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Michael R Harrison - One of the best experts on this subject based on the ideXlab platform.
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Biomaterials in Fetal Surgery
Biomaterials science, 2019Co-Authors: Sally M. Winkler, Michael R Harrison, Phillip B. MessersmithAbstract:Fetal Surgery and Fetal therapy involve surgical interventions on the fetus in utero to correct or ameliorate congenital abnormalities and give a developing fetus the best chance at a healthy life. Historical use of biomaterials in Fetal Surgery has been limited, and most biomaterials used in Fetal surgeries today were originally developed for adult or pediatric patients. However, as the field of Fetal Surgery moves from open surgeries to minimally invasive procedures, many opportunities exist for innovative biomaterials engineers to create materials designed specifically for the unique challenges and opportunities of maternal–Fetal Surgery. Here, we review biomaterials currently used in clinical Fetal Surgery as well as promising biomaterials in development for eventual clinical translation. We also highlight unmet challenges in Fetal Surgery that could particularly benefit from novel biomaterials, including Fetal membrane sealing and minimally invasive myelomeningocele defect repair. Finally, we conclude with a discussion of the underdeveloped Fetal immune system and opportunities for exploitation with novel immunomodulating biomaterials.
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Minimally Invasive Fetal Surgery
Clinics in perinatology, 2017Co-Authors: Claire E. Graves, Michael R Harrison, Benjamin E. PadillaAbstract: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.
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The making of Fetal Surgery.
Prenatal diagnosis, 2010Co-Authors: Jan Deprest, Mark P Johnson, Alan W. Flake, N. Scott Adzick, E Gratacos, Yves Ville, Kurt Hecher, Kypros H. Nicolaides, Francois I. Luks, Michael R HarrisonAbstract:Fetal diagnosis prompts the question for Fetal therapy in highly selected cases. Some conditions are suitable for in utero surgical intervention. This paper reviews historically important steps in the development of Fetal Surgery. The first invasive Fetal intervention in 1963 was an intra-uterine blood transfusion. It took another 20 years to understand the pathophysiology of other candidate Fetal conditions and to develop safe anaesthetic and surgical techniques before the team at the University of California at San Francisco performed its first urinary diversion through hysterotomy. This procedure would be abandoned as renal and pulmonary function could be just as effectively salvaged by ultrasound-guided insertion of a bladder shunt. Fetoscopy is another method for direct access to the feto-placental unit. It was historically used for Fetal visualisation to guide biopsies or for vascular access but was also abandoned following the introduction of high-resolution ultrasound. Miniaturisation revived fetoscopy in the 1990s, since when it has been successfully used to operate on the placenta and umbilical cord. Today, it is also used in fetuses with congenital diaphragmatic hernia (CDH), in whom lung growth is triggered by percutaneous tracheal occlusion. It can also be used to diagnose and treat urinary obstruction. Many Fetal interventions remain investigational but for a number of conditions randomised trials have established the role of in utero Surgery, making Fetal Surgery a clinical reality in a number of Fetal therapy programmes. The safety of Fetal Surgery is such that even non-lethal conditions, such as myelomeningocoele repair, are at this moment considered a potential indication. This, as well as Fetal intervention for CDH, is currently being investigated in randomised trials. Copyright © 2010 John Wiley & Sons, Ltd.
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A history of Fetal Surgery.
Clinics in perinatology, 2009Co-Authors: Timothy Jancelewicz, Michael R HarrisonAbstract:Over the past 3 decades, Fetal Surgery for congenital disease has evolved from merely a fanciful concept to a medical field in its own right. Techniques for open hysterotomy, minimal-access hysteroscopy, and image-guided percutaneous Fetal access have become well established, first in animal models and subsequently in humans. At the same time, major advances in Fetal imaging and diagnosis, anesthesia, and tocolysis have allowed Fetal intervention to become a vital tool for subsets of patients who would otherwise endure significant morbidity and mortality. This article offers a concise overview of the history of Fetal Surgery, from its tumultuous early days to its current status as an important means for the early treatment of potentially devastating congenital anomalies.
