Prenatal regenerative fetoscopic interventions for congenital anomalies.

Fetal intervention has progressed in the past two decades from experimental proof-of-concept to practice-adopted, life saving interventions in human fetuses with congenital anomalies. This progress is informed by advances in innovative research, prenatal diagnosis, and fetal surgical techniques. Invasive open hysterotomy, associated with notable maternal-fetal risks, is steadily replaced by less invasive fetoscopic alternatives. A better understanding of the natural history and pathophysiology of congenital diseases has advanced the prenatal regenerative paradigm. By altering the natural course of disease through regrowth or redevelopment of malformed fetal organs, prenatal regenerative medicine has transformed maternal-fetal care. This review discusses the uses of regenerative medicine in the prenatal diagnosis and management of three congenital diseases: congenital diaphragmatic hernia, lower urinary tract obstruction, and spina bifida.

Minimally Invasive Fetal Surgery.

Fetal surgery corrects severe congenital anomalies in utero to prevent their severe consequences on fetal development. The significant risk of open fetal operations to the pregnant mother has driven innovation toward minimally invasive procedures that decrease the risks inherent to hysterotomy. In this article, we discuss the basic principles of minimally invasive fetal surgery, the general history of its development, specific conditions and procedures used to treat them, and the future of the field.

Fetal surgery for congenital diaphragmatic hernia is back from never gone.

Over half of the cases of congenital diaphragmatic hernia are picked up prenatally. Prenatal assessment aims to rule out associated anomalies and to make an individual prognosis. Prediction of outcome is based on measurements of lung size and vasculature as well as on liver herniation. A subset of fetuses likely to die in the postnatal period is eligible for a fetal intervention that can promote lung growth. Two randomized trials have shown that fetal surgery using open anatomical repair or tracheal occlusion via hysterostomy has no benefit. Since then, a percutaneous fetoscopic technique has been introduced, which has been shown to be safe and seems to improve survival when compared to historical controls. Rupture of the fetal membranes and early delivery, nevertheless, remain an issue, but are less likely as compared to earlier experience. Improved outcomes are confirmed in two other studies published in this issue of Fetal Diagnosis and Therapy. This paper summarizes the experimental and clinical history of fetal surgery for congenital diaphragmatic hernia. It stresses the need for another randomized trial. This trial started in Europe and patients should be asked whether they would like to participate.

[Disputes and history of fetal heart monitoring]. / Controversias e historia del monitoreo cardiaco fetal.

The concept of fetal heart monitoring to determine the fetal wellbeing state has been employed for almost 300 years, but in the last 50 years it has observed drastic changes due to the incorporation of the electronic devices that has started controversy since the moment of its description and point of start. The purpose of this article is to mention the key points and controversial moments in the history of the cardiotocography

Fetoscopic laser therapy for twin-twin transfusion syndrome.

Twin-twin transfusion syndrome (TTTS) complicates approximately 1 in 5 of all monochorionic, diamniotic twin pregnancies. If of early onset and untreated, severe TTTS is associated with a dismal prognosis, with perinatal mortality rates exceeding 90%. The most controversial issue regarding the optimal treatment of TTTS has centered on the use of amniocentesis or laser until the first and only randomized trial on interventions for TTTS was published a couple of years ago, comparing laser to amnioreduction. That report confirmed that the laser group had a higher likelihood of the survival of at least one twin to 28 days of age and to 6 months of age. Infants in the laser group also had a lower incidence of cystic periventricular leukomalacia and were more likely to be free of neurologic complications at 6 months of age (52% vs. 31%, p = 0.003). Although not every case of TTTS is an eligible candidate for fetoscopic-guided laser therapy, it is recommended that obstetricians who have the chance to manage TTTS in their daily practice be familiar with the rationale behind this laser treatment for TTTS.