Fetoscopic laser photocoagulation: a medically reasonable treatment option in the management of types II and III vasa previa.

Vasa previa is a condition where unprotected fetal vessels cross the cervix within the membranes, posing a considerable risk of fetal death or severe morbidity if the membranes rupture before or during delivery. There has not been a definitive in utero treatment for this condition. Patients are typically closely monitored and hospitalized in the early third trimester and scheduled for cesarean delivery before term. This approach poses considerable physical, social, psychological, and financial challenges for pregnant patients and their families. Furthermore, fetal vessel rupture may lead to severe hypoxic-ischemic injury and consequent neurodevelopmental impairment. Finally, babies delivered early due to vasa previa may face both the short- and long-term consequences of prematurity. Recently, fetoscopic laser photocoagulation using a single-port fetoscope has emerged as a potential therapeutic option for patients with types II and III vasa previa. This innovative approach aims to reduce hospital stays, increases the chance of successful vaginal delivery, and potentially allows pregnancies to reach full term, providing lifelong benefits for the infant. Preliminary clinical studies on human subjects have demonstrated promising results concerning the feasibility, safety, and efficacy of this intervention for a subset of patients with types II and III vasa previa. After reviewing the current state of the art, we argued that offering fetoscopic laser photocoagulation in specialized centers under IRB supervision meets the ethical obligations of beneficence and non-maleficence for both pregnant and fetal patients, as well as the autonomy-based obligations for pregnant patients.

Javinani A ，Oyelese Y ，Chervenak FA ，Grünebaum A ，Chmait RH ，Papanna R ，Shamshirsaz AA ... -  《-》

Third-trimester fetoscopic ablation therapy for types II and III vasa previa.

Chmait RH ，Monson MA ，Chon AH ，Masri J ，Korst LM ，Incerpi MH ... -  《-》

Term vaginal delivery following fetoscopic laser photocoagulation of type II vasa previa.

Unrecognized vasa previa carries a significant risk of fetal mortality. Advances in ultrasound have improved detection of vasa previa and led to a dramatic reduction in fetal morbidity and mortality. However, current management strategies require prolonged hospitalized surveillance, preterm delivery prior to the onset of labor or rupture of membranes, and a cesarean delivery. Fetoscopic laser ablation of type II vasa previa allows for the possibility of term vaginal delivery. We present a patient who underwent successful laser photocoagulation of a type II vasa previa at 32(5)/7 weeks' gestation. She subsequently delivered vaginally at term without complications. The potential benefits of definitive in utero treatment of non-type I vasa previa, such as vaginal delivery at term, must be weighed against the procedure-related risks of operative fetoscopy.

Johnston R ，Shrivastava VK ，Chmait RH 《-》

Third trimester fetoscopic laser ablation of type II vasa previa.

Chmait RH ，Chavira E ，Kontopoulos EV ，Quintero RA ... -  《-》

Fetoscopic Laser Ablation Therapy for Type II Vasa Previa.

In type II vasa previa, fetoscopic laser ablation has the potential to avoid prolonged hospitalization, elective prematurity, and cesarean delivery associated with traditional conservative management. To assess the feasibility and to report perinatal outcomes of type II vasa previa patients treated via fetoscopic laser ablation. This is a retrospective descriptive study of all women with vasa previa treated with laser at our center between 2006 and 2019. After 2010, laser ablation of vasa previa was only offered after 31 gestational weeks. Continuous variables are expressed as means ± SD. 33 patients were evaluated for laser ablation of suspected vasa previa. Fifteen were not candidates (7 had type I vasa previa and 8 had no vasa previa), and the 18 remaining had type II vasa previa. Ten (56%) elected to undergo in utero laser ablation of the vasa previa vessel(s), which was successful in all patients. The mean gestational age (GA) at the time of the procedure was 28.8 ± 5.4 weeks, and the total operative time was 48.1 ± 21.3 min; there were no perioperative complications. The number of vessels lasered were distributed as follows: 1 (2 cases), 2 (5 cases), and 3 (3 cases). All patients except for 1 were subsequently managed as outpatients. The mean GA at delivery was 35.5 ± 3.2 weeks, and vaginal delivery occurred in 5 cases. The 5 patients with singletons who underwent laser ablation for primary diagnosis of type II vasa previa after the protocol change in 2010 had the following outcomes: mean GA of surgery was 32.5 ± 0.8 weeks, mean GA at delivery was 38.1 ± 1.4 weeks, vaginal delivery occurred in all cases, mean birth weight was 2,965 ± 596 g, and none were admitted to the neonatal intensive care unit. This cohort represents the largest number of vasa previa cases treated via in utero laser reported to date. Laser occlusion of type II vasa previa was technically achievable in all cases and resulted in favorable outcomes.

Chmait RH ，Catanzarite V ，Chon AH ，Korst LM ，Llanes A ，Ouzounian JG ... -  《-》