- Email: [email protected]
558: Short term neonatal morbidity in severe left-sided congenital diaphragmatic hernia treated by tracheal occlusion before 30 weeks
SMFM Abstracts 558
www.AJOG.org
SHORT TERM NEONATAL MORBIDITY IN SEVERE LEFT-SIDED CONGENITAL DIAPHRAGMATIC HERNIA TREATED BY TRACHEAL OCCLUSION BEFORE 30 WEEKS JACQUES JANI1, KYPROS NICOLAIDES1, EDUARD GRATACOS2, KAREL ALLEGAERT3, ANNE GREENOUGH4, OSCAR MORENO2, JAN DEPREST5, 1King’s College Hospital, OB/GYN, London, United Kingdom, 2University of Barcelona, Barcelona, Spain, 3University Hospital Leuven, Neonatology, Leuven, Belgium, 4King’s College London, Neonatology, London, United Kingdom, 5University Hospitals Leuven, OB/GYN, Leuven, Belgium OBJECTIVE: Neonatal survival and morbidity can be predicted by the observed/ expected lung-head ratio (O/ELHR) in isolated left-sided congenital diaphragmatic hernia. In severe cases (O/ELHR⬍26%) with predicted survival of⬍15%, we offer fetoscopic endoluminal tracheal occlusion (FETO). We aimed to report on their neonatal morbidity as compared to that of babies with intermediate severity (26%ⱕO/ELHR⬍45%) managed expectantly. STUDY DESIGN: Multicenter retrospective study on 37 fetuses undergoing FETO. Outcome measures were GA at birth, need for patch repair, O2 supplementation at 28 d, duration of ventilation, days of life at full enteral feeding and discharge from NICU. 50 cases with intermediate hypoplasia were earlier reported on (Antenatal CDH registry, AJOG 195; 164:S60). RESULTS: FETO resp balloon removal were at 27 (24-29.6) weeks resp. 33.6 (27.5-38.5), GA at delivery was 36.2 (27.5-40.3) and birth-weight 2718 (1204-3930) g. One neonate, born at 32.3 wks, had severe developmental delay and one had a strongly increased tracheal diameter. Babies with intermediate lung hypoplasia had a lower need for patch repair but other morbidity indicators were comparable despite increased severity in FETO cases. CONCLUSION: It is difficult to compare outcome following FETO to neonatally managed controls, because only few with O/ELHR⬍26% survive. Morbidity after FETO is better than expected based on severity of lung hypoplasia.
Morbidity
FETO (n⫽37)
Expectant O/E LHR 26-45 (n⫽50)
P value
Days in NICU Need for patch (%) Days on ventilator Supplemental O2 at 28 days (%) Days at full enteral feeding
37 (3-121) 83.7 15 (3-115) 43.2 27 (6-150)
30.5 (4-148) 32.0 16 (3-45) 30.0 27 (5-108)
0.136 ⬍0.001 0.342 0.202 0.506
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.582
559
FETOSCOPIC LASER COAGULATION IN TWIN-TO-TWIN TRANSFUSION SYNDROME: THE LEARNING CURVE SUZANNE PEETERS1, DICK OEPKES1, ENRICO LOPRIORE2, FRANS KLUMPER1, FRANK VANDENBUSSCHE1, ANNEMIEKE MIDDELDORP1, 1Leiden University Medical Center, Dept. of Obstetrics, Leiden, Netherlands, 2Leiden University Medical Center, Dept. of Pediatrics, Div of Neonatology, Leiden, Netherlands OBJECTIVE: To report the learning curve from our initial 176 fetoscopic laser surgery procedures for severe twin-to-twin transfusion syndrome (TTTS) STUDY DESIGN: A retrospective study performed on prospectively collected data on 176 monochorionic twin pregnancies with severe mid-trimester TTTS treated with fetoscopic laser coagulation performed by four operators working in close collaboration between August 2000 and December 2006. RESULTS: The overall survival rate (at least one survivor, up to at least 4 weeks of age) was 83%. The percentage of pregnancies with survival of both fetuses was 56%. The change over time, or learning curve, is shown in the figure. CONCLUSION: This study showed a trend towards an increase in survival rates with growing experience in fetoscopic laser coagulation technique. Results of our center with four operators showed similar pregnancy outcomes as published series with one operator. Factors affecting the learning curve such as teamwork and placental injection studies will be discussed.
