Publications by authors named "Michael A Belfort"

189 Publications

Fetal endoscopic tracheal occlusion and pulmonary hypertension in moderate congenital diaphragmatic hernia.

J Matern Fetal Neonatal Med 2021 Jun 6:1-6. Epub 2021 Jun 6.

Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA.

Objective: To study the role of fetal endoscopic tracheal occlusion (FETO) on resolution of pulmonary hypertension (PH) in fetuses with isolated moderate left-sided diaphragmatic hernia (CDH).

Methods: This retrospective study included fetuses with CDH evaluated between February 2004 and July 2017. Using the tracheal occlusion to accelerate lung growth (TOTAL) trial definition, we classified fetuses into moderate left CDH if O/E-LHR (observed/expected-lung head ratio) was 25-34.9% regardless of liver position or O/E-LHR of 35-44.9% if liver was in the chest. Postnatal echocardiograms were used to diagnose PH. Logistic regression analyses were performed to determine the relationship of FETO with study outcomes.

Results: Of 184 cases with no other major anomalies, 30 (16%) met criteria. There were nine FETO and 21 non-FETO cases. By hospital discharge, a higher proportion of infants in the FETO group had resolution of PH (87.5 (7/8) vs. 40% (8/20); =.013). FETO was associated with adjusted odds ratio of 17.3 (95% CI: 1.75-171; =.015) to resolve PH by hospital discharge. No significant differences were noted in need for ECMO or survival to discharge between groups.

Conclusions: Infants with moderate left-sided CDH according to O/E-LHR, FETO is associated with resolution of PH by the time of hospital discharge.
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http://dx.doi.org/10.1080/14767058.2021.1932806DOI Listing
June 2021

Experience of 300 cases of prenatal fetoscopic open spina bifida repair: Report of the International Fetoscopic Neural Tube Defect Repair Consortium.

Am J Obstet Gynecol 2021 Jun 2. Epub 2021 Jun 2.

Fetal Medicine Foundation, London, UK.

Background: The multicenter randomized control trial Management of Myelomeningocele Study (MOMS) demonstrated that prenatal repair of open spina bifida (OSB) via hysterotomy, compared with postnatal repair, decreases the need for ventriculoperitoneal shunting and increases the chances of independent ambulation. However, the hysterotomy approach is associated with risks that are inherent to the uterine incision. Fetal surgeons from around the world embarked on fetoscopic OSB repair aiming to reduce maternal and fetal/neonatal risks while preserving the neurologic benefits of in-utero surgery to the child.

Objective: To report the main obstetrical, perinatal and neurosurgical outcomes in the first 12 months of life of children undergoing prenatal fetoscopic repair of open spina bifida included in an international registry and to compare these with the results reported in the MOMS trial and in a subsequent large cohort of patients who received an open fetal surgery repair.

Study Design: All known centers performing fetoscopic spina bifida repair were contacted and invited to participate in a Fetoscopic Myelomeningocele Repair Consortium and enroll their patients in a registry. Patient data entered into this fetoscopic registry were analyzed for this report. Fisher's exact test was performed for comparison of categorical variables in the registry vs. both the MOMS trial and a post MOMS cohort. Binary logistic regression analyses were used to assess the registry data for predictors of preterm birth <30 weeks of gestation, preterm prelabor rupture of membranes (PPROM) and need for postnatal cerebrospinal fluid (CSF) diversion in the fetoscopic registry.

Results: There were 300 patients in the fetoscopic registry, 78 in the MOMS trial and 100 in the post MOMS cohort. The three datasets showed similar anatomic levels of the spinal lesion, mean gestational age at delivery, distribution of motor function compared to upper anatomic level of the lesion in the neonates, and perinatal death. In the MOMS trial (26.16 ± 1.6 weeks) and post MOMS cohort [23.3(20.2-25.6) weeks], compared to the fetoscopic registry group (23.6 ± 1.4 weeks), the gestational age at surgery was lower (comparing fetoscopic repair group vs. MOMS trial: p<0.01). After open fetal surgery all patients were delivered by cesarean section, whereas in the fetoscopic registry about one-third were delivered vaginally (p<0.01). At cesarean section, areas of dehiscence or thinning in the scar were observed in 34% of cases in the MOMS trial, in 49% in the post MOMS cohort, and in 0% in the fetoscopic registry (p<0.01 for both comparisons). At 12 months of age there was no significant difference in the number of patients requiring treatment for hydrocephalus between those in the fetoscopic registry and the MOMS trial.

Conclusion: Prenatal and postnatal outcomes up to 12 months of age after prenatal fetoscopic and open fetal surgery repair of open spina bifida are similar. Fetoscopic repair allows for having a vaginal delivery and eliminates the risk of uterine scar dehiscence therefore protecting subsequent pregnancies of unnecessary maternal and fetal risks.
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http://dx.doi.org/10.1016/j.ajog.2021.05.044DOI Listing
June 2021

Novel scoring system for determining fetal candidacy for prenatal intervention for severe congenital lower urinary tract obstruction.

Eur J Obstet Gynecol Reprod Biol 2021 May 11;262:118-123. Epub 2021 May 11.

Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, United States.

Objectives: To evaluate a novel scoring system that combines several prenatal parameters for selecting ideal candidates for fetal intervention, and for predicting postnatal survival in patients with severe fetal lower urinary tract obstruction (LUTO).

Methods: We retrospectively reviewed all cases of severe LUTO evaluated for fetal intervention in a single large fetal center between January 2013 and December 2017. A scoring system for determining fetal candidacy for intervention was retrospectively developed based on postnatal outcomes. The proposed scoring system included fetal urinary biochemistry, renal ultrasound parameters, initial bladder volume, and degree of bladder refill. Relevant demographic characteristics, ultrasound reports and laboratory results were reviewed. Receiver operating characteristic (ROC) curves were used to select the cut-off values for initial bladder volume and degree of bladder refill and to evaluate the performance of the scoring system in predicting postnatal death.

Results: Of the 79 LUTO patients evaluated, 31 were eligible for the study. The overall 6-month postnatal survival was 64.5 % (20/31). A scoring system (0-8) was suggested with 2 points for unfavorable biochemistry, 4 points for ultrasound evidence of dysplastic kidneys, 1 point for inadequate initial bladder volume and 1 point for inadequate bladder refill. Scores>3 (N = 7) were associated with 0 % 6-month survival. The ROC curve for predicting postnatal mortality showed area under curve (AUC) of 0.82 (95 % CI 0.65-0.99). Subgroup analysis within subjects who underwent fetal intervention (N = 22) also confirmed the significance of the distribution of the scoring system between groups who survived and those who did not after adjustment for GA at delivery (p = 0.01).

