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Nathaniel M Fried - One of the best experts on this subject based on the ideXlab platform.
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optical coherence tomography vs high frequency ultrasound during noninvasive Laser Coagulation of the canine vas deferens
Proceedings of SPIE, 2012Co-Authors: Christopher M Cilip, Nathaniel M Fried, Mohamad E AllafAbstract:A noninvasive approach to vasectomy may eliminate male fear of complications related to surgery and increase its acceptance. Noninvasive Laser thermal occlusion of the canine vas deferens has recently been reported. In this study, optical coherence tomography (OCT) and high-frequency ultrasound (HFUS) are compared for monitoring Laser thermal Coagulation of the vas in an acute canine model. Bilateral noninvasive Laser Coagulation of the vas was performed in 6 dogs (n=12 vasa) using a Ytterbium fiber Laser wavelength of 1075 nm, incident power of 9.0 W, pulse duration of 500 ms, pulse rate of 1 Hz, and 3-mm-diameter spot. Cryogen spray cooling was used to prevent skin burns during the procedure. An OCT system with endoscopic probe and a HFUS system with 20-MHz transducer were used to image the vas immediately before and after the procedure. Vasa were then excised and processed for gross and histologic analysis for comparison with OCT and HFUS images. OCT provided high-resolution, superficial imaging of the compressed vas within the vas ring clamp, while HFUS provided deeper imaging of the vas held manually in the scrotal fold. Both OCT and high HFUS are promising imaging modalities for real-time confirmation of vas occlusion during noninvasive Laser vasectomy.
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high frequency ultrasound imaging of noninvasive Laser Coagulation of the canine vas deferens
Lasers in Surgery and Medicine, 2011Co-Authors: Christopher M Cilip, Ashley E Ross, Phillip M Pierorazio, Mohamad E Allaf, Nathaniel M FriedAbstract:Background and Objectives A noninvasive approach to vasectomy may eliminate male fear of complications related to surgery (e.g., hematoma, infection, acute and chronic pain, sterilization failure) and increase its acceptance. Noninvasive Laser thermal occlusion of the canine vas deferens has recently been reported. In this study, high-frequency ultrasound is used to confirm successful Laser thermal Coagulation and scarring of the vas in a short-term canine model. Materials and Methods Bilateral noninvasive Laser Coagulation of the vas was performed in a total of nine dogs using a Laser wavelength of 1,075 nm, incident power of 9.0 W, pulse duration of 500 milliseconds, pulse rate of 0.5 Hz, and 3-mm-diameter spot. Cryogen spray was used to cool the scrotal skin surface and prevent burns during the procedure. A clinical ultrasound system with a 13.2-MHz high-frequency transducer was used to image the vas before and after the procedure. Burst pressure measurements were performed on excised vas to confirm thermal occlusion. Results Day 0 and 28 burst pressures averaged 291 ± 31 mmHg and 297 ± 26 mmHg, respectively, significantly greater than ejaculation pressures of 136 ± 29 mmHg. Ultrasound showed a hyperechoic vas segment after thermal Coagulation (Day 0) and scarring (Day 28). Doppler ultrasound showed normal blood flow through the testicular artery, indicating no collateral thermal damage to proximal structures. Conclusions High-frequency ultrasound may be used as a noninvasive diagnostic tool to assist in determining successful short-term Laser thermal Coagulation and scarring of the vas. Lasers Surg. Med. © 2011 Wiley-Liss, Inc.
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application of an optical clearing agent during noninvasive Laser Coagulation of the canine vas deferens
Journal of Biomedical Optics, 2010Co-Authors: Christopher M Cilip, E Ashley M D Ross, P Jonathan M D Jarow, Nathaniel M FriedAbstract:Development of a noninvasive vasectomy technique may eliminate male fear of complications and result in a more popular procedure. This study explores application of an optical clearing agent (OCA) to scrotal skin to reduce Laser power necessary for successful noninvasive Laser vasectomy and eliminate scrotal skin burns. A mixture of dimethyl sulfoxide and glycerol was noninvasively delivered into scrotal skin using a pneumatic jet device. Near-infrared Laser radiation was delivered in conjunction with cryogen spray cooling to the skin surface in a canine model, ex vivo and in vivo. Burst pressure (BP) measurements were conducted to quantify strength of vas closure. A 30-min application of OCA improved skin transparency by 26±3%, reducing average power necessary for successful noninvasive Laser vasectomy from 9.2 W without OCA (BP=291±31 mmHg) to 7.0 W with OCA (BP=292±19 mmHg). Control studies without OCA at 7.0 W failed to coagulate the vas with burst pressures (82±28 mmHg) significantly below typical ejaculation pressures (136±29 mmHg). Application of an OCA reduced the Laser power necessary for successful noninvasive thermal Coagulation of the vas by ~25%. This technique may result in use of a less expensive Laser and eliminate the formation of scrotal skin burns during the procedure.