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.583
560
QUANTIFICATION OF DONOR TO RECIPIENT TRANSFUSION RATE THROUGH A SINGLE PLACENTAL ARTERIO-VENOUS ANASTOMOSIS IN A MONOCHORIONIC TWIN PREGNANCY ENRICO LOPRIORE1, DICK OEPKES2, JEROEN VAN DEN WIJNGAARD3, SUZANNE PASMAN4, FRANS WALTHER1, MARTIN VAN GEMERT3, FRANK VANDENBUSSCHE2, 1Leiden University Medical Center, Dept. of Pediatrics, Div.of Neonatology, Leiden, Netherlands, 2Leiden University Medical Center, Dept. of Obstetrics, Leiden, Netherlands, 3University of Amsterdam, Laser Center and Department of Obstetrics and Gynecology, Academical Medical Center, Amsterdam, Netherlands, 4Leiden University Medical Centre, Dept. of Obstetrics, Leiden, Netherlands OBJECTIVE: Twin-to-twin transfusion syndrome (TTTS) is due to unbalanced inter-twin blood flow through placental vascular anastomoses. We present a case of TTTS that allowed us to calculate the net inter-twin blood flow. STUDY DESIGN: Case report.The case was treated with fetoscopic laser surgery at 22 weeks= gestation. In the following weeks, the ex-recipient developed severe fetal anemia, requiring treatment with an intrauterine adult red cell transfusion at 26 and 28 weeks= gestation. A cesarean section was performed one week after the second intrauterine transfusion because of recurring fetal anemia in the ex-recipient. After birth, placental injection with color-latex identified a single residual unidirectional arterio-venous anastomosis from the ex-recipient to the ex-donor with a diameter of about 0.5 mm. We measured the fetal and adult hemoglobin concentrations in the ex-recipient before and after both intrauterine transfusions and in both twins at birth. RESULTS: On the basis of these measurements (table) we then calculated the blood flow across the residual arterio-venous anastomosis and found it to be 12 ml/24 h after the first transfusion and 15 ml/24 h after the second transfusion. CONCLUSION: This is the first accurate recording of blood flow volume through one arterio-venous anastomosis in TTTS. Blood values in the ex-recipient before and after the first and second intrauterine transfusion (IUT), and at birth
Hb g/dl Ht % MCV Retic HbF % HbA %
Before 1st IUT
After 1st IUT
Before 2nd IUT
After 2nd IUT
Ex-recip at birth
Ex-donor at birth
4.0 14 150 444 94 6
12.6 38 102 115 23 77
5.4 18 130 305 76 23
13.3 41 106 92 22 78
9.4 30 111 84 39 61
23.5 68 116 28 72 28
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.584
S162
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2007
www.AJOG.org
SHORT TERM NEONATAL MORBIDITY IN SEVERE LEFT-SIDED CONGENITAL DIAPHRAGMATIC HERNIA TREATED BY TRACHEAL OCCLUSION BEFORE 30 WEEKS JACQUES JANI1, KYPROS NICOLAIDES1, EDUARD GRATACOS2, KAREL ALLEGAERT3, ANNE GREENOUGH4, OSCAR MORENO2, JAN DEPREST5, 1King’s College Hospital, OB/GYN, London, United Kingdom, 2University of Barcelona, Barcelona, Spain, 3University Hospital Leuven, Neonatology, Leuven, Belgium, 4King’s College London, Neonatology, London, United Kingdom, 5University Hospitals Leuven, OB/GYN, Leuven, Belgium OBJECTIVE: Neonatal survival and morbidity can be predicted by the observed/ expected lung-head ratio (O/ELHR) in isolated left-sided congenital diaphragmatic hernia. In severe cases (O/ELHR⬍26%) with predicted survival of⬍15%, we offer fetoscopic endoluminal tracheal occlusion (FETO). We aimed to report on their neonatal morbidity as compared to that of babies with intermediate severity (26%ⱕO/ELHR⬍45%) managed expectantly. STUDY DESIGN: Multicenter retrospective study on 37 fetuses undergoing FETO. Outcome measures were GA at birth, need for patch repair, O2 supplementation at 28 d, duration of ventilation, days of life at full enteral feeding and discharge from NICU. 50 cases with intermediate hypoplasia were earlier reported on (Antenatal CDH registry, AJOG 195; 164:S60). RESULTS: FETO resp balloon removal were at 27 (24-29.6) weeks resp. 33.6 (27.5-38.5), GA at delivery was 36.2 (27.5-40.3) and birth-weight 2718 (1204-3930) g. One neonate, born at 32.3 wks, had severe developmental delay and one had a strongly increased tracheal diameter. Babies with intermediate lung hypoplasia had a lower need for patch repair but other morbidity indicators were comparable despite increased severity in FETO cases. CONCLUSION: It is difficult to compare outcome following FETO to neonatally managed controls, because only few with O/ELHR⬍26% survive. Morbidity after FETO is better than expected based on severity of lung hypoplasia.