Conclusion: We propose a novel scoring system for antenatal evaluation of patients with severe LUTO which may be useful in selecting those candidates most appropriate for intervention and in counseling parents about predicted postnatal outcome.
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http://dx.doi.org/10.1016/j.ejogrb.2021.05.015DOI Listing
May 2021

Two-port, exteriorized uterus, fetoscopic meningomyelocele closure has fewer adverse neonatal outcomes than open hysterotomy closure.

Am J Obstet Gynecol 2021 May 4. Epub 2021 May 4.

Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.

Background: In utero closure of meningomyelocele using an open hysterotomy approach is associated with preterm delivery and adverse neonatal outcomes.

Objective: This study compared the neonatal outcomes in in utero meningomyelocele closure using a 2-port, exteriorized uterus, fetoscopic approach vs the conventional open hysterotomy approach.

Study Design: This retrospective cohort study included all consecutive patients who underwent in utero meningomyelocele closure using open hysterotomy (n=44) or a 2-port, exteriorized uterus, fetoscopic approach (n=46) at a single institution between 2012 and 2020. The 2-port, exteriorized uterus, fetoscopic closure was composed of the following 3 layers: a bovine collagen patch, a myofascial layer, and a skin. The frequency of respiratory distress syndrome and a composite of other adverse neonatal outcomes, including retinopathy of prematurity, periventricular leukomalacia, and perinatal death, were compared between the study groups. Regression analyses were performed to determine any association between the fetoscopic closure and adverse neonatal outcomes, adjusted for several confounders, including gestational age of <37 weeks at delivery.

Results: The fetoscopic closure was associated with a lower rate of respiratory distress syndrome than the open hysterotomy closure (11.5% [5 of 45] vs 29.5% [13 of 44]; P=.037). The proportion of neonates with a composite of other adverse neonatal outcomes in the fetoscopic group was half of that observed patients in the open hysterotomy group; however, this difference did not reach statistical significance (4.3% [2 of 46] vs 9.1% [4 of 44]; P=.429]. Here, regression analysis has demonstrated that fetoscopic meningomyelocele closure was associated with a lower risk of respiratory distress syndrome (adjusted odds ratio, 0.23; 95% confidence interval, 0.06-0.84; P=.026] than open hysterotomy closure.

Conclusion: In utero meningomyelocele closure using a 2-port, exteriorized uterus, fetoscopic approach was associated with a lower risk of respiratory distress syndrome than the conventional open hysterotomy meningomyelocele closure.
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http://dx.doi.org/10.1016/j.ajog.2021.04.252DOI Listing
May 2021

Placenta Accreta Spectrum: Correlation between FIGO Clinical Classification and Histopathologic Findings.

Am J Perinatol 2021 May 2. Epub 2021 May 2.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.

Objective:  Placenta accreta spectrum (PAS) covers a wide spectrum of placental adherence/invasion with varied clinical significance. Histopathologic examination is considered the confirmatory gold standard, but is only obtained sometime after definitive treatment. The International Federation of Gynecology and Obstetrics (FIGO) has published a new clinical classification that can be assigned at delivery, and we aimed to investigate the association between this new FIGO classification and histopathology and also to assess its correlation with maternal outcomes.

Study Design:  We studied a retrospective cohort of 185 subjects with histopathologically proven PAS managed at our referral center between September 2012 and January 2019. Two experienced surgeons retrospectively reviewed charts and assigned the FIGO grading based on findings reported at delivery. A third experienced reviewer adjudicated to determine the classification used for final analysis. Categorical outcomes were compared with the use of chi-squared and the Fisher exact test, as appropriate. A multivariate model was designed to adjust outcomes in different FIGO groups for the involvement of a formal multidisciplinary management team.

Results:  Among 185 subjects, there were 41 (22%) placenta accreta, 44 (24%) placenta increta, and 100 (54%) placenta percreta on histopathology. The inter-rater reliability was found to be substantial with Kappa = 0.661 ( < 0.001), and 95% confidence interval (CI): 0.449-0.872. There was a significant association between all histopathology groupings and the FIGO clinical classification ( < 0.001). However, we found no association between FIGO classifications and maternal complications.

Conclusion:  The new FIGO clinical classification is strongly associated with histopathologic findings. A better understanding of the depth and extent of invasion as afforded by the clinical classification system will help standardize reporting and future research.

Key Points: · PAS includes a wide spectrum of placental invasion with varied clinical significance.. · Histopathological examination is considered the confirmatory gold standard.. · The new FIGO clinical classification is strongly associated with histopathologic findings..
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http://dx.doi.org/10.1055/s-0041-1728834DOI Listing
May 2021

The risk of placenta accreta spectrum in women with in vitro fertilization in different populations.

Am J Obstet Gynecol 2021 Apr 24. Epub 2021 Apr 24.

Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main St., 10th Floor, BCM610, Houston, TX 77030. Electronic address:

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http://dx.doi.org/10.1016/j.ajog.2021.04.245DOI Listing
April 2021

Enhanced Recovery after Surgery: Benefits for the Fetal Surgery Patient.

Fetal Diagn Ther 2021 Apr 14:1-8. Epub 2021 Apr 14.

Department of Anesthesiology, Perioperative and Pain Medicine,Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.

Background: The fetoscopic approach to the prenatal closure of a neural tube defect (NTD) may offer similar advantages to the newborn compared to prenatal open closure of a NTD, with a reduction in maternal risks. Enhanced recovery after surgery (ERAS) protocols have been applied to different surgical procedures with documented advantages. We modified the perioperative care of patients undergoing in utero repair of myelomeningocele with the goal of enhancing the recovery. A retrospective study comparing traditional management to the ERAS protocol was conducted.

Aims: Primary aim was to evaluate the length of stay (LOS). Secondary outcomes included pain scores, time to oral intake, opioid-induced side effects, and respiratory complications.