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noninvasive Laser Coagulation of the canine vas deferens in vivo
Bios, 2009Co-Authors: Christopher M Cilip, Ashley E Ross, Jonathan P Jarow, Nathaniel M FriedAbstract:Development of a noninvasive vasectomy technique may eliminate male fear of complications (incision, bleeding, infection, and scrotal pain) and result in a more popular procedure. This study builds upon previously reported ex vivo tissue studies by exploring acute and short-term chronic in vivo canine studies. Isolation of the canine vas was achieved using a conventional vas ring clamp method. No perforation of the scrotal skin was necessary to occlude the vas. Laser radiation with a wavelength of 1075 nm, average power of 11.2 W, 500-ms pulse duration, 0.5 Hz pulse rate, and 3-mm-diameter spot was synchronized with cryogen spray cooling of the scrotal skin surface in a total of 8 dogs (n = 16 vasa) for a treatment time of 60 s. Burst pressure measurements were conducted at Days 0 and 21 (n = 8 vasa each day) to quantify the strength of vas closure. The vas was successfully thermally occluded in 15/16 (94%) procedures with 14/15 (93%) vas recording burst pressures above ejaculation pressure. One vas was not present, and another vas recorded a bursting pressure below ejaculation pressure. The coagulated vas bursting pressure averaged 283 ± 34 mm Hg at Day 0 and 260 ± 77 mm Hg at Day 21, significantly higher than reported vas ejaculation pressures of 136 ± 29 mm Hg. Minor scrotal skin burns were observed during the recovery period. Noninvasive thermal occlusion of the vas is feasible in an in vivo canine model. Elimination of minor skin burns and longer term chronic in vivo canine studies are needed to confirm azospermia after vas occlusion without recanalization.
Kurt Hecher - One of the best experts on this subject based on the ideXlab platform.
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arabin cervical pessary for prevention of preterm birth in cases of twin to twin transfusion syndrome treated by fetoscopic Laser Coagulation the pecep Laser randomised controlled trial
BMC Pregnancy and Childbirth, 2017Co-Authors: Carlota Rodo, Liesbeth Lewi, S Arevalo, Isabel Couck, Bettina Hollwitz, Kurt Hecher, E CarrerasAbstract:Fetoscopic Laser Coagulation of the placental anastomoses has changed the prognosis of twin-twin transfusion syndrome. However, the prematurity rate in this cohort remains very high. To date, strategies proposed to decrease the prematurity rate have shown inconclusive, if not unfavourable results. This is a randomised controlled trial to investigate whether a prophylactic cervical pessary will lower the incidence of preterm delivery in cases of twin-twin transfusion syndrome requiring fetoscopic Laser Coagulation. Women eligible for the study will be randomised after surgery and allocated to either pessary or expectant management. The pessary will be left in place until 37 completed weeks or earlier if delivery occurs. The primary outcome is delivery before 32 completed weeks. Secondary outcomes are a composite of adverse neonatal outcome, fetal and neonatal death, maternal complications, preterm rupture of membranes and hospitalisation for threatened preterm labour. 352 women will be included in order to decrease the rate of preterm delivery before 32 weeks’ gestation from 40% to 26% with an alpha-error of 0.05 and 80% power. The trial aims at clarifying whether the cervical pessary prolongs the pregnancy in cases of twin-twin transfusion syndrome regardless of cervical length at the time of fetoscopy. ClinicalTrials.gov Identifier: NCT01334489 . Registered 04 December 2011.