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Maternal morbidity after maternal-Fetal Surgery
American journal of obstetrics and gynecology, 2006Co-Authors: Kirstin Golombeck, Robert H. Ball, Jody A. Farrell, Diana L. Farmer, Roy A Filly, Hanmin Lee, Volker R. Jacobs, Mark A. Rosen, Michael R HarrisonAbstract:Objective There is a paucity of published data on the maternal risks of Fetal surgical interventions. We analyzed maternal morbidity and mortality that were associated with different types of Fetal intervention (open hysterotomy, various endoscopic procedures and percutaneous techniques) to quantify this risk. Study design We performed a retrospective evaluation of a continuous series of 187 cases that had been performed between July 1989 and May 2003 at the Fetal Treatment Center, a highly specialized interdisciplinary center for Fetal Surgery at the University of California, San Francisco. The primary outcome was the frequency of maternal morbidity for open, endoscopic, and percutaneous procedures to access the fetus. Results There were 187 pregnant women with confirmed major Fetal malformations who were candidates for intrauterine Fetal intervention. Maternal-Fetal Surgery was performed in 87 cases by open hysterotomy, in 69 cases by endoscopic procedures, and in 31 cases by percutaneous techniques. There were no maternal deaths, but significant short-term morbidity was observed. There were no significant differences in the incidence of premature rupture of membranes, pulmonary edema, placental abruption, postoperative vaginal bleeding, preterm delivery, or interval from maternal-Fetal Surgery to delivery between endoscopic procedures and open Surgery. Complications were significantly less in the percutaneous ultrasound-guided procedures. Endoscopic procedures, even with a laparotomy, showed statistically significantly less morbidity compared with the open hysterotomy group regarding cesarean delivery as delivery mode (94.8% vs 58.8%; P P P = .001), and requirement for blood transfusions (2.9% vs 12.6%; P = .022). Chorion-amnion membrane separation (64.7% vs 20.3%; P Conclusion Short-term morbidities include increased rates of cesarean birth, treatment in intensive care, prolonged hospitalization, and blood transfusion, all of which were more common with hysterotomy compared with other techniques. Maternal-Fetal Surgery can be performed without maternal death. Results from this study provide helpful data for counseling prospective patients.
Alan W. Flake - One of the best experts on this subject based on the ideXlab platform.
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Fetal Surgery.
Pediatric clinics of North America, 2019Co-Authors: Heron D Baumgarten, Alan W. FlakeAbstract:Fetal Surgery is an established but still rapidly evolving specialty, born from the rationale that destructive embryologic processes, recognized early in gestation, can be curtailed by prenatal correction. As more and more centers begin offering Fetal interventions, quality of care must be verified through transparency about clinical capabilities and resources. Level designations should be assigned based on capability, as in trauma and neonatal ICU centers for excellence, and volume requirements must be set for Fetal Surgery certification. Regionalization of this specialty care may be required to optimize outcomes.
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Open Fetal Surgery for Central Bronchial Atresia
Fetal diagnosis and therapy, 2014Co-Authors: William H. Peranteau, Mark P Johnson, Alan W. Flake, N. Scott Adzick, Lori J. Howell, Julie S. Moldenhauer, Nahla Khalek, Juan Martinez-poyer, Holly L. HedrickAbstract:Mainstem or lobar bronchial atresia is associated with massive pulmonary hyperplasia, contralateral pulmonary hypoplasia, non-immune hydrops and a fatal Fetal prognosis. Open Fetal Surgery currently p
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The making of Fetal Surgery.
Prenatal diagnosis, 2010Co-Authors: Jan Deprest, Mark P Johnson, Alan W. Flake, N. Scott Adzick, E Gratacos, Yves Ville, Kurt Hecher, Kypros H. Nicolaides, Francois I. Luks, Michael R HarrisonAbstract:Fetal diagnosis prompts the question for Fetal therapy in highly selected cases. Some conditions are suitable for in utero surgical intervention. This paper reviews historically important steps in the development of Fetal Surgery. The first invasive Fetal intervention in 1963 was an intra-uterine blood transfusion. It took another 20 years to understand the pathophysiology of other candidate Fetal conditions and to develop safe anaesthetic and surgical techniques before the team at the University of California at San Francisco performed its first urinary diversion through hysterotomy. This procedure would be abandoned as renal and pulmonary function could be just as effectively salvaged by ultrasound-guided insertion of a bladder shunt. Fetoscopy is another method for direct access to the feto-placental unit. It was historically used for Fetal visualisation to guide biopsies or for vascular access but was also abandoned following the introduction of high-resolution ultrasound. Miniaturisation revived fetoscopy in the 1990s, since when it has been successfully used to operate on the placenta and umbilical cord. Today, it is also used in fetuses with congenital diaphragmatic hernia (CDH), in whom lung growth is triggered by percutaneous tracheal occlusion. It can also be used to diagnose and treat urinary obstruction. Many Fetal interventions remain investigational but for a number of conditions randomised trials have established the role of in utero Surgery, making Fetal Surgery a clinical reality in a number of Fetal therapy programmes. The safety of Fetal Surgery is such that even non-lethal conditions, such as myelomeningocoele repair, are at this moment considered a potential indication. This, as well as Fetal intervention for CDH, is currently being investigated in randomised trials. Copyright © 2010 John Wiley & Sons, Ltd.