Methods: Thirty patients who underwent a mid-gestation fetoscopic closure of a NTD were included. Data analyzed include demographics, comorbidities, LOS, anatomical location of the NTD, magnesium sulfate doses and duration of administration, oxygen requirements, duration of the postoperative epidural infusion, duration of surgery and anesthesia, incidence of postoperative nausea and vomiting, respiratory complications, time to oral intake, pain scores, and sedation scores. Differences between the treatment groups were compared using the independent sample t-test or Mann-Whitney Ʋ test.

Results: Of the 30 patients, 10 patients were managed according to the ERAS protocol and 20 patients according to the traditional management (1:2 ratio). The mean gestational age at the time of intervention for the traditional and ERAS groups was 24.9 ± 0.5 weeks and 24.8 ± 0.5 weeks, respectively. Compared to the traditional group, the LOS was reduced in the ERAS group to 112.5 ± 12.6 h (4.7 ± 0.5 days) from 179.7 ± 87.9 h (7.5 ± 3.7 days) (p = 0.012). The time to oral intake was also shorter 502.6 ± 473.4 min versus 1015.6 ± 698.2 min; p = 0.049. Oxygen requirements were prolonged in the traditional group (1843.7 ± 1262.6 min vs. 1051.7 ± 1078.1 min p = 0.052). The total duration of magnesium sulfate was longer for patients in the traditional group (2125.6 ± 727.1 min vs. 1429.5 ± 553.8 min; p = 0.006). No statistically significant difference in pain scores was observed between the groups.

Conclusions: Establishing an ERAS protocol for fetoscopic in utero repair of NTDs approach is feasible with the advantages of decreased postoperative LOS, reduced oxygen requirements, lower duration of magnesium sulfate infusion, and facilitation of earlier oral intake without compromising the pain scores.
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http://dx.doi.org/10.1159/000515550DOI Listing
April 2021

Perinatal outcome of twin-to-twin transfusion syndrome complicated with incidental septostomy after laser photocoagulation: A systematic review and meta-analysis.

Prenat Diagn 2021 Mar 29. Epub 2021 Mar 29.

Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA.

Aim: To evaluate perinatal outcomes of incidental septostomy (IS) after laser photocoagulation for twin-to-twin transfusion syndrome (TTTS), and to compare the outcomes with those who had intact intertwin membrane.

Methods: Databases such as PubMed, Web of Science, Scopus, and Embase were systematically searched from inception up to August 2020. The random-effects model was used to pool the mean difference (MD) or odds-ratio (OR) with the corresponding 95% confidence intervals (CIs). Primary outcome was incidence of preterm delivery, and preterm premature rupture of membranes (PPROM), while secondary outcomes included gestational age (GA) at intervention, GA at delivery, neonatal survival, and incidence of pseudoamniotic band syndrome (PABS).

Results: Four studies (1442 patients) met our inclusion criteria. Postoperative identification of IS was associated with earlier GA at delivery (MD = -2.52; 95% CI: -3.22, -1.82; p < 0.00), higher risk of PPROM < 32 weeks (OR = 2.82; 95% CI: 1.80, 4.40; p < 0.001), and preterm delivery < 32 weeks (OR = 4.01; 95% CI: 1.27, 12.63; p = 0.02). No differences were noted in pseudoamniotic band syndrome, at least one or dual neonatal survival rate between IS and non-IS groups.

Conclusions: Occurrence of IS after laser photocoagulation for TTTS is associated with earlier GA at delivery, increased risk for PPROM and preterm delivery <32 weeks' gestation. However, neonatal survival does not appear to be affected by this complication.
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http://dx.doi.org/10.1002/pd.5935DOI Listing
March 2021

Cost-effective fetal lung volumetry for assessment of congenital diaphragmatic hernia.

Eur J Obstet Gynecol Reprod Biol 2021 May 3;260:22-28. Epub 2021 Mar 3.

Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA. Electronic address:

Objectives: (1) To investigate the reproducibility of total fetal lung volume (TFLV) measurements using a free 3D modeling software (3DSlicer); (2) To correlate these measurements with lung-to-head ratio (LHR) or TFLV measured using PACS and; (3) To determine the role of 3DSlicer in predicting perinatal outcomes in cases with congenital diaphragmatic hernia (CDH) who had fetal tracheal occlusion (FETO).

Methods: Retrospective cohort study between 2012 and 2017 at Texas Children's Hospital (2011-2017), including all patients who underwent FETO for CDH. LHR was measured by ultrasound and TFLV was measured by MRI at the time of referral and 6 weeks after FETO using 3DSlicer and PACS. We evaluated intra- and inter-rater reliability of TFLV measurement using 3DSlicer, infant survival to 1 year, need for ECMO and pulmonary hypertension.

Results: The intra- and inter-rater reliability of TFLV measured with 3DSlicer was excellent before and after FETO (Intra-class correlation coefficient: 0.98-0.99 and 0.94-0.99, respectively). There was a good correlation between TFLV measured with PACS and with 3DSlicer before and after FETO (r = 0.78 and r = 0.99, respectively). Similarly, there was a good correlation between TFLV measurements using PACS or 3DSlicer and LHR after FETO (r = 0.86 and r = 0.88, respectively). Infants who survived to 1 year had a significantly higher TFLV evaluated with 3DSlicer before FETO compared to non-surviving infants (OR = 1.16[1.1-1.3], p = 0.03) as well as a significantly higher TFLV evaluated by 3DSlicer after FETO (OR = 1.2[1-1.4], p = 0.04).

Conclusion: Lung volume measurements using free 3DSlicer in infants with severe CDH who underwent FETO are reproducible and reliable, and have comparable predictive capability for survival as those measured using conventional software.
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http://dx.doi.org/10.1016/j.ejogrb.2021.02.025DOI Listing
May 2021

Selection of candidates for foetal intervention in congenital lower urinary tract obstruction.

Curr Opin Obstet Gynecol 2021 Apr;33(2):123-128

Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas.

Purpose Of Review: Congenital lower urinary tract obstruction (LUTO) is a rare group of conditions characterized by high perinatal morbidity and mortality if associated with oligohydramnios or anhydramnios in early pregnancy. Although foetal intervention has the potential to improve perinatal survival in a select group of foetuses with LUTO, the actual selection of those candidates most likely to benefit from intervention remains challenging.

