarias en pacientes con STFF. Método: Fotocoagulación láser por fetoscopia de 18 casos de SFF tratados en Clínica Alemana de Santiago entre los años 2005-2008. Resultados: 72,8 por ciento de los embarazos concluyeron con al menos un niño vivo. No se requirió una nueva fetoscopia en ningún caso. No hubo rotura de membranas posprocedimiento en pacientes previamente asintomáticas. No se ha presentado daño neurológico en los niños sobrevivientes. Conclusiones: El resultado materno-perinatal es similar a las series internacionales y demuestra la factibilidad de este procedimiento de ser realizado en nuestro país por profesionales capacitados.

Background: Twin to twin transfusion syndrome (TTTS) occurs in 15 percent of monochorionic twins and has a 90 percent mortality when diagnosed before 26 weeks. Objective: To evaluated the perinatal outcome following fetoscopy guided laser coagulation of placental anatomoses. Method: Retrospective analysis of 18 cases treated in Clinica Alemana, between 2005 and 2008. Results: 72.8 percent of the pregnancies had at least one survivor at neonatal discharge. No case needed a second fetoscopy. There was no rupture of the membranes in patients without symptoms before surgery. There were no neurological sequels in survivors. Conclusions: The maternal and perinatal outcome is similar to international series and demonstrates feasibility in our country by experienced operators.

Selective fetoscopic laser photocoagulation of superficial placental anastomoses for the treatment of severe twin-twin transfusion syndrome

OBJECTIVE: To report our initial institutional experience with fetoscopic laser photocoagulation of placental anastomoses in severe twin-twin transfusion syndrome using a 1.0 mm endoscope. METHODS: Between July 2006 and June 2008, 19 monochorionic diamniotic twin pregnancies complicated by severe TTTS (Quintero stages III and IV) underwent fetoscopic laser therapy. Perinatal data were prospectively collected and compared according to the Quintero stages. RESULTS: Nine patients were classified as stage III and ten as stage IV. The Mean gestational ages at diagnosis and procedure were 20 (range: 17-25) and 22.0 (range: 19.0-26.0) weeks, respectively, with no statistical difference between the two groups. Preterm premature rupture of the membranes occurred in two cases (10.5 percent), and spontaneous preterm delivery in eight (42.1 percent). Overall mean gestational age at delivery was 32.1 (range: 26.0-38.0) weeks. Prematurity was more severe in stage IV patients (p<0.01). Among all cases, the overall survival rate was 52.6 percent, and the percentages of pregnancies with survival of both babies and at least one twin were 26.3 percent and 78.9 percent, respectively. In the case of stage III patients, the overall survival rate was 61.1 percent. Of the stage III pregnancies, 33.3 percent resulted in both babies surviving, and 88.9 percent of these pregnancies resulted in at least one surviving twin. For stage IV, as the corresponding statistics were 45.0 percent, 20.0 percent and 70.0 percent respectively. CONCLUSIONS: Our initial institutional experience with 1.0 mm fetoscopic laser therapy for severe TTTS showed results similar to those reported in the literature for larger endoscopes.

Transabdominal Embryofetoscopy for the Detection of Short Rib-polydactyly Syndrome, Type II(Majewski), in the First Trimester

Our aim was to demonstrate the potential of first-trimester embryofetoscopy for prenatal diagnosis in a continuing pregnancy. A patient at risk for giving birth to an infant with short rib-polydactyly syndrome, type II (Majewski), presented for prenatal diagnosis at 9 weeks of gestation. A 1 mm semirigid fiberoptic endoscope with an 18 gauge examination sheath and a single-chip digital camera were used for transabdominal embryofetoscopy. Transabdominal embryofetoscopy was performed at 13 weeks of gestation. Direct visualization of the fetus was achieved and no gross limb or facial abnormalities were seen. This case shows that embryofetoscopy is a useful tool for early diagnosis in high-risk patients in the first trimester for continuing pregnancies.

