Texas Childrens Fetal Center

Houston, TX, United States

Texas Childrens Fetal Center

Houston, TX, United States

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Roman A.,Baylor College of Medicine | Papanna R.,Baylor College of Medicine | Papanna R.,Texas Childrens Fetal Center | Johnson A.,Baylor College of Medicine | And 6 more authors.
Ultrasound in Obstetrics and Gynecology | Year: 2010

Objective To compare radiofrequency ablation (RFA) and bipolar cord coagulation (BPC) methods for selective fetal reduction in the treatment of complicated monochorionic (MC) multifetal gestations. Methods This was a retrospective review of patients who underwent selective reduction by RFA and BPC. Computer-generated random sampling was performed to match patients who had undergone BPC with patients who had undergone RFA, in a 2:1 ratio, controlling for gestational age and indication. The primary outcome was fetal survival. Results Twenty patients in the RFA group were matched with 40 patients in the BPC group. Fewer additional intraoperative procedures were performed in the RFA group compared with the BPC group: amnioinfusion, 10% vs. 75%, respectively (P < 0.01); and amnioreduction, 5% vs. 40%, respectively (P = 0.004). The overall survival rates were 87.5% in the RFA group and 88% in the BPC group (P = 0.94). Median gestational age at delivery was 36 (range, 26-41) weeks in the RFA group and 39 (range, 19-40) weeks in the BPC group (P = 0.59). Preterm delivery (at <28, <32 or <37 weeks), weeks gained after the procedure and birth weight at delivery were also similar. Although the preterm premature rupture of membranes (PPROM) rate was higher in the BPC group (22.5%) compared with the RFA group (5%), the difference was not statistically significant (P = 0.09). Conclusions Overall fetal survival rate following selective reduction in complicated MC pregnancies is similar whether reduction is performed by RFA or BPC. Feweradditional intraoperative procedures are required for RFAthan for BPC. The possibility that RFA is associated witha lower rate of postoperative PPROM than is BPC willhave to be confirmed in larger series. Copyright © 2010 ISUOG. Published by John Wiley & Sons, Ltd.


Blumenthal-Barby J.S.,Baylor College of Medicine | Krieger H.,Baylor College of Medicine | Krieger H.,University of Houston | Wei A.,Rice University | And 5 more authors.
Journal of Perinatal Medicine | Year: 2016

To examine the style and content of consultations for maternal-fetal surgery and draw conclusions about best practices for informed consent and shared decision-making. Qualitative study of 15 h-long consultations with women diagnosed with fetal myelomeningocele (MMC, n=11) or congenital diaphragmatic hernia (CDH, n=4) who were potential candidates for maternal-fetal surgery at a large children's hospital in the Southwestern US. Major findings were that physicians tended to discuss the risks of fetal prognosis qualitatively more often than quantitatively (70% compared to 30%) and when mortality was a risk the "positive" (percentage survival) frame was always given rather than the morality frame. On average, families only talked 15% of the time and 45% of all their questions were about diagnostic or surgical procedure clarification. Efforts should be made to minimize qualitative presentation of risk, which can be vague and confusing to patients. Both survival and mortality frames should be used to avoid biased decision-making. Communication and decision support tools that facilitate more shared decision-making between families and physicians are needed. © 2016 2016 Walter de Gruyter GmbH, Berlin/Boston.


Shetty A.N.,Baylor College of Medicine | Shetty A.N.,Texas Childrens Fetal Center | Gabr R.E.,University of Texas Health Science Center at Houston | Rendon D.A.,Baylor College of Medicine | And 8 more authors.
Prenatal Diagnosis | Year: 2015