Recent Findings: Foetuses with LUTO who are potential candidates for prenatal intervention should undergo detailed multidisciplinary evaluation to ensure proper assessment and counselling. Using a combination of multiple ultrasound-based renal parameters, including measurement of foetal bladder volumes before and after vesicocentesis and kidney size and morphology, combined with repeated foetal urine biochemistry may allow for better selection than any single test.

Summary: Foetal intervention should be offered to women carrying a foetus with LUTO only after appropriate evaluation and counselling. A combined approach utilizing ultrasound and biochemical measurements of foetal renal function appears best. Research focusing on the development of more accurate markers is needed.
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http://dx.doi.org/10.1097/GCO.0000000000000693DOI Listing
April 2021

Magnesium sulfate titration reduces maternal complications following fetoscopic closure of spina bifida.

Prenat Diagn 2021 Feb 16. Epub 2021 Feb 16.

Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA.

Objective: To evaluate if magnesium sulfate (MgSO ) titration following fetoscopic spina bifida closure is associated with fewer maternal complications than the Management of Myelomeningocele Study (MOMS) tocolytic regimen.

Methods: This prospective cohort study included 73 consecutive patients undergoing fetoscopic closure of spina bifida between 2015 and 2020. A policy of using the MgSO regimen per the MOMS trial was changed to a flexible one in which MgSO was titrated according to the frequency of the uterine contractions following surgery. The frequency of maternal pulmonary edema, low maternal oxygen saturation requiring oxygen supplementation, atelectasis, hypocalcemia, and preterm delivery was compared before and after the policy was changed.

Results: A higher proportion of women in the group that used the MOMS MgSO regimen had pulmonary edema compared to those in the flexible one (26.1% [6/23] vs. 6% [3/50]; p = 0.024). Multivariate analysis showed that the MOMS tocolytic regimen was independently associated with a higher risk of pulmonary edema (adjusted odds ratio: 8.57; 95% confidence interval: 1.54-47.7; p = 0.014) than a flexible one. There was no difference in the rate of preterm delivery.

Conclusion: Following fetoscopic closure of spina bifida, the MOMS MgSO regimen is associated with an increased risk of pulmonary edema than a more flexible regimen.
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http://dx.doi.org/10.1002/pd.5923DOI Listing
February 2021

Massive Extra-Abdominal Umbilical Vein Varix: A Case Report.

Fetal Diagn Ther 2021 20;48(2):158-162. Epub 2021 Jan 20.

Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital-Pavilion for Women, Houston, Texas, USA,

Umbilical vein varices are rare umbilical cord anomalies that typically occur intra-abdominally. Extra-abdominal umbilical vein varices are exceedingly rare and usually diagnosed postnatally on gross pathologic examination. Umbilical vein varices have been associated with increased risk of fetal anemia, cardiac abnormalities, and intrauterine fetal demise. This case report discusses a patient who presented with a massive extra-abdominal umbilical vein varix, whose infant was ultimately delivered due to fetal distress and died in the neonatal period. This report also discusses associated fetal conditions and guidelines for antenatal testing and surveillance of known umbilical vein varices.
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http://dx.doi.org/10.1159/000512490DOI Listing
January 2021

Inter-twin differences in fetal echocardiographic findings are associated with decreased dual twin survival in twin-twin transfusion syndrome.

J Matern Fetal Neonatal Med 2021 Jan 17:1-7. Epub 2021 Jan 17.

Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital-Pavilion for Women, Houston, TX, USA.

Objective: To determine if inter-twin differences in fetal echocardiographic findings are associated with fetal survival in monochorionic pregnancies complicated by twin-to-twin transfusion syndrome (TTTS).

Methods: This study included women who underwent laser surgery for TTTS between 2012 and 2018 at a single institution. Echocardiographic cardiac parameters in the donor and recipient twins were compared using -scores and regression analyses (adjusted for confounding variables) to determine whether any measurable inter-twin differences were associated with neonatal survival at birth. Results are expressed as (Odds ratio [95% confidence interval], -value).

Results: Fetal echocardiography and delivery information was available in 124 TTTS cases. Dual live-birth occurred in 72% and at least one live-birth was seen in 89% of cases. Sixty-four percent (51/79) of recipient twins had evidence of cardiac dysfunction compared to 10% (8/79) of the donor twins ( < .01). In the logistic regression, inter-twin differences in left ventricle short axis dimension (0.62[0.44-0.87],  < .01), aortic valve diameter (0.67[0.45-0.99],  = .047), peak systolic velocity across the pulmonary artery (PA-PSV) (0.09[0.01-0.53],  < .01) and mitral valve diameter (0.56[0.38-0.84],  < .01) were associated with lower dual twin survival at birth.

Conclusion: Inter-twin differences in left cardiac geometry and function are associated with decreased survival at delivery in TTTS.
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http://dx.doi.org/10.1080/14767058.2021.1873268DOI Listing
January 2021

Perinatal characteristics and early childhood follow up after ex-utero intrapartum treatment for head and neck teratomas by prenatal diagnosis.

Prenat Diagn 2021 Mar 9;41(4):497-504. Epub 2021 Feb 9.

Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.

Background: Ex utero intrapartum treatment (EXIT) is utilized for safe delivery when a baby has a compromised airway. The purpose of this retrospective study was to examine the indications and outcomes of 11 children presenting with airway occluding oropharyngeal and cervical teratomas.

Methods: Study of all children with an airway occluding teratoma delivered via EXIT (2001-2018) in our unit. Primary outcomes included survival and tracheostomy at discharge. Data are reported using descriptive statistics as median (range) and rate (%).

Results: We performed 45 EXIT procedure performed between January 2001 and April 2018. Of these, eleven were for cervical and/or upper airway teratoma. Ten (91%) cases had associated polyhydramnios, two (18%) developed nonimmune hydrops, and eight (72%) delivered preterm. Six (45.5%) were performed as an emergency. Estimated blood loss was 1000 ml (500, 1000). The neonatal mortality rate was 18% (2/11) and 33% (3/9) of the survivors were discharged with a tracheostomy.

Conclusion: EXIT is a reasonable option for delivery of babies with an occlusive upper airway mass. Neonatal survival depends on individualized factors but may be as high as 82% in those with teratoma.
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http://dx.doi.org/10.1002/pd.5894DOI Listing
March 2021

Amniotic fluid embolism syndrome: analysis of the Unites States International Registry.