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long term neurodevelopmental outcome of 167 children after intrauterine Laser treatment for severe twin twin transfusion syndrome
American Journal of Obstetrics and Gynecology, 2006Co-Authors: Cornelia Graef, B J Hackeloer, Kurt Hecher, Birte Ellenrieder, Agnes Huber, Peter BartmannAbstract:Objective This study was undertaken to investigate long-term neurodevelopmental outcome of children born after intrauterine Laser Coagulation for severe twin-twin transfusion syndrome. Study design One hundred sixty-seven surviving infants treated between June 1997 and September 1999 were investigated at a median age of 3 years and 2 months. All children underwent a detailed standardized physical and neurologic examination and a standardized developmental test (Griffiths' Developmental Test Scales and Snijders-Oomen Non-Verbal-Intelligence Test). Results One hundred forty-five infants (86.8%) showed normal development, 12 infants (7.2%) showed minor neurologic abnormalities, and 10 infants (6.0%) major neurologic abnormalities. There was no difference in outcome for the former donors/recipients (P = .349) and between infants who were born as twins or singletons (P = .088). Conclusion With a high rate (86.8%) of normal neurodevelopmental outcome and an incidence of only 6.0% of major neurologic deficiencies, intrauterine Laser Coagulation seems to be the best treatment option for severe twin-twin transfusion syndrome.
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perinatal outcome in monochorionic twin pregnancies complicated by amniotic fluid discordance without severe twin twin transfusion syndrome
Ultrasound in Obstetrics & Gynecology, 2005Co-Authors: Agnes Huber, T Bregenzer, B J Hackeloer, W Diehl, L Zikulnig, Kurt HecherAbstract:Objectives To assess the natural history and perinatal outcome in monochorionic diamniotic twin pregnancies with discordant amniotic fluid volume without signs of severe twin–twin transfusion syndrome (TTTS). Methods This was an observational study of 84 consecutive monochorionic twin pregnancies which did not meet the criteria for severe TTTS and endoscopic Laser Coagulation of placental anastomoses at initial presentation. The population was subdivided into two groups. Group 1 consisted of 64 pregnancies (median gestational age, 20.1 (range, 15.6–24.7) weeks) with amniotic fluid discordance and no signs of congestive heart failure in the twin with the larger amniotic fluid volume (Twin 1) and positive end-diastolic flow in the umbilical artery of the twin with the smaller amniotic fluid volume (Twin 2). Group 2 (median gestational age, 19.1 (range, 16.0–24.4) weeks) consisted of 20 pregnancies with amniotic fluid discordance and intrauterine growth restriction (IUGR) (abdominal circumference < 5th percentile) in combination with absent or reversed end-diastolic (ARED) flow in the umbilical artery of Twin 2. After exclusion of one patient from Group 1, who opted for termination of pregnancy, nine patients in Group 1 and one in Group 2 developed severe TTTS, and Laser Coagulation was offered. The remaining 54 pregnancies of Group 1 were compared with the remaining 19 pregnancies of Group 2. Results Fetuses in Group 1 showed significantly higher survival rates (overall survival, 100/108 (92.6%) vs. 23/38 (60%), P < 0.0001; survival of both fetuses, 49/54 (90.7%) vs. 9/19 (47.4%), P = 0.0002) and median gestational age at delivery (33.6, (range, 27.6–37.8) weeks vs. 32.0 (range, 26.9–36.3) weeks, P = 0.0457). Overall, there was a significantly higher incidence of complications, defined as necessity for intrauterine intervention, fetal or neonatal death or delivery prior to 32 weeks, in Group 2 (Group 1: 30/63 (47.6%); Group 2: 16/20 (80%), P = 0.0188). Conclusions Our data suggest that amniotic fluid discordance in monochorionic diamniotic twin pregnancies in combination with IUGR and umbilical artery ARED flow in one fetus represents an extremely high-risk constellation for adverse pregnancy outcome. Copyright © 2005 ISUOG. Published by John Wiley & Sons, Ltd.
Liesbeth Lewi - One of the best experts on this subject based on the ideXlab platform.
