Should we stitch-close the fetoscopic percutaneous access? A case-series of laparotomy to trans-amniotic membrane suturing for intrauterine port placement in fetoscopic surgery for twins.

INTRODUCTION: Maternal laparotomy-assisted fetoscopic surgery for in-utero myelomeningocele repair has shown that a trans-amniotic membrane suture during fetoscopic port placement can reduce postsurgical complications. Fetoscopic laser photocoagulation (FLP) for complex twins is typically performed percutaneously without a transmembrane stitch. However, in scenarios without a placental free window, maternal laparotomy may be used for recipient sac access. Here, we present the outcomes of our series of laparotomy-assisted FLP cases, including a trans-amniotic membrane suturing of the fetoscopic port. METHODS: Retrospective series of twin-twin transfusion syndrome (TTTS) or twin anemia-polycythemia (TAPS) cases treated at 2 fetal centers that underwent maternal laparotomy to FLP from 9/2017 to 1/2023. We recorded preoperative and operative characteristics, as well as pregnancy and neonatal outcomes. RESULTS: During the study period, 9 maternal laparotomy to FLP cases were performed. Two were excluded for prior percutaneous FLP in the pregnancy. The remaining seven utilized a maternal laparotomy to trans-amniotic membrane stitch with confirmation of proper suture placement under ultrasound guidance, and all surgeries were performed with a single 10 F Check-Flo® cannula via sharp. Mean gestational age (GA) at surgery was 19.1 weeks (range 16w4d-23w3d), with delivery occurring at a mean GA of 35.0 weeks (range 32w0d-37w1d), resulting in a mean latency of 15.8 weeks, significantly longer than what is reported in the literature and our own data (mean latency for percutaneous FLP 10.2, 95% CI 9.9-10.5). Furthermore, all cases underwent iatrogenic delivery before labor onset, with the only delivery prior to 34 weeks due to concern for post-laser TAPS. CONCLUSION: This case series of laparotomy to FLP with trans-amniotic stitch, demonstrated no cases of spontaneous preterm birth and a longer-than-expected latency from surgery to delivery. Larger studies are warranted to investigate this approach.

Fetal surgery for obstructive ureterocele using an ultrasound-guided needle laser ablation technique: a case series.

INTRODUCTION: Obstructive ureterocele is an intravesical cystic dilation of the distal end of the ureter associated with anhidramnios and dilation of both renal pelvises. METHODS: This is a case-series of prenatally diagnosed ureterocele. Cases were selected at a third level reference hospital in Monterrey Mexico between 2010 and 2018. Eligible patients for fetal therapy were selected when bilateral hydronephrosis and severe oligohydramnios were found before 26+0 weeks of gestation. The fetal intervention comprised an ultrasound-guided needle laser technique for ureterocele ablation. RESULTS: There were six cases of prenatal diagnosed of ureterocele, two cases showed anhidramnios at 23 weeks of gestation and were considered obstructive ureterocele. For these two cases, fetal surgery was performed using laser ablation of the ureterocele through an ultrasound-guided needle. In both, the urinary tract was decompressed, and the volume of amniotic fluid improved allowing to carry both pregnancies until term, one of them vaginally and the other by cesarean section. In the postnatal follow-up of both cases, the first neonate died due to neonatal asphyxia at 48-hours, and the second neonate required removal of the abnormal collecting system. CONCLUSIONS: The use of ultrasound-guided laser ablation for the decompression of obstructive ureterocele is a safe and feasible technique in extremely premature fetuses that could allow survival of the affected fetus until term. Patients receiving an early prenatal diagnosis of obstructive ureterocele may benefit from fetal therapy to reduce the risk of lung hypoplasia and stillbirth.Established factsPrenatal mortality of bilateral obstructive ureterocele is up to 45%.Only a few techniques have been described for the management of prenatally bilateral obstructive ureterocele; among them, the puncturing of the ureterocele which may require more than one intervention during fetal, laser by fetoscopy which may increase the risk of postoperative complications, and ultrasound-guided laser fulguration which seems to be effective and safe.Novel insightsThe present is the first description of a case series on ureteroceles comprising two ultrasound-guided laser therapy as an effective treatment for bilateral obstructive ureterocele requiring a single intervention.The use of ultrasound-guided laser in obstructive cases avoids fatality and lung hypoplasia due to severe oligohydramnios. Still, the neonatal prognosis of the affected side at two years of age remains unchanged.