Morbidity
FETO (n⫽37)
Expectant O/E LHR 26-45 (n⫽50)
P value
Days in NICU Need for patch (%) Days on ventilator Supplemental O2 at 28 days (%) Days at full enteral feeding
37 (3-121) 83.7 15 (3-115) 43.2 27 (6-150)
30.5 (4-148) 32.0 16 (3-45) 30.0 27 (5-108)
0.136 ⬍0.001 0.342 0.202 0.506
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.582
559
FETOSCOPIC LASER COAGULATION IN TWIN-TO-TWIN TRANSFUSION SYNDROME: THE LEARNING CURVE SUZANNE PEETERS1, DICK OEPKES1, ENRICO LOPRIORE2, FRANS KLUMPER1, FRANK VANDENBUSSCHE1, ANNEMIEKE MIDDELDORP1, 1Leiden University Medical Center, Dept. of Obstetrics, Leiden, Netherlands, 2Leiden University Medical Center, Dept. of Pediatrics, Div of Neonatology, Leiden, Netherlands OBJECTIVE: To report the learning curve from our initial 176 fetoscopic laser surgery procedures for severe twin-to-twin transfusion syndrome (TTTS) STUDY DESIGN: A retrospective study performed on prospectively collected data on 176 monochorionic twin pregnancies with severe mid-trimester TTTS treated with fetoscopic laser coagulation performed by four operators working in close collaboration between August 2000 and December 2006. RESULTS: The overall survival rate (at least one survivor, up to at least 4 weeks of age) was 83%. The percentage of pregnancies with survival of both fetuses was 56%. The change over time, or learning curve, is shown in the figure. CONCLUSION: This study showed a trend towards an increase in survival rates with growing experience in fetoscopic laser coagulation technique. Results of our center with four operators showed similar pregnancy outcomes as published series with one operator. Factors affecting the learning curve such as teamwork and placental injection studies will be discussed.
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.583
560
QUANTIFICATION OF DONOR TO RECIPIENT TRANSFUSION RATE THROUGH A SINGLE PLACENTAL ARTERIO-VENOUS ANASTOMOSIS IN A MONOCHORIONIC TWIN PREGNANCY ENRICO LOPRIORE1, DICK OEPKES2, JEROEN VAN DEN WIJNGAARD3, SUZANNE PASMAN4, FRANS WALTHER1, MARTIN VAN GEMERT3, FRANK VANDENBUSSCHE2, 1Leiden University Medical Center, Dept. of Pediatrics, Div.of Neonatology, Leiden, Netherlands, 2Leiden University Medical Center, Dept. of Obstetrics, Leiden, Netherlands, 3University of Amsterdam, Laser Center and Department of Obstetrics and Gynecology, Academical Medical Center, Amsterdam, Netherlands, 4Leiden University Medical Centre, Dept. of Obstetrics, Leiden, Netherlands OBJECTIVE: Twin-to-twin transfusion syndrome (TTTS) is due to unbalanced inter-twin blood flow through placental vascular anastomoses. We present a case of TTTS that allowed us to calculate the net inter-twin blood flow. STUDY DESIGN: Case report.The case was treated with fetoscopic laser surgery at 22 weeks= gestation. In the following weeks, the ex-recipient developed severe fetal anemia, requiring treatment with an intrauterine adult red cell transfusion at 26 and 28 weeks= gestation. A cesarean section was performed one week after the second intrauterine transfusion because of recurring fetal anemia in the ex-recipient. After birth, placental injection with color-latex identified a single residual unidirectional arterio-venous anastomosis from the ex-recipient to the ex-donor with a diameter of about 0.5 mm. We measured the fetal and adult hemoglobin concentrations in the ex-recipient before and after both intrauterine transfusions and in both twins at birth. RESULTS: On the basis of these measurements (table) we then calculated the blood flow across the residual arterio-venous anastomosis and found it to be 12 ml/24 h after the first transfusion and 15 ml/24 h after the second transfusion. CONCLUSION: This is the first accurate recording of blood flow volume through one arterio-venous anastomosis in TTTS. Blood values in the ex-recipient before and after the first and second intrauterine transfusion (IUT), and at birth
Hb g/dl Ht % MCV Retic HbF % HbA %
Before 1st IUT
After 1st IUT
Before 2nd IUT
After 2nd IUT
Ex-recip at birth
Ex-donor at birth
4.0 14 150 444 94 6
12.6 38 102 115 23 77
5.4 18 130 305 76 23
13.3 41 106 92 22 78
9.4 30 111 84 39 61
23.5 68 116 28 72 28
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.584
S162
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2007