Original Article
Brief Report
Umbilical-Cord Ligation of an Acardiac Twin by Fetoscopy at 19 Weeks of Gestation
N Engl J Med 1994; 330:469-471February 17, 1994
- Article
Twin reversed-arterial-perfusion sequence is a serious complication of monozygotic multiple gestations, affecting 1 percent of monozygotic twins, or 1 in 35,000 births1. It has been hypothesized that in the presence of artery-to-artery and vein-to-vein anastomoses in a monozygotic placenta, blood is perfused by the hemodynamically advantaged twin (“pump” twin) to the other twin (“recipient” twin) by means of retrograde flow2. Inadequate perfusion of the recipient twin is responsible for the development of a characteristic and invariably lethal set of anomalies, including acardia and acephalus. Typically, the pump twin is structurally normal, but it is at risk for in utero cardiac failure and without treatment dies in 50 to 75 percent of cases, particularly if the recipient twin weighs more than half as much as the pump twin3. The therapeutic goal of interrupting the vascular communication between the twins, although simple in concept,4 has been difficult to accomplish. Methods have ranged from removal of the anomalous twin (sectio parva)5-7 to ultrasound-directed thrombosis of the umbilical circulation of the perfused twin8-11. The maternal morbidity associated with the performance of a hysterotomy in the former method and the unreliable outcome of ultrasound-directed procedures prompted us to explore a different therapeutic approach.
Transabdominal fetoscopy was developed as a method of prenatal diagnosis12. We now report on the use of in utero operative endoscopic techniques to ligate the umbilical cord of an acardiac twin at 19 weeks' gestation. The procedure was followed by the uncomplicated birth of a normal twin at 36 weeks' gestation.
Case Report
A twin pregnancy with twin reversed-arterial-perfusion sequence was diagnosed at 18 weeks' gestation in a 24-year-old woman (gravida 3, para 1) at our institution. The affected fetus was an acardius acephalus, had characteristic cystic structures in the thoracoabdominal areas, and had no upper limbs. Analysis of color Doppler wave forms (Acuson 128-VP/10 OB, Mountain View, Calif.) confirmed arterial flow from the placenta toward the acardiac twin (Figure 1Figure 1
Color Doppler Demonstration of Reversed Arterial Perfusion in the Acardiac Twin.). The abdominal circumference of the acardiac twin was much larger than that of the normal twin (195 mm vs. 125 mm, a recipient twin:pump twin ratio of 156 percent). The pump twin appeared structurally normal with no hydramnios. Chromosomal studies indicated a normal 46,XY karyotype in both fetuses.Therapeutic alternatives discussed with the parents included medical treatment with digoxin if cardiac failure was diagnosed in the normal twin13; removal of the acardiac fetus by laparotomy; percutaneous, ultrasound-guided thrombosis of the umbilical cord with thrombogenic coils; termination of pregnancy; and fetoscopic umbilical-cord ligation. After being informed of the risks and potential benefits of each therapeutic approach, the couple agreed to try fetoscopic umbilical-cord ligation. Approval was obtained from the Human Investigations Committee of Hutzel Hospital.