Laser for the treatment of twin to twin transfusion syndrome

OBJETIVO: Nosso objetivo é relatar a experiência inicial no país com uma nova técnica de tratamento para a síndrome de transfusão feto-fetal (STT), onde se utiliza o raio laser para coagulação dos vasos placentários responsáveis pela transfusão entre gêmeos durante a gravidez. MÉTODOS: Estudo prospectivo de 8 casos com diagnóstico de STT avaliados pelo nosso serviço de janeiro de 2001 a junho de 2005. Introduzindo-se um fetoscópio de 2,0 mm de diâmetro na cavidade uterina, por via percutânea, foram diretamente visualizados os vasos da superfície placentária. Aqueles vasos identificados como responsáveis pela transfusão foram coagulados através do laser. O procedimento combina a ultra-sonografia e a fetoscopia, no que se denomina uma abordagem sono-endoscópica (FETENDO). RESULTADOS: Dentre as oito gestações avaliadas, o procedimento foi realizado em cinco casos (10 fetos). Todos os fetos sobreviveram por um período mínimo de cinco semanas após a cirurgia. Na evolução, oito fetos nasceram vivos e cinco sobreviveram ao período neonatal. No seguimento pós-natal de 18 meses, todos os cinco estão vivos e bem, tendo atualmente uma idade média de 10,6 meses. A sobrevida geral foi de 50%, sendo que em três gestações, pelo menos um feto sobreviveu. CONCLUSÕES: A fetoscopia com laser é atualmente considerada "gold-standard" no tratamento da STT. No entanto, a técnica é sofisticada e depende de treinamento adequado. Nosso serviço é o primeiro do país a oferecer esta técnica cirúrgica e nossos índices de sucesso se comparam aos índices mundiais.

Prenatal intervention for urinary obstruction and myelomeningocele

Widespread use of ultrasonography has resulted in an increase in the recognition of fetal hydronephrosis. The enthusiasm that accompanied early interventions has been tempered by the experience and results obtained over the past 2 decades. The goal has remained the same: to identify patients with serious prenatal obstruction and to identify those which may benefit from intervention. Myelomeningocele remains a devastating congenital anomaly. Fetal and experimental studies suggested that patients with myelomeningocele could benefit from prenatal intervention. Advances in technology and perinatal management have made intervention for more complex malformations such as myelomeningocele possible. This article will review current knowledge and will detail rational management for the management of prenatal hydronephrosis. The current state of antenatal myelomeningocele repair and the urologic implications will be described as well.

Endoscopic techniques in fetal surgery

Fetal endoscopic surgery (FETENDO) involves many techniques that allow surgical procedures to be performed inside the uterus without an hysterotomy. The impetus for developing these minimal access techniques for fetal surgery is the unusual occurrence with an open hysterotomy of preterm labor, premature rupture of membranes, and maternal complications resulting from tocolytic therapy. The unique requirements of this approach necessitated a modification of existing endoscopic techniques, the development of novel fetoscopic instruments, and the inclusion of a wide variety of specialists. Technical expertise in the field and a natural evolution of techniques have given rise to innovative repairs previously not envisioned. Severe congenital diaphragmatic hernia, diseases of monochorionic twins, and obstructive uropathy have already been successfully treated using fetoscopic surgical techniques. Fetoscopic correction of many other non-life threatening anomalies continues to evolve. The future of fetoscopic surgical intervention depends on the continual evolution of novel approaches to disease, the elucidation of the pathophysiology and treatment of other fetal disorders, and a better understanding of treatment of complications of such intervention.

Evaluación ecográfica de la cara fetal / Ecographic evaluation of the fetal face

En el presente trabajo presentamos hallazgos patológicos de la cara fetal, encontrados en evaluaciones ecosonográficas de rutina, permitiendo en algunos casos la orientación diagnóstica y manejo prenatal. Se hace una descripción de cada caso, hallazgos y manejo realizado, se elaboran recomendaciones