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      Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta‐analysis

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          To establish maternal complication rates for fetoscopic or open fetal surgery.


          We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy.


          One hundred sixty‐six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22‐27.13) for open fetal and 6.2% (95%CI, 4.93‐7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien‐Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24‐5.98) for open fetal and 1.7% (95% CI, 1.19‐2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications.


          Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures.

          Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.


          What's already known about this topic?

          • Fetal surgery, both open and fetoscopic, is now widely performed.

          • Fetoscopy is perceived as safe for the mother, although specific data on maternal complications is lacking.

          • Open fetal surgery is known to cause maternal morbidity, but the exact nature and frequency of complications is not well established across different centres and types of surgery.

          What does this study add?

          • This study estimates the nature and frequency of maternal complications following fetoscopic and open fetal surgery.

          • For open fetal surgery, the severe complication rate (grades III to V according to the Clavien‐Dindo classification of surgical complications) is approximately 4% and minor complication rate is 16%.

          • For fetoscopic fetal surgery, the severe complication rate is approximately 2% and minor complication rate is 4%.

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          Most cited references 174

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          Maternal age and fetal loss: population based register linkage study.

          To estimate the association between maternal age and fetal death (spontaneous abortion, ectopic pregnancy, stillbirth), taking into account a woman's reproductive history. Prospective register linkage study. All women with a reproductive outcome (live birth, stillbirth, spontaneous abortion leading to admission to hospital, induced abortion, ectopic pregnancy, or hydatidiform mole) in Denmark from 1978 to 1992; a total of 634 272 women and 1 221 546 pregnancy outcomes. Age related risk of fetal loss, ectopic pregnancy, and stillbirth, and age related risk of spontaneous abortion stratified according to parity and previous spontaneous abortions. Overall, 13.5% of the pregnancies intended to be carried to term ended with fetal loss. At age 42 years, more than half of such pregnancies resulted in fetal loss. The risk of a spontaneous abortion was 8.9% in women aged 20-24 years and 74.7% in those aged 45 years or more. High maternal age was a significant risk factor for spontaneous abortion irrespective of the number of previous miscarriages, parity, or calendar period. The risk of an ectopic pregnancy and stillbirth also increased with increasing maternal age. Fetal loss is high in women in their late 30s or older, irrespective of reproductive history. This should be taken into consideration in pregnancy planning and counselling.
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            A randomized trial of fetal endoscopic tracheal occlusion for severe fetal congenital diaphragmatic hernia.

            Experimental and clinical data suggest that fetal endoscopic tracheal occlusion to induce lung growth may improve the outcome of severe congenital diaphragmatic hernia. We performed a randomized, controlled trial comparing fetal tracheal occlusion with standard postnatal care. Women carrying fetuses that were between 22 and 27 weeks of gestation and that had severe, left-sided congenital diaphragmatic hernia (liver herniation and a lung-to-head ratio below 1.4), with no other detectable anomalies, were randomly assigned to fetal endoscopic tracheal occlusion or standard care. The primary outcome was survival at the age of 90 days; the secondary outcomes were measures of maternal and neonatal morbidity. Of 28 women who met the entry criteria, 24 agreed to randomization. Enrollment was stopped after 24 patients had been enrolled because of the unexpectedly high survival rate with standard care and the conclusion of the data safety monitoring board that further recruitment would not result in significant differences between the groups. Eight of 11 fetuses (73 percent) in the tracheal-occlusion group and 10 of 13 (77 percent) in the group that received standard care survived to 90 days of age (P=1.00). The severity of the congenital diaphragmatic hernia at randomization, as measured by the lung-to-head ratio, was inversely related to survival in both groups. Premature rupture of the membranes and preterm delivery were more common in the group receiving the intervention than in the group receiving standard care (mean [+/-SD] gestational age at delivery, 30.8+/-2.0 weeks vs. 37.0+/-1.5 weeks; P<0.001). The rates of neonatal morbidity did not differ between the groups. Tracheal occlusion did not improve survival or morbidity rates in this cohort of fetuses with congenital diaphragmatic hernia. Copyright 2003 Massachusetts Medical Society
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              Severe diaphragmatic hernia treated by fetal endoscopic tracheal occlusion.

