Fetoscopic Laser Photocoagulation of Feeding Vessels to a Large Placental Chorioangioma following Fetal Deterioration after Amnioreduction

Abstract

Large placental chorioangiomas (>4 cm) can precipitate severe polyhydramnios, fetal anemia, growth restriction, high-output cardiac failure, hydrops, and fetal demise. We report a case of a large chorioangioma that was treated in a stepwise fashion with amnioreduction to ameliorate maternal discomfort, followed by fetoscopic laser ablation of the feeding vessels after rapid evolution of heart failure. Although amnioreduction was helpful in improving maternal symptoms, we suspect that the drop in intrauterine pressure from the amniotic fluid decompression may have resulted in increased tumor perfusion, thereby promoting fetal deterioration due to a ‘steal’ phenomenon. Close scrutiny of the fetal status via ultrasound is required, particularly if amnioreduction is necessary, and definitive treatment should be considered once early signs of heart failure develop. Fetoscopic laser ablation of the feeding vessels is a feasible definitive treatment of a large chorioangioma in cases in which perfusion of the tumor is via a superficial nonterminus umbilical artery. Future reports should describe the anatomy of the blood supply to the chorioangioma, in the hopes that further guidelines for surgical candidacy may be established.

Giant Chorioangiomas: Perinatal Outcomes and Techniques in Fetoscopic Devascularization

“…This is not a benign procedure, however. Amnioreduction in the setting of high cardiac output and possible fetal compromise led to abrupt fetal decompensation and hydrops [10,11,12]. One explanation for this rapid deterioration is that the decrease in intrauterine pressure from amnioreduction results in a sudden expansion of the tumor leading to increased shunting or decreased vascular resistance within the tumor [10].…”

“…One explanation for this rapid deterioration is that the decrease in intrauterine pressure from amnioreduction results in a sudden expansion of the tumor leading to increased shunting or decreased vascular resistance within the tumor [10]. Therefore, amnioreduction should be performed cautiously while following the fetal cardiac status in a serial fashion [11]. Furthermore, devascularization should be considered prior to reduction in this setting [10].…”

“…However, in both cases, preterm labor and neonatal death followed, although a definite association to the procedure is difficult to make. Laser photocoagulation has been reported with the most success in cases using an ultrasound-guided interstitial approach [5,18] or the fetoscope [5,8,11,19,20]. In 1 of the cases of ultrasound guidance alone, revascularization and recurrent HCOS necessitated reapplication of the laser process [18].…”

“…Location of the blood supply with Doppler and direct visualization of the target vessel endoscopically seem to result in the optimal definitive devascularization without additional long-term effects. It should be noted in these previous reports of successful laser photocoagulation, hydrops had yet to appear and the vessels were all small in caliber and superficial [5,11,12,19,20]. Any report of survival statistics should take into account the predefined indications for surgery.…”

Can ultrasound be helpful in selecting optimal management methods for pregnancies complicated by placental non-trophpblastic tumors?

“…Arteriovenous shunt of the blood and fetal hypoxia caused by unoxygenated blood that bypasses the maternal circulation through chorioangioma can cause high cardiac output and secondary fetal cardiomegaly (26) . Ultrasound features of heart failure include enlargement of the heart, decreased contractility and pericardial effusion, increased cardiothoracic ratio and developing fetal hydrops (8, 27) . Coincidental presence of congenital anomalies with placental chorioangioma have been reported (28) .…”