Am J Obstet Gynecol MFM 2020 05 9;2(2):100083. Epub 2020 Jan 9.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX.

Background: Incidence, risk factors, and perinatal morbidity and mortality rates related to amniotic fluid embolism remain a challenge to evaluate, given the presence of differing international diagnostic criteria, the lack of a gold standard diagnostic test, and a significant overlap with other causes of obstetric morbidity and mortality.

Objective: The aims of this study were (1) to analyze the clinical features and outcomes of women using the largest United States-based contemporary international amniotic fluid embolism registry, and (2) to investigate differences in demographic and obstetric variables, clinical presentation, and outcomes between women with typical versus atypical amniotic fluid embolism, using previously published and validated criteria for the research reporting of amniotic fluid embolism.

Materials And Methods: The AFE Registry is an international database established at Baylor College of Medicine (Houston, TX) in partnership with the Amniotic Fluid Embolism Foundation (Vista, CA) and the Perinatology Research Branch of the Division of Intramural Research of the NICHD/NIH/DHHS (Detroit, MI). Charts submitted to the registry between August 2013 and September 2017 were reviewed, and cases were categorized into typical, atypical, non-amniotic fluid embolism, and indeterminate, using the previously published and validated criteria for the research reporting of AFE. Demographic and clinical variables, as well as outcomes for patients with typical and atypical AFE, were recorded and compared. Student t tests, χ tests, and analysis of variance tables were used to compare the groups, as appropriate, using SAS/STAT software, version 9.4.

Results: A total of 129 charts were available for review. Of these, 46% (59/129) represented typical amniotic fluid embolism and 12% (15/129) atypical amniotic fluid embolism, 21% (27/129) were non-amniotic fluid embolism cases with a clear alternative diagnosis, and 22% (28/129) had an uncertain diagnosis. Of the 27 women misclassified as an amniotic fluid embolism with an alternative diagnosis, the most common actual diagnosis was hypovolemic shock secondary to postpartum hemorrhage. Ten percent (6/59) of the women with typical amniotic fluid embolism had a pregnancy complicated by placenta previa, and 8% (5/61) had undergone in vitro fertilization to achieve pregnancy. In all, 66% (49/74) of the women with amniotic fluid embolism reported a history of atopy or latex, medication, or food allergy, compared to 34% of the obstetric population delivered at our hospital over the study period (P < .05).

Conclusion: Our data represent a series of women with amniotic fluid embolism whose diagnosis has been validated by detailed chart review, using recently published and validated criteria for research reporting of amniotic fluid embolism. Although no definitive risk factors were identified, a high rate of placenta previa, reported allergy, and conceptions achieved through in vitro fertilization was observed.
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http://dx.doi.org/10.1016/j.ajogmf.2019.100083DOI Listing
May 2020

EXIT ( Intrapartum Treatment) to Airway Procedure for Twin Fetuses With Oropharyngeal Teratomas: Lessons Learned.

Front Surg 2020 26;7:598121. Epub 2020 Oct 26.

Texas Children's Hospital, Houston, TX, United States.

intrapartum treatment (EXIT) to airway has been described as a safe method to secure challenging fetal airways while on placental support. Herein, we present a unique case of a monochorionic-diamniotic twin pregnancy where both fetuses presented with oropharyngeal tumors requiring airway securement on placental bypass. A multidisciplinary tabletop simulation was convened to allow for personnel coordination between multiple services, OR equipment allocation, and preparation for a range of possible clinical scenarios. A tabletop simulation was chosen for planning since this is a simulation methodology commonly used for preparation in acute, high intensity multidisciplinary situations such as disaster preparation, and allows for exploration of multiple potential scenarios when outcomes are uncertain. The twins were urgently delivered for decreased fetal movement and decelerations in Twin B at 28 weeks 6 days. Twin A was delivered EXIT to airway while Twin B had debulking of the tumor on placental support, with subsequent airway securement through a tracheostomy. In conclusion, for complex fetal procedures, detailed pre-operative planning with tabletop simulation may be a useful tool in achieving successful patient outcomes.
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http://dx.doi.org/10.3389/fsurg.2020.598121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649142PMC
October 2020

Accuracy of Ultrasound to Predict Neonatal Birth Weight Among Fetuses With Gastroschisis: Impact on Timing of Delivery.

J Ultrasound Med 2020 Oct 1. Epub 2020 Oct 1.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, and Texas Children's Hospital Fetal Center, Houston, Texas, USA.

Objectives: To determine the accuracy of ultrasound estimation of fetal weight among fetuses with gastroschisis and how the diagnosis of fetal growth restriction (FGR) affects the timing of delivery.

Methods: This was a retrospective cohort study including all fetuses with a diagnosis of gastroschisis at our institution from November 2012 through October 2017. We excluded multiple gestations, pregnancies with major structural or chromosomal abnormalities, and those for which prenatal and postnatal follow-up were unavailable. Performance characteristics of ultrasound to predict being small for gestational age (SGA) were calculated for the first and last ultrasound estimations of fetal weight.

Results: Our cohort included 75 cases of gastroschisis. At the initial ultrasound estimation, 15 of 58 (25.9%) fetuses met criteria for FGR; 48 of 70 (68.6%) met criteria at the time of the last ultrasound estimation (median, 34.7 weeks). Cesarean delivery was performed for 37 of 75 (49.3%), with FGR and concern for fetal distress as the indication for delivery in 17 of 37 (45.9%). Only 6 of 17 (35.3%) of the neonates born by cesarean delivery for an indication of FGR and fetal distress were SGA. The initial ultrasound designation of FGR corresponded to SGA at birth in 8 of 15 (53.3%), whereas the last ultrasound estimation corresponded to SGA in 17 of 48 (35.4%). The initial ultrasound estimation agreed with the last ultrasound estimation before delivery with the diagnosis of FGR in 13 of 15 (86.7%).

Conclusions: Ultrasound in the third trimester was sensitive but had a low positive predictive value and low accuracy for the diagnosis of SGA at birth for fetuses with gastroschisis. A large proportion of fetuses were born by cesarean delivery with indications related to FGR or fetal concerns.
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http://dx.doi.org/10.1002/jum.15519DOI Listing
October 2020

Circumferential amniotic band around the lower fetal abdomen associated with complete spontaneous chorioamniotic separation.

Am J Obstet Gynecol 2021 03 14;224(3):312-313. Epub 2020 Aug 14.

Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX.

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http://dx.doi.org/10.1016/j.ajog.2020.08.031DOI Listing
March 2021

Placenta Accreta Spectrum Without Placenta Previa.

Obstet Gynecol 2020 09;136(3):458-465

Harvard Medical School, Boston, Massachusetts; Baylor College of Medicine, Houston, Texas; Stanford University, Stanford, California; University of Utah, Salt Lake City, Utah; and the Pan-American Society for Placenta Accreta Spectrum, Houston, Texas.

Objective: To evaluate placenta accreta spectrum with and without placenta previa with regard to risk factors, antepartum diagnosis, and maternal morbidity.

Methods: We conducted a retrospective cohort study of pathology-confirmed placenta accreta spectrum deliveries with hysterectomy from two U.S. referral centers from January 2010-June 2019. Maternal, pregnancy, and delivery characteristics were compared among placenta accreta spectrum cases with (previa PAS group) and without (nonprevia PAS group) placenta previa. Surgical outcomes and a composite of severe maternal morbidities were evaluated, including eight or more blood cell units transfused, reoperation, pulmonary edema, acute kidney injury, thromboembolism, or death. Logistic regression was used with all analyses controlled for delivery location.

Results: Of 351 deliveries, 106 (30%) had no placenta previa at delivery. When compared with the previa group, nonprevia placenta accreta spectrum was less likely to be identified antepartum (38%, 95% CI 28-48% vs 87%, 82-91%), less likely to receive care from a multidisciplinary team (41%, 31-51% vs 86%, 81-90%), and less likely to have invasive placenta increta or percreta (51% 41-61% vs 80%, 74-84%). The nonprevia group had more operative hysteroscopy (24%, 16-33% vs 6%, 3-9%) or in vitro fertilization (31%, 22-41% vs 9%, 6-13%) and was less likely to have had a prior cesarean delivery (64%, 54-73% vs 93%, 89-96%) compared with the previa group, though the majority in each group had a prior cesarean delivery. Rates of severe maternal morbidity were similar in the two groups, at 19% (nonprevia) and 20% (previa), even after controlling for confounders (adjusted odds ratio for the nonprevia group 0.59, 95% CI 0.30-1.17).

Conclusion: Placenta accreta spectrum without previa is less likely to be diagnosed antepartum, potentially missing the opportunity for multidisciplinary team management. Despite the absence of placenta previa and less placental invasion, severe maternal morbidity at delivery was not lower. Broader recognition of patients at risk for placenta accreta spectrum may improve early clinical diagnosis and patient outcomes.
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http://dx.doi.org/10.1097/AOG.0000000000003970DOI Listing
September 2020

Repair of a large uterine dehiscence during the second trimester leading to successful prolongation of the pregnancy.

Am J Obstet Gynecol 2020 12 23;223(6):929-932. Epub 2020 Jul 23.

Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX.

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http://dx.doi.org/10.1016/j.ajog.2020.07.037DOI Listing
December 2020

Umbilical Artery Doppler Patterns and Right Ventricular Outflow Abnormalities in Twin-Twin Transfusion Syndrome.

J Ultrasound Med 2021 Jan 10;40(1):71-78. Epub 2020 Jul 10.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA.

Objectives: To evaluate the association of abnormal Doppler velocimetric patterns in the umbilical arteries (UAs) and right ventricular outflow tract abnormalities (RVOTAs) in twin- twin transfusion syndrome (TTTS) cases.

Methods: This retrospective study involved women who had laser surgery for TTTS between January 2012 and May 2018 at a single institution. The prevalence of an RVOTA in either twin was compared among TTTS cases in which both twins had positive end-diastolic flow (EDF) in the UA and those in which either twin had intermittent or persistent absent/reversed UA EDF. Nonparametric tests were used for comparisons. Logistic regression was performed to identify variables associated with an RVOTA in either twin, adjusted for moderate or severe tricuspid regurgitation, right ventricular hypertrophy, right ventricular systolic or diastolic dysfunction, the Quintero stage, and other confounders. P < .05 was considered significant.

Results: A total of 126 consecutive TTTS cases were included. Right ventricular outflow tract abnormalities were seen in 8.7% (11of 126) of cases, all in recipient twins. Significant differences in the rate of RVOTAs in the recipient twin were seen between TTTS cases with intermittent absent/reversed UA EDF and those with positive UA EDF (26.9% [7 of 26] versus 3.7% [3 of 82]; P = .002]. However, no significant differences were noted among the other study groups. Intermittent absent/reversed UA EDF was associated with a significantly increased risk for an RVOTA (adjusted odds ratio, 20.6 [95% confidence interval, 3.1-138]; P = .002) after adjusting for confounders.

Conclusions: Intermittent changes in vascular impedance to UA flow may contribute to the pathogenesis of acquired right-sided cardiac lesions in the recipient twin affected with TTTS.
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http://dx.doi.org/10.1002/jum.15377DOI Listing
January 2021

Prenatal Imaging to Predict Need for Urgent Perinatal Surgery in Congenital Lung Lesions.

J Surg Res 2020 11 1;255:463-468. Epub 2020 Jul 1.

Division of Pediatric Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas.

Background: Congenital lung malformations (CLMs) have a variable natural history: some patients require urgent perinatal surgical intervention (UPSI) and others remain asymptomatic. These lesions have potential growth until 26-28 wk gestation. CLM volume ratio (CVR) has been shown to predict the risk of hydrops in CLMs. However, no criteria exist to delineate lesions requiring urgent surgical intervention in the perinatal period. Our goal was to determine prenatal diagnostic features that predict the need for UPSI in patients diagnosed with CLM.

Methods: Records and imaging features of all fetuses evaluated by our fetal center between May 2015 and December 2018 were retrospectively reviewed. Data included demographics, fetal ultrasound and magnetic resonance imaging, CVR, surgical treatment, and outcome. Features were analyzed for their ability to predict the need for UPSI.

Results: Sixty-four patients were referred for CLM, with 48 patients serially followed. Nine (18.8%) patients were followed nonoperatively, 35 (72.9%) underwent resection, and four (8.3%) were lost to follow-up. Of the patients who underwent resection, 24 (68.5%) were electively resected and 11 were urgently resected. Five (14.3%) patients underwent ex utero intrapartum treatment resection, and six (17.1%) were urgently resected for symptomatic CLM. There were no cases of UPSI with final CVR <1.1. Of the patients with final CVR 1.1-1.7, 43% required urgent resection. CVR ≥1.1 has 100% sensitivity and 87.8% specificity to predict patients requiring UPSI (area under the curve of 0.98).