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arabin cervical pessary for prevention of preterm birth in cases of twin to twin transfusion syndrome treated by fetoscopic Laser Coagulation the pecep Laser randomised controlled trial
BMC Pregnancy and Childbirth, 2017Co-Authors: Carlota Rodo, Liesbeth Lewi, S Arevalo, Isabel Couck, Bettina Hollwitz, Kurt Hecher, E CarrerasAbstract:Fetoscopic Laser Coagulation of the placental anastomoses has changed the prognosis of twin-twin transfusion syndrome. However, the prematurity rate in this cohort remains very high. To date, strategies proposed to decrease the prematurity rate have shown inconclusive, if not unfavourable results. This is a randomised controlled trial to investigate whether a prophylactic cervical pessary will lower the incidence of preterm delivery in cases of twin-twin transfusion syndrome requiring fetoscopic Laser Coagulation. Women eligible for the study will be randomised after surgery and allocated to either pessary or expectant management. The pessary will be left in place until 37 completed weeks or earlier if delivery occurs. The primary outcome is delivery before 32 completed weeks. Secondary outcomes are a composite of adverse neonatal outcome, fetal and neonatal death, maternal complications, preterm rupture of membranes and hospitalisation for threatened preterm labour. 352 women will be included in order to decrease the rate of preterm delivery before 32 weeks’ gestation from 40% to 26% with an alpha-error of 0.05 and 80% power. The trial aims at clarifying whether the cervical pessary prolongs the pregnancy in cases of twin-twin transfusion syndrome regardless of cervical length at the time of fetoscopy. ClinicalTrials.gov Identifier: NCT01334489 . Registered 04 December 2011.
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fetoscopic Laser Coagulation of the vascular equator versus selective Coagulation for twin to twin transfusion syndrome an open label randomised controlled trial
The Lancet, 2014Co-Authors: Femke Slaghekke, Enrico Lopriore, F J Klumper, Liesbeth Lewi, Roland Devlieger, Johanna M Middeldorp, Erik W Van Zwet, A S Weingertner, Philip Dekoninck, Mark D KilbyAbstract:Summary Background Monochorionic twin pregnancies complicated by twin-to-twin transfusion syndrome are typically treated with fetoscopic Laser Coagulation. Postoperative complications can occur due to residual vascular anastomoses on the placenta. We aimed to assess the efficacy and safety of a novel surgery technique that uses Laser Coagulation of the entire vascular equator (Solomon technique). Methods We undertook an open-label, international, multicentre, randomised controlled trial at five European tertiary referral centres. Women with twin-to-twin transfusion syndrome were randomly assigned by online randomisation (1:1) with permuted blocks to the Solomon technique or standard Laser Coagulation. The primary outcome was a composite of incidence of twin anaemia polycythaemia sequence, recurrence of twin-to-twin transfusion syndrome, perinatal mortality, or severe neonatal morbidity. Analyses were by intention to treat, with results expressed as odds ratios (ORs) and 95% CIs. This trial is registered with the Dutch Trial Registry, number NTR1245. Findings Between March 11, 2008, and July 12, 2012, 274 women were randomly assigned to either the Solomon group (n=139) or the standard treatment group (n=135). The primary outcome occurred in 94 (34%) of 274 fetuses in the Solomon group versus 133 (49%) of 270 in the standard treatment group (OR 0·54; 95% CI 0·35–0·82). The Solomon technique was associated with a reduction in twin anaemia polycythaemia sequence (3% vs 16% for the standard treatment; OR 0·16, 95% CI 0·05–0·49) and recurrence of twin-to-twin transfusion syndrome (1% vs 7%; 0·21, 0·04–0·98). Perinatal mortality and severe neonatal morbidity did not differ significantly between the two groups. Outside of the common and well-known complications of twin-to-twin transfusion syndrome and its treatment, no serious adverse events occurred. Interpretation Fetoscopic Laser Coagulation of the entire vascular equator reduces postoperative fetal morbidity in severe twin-to-twin transfusion syndrome. We recommend that fetoscopic surgeons consider adopting this strategy for treatment of women with twin-to-twin transfusion syndrome. Funding Netherlands Organization for the Health Research and Development (ZonMw 92003545).