The procedure was performed with the use of general anesthesia to decrease fetal activity and minimize discomfort to the mother. Ultrasonography revealed that the placenta covered most of the anterior uterine wall. Areas free of placenta were identified for the insertion of the operating instruments. The placental and fetal sites of insertion of the umbilical cord were identified sonographically in both fetuses. The umbilical cord of the acardiac twin lay beneath the fetus, beside the posterior uterine wall. A 12-gauge trocar with a check-flow valve (Cook Ob/Gyn, Spencer, Ind.) was introduced percutaneously under ultrasound guidance into the amniotic cavity at the level of the uterine fundus through a 2-mm skin incision (the viewing port). A 5-degree multilens endoscope that was 1.9 mm in diameter and 11 cm long (Richard Wolf, Vernon Hills, Ill.) was inserted through this sleeve into the amniotic cavity of the normal twin. A video camera (Karl Storz, Culver City, Calif.) was attached to the eyepiece of the endoscope, and the fetoscopic images were recorded. Severe oligohydramnios of the acardiac twin precluded fetoscopic access to its umbilical cord. Therefore, an 18-gauge needle (Cook Ob/Gyn) was used to infuse the sac of the acardiac twin with Ringer's lactated solution. A second 12-gauge trocar (Cook Ob/Gyn) (the working port) was placed approximately 10 cm below the first port, to avoid the placenta. The amniotic membrane of the sac of the acardiac twin was cut with 5-French semirigid scissors (Richard Wolf) to expose the umbilical cord. A 3-0 Vicryl suture (Ethicon, Sommerville, N.J.) was passed beneath the umbilical cord with a 5-French semirigid automatic rat-tooth grasper (Cook Ob/ Gyn). The grasper was then passed over the cord so that the suture could be grasped on the other side. The suture was pulled through the trocar sleeve back outside the amniotic cavity to the level of the patient's skin. The other end of the suture had previously been fed through a 19.5-gauge knot pusher (Cook Ob/Gyn). A tight extracorporeal knot was tied with four throws with the knot pusher through the working port (Figure 2Figure 2
Umbilical-Cord Ligation of the Acardiac Twin.). Wave-form analysis of the umbilical artery of the normal fetus demonstrated an increase in the systolic:diastolic ratio from 3.9 before the procedure to 5.0 after ligation, but no signs of heart failure were apparent. The ends of the sutures were cut with the scissors within the amniotic cavity, approximately 1 cm away from the knot. A second knot was tied around the cord approximately 3 cm away from the first knot.Mild uterine irritability was easily controlled postoperatively with intravenous magnesium sulfate (a loading dose of 6 g followed by a maintenance dose of 2 g per hour) for 24 hours. The patient was sent home 36 hours after the procedure. Sonographic examinations were performed every week. No substantial change in the size or shape of the acardiac twin was noted for the first three weeks.
At 22 weeks' gestation, the patient reported the leakage of fluid from the vagina. Examination with a sterile speculum confirmed premature rupture of membranes (positive Nitrazine [Bristol-Myers, Princeton, N.J.], fern, and pool tests). Amniotic fluid obtained by amniocentesis was negative on Gram's staining and culture for microorganisms, and the leukocyte count and glucose concentration were within normal limits. Ultrasonography revealed decreased amniotic-fluid volume, with an amniotic-fluid index of 5 cm; the index decreased further to 2 cm during the next three days. After seven days of hospitalization, the patient noted no further leakage of fluid. Ultrasound assessment confirmed a progressively increasing amniotic-fluid volume (amniotic-fluid index of 8 cm on the 14th day of hospitalization). The patient was sent home. The cystic areas in the anomalous twin disappeared, but this fetus was still visible on ultrasonography throughout the pregnancy. The patient was hospitalized at 36 weeks' gestation with spontaneous rupture of the membranes. She went into spontaneous labor and delivered a healthy 2640-g boy with Apgar scores of 8 and 9 at one and five minutes, respectively. The neonate had a benign course, went home with his mother on the third day, and had a normal pediatric evaluation at three months of age. The acardiac acephalic twin weighed 31 g. Pathological analysis showed two distinct constrictions on the umbilical cord and fibrosis of the umbilical vessels distal to the ligation sites.
Discussion
The successful in utero management of twin reversed-arterial-perfusion sequence described in this report represents a new approach, that of operative fetoscopy, to the management of fetal disease. Previously used methods included selective delivery of the abnormal fetus through a hysterotomy5-7 and intraarterial injection of either thrombogenic coils8-10 or fibrin in the umbilical cord of the recipient twin11. Although these methods have been used with some success, the first approach requires a hysterotomy and a subsequent cesarean section and has been associated with abruptio placentae, preterm labor, preterm birth, and prolonged maternal hospitalization6. The insertion of thrombogenic coils or fibrin has been associated with the death of both twins9,11 and recanalization of the umbilical cord. Fetoscopic ligation of the umbilical cord is inherently less morbid than hysterotomy and does not have the recanalization problems associated with percutaneous, ultrasound-guided thrombosis of the umbilical cord.
