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Indomethacin modifies the fetal hemodynamic response induced by cordocentesis
SPO Abstracts
Volmne 176, N u m b e r 1, Part 2 A m J Obstet Gynecol
$19
41
INDOMETHACIN MODIFIES THE FETAL HEMODYNAMIC RESPONSE INDUCED BY CORDOCENTESIS. A, C a p ~ ~, G. Rizzo ~, L. Pasqui~ff ~, E. Tutti; D. Arduini x, C Romar~inff. Fetal Medicine Center, Dept. Ob/Gyn, Universita' di Roma "Tor Vergata", Roma Italy. OBJECTIVE: Cordocentesis is associated with a marked decrease in umbilical artery (IRA) impedance. We tested the hypothesis that the decrease is secondary to the release of prostanoids by pretreating the mother with indomethacin. STUDY DESIGN: Cordocentesis was performed in 16 singleton pregnancies treated for 3 days before the procedure with indometbacin (25 lng po q6h) for tocolysis and in 22 untreated pregnancies. All the procedures were uncomplicated and umbilical vein puncture was confirmed by pressure measurement. The UA Pulsatility Index (PI) and fetal heart rate were measured immediately before and after the procedure. The first and last aliquots of umbilical vein plasma obtained at the beginning and closing of the procedure were assayed for 6-keto-prostaglandin F l u (6-Keto-PGFlc0 and thromboxane B2 (TxB2). RESULTS: Cordocentesis in control pregnancies reduced the UA PI (mean paired difference 0.54; p<0.001) and increased the 6-Keto-PGFIe~ levels (mean paired difference 62.7 pg/ml; p--<0.002), but bad no ette'ct on the fetal heart rate and TxB2 levels. Indomethacin reduced the 6-KetoPGFI~ and TxB2 levels in the first sample (each p<0.001) compared to the untreated pregnancies. After indomethacin cordocentesis had no effect on the UA PI, and 6-Keto-PGFle~ and TxB2 levels did not change. However, fetal heart significantly rose (mean paired difference 12.4 bpm; p~<0.005). CONCLUSION: lndomethacin alters the fetal h e m o d ~ a m i c response to cordocentesis by preventing the release of prostanoids. As a result, the fietus responds with an increase in heart rate rather than a decrease in the UA PI.
43
PERCUTANEOUS LIGATION AND TRANSECTION OF THE UMBILICAL CORD IN COMPLICATED MONOAMNIOTIC TWIN GESTATIONS VIA OPERATIVE FETOSCOPY. RA..Quintero,~ Lanouette, CA. CmTefio ~, M. Ki~zg", MP. Johnson, C Sudz ~, R. Romero, and MI. Evans. Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI. OBJECTIVE: Monoamniotic twin gestations with a non-viable fetus represent an inordinately high therapeutic challenge. Cord entanglement or spontaneous tbtal demise of one of the fetuses may result in loss of the pregnancy. Since vascular communications are present in virtually all cases, KCI selective feticide cannot be performed, and other intravascular methods are unreliable. We report our experience with ligation and transection of the umbilical cord (L&T U-C) to manage these patients. STUDY DESIGN: Four patients ~dfla pre-viable monoamniofic twin gestations in which one fetus was considered non-viable were assessed. L&T U~] was off~ered if the abnormal twin was non-viable or if cord entanglement with obvious helnodynamic compromi~ of one of the fetuses was present. A normal kaiyotype was required. Percutmmous L&T U43 was performed under general anesthesia with combined endoscopic and sonographic guidance using 2-3 mm cuStOlndesigmed ports. Pefioperafve inu'avenous tocolysis and antibiotics were given. RESULTS: The mean gestational age at the time of the procedure was 17.5 weeks (range 16-19). Two patients had an acardiac twin with a normal co-twin, 1 patient had a discordant twin with cystic hygroma and dysplastic kidneys, and 1 patient had cord entanglement with pericardial effusion and evidence of hemodynamic decompensation of one of the fetuses by pulsed Doppler. L&T U-C was successfully performed in all cases. When possible, two knots were placed around the umbilical cord, and the transection was performed between the sutures; otherwise, the cord was transected proximal to the anomalous fetus. Post-operative disentanglelnent of the umbilical cords was documented with uhrasound. The average time gained after L&T U-C was 17 weeks (range 11-21), and all patients delivered after 30 weeks. Premature rupture of membranes (PROM) within three weeks of the procedure occurred in 1/4 (25%) cases, but was sealed with a percutaneous amniopatcb and the pregnancy progressed to term. Two patients (50%) were electively delivered at term. One patient developed oligohydraxnnios and placental insutficiency at 30 weeks, and the other delivered prematurely at 34 weeks. Neonatal outcmnes were mlremarkable. CONCLUSIONS: L&T U-C is a reliable technique for the management of complicated monoamniodc twin gestations. Transection of the cord effectively avoids the possibility of cord entanglement and subsequent death of the remaining twin. L&T U-G may also be used prior to spontaneous death of a non-viable twin to prevent neurologic and other complications in the sutaivor. L&T U-C probably should not be oifi~red to otherwise uncomplicated monoamniotic twins. Transection of the umbilical cord may also improve the outcome of complicated dianmiotic monochorionic gestations in which the dividing membrane has been breached during ligation of the umbilical cord.