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Fetal Surgery: Progress and Perspectives
Advances in pediatrics, 2010Co-Authors: Miho Watanabe, Alan W. FlakeAbstract:T he first description of open maternal Fetal Surgery for correction of an anatomic anomaly by Harrison and colleagues [1] was published nearly 30 years ago. At that time, the diagnostic and surgical tools for prenatal treatment of the fetus were just being developed and the concept of the fetus as a patient was the subject of philosophic and ethical debate [2]. Over the past 3 decades, great progress has been made in our ability to diagnose Fetal abnormalities, predict their outcome, and to perform surgical interventions when appropriate. The concept of the fetus as a patient has become a standard of care and the ethical framework for maternal Fetal intervention is well developed [3]. Although application of open Fetal Surgery has remained limited to a relatively small number of highly selected fetuses and is practiced in only a few centers, the development of this field has accelerated technological progress in prenatal diagnosis and intervention, led to improved understanding of the pathophysiology and natural history of candidate disorders, allowed comprehensive counseling of prospective parents in centers with focused expertise in Fetal anomalies, and driven the evolution of less invasive therapeutic approaches. The purpose of this review was to describe the current status of Fetal surgical intervention and to speculate regarding future developments in this rapidly evolving field.
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reproductive outcomes after pregnancy complicated by maternal Fetal Surgery
American Journal of Obstetrics and Gynecology, 2004Co-Authors: Douglas R Wilson, Mark P Johnson, Alan W. Flake, Timothy M. Crombleholme, Holly L. Hedrick, Jordan Wilson, Scott N AdzickAbstract:Objective The reproductive outcomes for women after the pregnancy complicated by maternal-Fetal Surgery were evaluated to obtain evidence-based information for prenatal risk counseling. Study design The retrospective review identified 83 women with maternal-Fetal Surgery from a single institution (1996-2002). These women were sent a consent form and a questionnaire to document postoperative problems, fertility, obstetric outcomes, and psychosocial concerns in pregnancy after the index Fetal therapy. Institutional Review Board approval was obtained from Committee for Protection of Human Subjects. Results The total return rate was 55 (66%). The pregnancy rate was 62% (18% spontaneous abortion, 24% preterm delivery, and 58% term delivery). Complications were reported in 12 of 34 pregnancies (35%), including uterine dehiscence/rupture (12%/6%), cesarean hysterectomy (3%), and antepartum hemorrhage requiring transfusion (9%). Conclusion The reproductive outcome of uterine dehiscence, rupture, and hysterectomy was 12%, 6%, and 3%, respectively, after a pregnancy complicated by maternal-Fetal Surgery. The uterine rupture rate is similar to the rupture rate after “classical” cesarean section (4%-9%).