Purpose: A common source of loss in signal-to-noise ratio (SNR) in fetal brain magnetic resonance spectroscopy (MRS) is from fetal movement and temporal magnetic field drift. We investigated the feasibility of using constructive averaging strategies for improving the spectral quality and recovering the SNR loss from these effects. Materials and Methods: Eight fetuses, between 20 3/7 and 38 2/7weeks' gestation, were scanned with MRS at 1.5T. Single-voxel point-resolved spectroscopy of the fetal brain with TE=144ms (in one case additional TE=288ms) was performed in a dynamic mode, and individual spectra of 128 acquisitions were saved. With constructive averaging strategy individual acquisitions were corrected for phase variations and frequency drift before averaging. Constructively averaged spectra were compared to those using conventional averaging to evaluate differences in spectral quality and SNR. Results: The definition of key metabolite peaks was qualitatively improved using constructive averaging, including the doublet structure of lactate in one case. Constructive averaging was associated with SNR increases, ranging from 11% to 40%, and the SNR further improved in one case when outliers from severe motion were rejected before averaging. Conclusion: Our results demonstrate the feasibility of using constructive averaging for improving SNR in fetal MRS, which is likely to improve the characterization of fetal brain metabolites. What's already known about this topic? Signal to noise (SNR) in fetal brain MR spectroscopy is affected by the fetal motion and temporal magnetic field drift. What does this study add? Constructive averaging strategy recovers SNR loss from these effects. © 2015 John Wiley & Sons, Ltd.


Ruano R.,Baylor College of Medicine | Ruano R.,Texas Childrens Fetal Center | Ali R.A.,Baylor College of Medicine | Patel P.,Drexel University | And 4 more authors.
Obstetrical and Gynecological Survey | Year: 2014

: In the present study, we review the indications, technical aspects, preliminary results, risks, and clinical implications of fetal endoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia (CDH) performed outside the United States and its potential future directions in this country and globally. : Congenital diaphragmatic hernia occurs in approximately 1 in 2500 live births and results in high neonatal morbidity and mortality, largely associated with the severity of pulmonary hypoplasia and pulmonary arterial hypertension. With the advent of prenatal imaging, CDH can be diagnosed before birth, and in utero treatment is now available in some centers. The prognosis of CDH can be evaluated by assessing the fetal lung size, the degree of liver herniation, and the fetal pulmonary vasculature in isolated forms of CDH. These parameters help classify fetuses as having mild, moderate, severe, or extremely severe isolated CDH. Severe and extremely severe diaphragmatic hernias have poor outcomes and thus are candidates for innovative therapies such as FETO. : Fetal endoscopic tracheal occlusion is usually performed between 26 and 30 weeks' gestation. In utero, an endoscope is passed through the fetal mouth and down to the carina; the balloon is deployed just above the carina. After the procedure, ultrasound surveillance every 2 weeks ensures the balloon's structural integrity and measures the fetal pulmonary response. At approximately 34 weeks' gestation, the balloon is deflated and removed. Fetal endoscopic tracheal occlusion is thought to improve outcomes by decreasing mortality and allowing more rapid neonatal stabilization. Ultimately, the goal of FETO is to minimize pulmonary hypoplasia and pulmonary arterial hypertension. Following delivery, neonates still require diaphragm repair. TARGET AUDIENCE: Obstetricians and gynecologists, family physicians LEARNING OBJECTIVES: After completing this CME activity, physicians should be better able to evaluate the different imaging modalities available for determining prognosis in fetuses with congenital diaphragmatic hernias, identify the indications for fetal endoscopic tracheal occlusion, and compare the potential benefits and complications of fetal endoscopic tracheal occlusion. © 2014 Lippincott Williams & Wilkins.


Molina S.,Texas Childrens Fetal Center | Papanna R.,Texas Childrens Fetal Center | Moise Jr. K.J.,Texas Childrens Fetal Center | Johnson A.,Texas Childrens Fetal Center
Ultrasound in Obstetrics and Gynecology | Year: 2010

Objective To determine practice patterns for evaluation and treatment of Stage I twin-to-twin transfusion syndrome (TTTS) among international physicians. Methods An e-mail cross-sectional survey of members from the IFMSS, NAFTNet and SMFM societies and participants at a Eurofoetus-sponsored TTTS meeting was undertaken between May 2008 and November 2008. Questionnaires consisted of physician demographics and their recommendations for managing Stage I TTTS. Alternative therapies to expectant management were assessed based on the following special circumstances of the patient: residence more than 200 miles from the center, severe symptoms, or a cervical length of ≤15 mm. Results Eighty-one surveys were returned, giving a response rate of 84%. Five surveys were excluded as a result of duplication or missing data. Of the remaining 76 surveys, 48 were from North America, 20 were from Europe and eight were from other continents. Expectant management was the predominant recommendation (78%), followed by amnioreduction (11%), laser ablation (11%) and septostomy (1%). Recommendations for amnioreduction were exclusively from North American centers. Laser centers recommended expectant management more frequently than non-laser facilities (89% vs. 59%; P < 0.01). When examples of special patient circumstances were presented, North American centers changed their recommendation from expectant management to amnioreduction more often than did European centers. However, a greater proportion of European centers recommended laser surgery for special patient circumstances. Conclusion Expectant management remains the predominant management of Stage I TTTS. In some patient circumstances, North American centers are more likely to recommend amnioreduction while European centers aremore likely to recommend laser therapy. A randomizedcontrolled trial will be necessary to evaluate the most effi-cacious management strategy for Stage I TTTS. Copyright © 2010 ISUOG. Published by John Wiley & Sons, Ltd.