42
DIRECT MEASUREMENTS OF CENTRAL VENOUS PRESSURE IN HUMAN FETUSES. Z. Weine~; ~ Z s ~ E . Z Zimmer, x J. Itskovitz-Eldor, ~ J.A. Copel, Dept. Ob/Gyn. Rambaln Medical Center, Haifa, Israel and Dept. Ob/Gyn. Yale University School of Medicine, New Haven, CT. OBJECTIVE: To obtain direct measurements of the central venous pressure (CVP) in hmnan fetuses in order to understand tbe fetal cardiovascular function in normal and in pathological conditions. STUDY DESIGN: We studied 19 patients undergoing late termination of pregnancy between 23-25 weeks' gestation for tetal or maternal indications. Prior to intracardiac injection of Potassium Chloride (KCL) 15% and intra-amniotic installation of prostaglandin (PG) F2 alpha to induce labor, a CVP manometer set was used to measure the right and left atrial, and the intra-amniotic pressures. Subtraction manometi T was used to measure the right and left atrial pressures. The true right or left atrial pressure was the pressure difference between the values measured within the atria, and the pressure measured within the anmiotic cavity. RESULTS: Amniotic fluid, right atrial, and left atrial pressures ranged from 7.7-16.9 mmHg (mean+SD, 12.5_+3.4 mmHg), 2.9-7.3 mmHg (4.2_+1.9 mmHg), and 1.1-3.7 (2.2-+0.9 mmHg), respectively, in 10 normal tietuses. Three fetuses with idiopathic nonimlnune hydrops (NIH) had significantly higher right atrial pressures (14.6, 15.6, and 17 mlnHg p=0.011, Mann*Whituey U test). Two non-hydropic fetuses with "infantile type" polycystic kidney also had an elevated right atrial pressure (10.3, and 11.7 mmHg). All 5 fetuses with an elevated right atrial pressure also had an increased left atrial pressure. In one tbtus with a complete atrioventricular septal deflect without valve regurgitation, there was no pressure difference between right and left atria, both of which fell in the normal range. Normal atrial pressures were measured in 2 fetuses with tetralogy of Fallot and in one tetus with aortic stenosis and ventricular septal defect. CONCLUSIONS: The CVP has been documented fi0r the first time in human fetuses. Our data confirm that the patfiophysiology of idiopathic NIH is associated with an elevated CVP. Both right and left atrial pressures may reflect the CVP in the fetus.
44
AMNIOT1C SEPTOSTOMY FOR THE TREATMENT OF THE STUCK TWIN SEQUENCE. D. Be~y\ L. Montgumery, A. Johnson, G. Saade, K. Moise. Dept. Ob/Gyn, Baylor College of Medicine, Houston, TX, Tulsa Perinatal Associates, Tulsa, OK and Prenatal Diagnostic Center, Lexington, MA. OBJECTIVE: To report our experience of intentional puncture of the intervening membrane ("septostomy") and subsequent pregnancy outcome for twin gestations complicated by the stuck twin sequence. STUDY DESIGN: Nine patients were diagnosed with a stuck twin sequence based on polyhydramnios in the larger twin and severe oligohydramnios and discordant growth in the smaller twin. A 22 gauge spinal needle was used to pertbrm a diagnostic and limited reduction anmiocentesis of the polyhydramniotic sac followed by selective puncture of the membrane between the twins, lrmnediate and long-term observations were made regarding subsequent t~etal growth and pregnancy outcomes. RESULTS: Alnniotic septostomy was perfbrmed in 5 second trimester and 4 third trimester pregnancies (median gestation: 21.ti weeks, range: 16.9-27.0 weeks). The median discordance based on ultrasound estimates of fetal weight was 34% 110-42%). hnmediate decompression of the "stuck twin" occurred in all cases followed by increased fetal movement, and improved mnbilical artery velocimetlT. Three of the 18 fetuses (17%) died in utero in two of the atfiected pregnancies. Delivery occurred at a median of 34 weeks' gestation (21.6..35.0). The median discordance at delivery was 31.5% (19-44%) suggesting no worsening of growth discrepancy after the septostonly was pertormed. No incidences of cord entanglement were encountered. CONCLUSIONS: Anmiotic septostolny may be utilized to treat the stuck twin sequence with a perinatal survival of up to 83%.
