Prenatal Counseling for Maternal–Fetal Surgery

This chapter analyzes potential biases and competing interests in prenatal counseling when conditions are diagnosed for which intrauterine surgery may be possible. Such counseling often occurs at the multidimensional interface of obstetrics and pediatrics. After considering clinical, social, and historical contexts of such counseling, the chapter presents a case that illustrates how physician demographics, interspecialty differences, divergent clinical experiences, and larger organizational factors may compound practice variation. It considers how biased counseling may influence patients’ decisions and questions whether value-neutral counseling is attainable when such fetal conditions are diagnosed. It concludes that declared commitments to value neutrality cannot insulate pregnant patients from biases and competing interests. In its recommendations, it discusses organizational responses analogous to conflict-of-interest policies. It further suggests that conversations between clinicians and patients that are mutually open about values may enhance rather than undermine patients’ ability to formulate decisions that most closely embody their true preferences.

Efficacy of Applying Hyaluronic Acid Gels in the Primary Prevention of Intrauterine Adhesion after Hysteroscopic Myomectomy: A Meta-Analysis of Randomized Controlled Trials

Intrauterine adhesion (IUA), which mainly occurs after intrauterine surgery or an inflammatory process, is an important but often neglected condition in women of reproductive age. The presentation of IUA varies greatly, ranging from symptom-free to severe, with amenorrhea or infertility. With much advanced development of intrauterine instruments, more intrauterine diseases can be successfully cured by hysteroscopic surgery. Among these, submucosal myoma is one of the best examples. Submucosal myomas are often related to abnormal bleeding, anemia, and possible infertility or miscarriage. However, submucosal myoma after hysteroscopic myomectomy may be complicated by IUA in various grades of severity, and its incidence and prevalence might be nearly one-quarter to one-third of patients, suggesting an urgent need for efforts to decrease the risk of developing IUA after hysteroscopic myomectomy. Many strategies have been reported to be useful for this purpose, and intrauterine application of anti-adhesive gels, such as polyethylene oxide–sodium carboxymethylcellulose (PEO-NaCMC) or auto-crosslinked hyaluronic acid (ACHA), has become increasingly popular in routine clinical practice. This meta-analysis is aimed at investigating the effect of ACHA on the primary prevention of IUA formation after hysteroscopic myomectomy. A pooled analysis of three studies (hysteroscopic surgeries for fibroids, polyps, and septum) including 242 women showed that using PEO-NaCMC or ACHA gel decreased the IUA rate with an odds ratio (OR) of 0.364 (95% confidence interval (CI) 0.189–0.703, p = 0.03). Pooled analysis of two studies that limited the use of ACHA in 119 women showed that the application of ACHA gel for the primary prevention of IUA in patients after hysteroscopic myomectomy led to a statistically significant reduction of the development of IUA postoperatively (OR 0.285, 95% CI 0.116–0.701, p = 0.006). All of this suggests that the use of ACHA gel in patients after hysteroscopic myomectomy could significantly reduce de novo IUA, although more evidence is needed.

Fetal cardiovascular alterations in twin-to-twin transfusion syndrome

Twin-to-twin transfusion syndrome (TTTS) is the consequence of vascular anastomoses of the shared placenta of monochorionic twin pregnancies. Both circulating inter-twin blood flow and vasoactive mediators imbalance cause hypovolemia in the donor and hypervolemia in the recipient fetus. If left untreated, TTTS has a high perinatal mortality rate and adverse long-term outcomes mainly cardiovascular and neurological. The recipient has cardiovascular changes including atrioventricular valve regurgitation, diastolic dysfunction and pulmonary stenosis/atresia. The maladaptive response to vascular changes determines a constant decreased blood flow in the donor that permanently modifies the arterial structure leading to postnatal alterations in the vascular system. Fetoscopic LASER surgery of placental vascular anastomoses may disrupt the underlying pathophysiology and improves cardiovascular function with normalization of systolic and diastolic function within weeks after treatment. The impact of cardiovascular changes is relevant for the safety of the management of a TTTS case. The improvement of the perinatal survival after intrauterine surgery leads to viable infants with the longer-term sequelae. Therefore accurate quantification of cardiovascular involvement is essential for clinicians for pregnancy management but also for patient counseling about the potential treatment options the outcome.

Alterações neuroanatômicas do encéfalo na malformação Arnold-Chiari II

Objetivo: Descrever as alterações neuroanatômicas do SNC encontradas nos exames de neuroimagem nos pacientes com malformação de Chiari II. Métodos: Trata-se de uma revisão descritiva baseada em artigos provenientes da base de dados BVS, Scielo e PubMed. Foram utilizados artigos compreendidos em um período de 21 anos (entre 1997 e 2016). Os descritores utilizados foram “Chiari II”, “fetal surgery”, “hydrocephalus”, “intrauterine surgery”, “myelomeningocele”, “prenatal”, “symptomatic Chiari II”, “spina bifida” e “spinal dysraphisms”. Resultados: As malformações de Chiari II encontram-se inseridas no espectro de anormalidades congênitas do sistema nervoso central (SNC). É caracterizada por uma deformidade complexa da fossa posterior associada quase sempre a uma malformação da coluna vertebral. As alterações encefálicas mais sugestivas dessa patologia são anormalidades cerebelares; deslocamento caudal da ponte, IV ventrículo e bulbo; torção medular; IV ventrículo em formato anormal e hipoplasia da tenda do cerebelo e do teto do mesencéfalo. O diagnóstico pode ser realizado através da ultrassonografia, tomografia computadorizada e ressonância magnética. Considerações finais: A Malformação de Chiari II é uma doença que apresenta quadro clínico e alterações radiológicas complexas e extensas. Mais estudos que considerem as alterações morfológicas são necessários.

Updated Protocol for Management of Placenta Previa

Background: Antepartum hemorrhage complicates 2-5% of pregnancies, whichapproximately one-third are due to placenta previa. Placenta previa is acondition derived to an abnormal implantation of the embryos in thelower uterine segment. In placenta previa hemorrhage is more likely to occur during third trimester,as a consequence of the development of the lower uterine segment and of the dilation of the cervix due to the uterine contractions; alsovaginal examination may lead to an antepartum hemorrhage. Risk factors for the development of placenta previa include prior cesarean delivery, pregnancy termination, intrauterine surgery, smoking, multifetal gestation, increasing parity, maternal age and the rising rates of Cesarean section. Placenta previa is associated with adverse consequences for both mother and children, such as Intra-Uterine Growth Restriction (IUGR), preterm birth, antenatal and intra-partum hemorrhage, maternal blood transfusion and emergency hysterectomy. Placenta previa has been diagnosed increasingly in recent decades, due to mostly to the widespread use of ultrasound (US). Apart from ultrasound a valid imaging modality to study and investigate placenta in antepartum period seems to be magnetic resonance (MR).Careful monitoring of high risk pregnancies is of utmost importance. Avoidance of unnecessary caesarean sections and early week’s pregnancy terminations can minimize the placenta previa. In diagnosed cases, preoperative planning, preoperative decisions and good postoperative management can safe a mother and child.J Shaheed Suhrawardy Med Coll, June 2017, Vol.9(1); 26-30