Ethun C.G.,Baylor College of Medicine | Zamora I.J.,Baylor College of Medicine | Zamora I.J.,Texas Childrens Fetal Center | Roth D.R.,Baylor College of Medicine | And 11 more authors.
Journal of Pediatric Surgery | Year: 2013

AbstractPurpose The purpose of this manuscript was to examine the outcomes of patients with lower urinary tract obstruction (LUTO) treated with vesicoamniotic shunt (VAS) to improve the quality of prenatal consultation and therapy. Methods The medical records of all patients diagnosed with LUTO at our center between January 2004 and March 2012 were reviewed retrospectively. Results Of 14 male fetuses with LUTO, all with characteristic ultrasound findings, 11 underwent intervention. One patient received vesicocentesis alone, while 10 had VAS. Two fetuses additionally underwent cystoscopy (one with attempted valve ablation), and two had peritoneoamniotic shunts. Of 16 total VAS, 13 were placed successfully, 8 dislodged (median 7 days), and 1 obstructed (84 days). Two fetuses suffered in utero demise, and two have unknown outcomes. LUTO was confirmed in six of eight live-born fetuses. One patient died in the neonatal period, while seven survived. All six available at follow-up (median 3.7 years), had significant genitourinary morbidity. Five patients had chronic kidney disease, but only one has required dialysis and transplant. Three had respiratory insufficiency, and one required a tracheostomy. Conclusion Despite significant perinatal and long-term morbidity, VAS offers patients faced with a poor prognosis an improved chance of survival. Our results underscore the need for further research into the diagnosis and treatment of LUTO. © 2013 Elsevier Inc. All rights reserved.


PubMed | Texas Childrens Fetal Center, University of Texas Health Science Center at Houston and Baylor College of Medicine
Type: Clinical Trial | Journal: Prenatal diagnosis | Year: 2016

A common source of loss in signal-to-noise ratio (SNR) in fetal brain magnetic resonance spectroscopy (MRS) is from fetal movement and temporal magnetic field drift. We investigated the feasibility of using constructive averaging strategies for improving the spectral quality and recovering the SNR loss from these effects.Eight fetuses, between 20 3/7 and 38 2/7weeks gestation, were scanned with MRS at 1.5T. Single-voxel point-resolved spectroscopy of the fetal brain with TE=144ms (in one case additional TE=288ms) was performed in a dynamic mode, and individual spectra of 128 acquisitions were saved. With constructive averaging strategy individual acquisitions were corrected for phase variations and frequency drift before averaging. Constructively averaged spectra were compared to those using conventional averaging to evaluate differences in spectral quality and SNR.The definition of key metabolite peaks was qualitatively improved using constructive averaging, including the doublet structure of lactate in one case. Constructive averaging was associated with SNR increases, ranging from 11% to 40%, and the SNR further improved in one case when outliers from severe motion were rejected before averaging.Our results demonstrate the feasibility of using constructive averaging for improving SNR in fetal MRS, which is likely to improve the characterization of fetal brain metabolites.