Volmne 176, N u m b e r 1, Part 2 A m J Obstet Gynecol
$19
41
INDOMETHACIN MODIFIES THE FETAL HEMODYNAMIC RESPONSE INDUCED BY CORDOCENTESIS. A, C a p ~ ~, G. Rizzo ~, L. Pasqui~ff ~, E. Tutti; D. Arduini x, C Romar~inff. Fetal Medicine Center, Dept. Ob/Gyn, Universita' di Roma "Tor Vergata", Roma Italy. OBJECTIVE: Cordocentesis is associated with a marked decrease in umbilical artery (IRA) impedance. We tested the hypothesis that the decrease is secondary to the release of prostanoids by pretreating the mother with indomethacin. STUDY DESIGN: Cordocentesis was performed in 16 singleton pregnancies treated for 3 days before the procedure with indometbacin (25 lng po q6h) for tocolysis and in 22 untreated pregnancies. All the procedures were uncomplicated and umbilical vein puncture was confirmed by pressure measurement. The UA Pulsatility Index (PI) and fetal heart rate were measured immediately before and after the procedure. The first and last aliquots of umbilical vein plasma obtained at the beginning and closing of the procedure were assayed for 6-keto-prostaglandin F l u (6-Keto-PGFlc0 and thromboxane B2 (TxB2). RESULTS: Cordocentesis in control pregnancies reduced the UA PI (mean paired difference 0.54; p<0.001) and increased the 6-Keto-PGFIe~ levels (mean paired difference 62.7 pg/ml; p--<0.002), but bad no ette'ct on the fetal heart rate and TxB2 levels. Indomethacin reduced the 6-KetoPGFI~ and TxB2 levels in the first sample (each p<0.001) compared to the untreated pregnancies. After indomethacin cordocentesis had no effect on the UA PI, and 6-Keto-PGFle~ and TxB2 levels did not change. However, fetal heart significantly rose (mean paired difference 12.4 bpm; p~<0.005). CONCLUSION: lndomethacin alters the fetal h e m o d ~ a m i c response to cordocentesis by preventing the release of prostanoids. As a result, the fietus responds with an increase in heart rate rather than a decrease in the UA PI.
43
PERCUTANEOUS LIGATION AND TRANSECTION OF THE UMBILICAL CORD IN COMPLICATED MONOAMNIOTIC TWIN GESTATIONS VIA OPERATIVE FETOSCOPY. RA..Quintero,~ Lanouette, CA. CmTefio ~, M. Ki~zg", MP. Johnson, C Sudz ~, R. Romero, and MI. Evans. Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI. OBJECTIVE: Monoamniotic twin gestations with a non-viable fetus represent an inordinately high therapeutic challenge. Cord entanglement or spontaneous tbtal demise of one of the fetuses may result in loss of the pregnancy. Since vascular communications are present in virtually all cases, KCI selective feticide cannot be performed, and other intravascular methods are unreliable. We report our experience with ligation and transection of the umbilical cord (L&T U-C) to manage these patients. STUDY DESIGN: Four patients ~dfla pre-viable monoamniofic twin gestations in which one fetus was considered non-viable were assessed. L&T U~] was off~ered if the abnormal twin was non-viable or if cord entanglement with obvious helnodynamic compromi~ of one of the fetuses was present. A normal kaiyotype was required. Percutmmous L&T U43 was performed under general anesthesia with combined endoscopic and sonographic guidance using 2-3 mm cuStOlndesigmed ports. Pefioperafve inu'avenous tocolysis and antibiotics were given. RESULTS: The mean gestational age at the time of the procedure was 17.5 weeks (range 16-19). Two patients had an acardiac twin with a normal co-twin, 1 patient had a discordant twin with cystic hygroma and dysplastic kidneys, and 1 patient had cord entanglement with pericardial effusion and evidence of hemodynamic decompensation of one of the fetuses by pulsed Doppler. L&T U-C was successfully performed in all cases. When possible, two knots were placed around the umbilical cord, and the transection was performed between the sutures; otherwise, the cord was transected proximal to the anomalous fetus. Post-operative disentanglelnent of the umbilical cords was documented with uhrasound. The average time gained after L&T U-C was 17 weeks (range 11-21), and all patients delivered after 30 weeks. Premature rupture of membranes (PROM) within three weeks of the procedure occurred in 1/4 (25%) cases, but was sealed with a percutaneous amniopatcb and the pregnancy progressed to term. Two patients (50%) were electively delivered at term. One patient developed oligohydraxnnios and placental insutficiency at 30 weeks, and the other delivered prematurely at 34 weeks. Neonatal outcmnes were mlremarkable. CONCLUSIONS: L&T U-C is a reliable technique for the management of complicated monoamniodc twin gestations. Transection of the cord effectively avoids the possibility of cord entanglement and subsequent death of the remaining twin. L&T U-G may also be used prior to spontaneous death of a non-viable twin to prevent neurologic and other complications in the sutaivor. L&T U-C probably should not be oifi~red to otherwise uncomplicated monoamniotic twins. Transection of the umbilical cord may also improve the outcome of complicated dianmiotic monochorionic gestations in which the dividing membrane has been breached during ligation of the umbilical cord.
