The use of endoscopy in fetal medicine

Abstract

We aimed to review the state of affairs in the field of embryo-fetoscopy as well as its instrumental requirements. Today, endoscopic procedures of limited complexity are easily possible within the amniotic cavity. Embryoscopy is typically done for diagnostic purposes, such as the demonstration of external anomalies very early in pregnancy and/or obtaining embryonic tissues in recurrent miscarriages. Fetoscopy is the direct visualization of the amniotic cavity from the second trimester onwards. Its principal indications are complications of monochorionic twinning and severe congenital diaphragmatic hernia. There is level I evidence that fetoscopic laser surgery for twintwin-transfusion syndrome is superior over amniodrainage. Fetoscopic endoluminal tracheal occlusion is done for severe diaphragmatic hernia. Whether tracheal occlusion yields better outcomes than expectant management during pregnancies is currently being investigated in a randomized trial. There are a number of less common procedures discussed as well. Overall, maternal risks of embryofetoscopy are minimal. The most frequent complication is rupture of the membranes and as a consequence preterm delivery. Fetal surgery seems safe and has, therefore, become a clinical reality. Although the stage of technical experimentation is over, most interventions remain investigational. Inclusion of patients into trials whenever possible should be encouraged, rather than building up casuistic experience.

Technical aspects of fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia

“…In addition to the EuroSTEC (www.eurostec.eu) project for the application of tissue engineering for congenital birth defects, there is also a research line for prenatal intervention for CDH. Engineers of Karl Storz Endoskope (Tuttlingen, Germany) designed instruments in collaboration with clinicians from the FETO Task Force, analogous to what happened earlier in the Eurofetus project [42][43][44]. Some instruments were borrowed from other fetoscopic procedures, but many others had to be purposely designed.…”

“…If not considered possible or safe, this can also be done at the time of delivery, either when still connected to the placenta or, in the worst scenario, on the resuscitation table. Although we initially performed an ex utero intrapartum treatment procedure, we have moved to balloon extraction while still on the umbilical A C B [43], with permission from the publisher. cord during conventional cesarean section under locoregional anesthesia [49].…”

The making of fetal surgery

“…ABS, amniotic band syndrome; CO, cord occlusion; FETO, fetoscopic endoluminal tracheal occlusion. References in last column can be found in the original publication (Beck et al, 2010). no exception, but such trials are ethically challenging, difficult to organise and finance, and hard to execute effectively.…”

“…In some conditions selective feticide is a goal in itself Amniotic band syndrome Prevention of deformities and functional loss Chorioangioma Prevention/reversal of cardiac failure, hydrops fetoplacentalis and polyhydramnios Table 2-Criteria for fetal surgery Rupture rates (%) are those reported ≤37 weeks, or at the time point specified (from Beck et al, 2010). ABS, amniotic band syndrome; CO, cord occlusion; FETO, fetoscopic endoluminal tracheal occlusion.…”

Thrombin Generation by Fetoscopic Trauma to the Fetal Membranes: An in vivo and in vitro Study

“…This induces a risk (5-30%) of iatrogenic preterm premature rupture of membranes (PPROM) and an undefined risk of chorionic membrane separation [1]. Amniorrhexis after fetoscopy may start days to weeks after the initial trauma [2].…”