Cassady C.I.,Texas Childrens Fetal Center | Mehollin-Ray A.R.,Texas Childrens Fetal Center | Olutoye O.O.,Texas Childrens Fetal Center | Cass D.L.,Texas Childrens Fetal Center
Fetal Diagnosis and Therapy | Year: 2011

Magnetic resonance imaging (MRI) is used routinely in many fetal care centers for the evaluation of the fetus with congenital diaphragmatic hernia (CDH). Current MRI strategies focus on identifying the type of hernia and its contents, as well as calculating fetal lung volumes, in order to plan appropriately for neonatal support, including the use of extracorporeal membrane oxygenation (ECMO). Single-shot fast spin-echo T 2-weighted sequences are fundamental, with additional sequences used variably as indicated. We report the case of a fetus with CDH in whom ECMO cannulation was attempted as a neonate but was unsuccessful because of variant anatomy of the internal jugular vein. A retrospective review of gradient echo sequences obtained through the fetal neck and chest showed the abnormality could have been anticipated. During multidisciplinary assessment of the fetus with CDH, consideration should be given to imaging evaluation of the neck to evaluate the cervical vascular anatomy, particularly in cases with poorer prognosis in whom it is anticipated that neonatal ECMO may be an option. Copyright © 2011 S. Karger AG, Basel.


PubMed | Texas Childrens Fetal Center
Type: Journal Article | Journal: Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology | Year: 2015

To describe a method of quantifying the amount of liver herniation in fetuses with isolated congenital diaphragmatic hernia (CDH) using two-dimensional ultrasonography and to correlate this finding with neonatal outcome.Ultrasound images obtained from 77 consecutive fetuses that presented with isolated CDH between January 2004 and July 2012 were reviewed. Liver herniation and thoracic area were measured in a cross-sectional plane of the fetal chest at the level of the four-chamber view of the heart (the same section as is used to measure the lung area-to-head circumference ratio) and the ultrasound-derived liver-to-thoracic area ratio (US-LiTR) was calculated by dividing the liver herniation area by the thoracic area. Receiver-operating characteristics (ROC) curve analysis was used to evaluate the performance of US-LiTR in predicting neonatal outcome (survival to 6months after delivery and need for extracorporeal membrane oxygenation (ECMO)). In addition, the US-LiTR was compared with the magnetic resonance imaging (MRI)-derived volume ratio (MRI-LiTR) and percentage of liver herniation (MRI-%LH).The overall neonatal mortality in the 77 cases with isolated CDH was 20.8% (16/77). ECMO was needed in 35.5% (27/76) of the newborns, with a survival rate of 52%. The US-LiTR was associated statistically with mortality (P<0.01) and with the need for ECMO (P<0.01). Good correlations were observed between US-LiTR and MRI-LiTR (r=0.87; P<0.001) and between US-LiTR and MRI-%LH (r=0.90; P<0.001). Based on ROC curve analysis, all three parameters had similar accuracy in predicting mortality (US-LiTR: area under the ROC curve (AUC), 0.78 (95%CI, 0.65-0.92), P<0.01; MRI-LiTR: AUC, 0.77 (95%CI, 0.63-0.90), P<0.01; MRI-%LH: AUC, 0.79 (95%CI, 0.65-0.92), P<0.01, respectively) as well as the need for ECMO (US-LiTR: AUC, 0.72 (95%CI, 0.60-0.84), P<0.01; MRI-LiTR: AUC, 0.73 (95%CI, 0.60-0.88), P<0.01; MRI-%LH: AUC, 0.77 (95%CI, 0.64-0.89), P<0.01, respectively).Two-dimensional ultrasound measurement of the amount of liver herniation in fetuses with isolated CDH is feasible and demonstrates a predictive accuracy for neonatal outcome similar to that of MRI.


Magnetic resonance imaging (MRI) is used routinely in many fetal care centers for the evaluation of the fetus with congenital diaphragmatic hernia (CDH). Current MRI strategies focus on identifying the type of hernia and its contents, as well as calculating fetal lung volumes, in order to plan appropriately for neonatal support, including the use of extracorporeal membrane oxygenation (ECMO). Single-shot fast spin-echo T(2)-weighted sequences are fundamental, with additional sequences used variably as indicated. We report the case of a fetus with CDH in whom ECMO cannulation was attempted as a neonate but was unsuccessful because of variant anatomy of the internal jugular vein. A retrospective review of gradient echo sequences obtained through the fetal neck and chest showed the abnormality could have been anticipated. During multidisciplinary assessment of the fetus with CDH, consideration should be given to imaging evaluation of the neck to evaluate the cervical vascular anatomy, particularly in cases with poorer prognosis in whom it is anticipated that neonatal ECMO may be an option.

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