N. Scott Adzick - One of the best experts on this subject based on the ideXlab platform.
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Open Fetal Surgery for Central Bronchial Atresia
Fetal diagnosis and therapy, 2014Co-Authors: William H. Peranteau, Mark P Johnson, Alan W. Flake, N. Scott Adzick, Lori J. Howell, Julie S. Moldenhauer, Nahla Khalek, Juan Martinez-poyer, Holly L. HedrickAbstract:Mainstem or lobar bronchial atresia is associated with massive pulmonary hyperplasia, contralateral pulmonary hypoplasia, non-immune hydrops and a fatal Fetal prognosis. Open Fetal Surgery currently p
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Fetal Surgery for myelomeningocele: progress and perspectives
Developmental medicine and child neurology, 2011Co-Authors: Enrico Danzer, Mark P Johnson, N. Scott AdzickAbstract:Myelomeningocele (MMC), one of the most common congenital malformations, can result in severe lifelong disabilities, including paraplegia, hydrocephalus, Chiari II malformation, bowel and bladder dysfunction, skeletal deformations, and neurocognitive impairment. Experimental studies provide compelling evidence that the neurological deficits associated with MMC are not simply caused by incomplete neurulation but rather by the prolonged exposure of the vulnerable neural elements to the intrauterine environment. MMC is the first non-lethal anomaly considered for Fetal surgical intervention, necessitating a careful analysis of risks and benefits. Retrospective and prospective randomized studies suggest that Fetal Surgery of MMC before 26 weeks of gestation may preserve neuromotor function, reverse hindbrain herniation, and reduce the need for ventriculoperitoneal shunting. However, these studies also demonstrate that Fetal Surgery is associated with significant maternal and Fetal risks. Consequently, additional research is necessary to further elucidate the pathophysiology of MMC, to define the ideal timing and technique of Fetal closure, and to evaluate the long-term implications of prenatal intervention.
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The making of Fetal Surgery.
Prenatal diagnosis, 2010Co-Authors: Jan Deprest, Mark P Johnson, Alan W. Flake, N. Scott Adzick, E Gratacos, Yves Ville, Kurt Hecher, Kypros H. Nicolaides, Francois I. Luks, Michael R HarrisonAbstract:Fetal diagnosis prompts the question for Fetal therapy in highly selected cases. Some conditions are suitable for in utero surgical intervention. This paper reviews historically important steps in the development of Fetal Surgery. The first invasive Fetal intervention in 1963 was an intra-uterine blood transfusion. It took another 20 years to understand the pathophysiology of other candidate Fetal conditions and to develop safe anaesthetic and surgical techniques before the team at the University of California at San Francisco performed its first urinary diversion through hysterotomy. This procedure would be abandoned as renal and pulmonary function could be just as effectively salvaged by ultrasound-guided insertion of a bladder shunt. Fetoscopy is another method for direct access to the feto-placental unit. It was historically used for Fetal visualisation to guide biopsies or for vascular access but was also abandoned following the introduction of high-resolution ultrasound. Miniaturisation revived fetoscopy in the 1990s, since when it has been successfully used to operate on the placenta and umbilical cord. Today, it is also used in fetuses with congenital diaphragmatic hernia (CDH), in whom lung growth is triggered by percutaneous tracheal occlusion. It can also be used to diagnose and treat urinary obstruction. Many Fetal interventions remain investigational but for a number of conditions randomised trials have established the role of in utero Surgery, making Fetal Surgery a clinical reality in a number of Fetal therapy programmes. The safety of Fetal Surgery is such that even non-lethal conditions, such as myelomeningocoele repair, are at this moment considered a potential indication. This, as well as Fetal intervention for CDH, is currently being investigated in randomised trials. Copyright © 2010 John Wiley & Sons, Ltd.
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Open Fetal Surgery for life-threatening Fetal anomalies.
Seminars in fetal & neonatal medicine, 2009Co-Authors: N. Scott AdzickAbstract:After more than two decades of experimental and clinical work, Fetal Surgery is an accepted treatment option for highly selected fetuses with life-threatening anomalies. Fetal lung masses associated with hydrops are usually fatal. These lesions can be resected in utero if they are predominantly solid or multicystic. Fetal sacrococcygeal teratoma complicated with progressive high output cardiac failure may benefit from in-utero resection of the tumor. Important lessons have been learned about perioperative management and maternal, Fetal, and neonatal outcomes after open Fetal Surgery.
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Advances in Fetal Surgery
Journal of Intensive Care Medicine, 2001Co-Authors: Tippi C. Mackenzie, N. Scott AdzickAbstract:Advances in prenatal screening and diagnosis, combined with an understanding of the pathophysiology of congenital anomalies, have brought incredible impetus to the field of Fetal Surgery. Identification of Fetal anomalies can lead to counseling of the affected family so that informed decisions can be made on how to proceed with the pregnancy. Counseling may lead to pregnancy termination, changes in the timing or mode of delivery, and, in select cases, prenatal intervention. Open Fetal Surgery may be considered in severe cases of congenital diaphragmatic hernia, congenital chest lesions, sacrococcygeal teratoma, urinary tract obstruction, and myelomeningocele. The ex utero intrapartum treatment procedure may be lifesaving for fetuses with giant neck masses. Finally, fetoscopic Surgery may be offered for select cases of twin-twin transfusion syndrome and twin reversed arterial perfusion sequence. Fetal intervention in all of these cases depends on a team approach to the patient and on the objective comparis...
