Intrauterine surgery has become an accepted procedure for life threatening anomalies. The surgeon must consider both the health of the child and the health of mother. The indications for intrauterine surgery are expanding to include myelomeningocele and amniotic band syndrome. The authors from Barcelona, Spain presented two cases of amniotic disruption sequence treated with fetoscopic release.
The first patient was a 33 year old female who had diagnosis of extremity amniotic band after her ultrasound. There was a severe constriction in the distal third of the fetal left leg with markedly edematous ankle and foot. Color Doppler imaging showed minimal blood flow distally through the constriction. Fetoscopic release guided by ultrasound was performed at 22 weeks gestational age. A laser was used to release the left leg constriction, by performing a posterolateral longitudinal incision. There was an increase in Doppler flow and decrease in distal edema on subsequent ultrasounds and Doppler. The newborn was delivered at 31 weeks because of premature rupture of the membranes. There was residual constriction but good capillary fill, mild distal edema, active ankle motion, and presence of sensibility. Multiple Z-plasties were necessary in the postnatal period.
The second patient was a 31 year old female who had a similar diagnosis of distal left leg constriction with a markedly edematous ankle and foot. Fetoscopic surgery was performed in a similar fashion with posterolateral longitudinal incision to release the constriction. Postoperatively, retroamniotic detachment was diagnosed within the first 24 hours. The newborn was delivered at 28 weeks because of premature rupture of the membranes. Fortunately there were no complications despite the newborns prematurity. Additional Z-plasty was necessary to release a severe band.
The field of fetoscopic surgery has inherited risks to mother and child. Previous isolated cases of amniotic band release have been performed. Fetoscopic band release is limited to progressive edema and loss of circulation that most likely will result in loss of limb. However, one must discuss with the family the chances of spontaneous abortion which is about 6-10% following global fetoscopic procedures. In the second case, premature rupture of membranes was a complication directly related to fetoscopic release. This article presents intriguing information regarding fetoscopic release of amniotic bands. Similar to other innovative procedures, the exact indications and techniques will have to improve to make this a safe and efficacious procedure.