Volume If)..! "'umber l. Part 2

27 A FIVE YEAR STATE WIDE EXPERIENCE WITH CONGENITAL DIAPHRAGMATIC HERNIA. K. Wenstrom, M.D., C. Weiner, M.D., J. Hanson, M.D:, Depts. Ob/Gyn & Genetics, Vniv. of Iowa, Iowa City, IA 52242

Attempted in utero surgical correction of congenital diaphragmatic hernia has been justified by previously reported neonatal survival rates of only 20-23 %. These rates were calculated from physician surveys and infant death registries, and may have been subject to bias of ascertainment. To obtain a comprehensive view of the natural history of this malformation, we used the State Birth Defects Registry (which records all infants born in the state at > 20 weeks' gestation or > 500 grams with congenital defects) to identify all infants with congenital diaphragmatic hernia born during a five year period from 1983-88 (N=65). Results: 41.5% (27/65) survived. 89% of survivors were delivered in Level 1 hospitals, and 42% of these also had corrective surgery in Level 1 hospitals. 17 of the 38 fatalities, compared to only 1 of the 27 survivors, had additional severe maifonnaJions unrelated to the diaphragmatic hernia (p = O. 0012). All were potentially identifiable prenatally by ultrasound or chromosome analysis (Trisomies, cardiac or neural tube defects, hygroma/hydrops, etc). When these 17 were excluded, the corrected survival rate for infants with isolated diaphragmatic hernia (N=48) was 56%. Mortality in this subgroup was related to serious pUlmonary or cardiac problems secondary to the hernia (N = 19) and postoperative complications (N =2). Conclusion: Any consideration of attempted antenatal correction of diaphragmatic hernia must take into account the natural history of the disorder. This complete population survey indicates that 56% of infants with isolated diaphragmatic hernia will survive without in utero therapy.

28 EFFICACY OF MULTIFETAL PREGNANCY REDUCTION (MFPR): COLLABORATIVE EXPERIENCE OF THE WORLD'S LARGEST CENTERS, Y DumezX, M.I..&am, RJ Wapner, L Lynch, M DommerguesX,

JD Goldberg, MP Johnsonx, MS Golbusx & RL Berkowiz, Matern~e Port Royale, Paris; OB/GYN Wayne State, Detroit; Jefferson, Philadelphia; UC-San Francisco; Mt Silai, New York

MFPR has emerged as an option in iatrogenic, multifetal pregnancies. Because no one center has enough data for definitive conclusIOns, we have combined our data and present here 399 patients (310 delivered). Most procedures were done at 10-12 wks GA, all were by transabdominal, intrathoracic KCI. Database includes 26 cases of 6+, 29 quints, 130 quads, 106 triplets, all mostly reduced to twins, and 19 twins reduced to singletons. Of 310 concluded pregnancies total loss rate was 16.9% of which 6.4% were early losses (EL) (within 2 wks of procedure) and 11.7% were late losses (LL) mostly >4 wks. Loss rates for both EL and LL percentages were directly related to starting fetal number and number reduced. Total loss rate was 0% for 2~1, 18.4% for 3~2, 21.2% for 4~2, 31 % for 5-9~2. 16/266 (6.0%) twins delivered at <30 wks, 25/266 (9.4%) at 30-33 wks, 45/266 (19.9%) at 34-35 wks, 84/266 (31.6%) at 36-37, and 96/266 (36.1 %) at 38+ wks with a 1 % congenital abnormality rate. Average GA at delivery was inversely correlated with starting and finishing number. GA 7+~2 = 31.75+6~2 = 35.5, 4~2 = 34.9 wks, 3~2 = 36.2 wks, 2~1 = 38.0 wks .. There were no maternal complications. We conclude 1) fetal loss is directly related to initial and final fetal numbers. 2) GA at delivery is inversely related to initial and final fetal numbers. 3) MRPR increases the chance of viable outcomes at greater GA with decreased neonatal morbidity.

SPO Abstracts 255

29 GAINING ACCESS TO THE EMBRYONIC CIRCULATION VIA FIRST-TRIMESTER ENIlOSCOPY: TOWARD A NEW VIEWPOINT FOR PRENATAL DIAGNOSIS AND TREATMENT. Reece EA, Whet""'" J, Rotmensch S', Cullen M, Hobbins J. \lepartlllent of OB/GYN; Yale University School of Medicine, IIew Haven, CT.