Craig T. Albanese - One of the best experts on this subject based on the ideXlab platform.
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Minimal access Fetal Surgery.
European journal of obstetrics gynecology and reproductive biology, 2003Co-Authors: Enrico Danzer, Michael R Harrison, Roman M. Sydorak, Craig T. AlbaneseAbstract:The development of Fetal Surgery has led to promising therapeutic options for a number of congenital malformations. However, preterm labor (PTL) and premature rupture of membranes continue to be ubiquitous risks for both mother and fetus. To reduce maternal morbidity and the risk of prematurity, minimal access surgical techniques were developed and are increasingly employed. Congenital diaphragmatic hernia (CDH), obstructive uropathy, twin-to-twin transfusion syndrome (TTTS), and sacrococcygeal teratoma have already been successfully treated using minimal access Fetal surgical procedures. Other life-threatening diseases as well as severely disabling but not life-threatening conditions are potentially amenable to treatment. The wider application of minimal access Fetal Surgery depends on a continued improvement in technology and a better understanding of complications associated with Fetal intervention.
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chorioamniotic membrane separation following Fetal Surgery
Journal of Perinatology, 2002Co-Authors: Roman M. Sydorak, Michael R Harrison, Per L. Sandberg, Shinjiro Hirose, Diana L. Farmer, Roy A Filly, Craig T. AlbaneseAbstract:OBJECTIVE: As the volume of Fetal Surgery cases has steadily increased, an increasing incidence of chorioamniotic membrane separation (CMS) has been noted. Due to the potential adverse consequences from this abnormality, we reviewed the last decade of experience with Fetal intervention at our institution and examined the incidence and outcomes of fetuses given this diagnosis. STUDY DESIGN: A retrospective chart review of 75 Fetal Surgery cases at our institution was performed. Variables analyzed included preoperative, operative, and outcome data. Postoperative ultrasounds were evaluated for the presence of CMS. RESULTS: Excluding operative deaths, the incidence of CMS was 47%. There were significant differences (p<0.05) in time to delivery (7 vs 5 weeks), cases using a perfusion pump (80% vs 60%), and number of trocars (2.13 vs 1.54) in cases of CMS versus those without. Ultrasounds showed normal to high levels of amniotic fluid in 97% of cases. There was an increased incidence of premature rupture of membranes (63% vs 45%), preterm labor (57% vs 38%), and chorioamnionitis (29% vs 15%) with CMS, but no difference in mortality rate. CONCLUSION: CMS is a frequent finding following Fetal Surgery. It is associated with significant morbidity but is manageable with close follow-up in a hospital setting. Following Fetal Surgery, the finding of CMS can be a life-threatening complication that warrants further study to understand its etiology and prevention.
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Chorioamniotic membrane separation following Fetal Surgery.
Journal of perinatology : official journal of the California Perinatal Association, 2002Co-Authors: Roman M. Sydorak, Michael R Harrison, Per L. Sandberg, Shinjiro Hirose, Diana L. Farmer, Roy A Filly, Craig T. AlbaneseAbstract:OBJECTIVE: As the volume of Fetal Surgery cases has steadily increased, an increasing incidence of chorioamniotic membrane separation (CMS) has been noted. Due to the potential adverse consequences from this abnormality, we reviewed the last decade of experience with Fetal intervention at our institution and examined the incidence and outcomes of fetuses given this diagnosis. STUDY DESIGN: A retrospective chart review of 75 Fetal Surgery cases at our institution was performed. Variables analyzed included preoperative, operative, and outcome data. Postoperative ultrasounds were evaluated for the presence of CMS. RESULTS: Excluding operative deaths, the incidence of CMS was 47%. There were significant differences (p
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Fetal Surgery for myelomeningocele.
