Schenone, Mauro H

ImportanceEarly anhydramnios during pregnancy, resulting from fetal bilateral renal agenesis, causes lethal pulmonary hypoplasia in neonates. Restoring amniotic fluid via serial amnioinfusions may promote lung development, enabling survival.ObjectiveTo assess neonatal outcomes of serial amnioinfusions initiated before 26 weeks’ gestation to mitigate lethal pulmonary hypoplasia.Design, Setting, and ParticipantsProspective, nonrandomized clinical trial conducted at 9 US fetal therapy centers between December 2018 and July 2022. Outcomes are reported for 21 maternal-fetal pairs with confirmed anhydramnios due to isolated fetal bilateral renal agenesis without other identified congenital anomalies.ExposureEnrolled participants initiated ultrasound-guided percutaneous amnioinfusions of isotonic fluid before 26 weeks’ gestation, with frequency of infusions individualized to maintain normal amniotic fluid levels for gestational age.Main Outcomes and MeasuresThe primary end point was postnatal infant survival to 14 days of life or longer with dialysis access placement.ResultsThe trial was stopped early based on an interim analysis of 18 maternal-fetal pairs given concern about neonatal morbidity and mortality beyond the primary end point despite demonstration of the efficacy of the intervention. There were 17 live births (94%), with a median gestational age at delivery of 32 weeks, 4 days (IQR, 32-34 weeks). All participants delivered prior to 37 weeks’ gestation. The primary outcome was achieved in 14 (82%) of 17 live-born infants (95% CI, 44%-99%). Factors associated with survival to the primary outcome included a higher number of amnioinfusions (P = .01), gestational age greater than 32 weeks (P = .005), and higher birth weight (P = .03). Only 6 (35%) of the 17 neonates born alive survived to hospital discharge while receiving peritoneal dialysis at a median age of 24 weeks of life (range, 12-32 weeks).Conclusions and RelevanceSerial amnioinfusions mitigated lethal pulmonary hypoplasia but were associated with preterm delivery. The lower rate of survival to discharge highlights the additional mortality burden independent of lung function. Additional long-term data are needed to fully characterize the outcomes in surviving neonates and assess the morbidity and mortality burden.Trial RegistrationClinicalTrials.gov Identifier: NCT03101891

INTRODUCTION: Perinatal mental illness imparts a significant health burden. A multitude of factors are hypothesized to increase the incidence of perinatal mood and anxiety disorders (PMADs) in the fetal surgical population, including uncertain fetal prognosis and the inherent risks of surgery and preterm delivery. We sought to determine the disease course of PMADs in the fetal surgery population. METHODS: A retrospective chart review was conducted of fetal surgery patients from 2017 to 2021 at a tertiary care center. Demographics, surgical, obstetric, and psychiatric diagnoses were recorded. Standard descriptive analyses were performed. RESULTS: One hundred nineteen eligible patients were identified. Fetal surgery was performed at a median gestational age of 23.0 (range 16.0–34.0) weeks. Laser ablation of placental anastomoses (n=51) and in utero myelomeningocele repair (n=22) were the most common procedures. 26.8% (32/119) had preexisting mood disorders, with 59.3% (19/32) and 53.1% (17/32) on a baseline medication for depression or anxiety, respectively, prior to surgery. 26.4% (23/87) of patients without a history of anxiety or depression had a new diagnosis of PMAD. Two patients experienced suicidal ideation. 6.7% (8/119) and 10.1% (12/119) initiated a new psychiatric medication during or post-pregnancy, respectively. 19.8% (21/113) received a therapy referral. Among patients with baseline anxiety or depression, 62.5% (20/32) experienced an exacerbation postpartum with 25.0% (8/32) referred for therapy, and 34.3% (11/32) changing dose or medication for anxiety and 37.5% (12/32) for depression. CONCLUSION: Among patients undergoing fetal surgery, a high incidence of PMAD was identified. Most patients with prepregnancy anxiety or depression experienced an exacerbation postpartum. Further research into effective supportive interventions is warranted.

