Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, JIPMER, Puducherry, India.
Department of Interventional Radiology, JIPMER, Puducherry, India.
Prenat Diagn. 2024 Oct;44(11):1367-1371. doi: 10.1002/pd.6662. Epub 2024 Sep 7.
To treat the fetus presenting with in utero compromise due to a large vein of Galen malformation (VOGM) using glue embolization.
The fetus that was referred for termination of pregnancy at 30 weeks of gestation due to severe cardiomegaly, mild pericardial effusion and large VOGM was evaluated using ultrasound. There was reversed end diastolic flow in the umbilical artery Doppler indicating imminent fetal demise in the premature fetus weighing <1200 g. Considering the request of parents, a treatment similar to recently reported cases of VOGM embolization in utero was attempted as an emergency procedure to salvage the baby. Due to unavailability of coils, financial constraints and urgent need for intervention, n-butyl cyanoacrylate glue with lipiodol was used to embolize the venous outflow of VOGM outflow under ultrasonographic guidance.
There was immediate correction of the umbilical artery Doppler waveform with the establishment of a normal flow pattern. The cardiomegaly resolved over 3 weeks and fetal MRI done 2 weeks later showed normal brain architecture with no evidence of hemorrhage or infarction. Pregnancy was continued for 4 weeks after the procedure and terminated at 36 weeks. A female baby weighing 1900 g was delivered by Cesarean section with an Apgar of 8/10. Though initially the baby did well, with mild ventriculomegaly reported on postnatal day 5, she eventually presented at 3 months of age with cardiac failure. As the MRI showed encephalomalacia, due to uncertainty of neurological outcome, further treatment was not pursued by the parents and the baby died a few days later.
To our knowledge, this is the first report on the use of glue to treat VOGM prenatally. Though technically successful in correcting the in utero compromise, the baby eventually expired. Cases of in utero embolization using coils and glue have shown success in reversing prenatal pathology and improving survival. However, long-term outcomes including neurological status are yet to be reported.
通过胶栓塞治疗因巨大静脉瘤（VOGM）引起的宫内胎儿受累。
该胎儿因严重心脏肿大、轻度心包积液和巨大 VOGM 于 30 孕周转诊行终止妊娠，经超声评估。胎儿体重<1200g，胎心率减速末期反向血流，提示胎死宫内。考虑到父母的要求，尝试了类似最近报道的 VOGM 宫内栓塞病例的治疗方法，作为紧急程序来抢救婴儿。由于无法获得线圈、资金限制和急需干预，在超声引导下使用 n-丁基氰基丙烯酸酯胶与碘油栓塞 VOGM 静脉流出。
脐动脉多普勒波形立即纠正，血流模式正常。心脏肿大在 3 周内消退，2 周后行胎儿 MRI 显示正常脑结构，无出血或梗死证据。在手术 4 周后继续妊娠，于 36 孕周行剖宫产术。分娩一女婴，体重 1900g，Apgar 评分为 8/10。尽管婴儿最初情况良好，出生后第 5 天报告轻度脑室扩大，但最终在 3 个月龄时出现心力衰竭。由于 MRI 显示脑软化，考虑到神经预后不确定，父母未再进行进一步治疗，几天后婴儿死亡。
据我们所知，这是首例使用胶治疗 VOGM 产前病例的报道。虽然在纠正宫内受累方面技术上是成功的，但婴儿最终死亡。使用线圈和胶进行宫内栓塞的病例已经成功地逆转了产前病理，并提高了生存率。然而，长期结局包括神经状态尚未报道。