Conclusions: A final CVR ≥1.1 is highly predictive for UPSI. Patients with a final CVR ≥1.1 should be referred for delivery at centers with pediatric surgeons equipped for potential UPSI for CLM.
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http://dx.doi.org/10.1016/j.jss.2020.06.001DOI Listing
November 2020

Intravenous labetalol versus oral nifedipine for acute hypertension in pregnancy: effects on cerebral perfusion pressure.

Am J Obstet Gynecol 2020 09 13;223(3):441.e1-441.e8. Epub 2020 Jun 13.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX.

Background: Pregnant women with preeclampsia have been found to have elevated cerebral perfusion pressure and impaired cerebral autoregulation compared with normal pregnant women. Transcranial Doppler is a noninvasive technique used to estimate cerebral perfusion pressure. The effects of different antihypertensive medications on cerebral perfusion pressure in preeclampsia are unknown.

Objective: To compare the change in cerebral perfusion pressure before and after intravenous labetalol vs oral nifedipine in the setting of acute severe hypertension in pregnancy.

Study Design: This is a prospective cohort study of pregnant women between 24 and 42 weeks' gestation with severe hypertension (systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥110 mm Hg). Women who consented to the study and received either intravenous labetalol or oral nifedipine were included. Exclusion criteria included active labor or receipt of any antihypertensive medication within 2 hours of initial cerebral perfusion pressure measurement. Peripheral blood pressure and transcranial Doppler studies for middle cerebral artery hemodynamics were performed prior to the administration of antihypertensive medications and repeated 30 minutes after medication administration.

Results: A total of 16 women with acute severe hypertension were enrolled; 8 received intravenous labetalol and 8 received oral nifedipine. There were no significant differences between the labetalol and nifedipine groups in baseline characteristics such as maternal age, race and ethnicity, payment, hospital site, body mass index, nulliparity, gestational age, preexisting diabetes mellitus or chronic hypertension, fetal growth restriction, magnesium sulfate administration, and symptomatology (P>.05). When examined 30 minutes after the administration of either intravenous labetalol or oral nifedipine, there was a significantly greater decrease in systolic blood pressure (-9.8 mm Hg vs -39 mm Hg; P=.003), mean arterial pressure (-7.1 mm Hg vs -22.3 mm Hg; P=.02), and cerebral perfusion pressure (-2.5 mm Hg vs -27.7 mm Hg; P=.01) in the nifedipine group. There was no statistically significant decrease in diastolic blood pressure (-12.9 mm Hg vs -5.4 mm Hg; P=.15). The change in middle cerebral artery velocity by transcranial Doppler was compared between the groups and was not different (0.07 cm/s vs 0.16 cm/s; P=.64).

Conclusion: Oral nifedipine resulted in a significant decrease in cerebral perfusion pressure, whereas labetalol did not, after administration for acute severe hypertension among women with preeclampsia. This decrease seems to be driven by a decrease in peripheral arterial blood pressure rather than a direct change in cerebral blood flow.
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http://dx.doi.org/10.1016/j.ajog.2020.06.018DOI Listing
September 2020

Outcomes of prenatally diagnosed spontaneous chorioamniotic membrane separation in singleton pregnancies: A systematic review of case series and case reports.

Prenat Diagn 2020 10 12;40(11):1366-1374. Epub 2020 Aug 12.

Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, Texas, USA.

Objectives: To provide an overview of perinatal outcomes in prenatally diagnosed spontaneous chorioamniotic separation (sCAS).

Methods: A systematic search of the literature was performed from inception to July 2019, including PubMed, Ovid MEDLINE, and Ovid EMBASE. All studies reporting prenatally diagnosed sCAS after 16 weeks' gestation in singleton pregnancies were eligible. Two independent reviewers used standardized forms for data abstraction.

Results: Of 408 screened abstracts, 17 studies reporting 118 cases of sCAS were included. Among 113 cases with delivery outcomes, preterm birth (PTB) occurred in 60 (53.1%, 95% confidence interval [CI] 43.9-62.3%). Intrauterine fetal demise (IUFD) occurred in seven (6.2%, 95% CI 1.8-10.6%) cases, with four due to cord strangulation. Spontaneous abortion occurred in one (0.88%, 95% CI -0.84-2.6%) case. Among 104 cases with postnatal follow-up, there were six (5.8%, 95% CI 1.3-10.3%) neonatal deaths and one (0.96%, 95% CI -0.91-2.8%) infant death. Perinatal mortality (IUFD and neonatal deaths) was 11.0% (95% CI 5.4-16.7%).

Conclusions: sCAS may be associated with increased risk of PTB, however, the available data are largely case reports and series. Antepartum surveillance after viability can be considered due to risk of cord accidents. Prospective study is necessary to understand the clinical implications of sCAS.
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http://dx.doi.org/10.1002/pd.5767DOI Listing
October 2020

In vitro fertilization as an independent risk factor for placenta accreta spectrum.

Am J Obstet Gynecol 2020 10 30;223(4):568.e1-568.e5. Epub 2020 Apr 30.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX. Electronic address:

Background: Placenta accreta spectrum is well known for its association with catastrophic maternal outcomes. However, its pathophysiology is not well defined. There have been emerging data that in vitro fertilization may be a risk factor for placenta accreta spectrum.

Objective: We investigated the hypothesis that in vitro fertilization is an independent risk factor for placenta accreta spectrum.

Study Design: A retrospective analysis of all deliveries in a prospective, population-based cohort (2012-2019) was performed in a tertiary academic center. Primary outcome variable was placenta accreta spectrum. Univariate analysis was performed on potential risk factors for predicting placenta accreta spectrum, and a multivariate model was designed to best fit the prediction of placenta accreta spectrum adjusted for risk factors such as cesarean delivery, placenta previa, age, and parity. History of previous cesarean delivery was known as a risk factor for both placenta previa and placenta accreta spectrum; hence, the interaction between "placenta previa" and "previous cesarean delivery" was included in the final model. Odds ratios were calculated as exponential of beta coefficients from the multivariate regression analysis.