The execution of this procedure required the development of a set of instruments and skills suitable for the performance of intrauterine surgery under endoscopic control. These instruments and techniques were tested first on animals (unpublished data). Special 2-mm trocars (to minimize trauma to the fetal membranes) with check-flow valves were adapted to allow the introduction of the operative and optical instruments without interrupting amniotic-fluid exchange and the monitoring of intraamniotic pressure. Skills were developed to allow the precise orientation of operative instruments inside the uterine cavity under simultaneous endoscopic and sonographic control. Purple Vicryl 3-0 suture was used because of its color, strength, ease of handling, degree of friction, and pliability. The extracorporeal knot-pushing technique used was similar to that described by Clarke14.
The patient's postoperative course was complicated by premature rupture of the membranes three weeks after the procedure. Given that the membranes resealed, we wonder whether rupture of the membranes after operative fetoscopy may not follow the same natural history as spontaneous premature rupture of the membranes.
We anticipate that in utero operative endoscopic techniques will have a role in the care of monochorionic twins discordant for anomalies, pedunculated sacrococcygeal teratomas, and other fetal and placental diseases amenable to surgical treatment. However, one must exercise appropriate prudence and caution when applying recent advances in endoscopic surgery from other fields and from experiments in animals to human fetal surgery. Operative fetoscopy is a new frontier in fetal medicine.
We are indebted to our sonographer, Ms. Mary King, for her support in the evaluation of the patient, to Dr. Faisal Qureshi for the pathological analysis of the acardiac twin and placenta, and to Mr. Rodney Bosley of Cook Ob/Gyn and Mr. Bart Bracy of Richard Wolf, Inc., for their invaluable and pivotal technical assistance.
Source Information
From the Center for Fetal Diagnosis and Therapy, Fetal Endoscopy Program, Department of Obstetrics and Gynecology, Hutzel Hospital, Wayne State University, Detroit (R.A.Q., K.S.P., M.B., M.I.E., D.B.C., R.R.); Wyoming Valley Gyn Associates, Kingston, Pa. (H.R.); and the Perinatology Research Branch, National Institutes of Child Health and Human Development, Bethesda, Md. (R.R.).
Address reprint requests to Dr. Quintero at Hutzel Hospital, 4707 St. Antoine Blvd., Detroit, MI 48201.
- References
References
1
James WH . A note on the epidemiology of acardiac monsters. Teratology 1977;16:211-216
CrossRef | Medline2
Van Allen MI ,Smith DW ,Shepard TH . Twin reversed arterial perfusion (TRAP) sequence: a study of 14 twin pregnancies with acardius. Semin Perinatol 1983;7:285-293
Web of Science | Medline3
Moore TR ,Gale S ,Benirschke K . Perinatal outcome of forty-nine pregnancies complicated by acardiac twinning. Am J Obstet Gynecol 1990;163:907-912
Web of Science | Medline4
Platt LD ,DeVore GR ,Bieniarz A ,Benner P ,Rao R . Antenatal diagnosis of acephalus acardia: a proposed management scheme. Am J Obstet Gynecol 1983;146:857-859
Web of Science | Medline5