Displasia mesenquimal placentaria asociada con restricción del crecimiento intrauterino de inicio temprano: reporte de un caso / Placental mesenchymal dysplasia associated with early onset intrauterine growth restriction: a case report

Resumen ANTECEDENTES: La displasia mesenquimal placentaria es una anomalía de la vasculatura y del tejido conectivo placentario que altera la estructura y la función de las vellosidades, se asocia con un desenlace perinatal adverso. CASO CLÍNICO: Paciente de 21 años, primigesta, con 15.2 semanas de embarazo establecidas por fetometría, con placenta corporal anterior, de morfología anormal, con múltiples imágenes hipoecogénicas que semejan racimos de uvas, sin flujo vascular en el Doppler color. La valoración ecográfica de las 33 semanas reportó fetometría para 27.2 semanas, anhidramnios y placentomagelia, con alteración en los parámetros de la flujometría Doppler. En la prueba sin estrés se diagnosticó restricción del crecimiento intrauterino estadio IV. La imagen del feto fue heterogénea en el flanco derecho de 4.7 x 4.1 cm. El embarazo finalizó por cesárea con una recién nacida con Apgar 8-9, de 930 gramos, placenta agrandada con vellosidades hidrópicas. El estudio histopatológico reportó: displasia mesenquimal placentaria. La resección del tumor abdominal fue electiva, por vía laparoscópica, al cuarto mes de vida, con diagnóstico histopatológico de hamartoma mesenquimal hepático. CONCLUSIÓN: La displasia mesenquimal placentaria es una anomalía placentaria benigna, relacionada con restricción del crecimiento intrauterino de inicio temprano que puede evolucionar, incluso, a la muerte del feto por hipoxia crónica debido a las anomalías en la vasculatura microscópica que afectan el desarrollo de las vellosidades terminales e interfiere en el intercambio de gases, nutrientes y electrolitos en el espacio intervelloso.

Abstract BACKGROUND: Placental mesenchymal dysplasia is an anomaly of the vasculature and placental connective tissue which alters the structure and function of the villi, being associated with an adverse perinatal outcome. CLINICAL CASE: Patient 21 years old, primigestation, with 15.2 weeks of pregnancy established by fetometry, with anterior body placenta, abnormal morphology, with multiple hypoechogenic images resembling clusters of grapes, without vascular flow in color Doppler. Ultrasound evaluation at 33 weeks, reporting fetometry for 27.2 weeks, anhydramnios and placentomagelia, with alteration in Doppler parameters, as well as in a non-stress test diagnosing fetal growth restriction stage IV. Fetus with heterogeneous image on the right flank of 4.7 x 4.1 cm. Abdominal pregnancy interruption was decided, obtaining a live female newborn, Apgar 8/9, weight 930 grams, enlarged placenta with hydropic villi. The histopathology study reports placental mesenchymal dysplasia. Abdominal tumor resection was performed electively by laparoscopy at 4 months of age with a histopathological diagnosis of hepatic mesenchymal hamartoma. CONCLUSION: Placental mesenchymal dysplasia is a benign placental anomaly, related to early-onset intrauterine growth restriction that can even progress to fetal death by chronic hypoxia due to abnormalities in the microscopic vasculature that affect the development of the terminal villi and interfere with the exchange of gases, nutrients and electrolytes in the intervillous space.

Intracranial Translucency, Its Use as a Potential First Trimester Ultrasound Marker for Screening of Neural Tube Defects.

The objective of the study was to describe a case-series of neural tube defects (NTD) with an abnormal intracranial translucency (IT) detected during the first-trimester ultrasound scan, performed on a low-risk obstetric population in Mexico. Certified Fetal Medicine specialists performed all US scans; the IT was assessed using the mid-sagittal view of the fetal head, which is already systematically used for nuchal translucency and nasal bone evaluation. During the study, we were able to find that eight fetuses had an absence of the intracranial translucency, out of which two were reassessed at 14 weeks' gestation and IT was normal, six of them were later diagnosed to have an NTD that consisted in spina bifida aperta (n = 5) and encephalocele (n = 1). Conclusion: As previous studies have shown, IT evaluation during the first-trimester US routine scan may be a useful screening marker for early detection of NTDs.

Successful Management of Heterotopic Cervical Pregnancy with Ultrasonographic-guided Laser Ablation.