Results: A total of 37,461 deliveries were included in this analysis, 5464 (15%) of which had a history of cesarean delivery, 281 (0.7%) had placenta previa in their index pregnancy, and 571 (1.5%) had in vitro fertilization pregnancy. The frequency of placenta accreta spectrum was 230 (0.6%). Independent risk factors for placenta accreta spectrum were in vitro fertilization pregnancy (adjusted odds ratio, 8.7; 95% confidence interval, 3.8-20.3), history of previous cesarean delivery (adjusted odds ratio, 21.1; 95% confidence interval, 11.4-39.2), and presence of placenta previa (adjusted odds ratio, 94.6; 95% confidence interval, 29.3-305.1). After adjustment for number of previous cesarean deliveries, the correlation persisted for in vitro fertilization (adjusted odds ratio, 6.7; 95% confidence interval, 2.9-15.6).

Conclusion: Our data suggested that in vitro fertilization is an independent risk factor for placenta accreta spectrum, although its relative clinical importance compared with that of the presence of placenta previa and history of cesarean delivery is small. The pathophysiology behind this relationship remains to be investigated.
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http://dx.doi.org/10.1016/j.ajog.2020.04.026DOI Listing
October 2020

Population-Based Estimation of the Preterm Birth Rate in Lilongwe, Malawi: Making Every Birth Count.

AJP Rep 2020 Jan 9;10(1):e78-e86. Epub 2020 Mar 9.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.

 The objective of this study was to perform a population-based estimation of the preterm birth (PTB) rate in regions surrounding Lilongwe, Malawi.  We partnered with obstetrician specialists, community health workers, local midwives, and clinicians in a 50 km region surrounding Lilongwe, Malawi, to perform a population-based estimation of the PTB rate during the study period from December 1, 2012 to May 19, 2015.  Of the 14,792 births captured, 19.3% of births were preterm, including preterm early neonatal deaths. Additional PTB risk factors were similarly prevalent including domestic violence, HIV, malaria, anemia, and malnutrition.  When performing a population-based estimation of the rate of PTB, including women without antenatal care and women delivering at home, the 19.3% rate of PTB is among the highest recorded globally. This is accompanied by a high rate of risk factors and comorbid conditions.
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http://dx.doi.org/10.1055/s-0040-1708491DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7062552PMC
January 2020

Prenatal counseling for myelomeningocele in the era of fetal surgery: a shared decision-making approach.

J Neurosurg Pediatr 2020 Feb 28:1-8. Epub 2020 Feb 28.

1Division of Pediatric Neurosurgery.

Objective: The Management of Myelomeningocele Study demonstrated that fetal surgery, as compared to postnatal repair, decreases the rate of hydrocephalus and improves expected motor function. However, fetal surgery is associated with significant maternal and neonatal risks including uterine wall dehiscence, prematurity, and fetal or neonatal death. The goal of this study was to provide information about counseling expectant mothers regarding myelomeningocele in the era of fetal surgery.

Methods: The authors conducted an extensive review of topics pertinent to counseling in the setting of myelomeningocele and introduce a new model for shared decision-making to aid practitioners during counseling.

Results: Expectant mothers must decide in a timely manner among several potential options, namely termination of pregnancy, postnatal surgery, or fetal surgery. Multiple factors influence the decision, including maternal health, fetal heath, financial resources, social support, risk aversion, access to care, family planning, and values. In many cases, it is a difficult decision that benefits from the guidance of a pediatric neurosurgeon.

Conclusions: The authors review critical issues of prenatal counseling for myelomeningocele and discuss the process of shared decision-making as a framework to aid expectant mothers in choosing the treatment option best for them.
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http://dx.doi.org/10.3171/2019.12.PEDS19449DOI Listing
February 2020

New approaches to congenital diaphragmatic hernia.

Curr Opin Obstet Gynecol 2020 04;32(2):121-127

Fetal Surgery Department of Obstetrics and Gynecology.

Purpose Of Review: Congenital diaphragmatic hernia (CDH) is a structural birth defect that results in significant neonatal morbidity and mortality. CDH occurs in 2-4 per 10 000 pregnancies, and despite meaningful advances in neonatal intensive care, the mortality rate in infants with isolated CDH is still 25-30%. In this review, we will present data on the molecular underpinnings of pathological lung development in CDH, prenatal diagnosis, and prognostication in CDH cases, existing fetal therapy modalities, and future directions.

Recent Findings: Developments in the prenatal assessment and in-utero therapy of pregnancies complicated by congenital diaphragmatic hernia are rapidly evolving. Although ultrasound has been the mainstay of prenatal diagnosis, fetal MRI appears to be an increasingly important modality for severity classification. While fetal endoscopic tracheal occlusion (FETO) may have a role in the prenatal management of severe CDH cases, it is possible that future therapeutic paradigms will incorporate adjunct medical interventions with either stem cells or sildenafil in order to address the vascular effects of CDH on the developing lung.

Summary: Both animal and human data have shown that the pathophysiological underpinnings of CDH are multifactorial, and it appears that future prenatal assessments and therapies will likely be as well.
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http://dx.doi.org/10.1097/GCO.0000000000000615DOI Listing
April 2020

Evidence based medicine - decades later.

J Matern Fetal Neonatal Med 2020 Feb 2:1-4. Epub 2020 Feb 2.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA.

After more than two decades of enthusiasm surrounding the concept of evidence based medicine, wide variation in its implementation is still present. Some have suggested that evidence based medicine may be a failed model. We propose that the highly formulaic approach of evidence based medicine has evolved toward a more personalized, integrated and contextualized method, consistent with the principle of shared decision making advanced by the Institute of Medicine. Evidence based medicine remains an essential prerequisite but ultimately, only the practitioner's clinical expertise, knowledge and practical wisdom will provide the ability to apply general rules of evidence to particular clinical situations.
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http://dx.doi.org/10.1080/14767058.2020.1722997DOI Listing
February 2020

Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020.

Am J Obstet Gynecol 2020 09 30;223(3):322-329. Epub 2020 Jan 30.

Maternal-Fetal Medicine Division, Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, TX.

The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless, a subset of women has the most severe form of placenta accreta spectrum, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infrarenal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe placenta accreta spectrum disorder.
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http://dx.doi.org/10.1016/j.ajog.2020.01.044DOI Listing
September 2020