Fetal Therapy - The PLAZA Group, LLC

Fetal Therapy: Current Status and Future Directions Ramen H. Chmait, M.D. Director, Los Angeles Fetal Therapy CHLA-USC Institute for Maternal Fetal Health At Hollywood Presbyterian Medical Center Assistant Professor of Clinical Division of Maternal-Fetal Medicine, Dept OB/GYN Keck School of Medicine, University of Southern California

Fetal Surgery 

Level I evidence currently available justifying fetal intervention for the following conditions: – – –

1. Twin-Twin Transfusion Syndrome 2. Congenital Diaphragmatic Hernia 3. Myelomeningocele

Twin-Twin Transfusion Syndrome



De Wikkellkinderen (The Swaddled Twins), Artist unknown, painting dated April 7, 1617. Currently housed in The Muiderslot, Amsterdam.

Twin-Twin Transfusion Syndrome 

High perinatal mortality –

 

Over 90% in conservatively managed patients with TTTS diagnosed before 26 weeks

High risk of long-term morbidity in untreated cases Fetuses structurally normal

Vascular Communications Donor

Recipient

Anatomical Basis of TTTS - Vascular Communications

Donor Twin Oliguria and Oligohydramnios

Recipient Twin Polyuria and Polyhydramnios

Differential Anatomical Effects of TTTS: Donor versus Recipient

Courtesy of Dr. Kurt Benirschke

TTTS - Ultrasound Diagnosis    

1. Establish chorionicity 2. Amniotic fluid discordance 3. Staging 4. Cervix

Chorionicity

TTTS - Diagnosis 

Amniotic Fluid Discordance –

Recipient 

–

Maximum vertical pocket greater than or equal to 8.0 cm

Donor 

Maximum vertical pocket less than or equal to 2.0 cm

TTTS -Recipient (MVP = 9.24 cm)

TTTS -Donor (MVP = 0 cm)

TTTS - Staging 

Quintero Staging System – – – – –

I. Amniotic Fluid Discordance II. Donor Bladder Not Visible III. Critically Abnormal Dopplers IV. Fetal Hydrops V. Fetal Demise

TTTS - Treatment     

Expectant management Termination of pregnancy Serial amnioreduction Laser therapy Umbilical cord occlusion

Eurofetus Trial

TTTS - Eurofoetus Trial

Survival (%) GA at Delivery (wks) Neurologic Abnl

Serial A/C (n=70) 51.4%

Laser (n=72) 76.4%

P value P=0.002

29.0 wks

33.3 wks

P=0.004

14.5%

5.6%

P=0.02

TTTS - Eurofoetus Trial 

Outcome measure: Neurologic Injury at 6 months of age –

Amnioreduction group 

–

19% of survivors had neurologic injury

Laser group 

7% of survivors had neurologic injury

TTTS - Metaanalysis 

Amnioreduction vs. Laser –

10 articles provided 611 TTTS cases 

–

4 articles directly compared the two treatment modalities

Results 

Fetuses undergoing laser had higher survival [OR 2.0 (1.52.8)] and lower neurologic morbidity [OR 0.2 (0.1-0.3)]

Rossi, D’Addario. Am J Obstet Gynecol. 2008.

TTTS Laser Perinatal Outcomes - Systematic Review 

Laser Surgery Perinatal Outcomes – – –

19 articles, 1995-2009 1484 cases Perinatal Survival  

At least 1 survivor: mean 81.2% (range 65.0 to 92.7%) Dual survivor: mean 48.2% (range 18 to 62%)

Ahmed S. Prenat Diagn. 2010.

USFetus Study

Am J Obstet Gynecol. 2011:204:393.e1-6.

USFetus Study Survival

Stage I

Stage II

Stage III

Stage IV

P value

30-Day

N =112

N = 177

N = 328

N = 63

At Least

92.0%

93.2%

88.4%

92.1%

0.30

78.6%

76.3%

58.5%

68.3%