              To examine operative and perinatal aspects of fetal endoscopic tracheal occlusion (FETO) in congenital diaphragmatic hernia (CDH). This was a multicenter study of singleton pregnancies with CDH treated by FETO. The entry criteria for FETO were severe CDH on the basis of sonographic evidence of intrathoracic herniation of the liver and low lung area to head circumference ratio (LHR) defined as the observed to the expected normal mean for gestation (o/e LHR) equivalent to an LHR of 1 or less. FETO was carried out in 210 cases, including 175 cases with left-sided, 34 right-sided and one with bilateral CDH. In 188 cases the CDH was isolated and in 22 there was an associated defect. FETO was performed at a median gestational age of 27.1 (range, 23.0-33.3) weeks. The first eight cases were done under general anesthesia, but subsequently either regional or local anesthesia was used. The median duration of FETO was 10 (range, 3-93) min. Successful placement of the balloon at the first procedure was achieved in 203 (96.7%) cases. Spontaneous preterm prelabor rupture of membranes (PPROM) occurred in 99 (47.1%) cases at 3-83 (median, 30) days after FETO and within 3 weeks of the procedure in 35 (16.7%) cases. Removal of the balloon was prenatal either by fetoscopy or ultrasound-guided puncture, intrapartum by ex-utero intrapartum treatment, or postnatal either by tracheoscopy or percutaneous puncture. Delivery was at 25.7-41.0 (median, 35.3) weeks and before 34 weeks in 65 (30.9%) cases. In 204 (97.1%) cases the babies were live born and 98 (48.0%) were discharged from the hospital alive. There were 10 deaths directly related to difficulties with removal of the balloon. Significant prediction of survival was provided by the o/e LHR and gestational age at delivery. On the basis of the relationship between survival and o/e LHR in expectantly managed fetuses with CDH, as reported in the antenatal CDH registry, we estimated that in fetuses with left CDH treated with FETO the survival rate increased from 24.1% to 49.1%, and in right CDH survival increased from 0% to 35.3% (P < 0.001). FETO in severe CDH is associated with a high incidence of PPROM and preterm delivery but a substantial improvement in survival.

                Author and article information

                Prenat Diagn
                Prenat. Diagn
                Prenatal Diagnosis
                John Wiley and Sons Inc. (Hoboken )
                27 February 2019
                March 2019
                : 39
                : 4 ( doiID: 10.1002/pd.v39.4 )
                : 251-268
                [ 1 ] Department of Maternal and Fetal Medicine Institute for Women's Health, University College London London UK
                [ 2 ] Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences KU Leuven Leuven Belgium
                [ 3 ] Department of Obstetrics and Gynaecology Mount Sinai Hospital and University of Toronto Toronto Ontario Canada
                [ 4 ] National Institute for Health Research University College London Hospitals Biomedical Research Centre London UK
                [ 5 ] Clinical Department Obstetrics and Gynaecology University Hospitals Leuven Leuven Belgium
                Author notes
                [* ] Correspondence

                Adalina Sacco, Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, 235 Euston Road, London NW1 2BU, UK.

                Email: a.sacco@ 123456ucl.ac.uk

                PD5421 PD-19-0002.R1
                © 2019 The Authors. Prenatal Diagnosis Published by John Wiley & Sons Ltd.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 1, Tables: 6, Pages: 18, Words: 4103
                Funded by: Erasmus + Programme of the European Union
                Award ID: 2013‐0040
                Funded by: Engineering and Physical Sciences Research Council
                Award ID: NS/A000027/1
                Funded by: Wellcome Trust
                Award ID: WT101957
                Custom metadata
                March 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version: mode:remove_FC converted:01.05.2019

                Obstetrics & Gynecology


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