Current opinion in obstetrics & gynecology, 2001Co-Authors: Shinjiro Hirose, Diana L. Farmer, Craig T. AlbaneseAbstract:Myelomeningocele is a morbid disease with a significant mortality within the first several decades of life. Fetal Surgery is a promising therapy to prevent progressive neurological dysfunction. Unfortunately, Fetal repair has not been shown thus far to improve leg or bladder function. Data from VUMC and CHOP suggest that hindbrain herniation and the need for VP shunting may be decreased. These potential improvements must be balanced with maternal safety considerations. The current funded trial in the United States will provide answers about the efficacy of Fetal Surgery for this disease, and, just as importantly, will provide the best data about the efficacy of the current multidisciplinary methods of treatment for MMC and the outcome of these children.
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Maternal fertility is not affected by Fetal Surgery.
Fetal diagnosis and therapy, 1999Co-Authors: Jody A. Farrell, Russell W Jennings, Craig T. Albanese, Sarah J. Kilpatrick, Barbara Bratton, Michael R HarrisonAbstract:The purpose of this report is to assess the impact of Fetal Surgery on future maternal fertility, subsequent pregnancy outcome, and the incidence of pregnancy complications. Retrospective data were collected on 70 mothers who underwent Fetal Surgery between April 1981 and June 1996. Indications for open hysterotomy Fetal Surgery included congenital diaphragmatic hernia (n = 44), congenital cystic adenomatoid malformation of the lung (n = 11), urinary obstruction (n = 9), sacrococcygeal teratoma (n = 4), heart block (n = 1), and acardiac-acephalic twin reduction (n = 1). The following data were obtained: number of pregnancy attempts, number of successful pregnancies, pregnancy outcome including obstetrical and neonatal complications, and infertility after Fetal Surgery. There were 45 respondents, of whom 35 attempted subsequent pregnancies. Thirty-two were successful, resulting in 31 livebirths. Two women had a strong preFetal Surgery history of infertility, 1 has only attempted to conceive for 3 months. We report this experience because the effect of open Fetal Surgery on futrue fertility is such an important question for our patients and referring physicians. This analysis suggests that hysterotomy and open Fetal Surgery has a negligible impact on maternal fertility.
Diana L. Farmer - One of the best experts on this subject based on the ideXlab platform.
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Fetal Surgery for Myelomeningocele
Clinics in perinatology, 2012Co-Authors: Payam Saadai, Diana L. FarmerAbstract:Fetal intervention for myelomeningocele (MMC) may improve hydrocephalus and hindbrain herniation associated with the Arnold-Chiari II malformation and may reduce the need for ventriculoperitoneal shunting. As of now, there is little evidence that prenatal repair of MMC improves neurologic function. MMC is the first nonlethal disease under consideration and study for Fetal Surgery. As a result, potential improvements in outcome must be balanced with maternal safety and well-being, in addition to that of the unborn patient.
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Open Fetal Surgery for myelomeningocele.
Journal of neurosurgery. Pediatrics, 2012Co-Authors: Nalin Gupta, Charles B. Cauldwell, Jody A. Farrell, Larry Rand, Diana L. FarmerAbstract:In a recently completed randomized, prospective clinical trial, Fetal repair for myelomeningocele was shown to result in reduced rates of hydrocephalus requiring placement of a ventriculoperitoneal shunt, improvement in Chiari malformation Type II, and improvement in neurological function compared with standard postnatal repair. Successful Fetal Surgery requires the active participation and interaction of several clinical teams. Each group has a specific role, and overlap is often required at different points of the treatment plan. Extensive multispecialty discussions with the patient and family are necessary before informed consent can be obtained. Fetal Surgery carries significant risks to the mother and fetus and these must be carefully considered prior to a final treatment decision. This review will summarize the evaluation and treatment of patients undergoing Fetal repair for myelomeningocele at one institution.