Heterotopic pregnancy refers to the simultaneous presence of ectopic pregnancy and intrauterine pregnancy. With the advent of assisted reproductive technology, the overall incidence of heterotopic pregnancies has risen. We report a case of a 36-year-old woman with type 2 diabetes mellitus and 1-year of primary infertility. Following oral ovulation induction cycles and intrauterine insemination, diagnosis of heterotopic cervical pregnancy was made by ultrasonography at 7.4 weeks of gestation. Laser ablation of the cervical pregnancy was performed achieving adequate homeostasis at the implantation site and preserving the intrauterine pregnancy. A healthy infant was delivered at 36 0/7 weeks by cesarean section. Laser ablation is a minimally invasive procedure that appears to lead to successful outcomes in the treatment of heterotopic cervical pregnancy.

Evaluación prenatal del feto con gastrosquisis: relación entre la dilatación del asa intestinal y el pronóstico del neonato / Prenatal diagnosis of the fetus with gastroschisis: Relationship of intestinal loop dilatation and prognosis of the neonate

Resumen OBJETIVO: Evaluar si la dilatación del asa intestinal, a partir de los 18 mm, es un factor pronóstico de morbilidad neonatal, debido al debate que aún prevalece acerca de la medición de la dilatación del asa intestinal y su validez como factor pronóstico. MATERIALES Y MÉTODOS: Estudio retrospectivo, transversal y analítico efectuado con los neonatos atendidos de 2013 a 2015. Variables analizadas: dilatación del asa intestinal y tipo de cierre de la pared abdominal como variables de pronóstico de morbilidad neonatal. Para el análisis de los datos se utilizó estadística descriptiva, prueba de U de Mann-Whitney y razón de momios. Se consideró estadísticamente significativo el valor de p ≤ 0.05. RESULTADOS: Se estudiaron 20 neonatos; el grupo con dilatación mayor de 18 mm experimentó complicaciones en 60% de los casos, y el grupo con dilatación ≤ 18 mm solo 13%. Se determinó que la dilatación del asa intestinal mayor de 18 mm es predictora de complicaciones neonatales, con sensibilidad de 85%, especificidad de 58.3% y razón de momios de 8.4 (IC95%: 1-67.8). Los neonatos con cierre primario de la pared abdominal tuvieron menor tiempo de inicio de la vía oral y menos días de nutrición parenteral versus el grupo con silo con un valor p = 0.009 y p = 0.041, respectivamente. La estancia hospitalaria fue similar en ambos grupos (p = 0.069). CONCLUSIÓN: La dilatación del asa intestinal parece ser un factor pronóstico en la predicción de complicaciones neonatales, pero no un factor que pueda predecir los días de estancia intrahospitalaria, el tiempo del inicio de la vía oral o los días de nutrición parenteral en el neonato.

Abstract OBJECTIVE: To assess whether intestinal loop dilatation by prenatal ultrasound is a prognostic factor of neonatal morbidity. MATERIALS AND METHODS: Retrospective analytical cross-sectional study that included cases during the period 2013 to 2015. Variables of intestinal loop dilation and type of abdominal wall closure were analyzed as prognostic variables of neonatal morbidity. For the analysis, descriptive statistics, Mann-Whitney U test and odds ratio were used. The value of p ≤ 0.05 was considered statistically significant. RESULTS: The total population was 20 neonates. The group with dilatation> 18mm presented complications in 60% of the cases, and the group with dilatation ≤ 18mm only 13%; It was determined that intestinal loop dilatation> 18mm is a predictor of neonatal complications with 85% sensitivity, 58.3% specificity and an OR of 8.4 (95%CI: 1-67.8). Neonates in whom primary closure of the abdominal wall was performed had shorter time of oral initiation and fewer days of parenteral nutrition when compared with the group in which Silo was placed, with a value of p = 0.009 and p = 0.041 respectively. While the hospital stay was similar in both groups (p = 0.069). CONCLUSION: Bowel dilation is a prognostic factor in the prediction of neonatal complications, but not a factor that can predict days of in-hospital stay, time of oral initiation or days of parenteral nutrition in the neonate.

[Mammary ductal ectasia child. Diagnostic and therapeutic approach]. / Ectasia ductal mamaria infantil. Aproximación diagnóstica y terapéutica.

Mammary duct ectasia in childhood is a rare disease. It appears typically as a periareolar mammary mass and/or nipple discharge. Even though in the adult age is an acquired disease, its occurrence in children suggests it may constitute a development mammary gland anomaly. Sonography is highly useful in the diagnosis. Differential diagnosis must include other nipple discharge and mammary mass causes as the juvenile fibroadenoma or malignant pathology. This usually is a self-limited process, so that a conservative approach is recommended, even though occasionally surgical treatment is required. We report the case of a 13 years old girl with nipple discharge who finally was diagnosed bilateral mammary duct ectasia.