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monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end diastolic flow type iii feasibility and perinatal outcome of fetoscopic placental Laser Coagulation
Ultrasound in Obstetrics & Gynecology, 2008Co-Authors: Liesbeth Lewi, Eduard Gratacos, Eugenia Antolin, J M Martinez, Edgar Hernandezandrade, Ruthy AcostarojasAbstract:Objectives To assess the feasibility and impact on perinatal outcome of fetoscopic Laser Coagulation of placental anastomoses in monochorionic twins with selective intrauterine growth restriction (sIUGR) and intermittent absent or reversed end-diastolic flow (iAREDF) in the umbilical artery (Type III), in comparison with expectant management. Methods This is a descriptive study of the outcome of 18 cases of monochorionic twins with Type III sIUGR treated with Laser, and 31 pregnancies managed expectantly over the same period. All newborns underwent neonatal brain ultrasound scans. Perinatal outcome and the incidence of neurological damage were compared between the two groups. Results Laser Coagulation could be performed in only 88.9% (16/18) of cases owing to technical difficulties, and in 12.5% (2/16) a second procedure was required to achieve complete Coagulation of the large artery-to-artery anastomosis. Mean gestational age at delivery was 31.0 (range, 26–33) weeks in the expectant management group and 32.6 (range, 23–38) weeks in the Laser group (P = 0.32). Overall perinatal survival was 85.5% (53/62) and 63.9% (23/36), respectively (P = 0.02). Intrauterine demise of the smaller twin occurred in 19.4% (6/31) and 66.7% (12/18), respectively (P = 0.001), and was associated with death of the cotwin in 50% (3/6) and 0% (0/12) of these cases, respectively (P = 0.02). The prevalence of periventricular leukomalacia in the larger fetus was 4/28 (14.3%) in the expectant management group and 1/17 (5.9%) in the Laser group (P = 0.63). Conclusions Laser Coagulation in sIUGR-iAREDF pregnancies is technically difficult and not always feasible. Placental dichorionization significantly increases the proportion of fetuses with intrauterine death of the growth-restricted twin, but it protects the normal twin from its cotwin's death in the event of demise of the growth-restricted twin. Copyright © 2008 ISUOG. Published by John Wiley & Sons, Ltd.
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monochorionic diamniotic twins complications and management options
Current Opinion in Obstetrics & Gynecology, 2003Co-Authors: Liesbeth Lewi, Eduard Gratacos, D Van Schoubroeck, Ingrid Witters, Dirk Timmerman, Jan DeprestAbstract:Purpose of review Monochorionic compared with dichorionic twins have disproportionately high fetal loss rates, perinatal mortality and morbidity. This is because of the unpredictable vascular anastomoses and the often asymmetrical distribution of the single placenta between both twins. Recent findings The pathophysiology of twin-to-twin transfusion syndrome is usually explained on an angioarchitectural basis, although certain hemodynamic and hormonal factors also may be involved. The results of the large randomized trials on amnioreduction, fetoscopic Laser Coagulation and septostomy are still awaited. An update is given on hardware and instruments required for fetoscopic Laser. Subsequently, the problem of the monochorionic twin set with severe early discordant growth is addressed. Several etiological mechanisms have been proposed, but little is known of its natural history. Also, umbilical artery Doppler waveforms may not have the same predictive value as in singletons. Prophylactic Laser Coagulation of the vascular anastomoses to protect against the adverse effects of single intrauterine demise, has so far not been shown to confer any benefit in outcome. Finally, pathophysiology and management of discordant structural and chromosomal anomalies in monochorionic twins are discussed. Laser and monopolar Coagulation, which can be introduced through a needle, may be used for selective feticide in early pregnancy or low hemodynamic conditions. Bipolar Coagulation seems more effective at later gestational ages and normal hemodynamic conditions. Summary Our insight into the complications associated with monochorionic twins has increased in recent years. It is hoped that this will lead to better surveillance and ultimately an improved outcome for these high-risk pregnancies.
Eduard Gratacos - One of the best experts on this subject based on the ideXlab platform.
