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Fetoscopic laser ablation of vasa previa in pregnancy complicated by giant fetal cervical lymphatic malformation

2015; Wiley; Volume: 46; Issue: 4 Linguagem: Inglês

10.1002/uog.14796

1469-0705

Pardis Hosseinzadeh, Alireza A. Shamshirsaz, Darrell L. Cass, Jimmy Espinoza, W. Lee, Bahram Salmanian, Rodrigo Ruano, M. Belfort,

Assisted Reproductive Technology and Twin Pregnancy

Vasa previa is a rare complication of pregnancy that is classified as Type 1 if velamentous umbilical cord insertion causes fetal blood vessels to traverse the internal cervical os and Type 2 if the fetal vessels are connected to a bilobed placenta and cover the internal cervical os1. It has been associated with high perinatal mortality due to fetal exsanguination following vessel damage at the time of membrane rupture. Accurate prenatal diagnosis and appropriate timing of Cesarean delivery improve neonatal outcome2. Successful cases of intrauterine laser photocoagulation of Type 2 vasa previa have been reported previously345. Here we describe our experience of a euploid pregnancy complicated by Type 2 vasa previa and severe polyhydramnios due to fetal cervical lymphatic malformation, managed by laser photocoagulation of the vessels in question. A 34-year-old pregnant woman, gravida 6, para 4, was referred to our center at 18 weeks' gestation due to a fetal neck mass diagnosed on routine ultrasound examination. Fetal magnetic resonance imaging (MRI) at 20 weeks confirmed a multicystic lymphatic malformation centered on the left jaw (Figure 1). Follow-up ultrasound at 29 weeks revealed vasa previa, with vessels bridging the main anterior portion of the placenta to a smaller (approximately 10% of the whole placental mass) posterior segment of the placenta with no evidence of placenta previa (Figures 2a and b). At 29 + 3 weeks' gestation, the patient experienced contractions and developed severe polyhydramnios with amniotic fluid index of 37.3 cm. Repeat MRI demonstrated significant interval enlargement of the lymphatic malformation. The patient received tocolytics and a course of betamethasone. Contractions persisted and progressive cervical dilatation became a risk. The main concern with continuing the pregnancy without intervention was that contractions (either spontaneous due to polyhydramnios or induced due to amnioreduction) would lead to preterm prelabor rupture of membranes (PPROM) and rupture of the vasa previa. Laser ablation was considered for concern of fetal exsanguination in the event of PPROM. After extensive counseling regarding expectant vs operative management, and after approval from the Fetal Therapy Board, the patient proceeded with fetoscopic laser photocoagulation of the vasa previa and amnioreduction (1250 mL). In-utero laser ablation of the connecting vessels was performed using a 600 µm laser fiber and a power setting between 25–45 Watts (D60 Multibeam Flexiplus, Dornier Medizintechnik, Wessling, Germany). Color Doppler evaluation following the procedure revealed no blood flow in the involved vessels (Figure 2c). The patient was subsequently managed as an inpatient and underwent a further two amnioreductions at 31 + 3 and 34 + 2 weeks' gestation. At 34 + 5 weeks, the patient experienced leakage of fluid, consistent with PPROM, and began contractions. An ex-utero intrapartum treatment (EXIT) procedure was performed due to evidence of fetal airway compression. A 2780-g male neonate was delivered with Apgar scores of 4 at both 1 min and 5 min. The infant was transferred to the neonatal intensive care unit and underwent uneventful partial resection of the neck mass 6 days postpartum. Pathological evaluation of the placenta showed it to be bilobed with intramembranous blood vessels with fibrous obliteration and fragmentation of red blood cells, consistent with prior laser ablation. A small succenturiate lobe was identified with an involved area of infarction covering < 5% of the placental mass (Figure 3). Fetoscopic laser ablation of the vasa previa allowed prolongation of pregnancy by almost 5 weeks, a safe EXIT procedure and good neonatal outcome. We do however recognize that this form of intervention has limited scope and that the prenatal diagnosis and characterization of the type of vasa previa and proportion of placenta affected need to be assessed carefully and that an individualized plan of care will be required for each case considered. P. Hosseinzadeh†, A. A. Shamshirsaz*†‡, D. L. Cass§, J. Espinoza†¶, W. Lee†¶, B. Salmanian†, R. Ruano†§ and M. A. Belfort†§ †Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA; ‡Division of Fetal Intervention, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA; §Division of Pediatric Surgery, Texas Children's Fetal Center and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; ¶Division of Women's and Fetal Imaging, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA *Correspondence. (e-mail: [email protected]; [email protected])