Robie GF ,Payne GG Jr ,Morgan MA . Selective delivery of an acardiac, acephalic twin. N Engl J Med 1989;320:512-513
Full Text | Web of Science | Medline6
Fries MH ,Goldberg JD ,Golbus MS . Treatment of acardiac-acephalus twin gestations by hysterotomy and selective delivery. Obstet Gynecol 1992;79:601-604
Web of Science | Medline7
Ginsberg NA ,Applebaum M ,Rabin SA , et al. Term birth after midtrimester hysterotomy and selective delivery of an acardiac twin. Am J Obstet Gynecol 1992;167:33-37
Web of Science | Medline8
Hamada H ,Okane M ,Koresawa M ,Kubo T ,Iwasaki H . Fetal therapy in utero by blockage of the umbilical blood flow of acardiac monster in twin pregnancy. Nippon Sanka Fujinka Gakkai Zasshi 1989;41:1803-1809
Medline9
Roberts RM ,Shah DM ,Jeanty P ,Beattie JF . Twin, acardiac, ultrasound-guided embolization. Fetus 1991;1:5-1010
Porreco RP ,Barton SM ,Haverkamp AD . Occlusion of umbilical artery in acardiac, acephalic twin. Lancet 1991;337:326-327
CrossRef | Web of Science | Medline11
Grab D ,Schneider V ,Keckstein J ,Terinde R . Twin, acardiac, outcome. Fetus 1992;2:11-1312
Quintero RA ,Abuhamad A ,Hobbis JC ,Mahoney MJ . Transabdominal thin-gauge embryofetoscopy: a technique for early prenatal diagnosis and its use in the diagnosis of a case of Meckel-Gruber syndrome. Am J Obstet Gynecol 1993;168:1552-1557
Web of Science | Medline13
Simpson PC ,Trudinger BJ ,Walker A ,Baird PJ . The intrauterine treatment of fetal cardiac failure in a twin pregnancy with an acardiac, acephalic monster. Am J Obstet Gynecol 1983;147:842-844
Web of Science | Medline14
Clarke HC . Laparoscopy -- new instruments for suturing and ligation. Fertil Steril 1972;23:274-277
Web of Science | Medline
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1
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Johanna M. Middeldorp, Frans J.C.M. Klumper, Dick Oepkes, Enrico Lopriore, Humphrey H.H. Kanhai, Frank P.H.A. Vandenbussche. (2008) Selective Feticide in Monoamniotic Twin Pregnancies by Umbilical Cord Occlusion and Transection. Fetal Diagnosis and Therapy 23:2, 121-125
CrossRef12
Zoi Russell, Rubén A. Quintero, Eftichia V. Kontopoulos. (2007) Intrauterine growth restriction in monochorionic twins. Seminars in Fetal and Neonatal Medicine 12:6, 439-449
CrossRef13
Joseph P. Bruner, R. Douglas Wilson, N. Scott Adzick, Louise Wilkins-Haug, Audrey C. Marshall, Ruben A. Quintero, M. Yamamoto, Y. Ville, Anthony Johnson, Julie S. Moldenhauer. 2006. Intrauterine Surgical Techniques. .
CrossRef14
Rubén A. Quintero, Ramen H. Chmait, Takeshi Murakoshi, Zofia Pankrac, Malgorzata Swiatkowska, Patricia W. Bornick, Mary H. Allen. (2006) Surgical management of twin reversed arterial perfusion sequence. American Journal of Obstetrics and Gynecology 194:4, 982-991
CrossRef15
Amy E. Wong, Waldo Sepulveda. (2005) Acardiac anomaly: current issues in prenatal assessment and treatment. Prenatal Diagnosis 25:9, 796-806
CrossRef16
Deborah Blizzard. (2005) A Trying Experience: Fetoscopy and Maternal Decision Making. Clinical Obstetrics and Gynecology 48:3, 562-573
CrossRef17
Allen Ayres, Timothy R. B. Johnson. (2005) Management of Multiple Pregnancy. Obstetrical & Gynecological Survey 60:8, 538-549
CrossRef18