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monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end diastolic flow type iii feasibility and perinatal outcome of fetoscopic placental Laser Coagulation
Ultrasound in Obstetrics & Gynecology, 2008Co-Authors: Liesbeth Lewi, Eduard Gratacos, Eugenia Antolin, J M Martinez, Edgar Hernandezandrade, Ruthy AcostarojasAbstract:Objectives To assess the feasibility and impact on perinatal outcome of fetoscopic Laser Coagulation of placental anastomoses in monochorionic twins with selective intrauterine growth restriction (sIUGR) and intermittent absent or reversed end-diastolic flow (iAREDF) in the umbilical artery (Type III), in comparison with expectant management. Methods This is a descriptive study of the outcome of 18 cases of monochorionic twins with Type III sIUGR treated with Laser, and 31 pregnancies managed expectantly over the same period. All newborns underwent neonatal brain ultrasound scans. Perinatal outcome and the incidence of neurological damage were compared between the two groups. Results Laser Coagulation could be performed in only 88.9% (16/18) of cases owing to technical difficulties, and in 12.5% (2/16) a second procedure was required to achieve complete Coagulation of the large artery-to-artery anastomosis. Mean gestational age at delivery was 31.0 (range, 26–33) weeks in the expectant management group and 32.6 (range, 23–38) weeks in the Laser group (P = 0.32). Overall perinatal survival was 85.5% (53/62) and 63.9% (23/36), respectively (P = 0.02). Intrauterine demise of the smaller twin occurred in 19.4% (6/31) and 66.7% (12/18), respectively (P = 0.001), and was associated with death of the cotwin in 50% (3/6) and 0% (0/12) of these cases, respectively (P = 0.02). The prevalence of periventricular leukomalacia in the larger fetus was 4/28 (14.3%) in the expectant management group and 1/17 (5.9%) in the Laser group (P = 0.63). Conclusions Laser Coagulation in sIUGR-iAREDF pregnancies is technically difficult and not always feasible. Placental dichorionization significantly increases the proportion of fetuses with intrauterine death of the growth-restricted twin, but it protects the normal twin from its cotwin's death in the event of demise of the growth-restricted twin. Copyright © 2008 ISUOG. Published by John Wiley & Sons, Ltd.
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monochorionic diamniotic twins complications and management options
Current Opinion in Obstetrics & Gynecology, 2003Co-Authors: Liesbeth Lewi, Eduard Gratacos, D Van Schoubroeck, Ingrid Witters, Dirk Timmerman, Jan DeprestAbstract:Purpose of review Monochorionic compared with dichorionic twins have disproportionately high fetal loss rates, perinatal mortality and morbidity. This is because of the unpredictable vascular anastomoses and the often asymmetrical distribution of the single placenta between both twins. Recent findings The pathophysiology of twin-to-twin transfusion syndrome is usually explained on an angioarchitectural basis, although certain hemodynamic and hormonal factors also may be involved. The results of the large randomized trials on amnioreduction, fetoscopic Laser Coagulation and septostomy are still awaited. An update is given on hardware and instruments required for fetoscopic Laser. Subsequently, the problem of the monochorionic twin set with severe early discordant growth is addressed. Several etiological mechanisms have been proposed, but little is known of its natural history. Also, umbilical artery Doppler waveforms may not have the same predictive value as in singletons. Prophylactic Laser Coagulation of the vascular anastomoses to protect against the adverse effects of single intrauterine demise, has so far not been shown to confer any benefit in outcome. Finally, pathophysiology and management of discordant structural and chromosomal anomalies in monochorionic twins are discussed. Laser and monopolar Coagulation, which can be introduced through a needle, may be used for selective feticide in early pregnancy or low hemodynamic conditions. Bipolar Coagulation seems more effective at later gestational ages and normal hemodynamic conditions. Summary Our insight into the complications associated with monochorionic twins has increased in recent years. It is hoped that this will lead to better surveillance and ultimately an improved outcome for these high-risk pregnancies.
