Bruner Joseph P, Davis George, Tulipan Noel
Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
Fetal Diagn Ther. 2006;21(6):532-9. doi: 10.1159/000095668. Epub 2006 Sep 12.
To determine the safety and efficacy of ventriculoamniotic shunt placement through a hysterotomy in the second trimester of pregnancy as treatment for isolated obstructive hydrocephalus.
Between 1999 and 2003, four pregnancies with isolated fetal obstructive hydrocephalus in the second trimester were treated at Vanderbilt University Medical Center. Preoperatively, all fetuses underwent serial ultrasonographic examinations and an ultrafast magnetic resonance imaging to confirm isolated aqueductal stenosis. A normal fetal karyotype and negative polymerase chain reaction or culture of the amniotic fluid for cytomegalovirus and toxoplasmosis were obtained. Serial enlargement of the lateral ventricles >1.5 mm/week and fetal macrocephaly were documented. Using epidural and GETA, a standard ultrasmall ventricular catheter and valve were inserted via a hysterotomy. The distal catheter, rather than being inserted into the fetal peritoneum, exited between the fetal scapulae. Patients were discharged home from the hospital, and the remainder of their prenatal care was provided by their local obstetrician. After delivery, the distal drain was converted to a ventriculoperitoneal shunt.
Cases were performed at 23 6/7, 25 5/7, 26 4/7, and 26 5/7 weeks. Shunts performed well during pregnancy, and were intact at delivery. Deliveries occurred at 34 1/7, 27 1/7, 28, and 32 4/7 weeks. Birthweights were 2,010, 907, 1,200, and 2,220 g. All Apgar scores were normal. Case 1 developed a neonatal shunt infection, and is now developmentally delayed, with swallowing dysfunction, hearing deficits and a poor pupillary response. Case 2 developed neonatal sepsis and is now developmentally delayed. Case 3 delivered preterm due to chorioamnionitis, and neonatal death occurred from sepsis. Case 4 is developmentally delayed.
Ventriculoamniotic shunt can be placed through a hysterotomy, overcoming many of the technical difficulties of earlier percutaneous shunts. However, recent developments in fetal imaging and molecular genetics have not improved case selection. Unless new breakthroughs occur, fetal shunting cannot reasonably be expected to improve perinatal outcome.
确定在妊娠中期通过子宫切开术置入脑室 - 羊膜分流管治疗孤立性梗阻性脑积水的安全性和有效性。
1999年至2003年期间，范德比尔特大学医学中心对4例妊娠中期患有孤立性胎儿梗阻性脑积水的孕妇进行了治疗。术前，所有胎儿均接受了系列超声检查和超快磁共振成像，以确认孤立性导水管狭窄。获得了正常的胎儿核型，羊水的巨细胞病毒和弓形虫聚合酶链反应或培养结果为阴性。记录侧脑室系列扩大>1.5 mm/周和胎儿巨头畸形。采用硬膜外麻醉和全身麻醉，通过子宫切开术插入标准的超小型脑室导管和瓣膜。远端导管未插入胎儿腹膜，而是从胎儿肩胛骨之间穿出。患者出院回家，其余产前护理由当地产科医生提供。分娩后，将远端引流管转换为脑室 - 腹腔分流管。
手术分别在23 6/7、25 5/7、26 4/7和26 5/7周进行。分流管在孕期运行良好，分娩时保持完好。分娩分别发生在34 1/7、27 1/7、28和32 4/7周。出生体重分别为2010、907、1200和2220 g。所有阿氏评分均正常。病例1发生了新生儿分流管感染，目前发育迟缓，有吞咽功能障碍、听力缺陷和瞳孔反应不良。病例2发生了新生儿败血症，目前发育迟缓。病例3因绒毛膜羊膜炎早产，新生儿因败血症死亡。病例4发育迟缓。
可通过子宫切开术置入脑室 - 羊膜分流管，克服了早期经皮分流术的许多技术难题。然而，胎儿影像学和分子遗传学的最新进展并未改善病例选择。除非出现新的突破，否则胎儿分流术不太可能改善围产期结局。