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Maternal morbidity after maternal-Fetal Surgery
American journal of obstetrics and gynecology, 2006Co-Authors: Kirstin Golombeck, Robert H. Ball, Jody A. Farrell, Diana L. Farmer, Roy A Filly, Hanmin Lee, Volker R. Jacobs, Mark A. Rosen, Michael R HarrisonAbstract:Objective There is a paucity of published data on the maternal risks of Fetal surgical interventions. We analyzed maternal morbidity and mortality that were associated with different types of Fetal intervention (open hysterotomy, various endoscopic procedures and percutaneous techniques) to quantify this risk. Study design We performed a retrospective evaluation of a continuous series of 187 cases that had been performed between July 1989 and May 2003 at the Fetal Treatment Center, a highly specialized interdisciplinary center for Fetal Surgery at the University of California, San Francisco. The primary outcome was the frequency of maternal morbidity for open, endoscopic, and percutaneous procedures to access the fetus. Results There were 187 pregnant women with confirmed major Fetal malformations who were candidates for intrauterine Fetal intervention. Maternal-Fetal Surgery was performed in 87 cases by open hysterotomy, in 69 cases by endoscopic procedures, and in 31 cases by percutaneous techniques. There were no maternal deaths, but significant short-term morbidity was observed. There were no significant differences in the incidence of premature rupture of membranes, pulmonary edema, placental abruption, postoperative vaginal bleeding, preterm delivery, or interval from maternal-Fetal Surgery to delivery between endoscopic procedures and open Surgery. Complications were significantly less in the percutaneous ultrasound-guided procedures. Endoscopic procedures, even with a laparotomy, showed statistically significantly less morbidity compared with the open hysterotomy group regarding cesarean delivery as delivery mode (94.8% vs 58.8%; P P P = .001), and requirement for blood transfusions (2.9% vs 12.6%; P = .022). Chorion-amnion membrane separation (64.7% vs 20.3%; P Conclusion Short-term morbidities include increased rates of cesarean birth, treatment in intensive care, prolonged hospitalization, and blood transfusion, all of which were more common with hysterotomy compared with other techniques. Maternal-Fetal Surgery can be performed without maternal death. Results from this study provide helpful data for counseling prospective patients.
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Recent advances in Fetal Surgery.
Seminars in perinatology, 2004Co-Authors: Raul A. Cortes, Diana L. FarmerAbstract:Fetal Surgery is now an accepted modality for treatment of a variety of lethal and non-lethal congenital conditions. It represents a new, fast-moving frontier of medicine in which cooperative mulitdisciplinary effort and input are required to assure both Fetal and maternal welfare. A wide range of therapeutic strategies from percutaneous to open invasive techniques has led to a complex list of different procedures for different diseases. This review identifies the most common disease entities managed by Fetal intervention, examines the evolution in development of techniques to those currently used, and describes the prospective, randomized trials presently underway that are designed to establish the safety and determine true efficacy of treatment. Fetal Surgery as a (multi)discipline continues to strive to minimize maternal and Fetal risk. Undoubtedly, as tocolytic therapy and neonatal intensive efforts improve, Fetal therapy will expand.
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chorioamniotic membrane separation following Fetal Surgery
Journal of Perinatology, 2002Co-Authors: Roman M. Sydorak, Michael R Harrison, Per L. Sandberg, Shinjiro Hirose, Diana L. Farmer, Roy A Filly, Craig T. AlbaneseAbstract:OBJECTIVE: As the volume of Fetal Surgery cases has steadily increased, an increasing incidence of chorioamniotic membrane separation (CMS) has been noted. Due to the potential adverse consequences from this abnormality, we reviewed the last decade of experience with Fetal intervention at our institution and examined the incidence and outcomes of fetuses given this diagnosis. STUDY DESIGN: A retrospective chart review of 75 Fetal Surgery cases at our institution was performed. Variables analyzed included preoperative, operative, and outcome data. Postoperative ultrasounds were evaluated for the presence of CMS. RESULTS: Excluding operative deaths, the incidence of CMS was 47%. There were significant differences (p<0.05) in time to delivery (7 vs 5 weeks), cases using a perfusion pump (80% vs 60%), and number of trocars (2.13 vs 1.54) in cases of CMS versus those without. Ultrasounds showed normal to high levels of amniotic fluid in 97% of cases. There was an increased incidence of premature rupture of membranes (63% vs 45%), preterm labor (57% vs 38%), and chorioamnionitis (29% vs 15%) with CMS, but no difference in mortality rate. CONCLUSION: CMS is a frequent finding following Fetal Surgery. It is associated with significant morbidity but is manageable with close follow-up in a hospital setting. Following Fetal Surgery, the finding of CMS can be a life-threatening complication that warrants further study to understand its etiology and prevention.