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impact of Laser Coagulation in severe twin twin transfusion syndrome on fetal doppler indices and venous blood flow volume
Ultrasound in Obstetrics & Gynecology, 2002Co-Authors: Eduard Gratacos, D Van Schoubroeck, E Carreras, Roland Devlieger, E Roma, L Cabero, Jan DeprestAbstract:Objective To evaluate the impact of fetoscopic Laser Coagulation of placental anastomoses in severe twin–twin transfusion syndrome on fetal Doppler indices and umbilical vein blood flow volume as calculated with Doppler and two-dimensional ultrasound. Methods Thirty-two cases of second-trimester severe twin–twin transfusion undergoing Laser therapy were examined with serial ultrasound before and 1, 3 and 5 days after therapy. Pulsatility indices in the umbilical artery and ductus venosus were measured. Blood volume flow at the level of the intra-abdominal umbilical vein was calculated by means of Doppler and two-dimensional ultrasound. The development of hydropic signs in donors was recorded. Perinatal outcome in terms of neonatal survival was recorded for all cases. Results In recipients, ductus venosus pulsatility index decreased progressively after therapy and, by day 5, median pulsatility index was significantly lower than that before therapy (0.97 vs. 0.82, P < 0.0001). Umbilical vein blood flow volume in recipient twins showed no significant variations before and after Laser. In donors, umbilical artery pulsatility index decreased significantly by the first day following therapy (2.1 vs. 1.6, P < 0.0001). Previously absent or reverse umbilical end-diastolic flow reappeared after therapy in 46% (7/15) of donors. Ductus venosus pulsatility index in donors increased significantly by day 1 after therapy (0.99 vs. 1.35, P < 0.0001) but, over days 3 and 5, it returned towards preoperative values. Umbilical vein flow volume measurements (mL/min/kg) in the donor increased by approximately 50% the day after treatment (151 vs. 232, P < 0.0001) and remained elevated. Umbilical vein flow volume before Laser therapy was significantly lower in donors compared to recipients (151 vs. 260, P < 0.0001), but the difference was non-significant after treatment (240 vs. 267). One or more hydropic signs developed in eight (25%) donors during the 5 days' observation after therapy. Conclusions Laser therapy induced important changes in fetal hemodynamic parameters, resulting in a reversion of the disturbances associated with severe twin–twin transfusion syndrome. The recipient twin showed a progressive improvement of previous signs of right cardiac overload. The donor experienced a substantial increase in umbilical vein blood volume flow accompanied by a transitory state of relative right overload, which may explain the development of transient hydropic signs in a proportion of donors. Copyright © 2000 International Society of Ultrasound in Obstetrics and Gynecology
B J Hackeloer - One of the best experts on this subject based on the ideXlab platform.
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long term neurodevelopmental outcome of 167 children after intrauterine Laser treatment for severe twin twin transfusion syndrome
American Journal of Obstetrics and Gynecology, 2006Co-Authors: Cornelia Graef, B J Hackeloer, Kurt Hecher, Birte Ellenrieder, Agnes Huber, Peter BartmannAbstract:Objective This study was undertaken to investigate long-term neurodevelopmental outcome of children born after intrauterine Laser Coagulation for severe twin-twin transfusion syndrome. Study design One hundred sixty-seven surviving infants treated between June 1997 and September 1999 were investigated at a median age of 3 years and 2 months. All children underwent a detailed standardized physical and neurologic examination and a standardized developmental test (Griffiths' Developmental Test Scales and Snijders-Oomen Non-Verbal-Intelligence Test). Results One hundred forty-five infants (86.8%) showed normal development, 12 infants (7.2%) showed minor neurologic abnormalities, and 10 infants (6.0%) major neurologic abnormalities. There was no difference in outcome for the former donors/recipients (P = .349) and between infants who were born as twins or singletons (P = .088). Conclusion With a high rate (86.8%) of normal neurodevelopmental outcome and an incidence of only 6.0% of major neurologic deficiencies, intrauterine Laser Coagulation seems to be the best treatment option for severe twin-twin transfusion syndrome.