30

The fetus has bec:c.! a bona fide patient as a result of tec:hoological advances pel'lllitting prenatal diagnosis and treabllent in the 2nd and 3rd triEsters. Access to the _ryonic circulation will significantly enhance our capabilities for early prenatal diagnosis and will pel'lllit gene and/or st....-cell ther~y at a tiE when the _ryo is iRIIIJnologically "naive. Early in utero genetic therapy will be of value in diseases which produce irreversible damage by the tillle of birth and reduce the likelihood of graft rejection. We reported previ ous 1 y on fetoscopy and subsequently on eoabryoscopy as Ethods by which the developing conceptus could be visualized and examined in utero. In the present study, we explored the feasibility of gaining access into the ""ryonic circulation as a prelude to studies on therapeutic interventions. Following informed consent, patients Undergoing lst-trimester pregnancy tennination were invited to partiCipate in this study. A 3.5 .. wi de-angle 1 ens f i beropt i c endoscope was passed transcervically through the chorion and into the extrac:eolOlRic cavity. Nonnal anatomic lananarks were studied in over 300 cases. With a modi fied endoscope adapted with a sheath and side channel, we have been able to gain access into the _ryanic circulation by passing a specially llilde 26-gauge heparinized needle through the side channel of the endoscope and into the ..ooilical vessels. This procedure will be demonstrated on videotape. Studies are currently in progress to infuse indigo cannine dye into the fetal circulation, foll<M!d by histopathological examinations for tissue localization of the dye. Our experience uniquely establishes the feasibility of access to the human embryonic circulation. This is expected to serve as a basis for further studies, attempting to diagnose and treat congenital diseases in early pregnancy.

TWIN GESTATION: FETAL POSITION AS A FUNCTION OF GESTATIONAL AGE. Mlchael Y. Dlvon, M.D., Morisa Mann. M.D.', Raphael N. Pollack, M.D', Cassandra Henderson. M.D .. Yeshayak Aboulafla, M.D., Irwin R. Merkatz, M.D.Albert Elnsteln College of Medlclne, Bronx, New York.

PaUCl ty of data eXl sts regardl ng the i nCl dence of spontaneous verSlOns in multiple gestatlOn. Therefore, antepartum counsell lng regardlng the mode of delivery is dlfficult. Purpose: to evaluate fetal posltion as a functlOn of gestatlOnal age (GA) in tWln pregnancy. Maten a 1 s and Methods: fetal and pl acenta 1 poSl t lOns were noted on serial ultrasound exams throughout the 3rd tnmester in patients wlth tWln gestatlOn Results: (n=119). mean blrth welght (BW) and GA at dellVery were 2640 gms and 37 weeks, respectively. 19% were dlscordant (>20%) and 33% were del ivered by CIS. Neither the pat 1 ent' span ty nor the presence of BW dlscordance or placental positlOn had a slgmficant assoclatlOn wlth the lncldenee of verSlOns. Spontaneous VerslOns (SV) Vs GA and fetal posltion lS shown below:

GA SV Fetal Posltlon n SV 28=3'0 63% cepha 1 I cepha 1 44 7% 30-32 48% cephal/transv 34 32% 32-34 55% breech/breech 6 66% 34-36 48% breech/cepha 1 6 66% 36-38 44% breech/transv 4 75% 38-40 30% cepha 1 Itransv 14 93% 40-42 25% other 8 100%

Cone 1 us ion. these data i ndl cate that the 1 nCl dence of spontaneous verslOns 1 n tWl n gestat lOn decreases Wl th gestat 1 ona 1 age, however, it remalns relatively high even at term. Patlents wlth a cephal lc/cephal lC presentatlOn have the lowest incldence of spontaneous verSlOn Whl 1 e all ather presentat ions are re 1 at 1 ve 1 y unstable. Thus, malpresentatlon ln term tWln gestations may be aSSOCl ated Wl th a Sl gm fl cant 1 nci dence of spontaneous verSlOn.