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.

Serum biomarkers and Doppler pulsatile index increases likelihood ratio for prediction of preeclampsia in the second trimester of pregnancy.

This study aims to compare the accuracy of risk prediction for preeclampsia (PE) of three calculators during the second trimester of gestation: American College of Obstetricians and Gynaecologists (ACOG), National Institute for Health and Care Excellence (NICE), and Foetal Medicine Foundation (FMF). Complete medical history, mean uterine artery Doppler pulsatile index were performed (PI) and venous blood samples for placental growth factor (PIGF), soluble fms-like tyrosine kinase-1 (sFLT-1), and Endoglin measurements were obtained from 214 women between 20-24 weeks gestation. PE frequency was 8.4% (18/214). Sensitivity and specificity were 94.4% and 37.2% and 44.4% and 74.5% for ACOG and NICE respectively. Sensitivity for FMF was 66.7% and 44.4% at <32 weeks and <36 weeks respectively and specificity was 97.2% and 98.1%. The highest positive likelihood ratio, 22, was obtained for FMF as compared to 1.49 and 1.76 for ACOG and NICE. These findings suggest that the addition of US and serum biomarkers in the FMF calculator increases accuracy for prediction of PE.Impact StatementWhat is already known on this subject? Several strategies have been implemented to evaluate risk for PE. The ACOG and NICE calculators, based on medical and anthropomorphic data, and the FMF calculator, which includes ultrasound and serum biomarkers, have been used for the prediction of PE risk in the first trimester of gestation.What do the results of this study add? Although the identification of markers for the prediction of PE during the first trimester of pregnancy has been of major clinical interest, in many countries women attend their first prenatal visit up until the second trimester of pregnancy. This is the first multicentre study in Latin American population to compare the three risk prediction systems including serum biomarkers during the second trimester of pregnancy.What are the implications of these findings for clinical practice and/or further research? We propose the FMF calculator (including PI and serum biomarkers) as a useful tool for PE risk detection during the second trimester of pregnancy. However, as this study is limited by its small sample size, larger multicenter studies are needed to confirm our findings and assert the usefulness of the FMF calculator.

Experience of 300 cases of prenatal fetoscopic open spina bifida repair: report of the International Fetoscopic Neural Tube Defect Repair Consortium.

BACKGROUND: The multicenter randomized controlled trial Management of Myelomeningocele Study demonstrated that prenatal repair of open spina bifida by hysterotomy, compared with postnatal repair, decreases the need for ventriculoperitoneal shunting and increases the chances of independent ambulation. However, the hysterotomy approach is associated with risks that are inherent to the uterine incision. Fetal surgeons from around the world embarked on fetoscopic open spina bifida repair aiming to reduce maternal and fetal/neonatal risks while preserving the neurologic benefits of in utero surgery to the child. OBJECTIVE: This study aimed to report the main obstetrical, perinatal, and neurosurgical outcomes in the first 12 months of life of children undergoing prenatal fetoscopic repair of open spina bifida included in an international registry and to compare these with the results reported in the Management of Myelomeningocele Study and in a subsequent large cohort of patients who received an open fetal surgery repair. STUDY DESIGN: All known centers performing fetoscopic spina bifida repair were contacted and invited to participate in a Fetoscopic Myelomeningocele Repair Consortium and enroll their patients in a registry. Patient data entered into this fetoscopic registry were analyzed for this report. Fisher exact test was performed for comparison of categorical variables in the registry with both the Management of Myelomeningocele Study and a post-Management of Myelomeningocele Study cohort. Binary logistic regression analyses were used to assess the registry data for predictors of preterm birth at <30 weeks' gestation, preterm premature rupture of membranes, and need for postnatal cerebrospinal fluid diversion in the fetoscopic registry. RESULTS: There were 300 patients in the fetoscopic registry, 78 in the Management of Myelomeningocele Study, and 100 in the post-Management of Myelomeningocele Study cohort. The 3 data sets showed similar anatomic levels of the spinal lesion, mean gestational age at delivery, distribution of motor function compared with upper anatomic level of the lesion in the neonates, and perinatal death. In the Management of Myelomeningocele Study (26.16±1.6 weeks) and post-Management of Myelomeningocele Study cohort (23.3 [20.2-25.6] weeks), compared with the fetoscopic registry group (23.6±1.4 weeks), the gestational age at surgery was lower (comparing fetoscopic repair group with the Management of Myelomeningocele Study; P<.01). After open fetal surgery, all patients were delivered by cesarean delivery, whereas in the fetoscopic registry approximately one-third were delivered vaginally (P<.01). At cesarean delivery, areas of dehiscence or thinning in the scar were observed in 34% of cases in the Management of Myelomeningocele Study, in 49% in the post-Management of Myelomeningocele Study cohort, and in 0% in the fetoscopic registry (P<.01 for both comparisons). At 12 months of age, there was no significant difference in the number of patients requiring treatment for hydrocephalus between those in the fetoscopic registry and the Management of Myelomeningocele Study. CONCLUSION: Prenatal and postnatal outcomes up to 12 months of age after prenatal fetoscopic and open fetal surgery repair of open spina bifida are similar. Fetoscopic repair allows for having a vaginal delivery and eliminates the risk of uterine scar dehiscence, therefore protecting subsequent pregnancies of unnecessary maternal and fetal risks.

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.