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perinatal outcome in monochorionic twin pregnancies complicated by amniotic fluid discordance without severe twin twin transfusion syndrome
Ultrasound in Obstetrics & Gynecology, 2005Co-Authors: Agnes Huber, T Bregenzer, B J Hackeloer, W Diehl, L Zikulnig, Kurt HecherAbstract:Objectives To assess the natural history and perinatal outcome in monochorionic diamniotic twin pregnancies with discordant amniotic fluid volume without signs of severe twin–twin transfusion syndrome (TTTS). Methods This was an observational study of 84 consecutive monochorionic twin pregnancies which did not meet the criteria for severe TTTS and endoscopic Laser Coagulation of placental anastomoses at initial presentation. The population was subdivided into two groups. Group 1 consisted of 64 pregnancies (median gestational age, 20.1 (range, 15.6–24.7) weeks) with amniotic fluid discordance and no signs of congestive heart failure in the twin with the larger amniotic fluid volume (Twin 1) and positive end-diastolic flow in the umbilical artery of the twin with the smaller amniotic fluid volume (Twin 2). Group 2 (median gestational age, 19.1 (range, 16.0–24.4) weeks) consisted of 20 pregnancies with amniotic fluid discordance and intrauterine growth restriction (IUGR) (abdominal circumference < 5th percentile) in combination with absent or reversed end-diastolic (ARED) flow in the umbilical artery of Twin 2. After exclusion of one patient from Group 1, who opted for termination of pregnancy, nine patients in Group 1 and one in Group 2 developed severe TTTS, and Laser Coagulation was offered. The remaining 54 pregnancies of Group 1 were compared with the remaining 19 pregnancies of Group 2. Results Fetuses in Group 1 showed significantly higher survival rates (overall survival, 100/108 (92.6%) vs. 23/38 (60%), P < 0.0001; survival of both fetuses, 49/54 (90.7%) vs. 9/19 (47.4%), P = 0.0002) and median gestational age at delivery (33.6, (range, 27.6–37.8) weeks vs. 32.0 (range, 26.9–36.3) weeks, P = 0.0457). Overall, there was a significantly higher incidence of complications, defined as necessity for intrauterine intervention, fetal or neonatal death or delivery prior to 32 weeks, in Group 2 (Group 1: 30/63 (47.6%); Group 2: 16/20 (80%), P = 0.0188). Conclusions Our data suggest that amniotic fluid discordance in monochorionic diamniotic twin pregnancies in combination with IUGR and umbilical artery ARED flow in one fetus represents an extremely high-risk constellation for adverse pregnancy outcome. Copyright © 2005 ISUOG. Published by John Wiley & Sons, Ltd.
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endoscopic Laser surgery versus serial amniocenteses in the treatment of severe twin twin transfusion syndrome
American Journal of Obstetrics and Gynecology, 1999Co-Authors: K Hecher, Hanno Plath, T Bregenzer, Manfred Hansmann, B J HackeloerAbstract:Abstract Objective: Severe twin-twin transfusion can be treated by either serial amniocenteses with removal of large volumes of amniotic fluid or by endoscopic Laser Coagulation of the communicating vessels. We investigated the benefit of Laser surgery in comparison to serial amniocenteses in terms of pregnancy outcome. Study Design: The data used in this comparative study were collected from 116 patients with severe twin-twin transfusion syndrome between 17 and 25 weeks' gestation. The patients were grouped according to the treatment center. The first group comprised 73 patients (median gestational age 20.7 weeks) treated in Hamburg by fetoscopic Laser Coagulation of the vascular placental anastomoses between January 1995 and May 1997. The second group comprised 43 patients (median gestational age 20.4 weeks), fulfilling identical diagnostic criteria and treated in Bonn by serial amniocenteses between 1992 and 1996. Results: The overall fetal survival rate was not significantly different (61%, 89/146, vs 51%, 44/86; P = .239). There was a significantly higher proportion of pregnancies with ≥1 survivor in the Laser-treated group (79%, 58/73, vs 60%, 26/43; P = .033). The number of cases with spontaneous intrauterine fetal death of both fetuses was significantly lower in the Laser-treated group (3%, 2/73, vs 19%, 8/43; P = .003). The incidence of abnormal ultrasonographic findings in the brain was significantly lower among surviving neonates after Laser surgery than after amniocenteses (6%, 5/89, vs 18%, 8/44; P = .03). For pregnancies with ≥1 live-born baby, a significantly longer interval between first intervention and delivery (median 90 vs 72 days, P = .022) leading to a significantly higher gestational age at delivery (median 33.7 vs 30.7 weeks, P = .018) was observed for the Laser-treated group. The birth weights of the donor fetuses were significantly higher in the Laser-treated group (median 1750 vs 1145 g, P = .034), and a trend toward higher birth weight was also found for recipient fetuses (median 2000 vs 1560 g, P = .076). Conclusions: These findings indicate that endoscopic Laser Coagulation of placental vascular anastomoses offers a more effective alternative to serial amniocenteses as a treatment of severe second-trimester twin-twin transfusion syndrome. (Am J Obstet Gynecol 1999;180:717-24.)
