Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA.
Ultrasound Obstet Gynecol. 2023 Dec;62(6):882-890. doi: 10.1002/uog.26307.
There is a paucity of literature providing evidence-based guidelines for the management of large placental chorioangioma (≥ 4 cm in diameter). The objectives of this study were to compare outcomes between patients managed expectantly and those undergoing in-utero intervention and to describe the different in-utero techniques used for cessation of blood flow to the tumor and the associated outcome.
This was a retrospective cohort study of 34 patients referred for the management of large placental chorioangioma in a single center between January 2011 and December 2022, who were managed expectantly or underwent in-utero intervention. In-utero intervention was performed when the fetus developed any signs of impending compromise, including high combined cardiac output (CCO), worsening polyhydramnios or abnormal fetal Doppler velocimetry findings. Interventions included radiofrequency ablation (RFA), interstitial laser ablation (ILA) and single-port or two-port fetoscopic laser photocoagulation (FLP). Treatment selection was dependent on the proximity of the tumor to the umbilical cord insertion (UCI) and placental location. The two-port technique was performed in patients with a chorioangioma with large feeding vessels (≥ 3 mm) located in the posterior placenta, in which one port was used for occlusion using bipolar forceps and the other port was used for laser photocoagulation of the feeding vessels downstream. The single-port technique was used for chorioangioma with small feeding vessels (< 3 mm) located in the posterior placenta. ILA or RFA was performed in cases with an anterior placenta. Supportive treatments, including amnioreduction and intrauterine transfusion (IUT), were performed for worsening polyhydramnios and suspected fetal anemia based on middle cerebral artery Doppler flow studies, respectively. Comparative statistical analysis between cases undergoing expectant management vs in-utero intervention was performed. Descriptive details were provided for patients who underwent in-utero intervention.
Thirty-four cases of large chorioangioma were evaluated, of which 25 (73.5%) were managed expectantly and nine (26.5%) underwent intervention. The frequency of polyhydramnios was significantly higher in the intervention group compared with the expectant-management group (66.7% vs 8.0%, P < 0.001). The live-birth rate among expectantly managed cases with large chorioangioma was significantly higher compared with that in cases that underwent in-utero intervention (96.0% vs 62.5%, P = 0.01). In the intervention group, preoperative CCO was elevated in all cases with available information and preoperative hydrops was present in 33.3% (3/9) of cases. One patient experienced fetal demise following IUT prior to planned FLP. Among the remaining eight patients, four underwent two-port FLP, two underwent single-port FLP, one underwent ILA and one underwent both ILA and RFA. All three cases in which hydrops was present at the time of intervention resulted in fetal demise.
In-utero interventions aimed at cessation of blood flow in the feeding vessels are a therapeutic option for the management of cases with large chorioangioma. The two-port percutaneous technique appears to improve the efficiency of FLP when a large chorioangioma with large feeding vessels is located in the posterior placenta. We propose that in-utero interventions for large chorioangioma should be initiated prior to the development of fetal hydrops. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
目前针对直径≥4cm 的大型胎盘绒毛膜血管瘤（placental chorioangioma）的管理，缺乏循证医学指南。本研究的目的是比较期待治疗与宫内干预治疗的结局，并描述用于停止肿瘤血流的不同宫内技术以及相关结局。
这是一项回顾性队列研究，纳入了 2011 年 1 月至 2022 年 12 月期间在一家中心因大型胎盘绒毛膜血管瘤而转诊的 34 例患者，这些患者接受了期待治疗或宫内干预。当胎儿出现即将出现并发症的迹象时，包括心脏输出量（cardiac output，CCO）升高、羊水过多加重或胎儿多普勒血流速度异常时，会进行宫内干预。干预措施包括射频消融（radiofrequency ablation，RFA）、间质激光消融（interstitial laser ablation，ILA）以及单端口或双端口胎儿镜激光光凝（fetoscopic laser photocoagulation，FLP）。治疗选择取决于肿瘤与脐带插入点（umbilical cord insertion，UCI）和胎盘位置的接近程度。当肿瘤有大的滋养血管（≥3mm）位于胎盘后时，采用双端口技术，一个端口用于用双极钳夹闭，另一个端口用于下游滋养血管的激光光凝。当肿瘤的滋养血管较小（<3mm）且位于胎盘后时，采用单端口技术。当胎盘前时，采用 ILA 或 RFA。根据大脑中动脉多普勒血流研究，分别对羊水过多加重和疑似胎儿贫血的患者进行羊水减少和宫内输血（intrauterine transfusion，IUT）等支持性治疗。对行期待治疗与宫内干预的病例进行了对比统计分析。对行宫内干预的患者提供了详细的描述。
评估了 34 例大型绒毛膜血管瘤病例，其中 25 例（73.5%）行期待治疗，9 例（26.5%）行干预。干预组羊水过多的发生率明显高于期待治疗组（66.7% vs. 8.0%，P<0.001）。期待治疗组的大型绒毛膜血管瘤活产率明显高于宫内干预组（96.0% vs. 62.5%，P=0.01）。在干预组中，所有有信息可查的病例术前 CCO 均升高，33.3%（3/9）的病例术前存在水肿。一例在计划行 FLP 前接受 IUT 后胎儿死亡。在其余 8 例患者中，4 例行双端口 FLP，2 例行单端口 FLP，1 例行 ILA，1 例行 ILA 和 RFA。所有在干预时存在水肿的 3 例患者均导致胎儿死亡。
针对滋养血管血流停止的宫内干预是治疗大型绒毛膜血管瘤的一种治疗选择。当大的胎盘后绒毛膜血管瘤伴有大的滋养血管时，双端口经皮技术似乎可以提高 FLP 的效率。我们建议，对于大型绒毛膜血管瘤，应在胎儿出现水肿之前进行宫内干预。