42
DIRECT MEASUREMENTS OF CENTRAL VENOUS PRESSURE IN HUMAN FETUSES. Z. Weine~; ~ Z s ~ E . Z Zimmer, x J. Itskovitz-Eldor, ~ J.A. Copel, Dept. Ob/Gyn. Rambaln Medical Center, Haifa, Israel and Dept. Ob/Gyn. Yale University School of Medicine, New Haven, CT. OBJECTIVE: To obtain direct measurements of the central venous pressure (CVP) in hmnan fetuses in order to understand tbe fetal cardiovascular function in normal and in pathological conditions. STUDY DESIGN: We studied 19 patients undergoing late termination of pregnancy between 23-25 weeks' gestation for tetal or maternal indications. Prior to intracardiac injection of Potassium Chloride (KCL) 15% and intra-amniotic installation of prostaglandin (PG) F2 alpha to induce labor, a CVP manometer set was used to measure the right and left atrial, and the intra-amniotic pressures. Subtraction manometi T was used to measure the right and left atrial pressures. The true right or left atrial pressure was the pressure difference between the values measured within the atria, and the pressure measured within the anmiotic cavity. RESULTS: Amniotic fluid, right atrial, and left atrial pressures ranged from 7.7-16.9 mmHg (mean+SD, 12.5_+3.4 mmHg), 2.9-7.3 mmHg (4.2_+1.9 mmHg), and 1.1-3.7 (2.2-+0.9 mmHg), respectively, in 10 normal tietuses. Three fetuses with idiopathic nonimlnune hydrops (NIH) had significantly higher right atrial pressures (14.6, 15.6, and 17 mlnHg p=0.011, Mann*Whituey U test). Two non-hydropic fetuses with "infantile type" polycystic kidney also had an elevated right atrial pressure (10.3, and 11.7 mmHg). All 5 fetuses with an elevated right atrial pressure also had an increased left atrial pressure. In one tbtus with a complete atrioventricular septal deflect without valve regurgitation, there was no pressure difference between right and left atria, both of which fell in the normal range. Normal atrial pressures were measured in 2 fetuses with tetralogy of Fallot and in one tetus with aortic stenosis and ventricular septal defect. CONCLUSIONS: The CVP has been documented fi0r the first time in human fetuses. Our data confirm that the patfiophysiology of idiopathic NIH is associated with an elevated CVP. Both right and left atrial pressures may reflect the CVP in the fetus.
44
AMNIOT1C SEPTOSTOMY FOR THE TREATMENT OF THE STUCK TWIN SEQUENCE. D. Be~y\ L. Montgumery, A. Johnson, G. Saade, K. Moise. Dept. Ob/Gyn, Baylor College of Medicine, Houston, TX, Tulsa Perinatal Associates, Tulsa, OK and Prenatal Diagnostic Center, Lexington, MA. OBJECTIVE: To report our experience of intentional puncture of the intervening membrane ("septostomy") and subsequent pregnancy outcome for twin gestations complicated by the stuck twin sequence. STUDY DESIGN: Nine patients were diagnosed with a stuck twin sequence based on polyhydramnios in the larger twin and severe oligohydramnios and discordant growth in the smaller twin. A 22 gauge spinal needle was used to pertbrm a diagnostic and limited reduction anmiocentesis of the polyhydramniotic sac followed by selective puncture of the membrane between the twins, lrmnediate and long-term observations were made regarding subsequent t~etal growth and pregnancy outcomes. RESULTS: Alnniotic septostomy was perfbrmed in 5 second trimester and 4 third trimester pregnancies (median gestation: 21.ti weeks, range: 16.9-27.0 weeks). The median discordance based on ultrasound estimates of fetal weight was 34% 110-42%). hnmediate decompression of the "stuck twin" occurred in all cases followed by increased fetal movement, and improved mnbilical artery velocimetlT. Three of the 18 fetuses (17%) died in utero in two of the atfiected pregnancies. Delivery occurred at a median of 34 weeks' gestation (21.6..35.0). The median discordance at delivery was 31.5% (19-44%) suggesting no worsening of growth discrepancy after the septostonly was pertormed. No incidences of cord entanglement were encountered. CONCLUSIONS: Anmiotic septostolny may be utilized to treat the stuck twin sequence with a perinatal survival of up to 83%.