AbstractObjectiveFetal surgery has improved neonatal outcomes; however, it is unknown if the intervention contributes to the developmental of inflammatory pathologies in the placenta. Here, an association between fetal surgery and placental pathology was examined.MethodThis case‐control study compared pregnancies with fetal surgery (n = 22), pregnancies with an indication for fetal surgery but without an intervention being done (n = 13), and gestational‐age and fetus‐number matched controls (n = 36). Data on maternal, infant, and placental outcomes were abstracted. Additionally, immunohistochemistry identified expression of lymphoid and myeloid cells in the placenta on a subset of cases. Comparisons were performed using Kruskal‐Wallis or Pearson's chi‐squared tests.ResultsMaternal characteristics were comparable between groups. Most fetal interventions were for diaphragmatic hernia, spina bifida, or twin‐to‐twin transfusion syndrome. Fetuses who were operated on before birth were more likely to be born preterm (p = 0.02). There was no increase in the rate of observed placental pathologies or immune cell infiltration in fetal surgery cases compared to controls.ConclusionThe data suggest that fetal surgery is not associated with increased inflammatory or morphologic pathology in the placenta. This observation supports the growing field of fetal surgery.

INTRODUCTION: While focal-occult placenta accreta spectrum (PAS) is known to lead to adverse outcomes, little is known of the morbidity in comparison to previa-associated PAS. METHODS: After IRB approval, retrospective review was conducted of pathologically confirmed (decidual layer absence or basal-plate myometrial fibers) PAS from 2018 to 2021 at a tertiary care center. Baseline characteristics and surgical, obstetric, and subsequent pregnancy outcomes were recorded. Focal-occult PAS was compared with previa-associated PAS using Kruskal-Wallis/Chi-square tests; P<.05 was considered significant. RESULTS: A total of 56 cases were identified: 22 previa-associated and 34 focal-occult PAS. All patients with previa-associated and 26.5% of those with focal-occult PAS underwent hysterectomy. Of the previa-associated PAS patients, 20 of 22 were diagnosed antenatally, as was 1 of 34 focal-occult PAS patients. Mean maternal age (32.5 vs. 33.1 year), number of previous dilation and curettage procedures (0.4 vs. 0.3), and in vitro fertilization rates (4.5% vs. 23.5%) were not significantly different between groups. Mean parity (3.7 vs. 1.4), gestational age at delivery (34.3 vs. 35.7 weeks), any previous cesarean delivery (95.5% vs. 29.4%), mean number of previous cesareans (2.5 vs. 0.5), and placental locations were significantly different between groups. All measures of morbidity, including postpartum hemorrhage rates (81.0% vs. 75.8%), median qualitative blood loss (1,500cc, range: 500–9,516cc vs. 1,660cc, range: 350–12,220cc), mean units of red blood cells transfused (1.8 vs. 1.9), massive transfusion (9.1% vs. 20.6%), ICU admission (9.1% vs. 14.7%), and reoperation rates (9.1% vs. 32.4%) were similar between groups. Six focal-occult PAS patients had a subsequent pregnancy, and two had recurrent PAS. CONCLUSION: Despite representing lower grade PAS, focal-occult PAS has similar measures of morbidity when compared to previa-associated PAS, potentially attributable to lack of antenatal detection.

Abstract The practice of maternal-fetal surgery (MFS) has expanded from lethal fetal conditions to conditions which are significantly disabling but not a lethal fetal abnormality. The inclusion of myelomeningocele within the scope of MFS in the 1990s sparked a renewed debate over the ethics of MFS. While demonstrating increasing efficacy and range of application, MFS continues to be ethically fraught due to the inherent tension between maternal and fetal interests. Ethical issues central to MFS include the patienthood of the fetus; the balance of risks and benefits between the woman and fetus; informed consent for experimental procedures; and determination of conditions that meet ethical qualifications for MFS intervention. These concerns are likely to persist and evolve as perinatal medicine continues to advance. Here we summarize the current state of MFS ethics, highlighting the major positions in the literature thus far as well as examine future directions. It is essential robust discussions of these important issues continue both to ensure ethical medical practice and to provide support to clinicians, pregnant women, and their families.