Chih-Ping Chen. (2005) Acardiac Twinning (Twin Reversed Arterial Perfusion Sequence): A Review of Prenatal Management. Taiwanese Journal of Obstetrics and Gynecology 44:2, 105-115
CrossRef19
Ahmet Gul, Altan Cebeci, Gokhan Yildirim, Halil Aslan, Yavuz Ceylan. (2005) Successful Intrauterine Treatment with Alcohol Ablation in a Case of Acardiac Twin Pregnancy. Journal of Perinatology 25:5, 352-355
CrossRef20
Neena Malhotra, Alka Sinha, Deepika Deka, Kallol K. Roy. (2004) Twin reversed arterial perfusion: Report of four cases. Journal of Clinical Ultrasound 32:8, 411-414
CrossRef21
Thomas Kohl. (2004) Fetoscopic surgery: where are we today?. Current Opinion in Anaesthesiology 17:4, 315-321
CrossRef22
Raul A Cortes, Diana L Farmer. (2004) Recent advances in fetal surgery. Seminars in Perinatology 28:3, 199-211
CrossRef23
L Lewi, D Van Schoubroeck, M Van Ranst, G Bries, M-P Emonds, B Arabin, R Welch, J Deprest. (2004) Successful Patching of Iatrogenic Rupture of the Fetal Membranes. Placenta 25:4, 352-356
CrossRef24
J EGAN, A BORGIDA. (2004) Multiple gestations: the importance of ultrasound. Obstetrics and Gynecology Clinics of North America 31:1, 141-158
CrossRef25
Mohamed Bédis Chanoufi, Riadh Ben Temime, Aïda Masmoudi, Kamilia Ounaïssa, Sami Jebnoun, Walid Abid, Rafika Nsiri, Héla Chelli, Naïma Khrouf, Soumaya Siala-Gaïgi. (2004) Clinical and Anatomic Features of Acardiac Twins. Medical Principles and Practice 13:6, 375-379
CrossRef26
D. Gallot, H. Laurichesse, D. Lemery. (2003) Selective feticide in monochorionic twin pregnancies by ultrasound-guided umbilical cord occlusion. Ultrasound in Obstetrics and Gynecology 22:5, 484-488
CrossRef27
Y. Ville, . (2003) Selective feticide in monochorionic pregnancies: toys for the boys or standard of care?. Ultrasound in Obstetrics and Gynecology 22:5, 448-450
CrossRef28
T. Y. T. Tan, W. Sepulveda. (2003) Acardiac twin: a systematic review of minimally invasive treatment modalities. Ultrasound in Obstetrics and Gynecology 22:4, 409-419
CrossRef29
Enrico Danzer, Roman M Sydorak, Michael R Harrison, Craig T Albanese. (2003) Minimal access fetal surgery. European Journal of Obstetrics & Gynecology and Reproductive Biology 108:1, 3-13
CrossRef30
TIMOTHY M. CROMBLEHOLME, MARK P. JOHNSON. (2003) Fetoscopic Surgery. Clinical Obstetrics and Gynecology 46:1, 76-91
CrossRef31
Shinjiro Hirose, Diana Farmer. (2002) Minimal Access Treatment of Fetal Birth Defects. Pediatric Endosurgery & Innovative Techniques 6:2, 117-124
CrossRef32
Theera Tongsong, Chanane Wanapirak, Supatra Sirichotiyakul, Pharuhas Chanprapaph. (2002) Intrauterine treatment for an acardiac twin with alcohol injection into the umbilical artery. Journal of Obstetrics and Gynaecology Research 28:2, 76-79
CrossRef33
M. J. O. Taylor, E. Shalev, S. Tanawattanacharoen, M. Jolly, S. Kumar, E. Weiner, P. M. Cox, N. M Fisk. (2002) Ultrasound-guided umbilical cord occlusion using bipolar diathermy for Stage III/IV twin-twin transfusion syndrome. Prenatal Diagnosis 22:1, 70-76
CrossRef34
M. Jolly, M. Taylor, G. Rose, L. Govender, N.M. Fisk. (2001) Interstitial laser: a new surgical technique for twin reversed arterial perfusion sequence in early pregnancy. BJOG: An International Journal of Obstetrics and Gynaecology 108:10, 1098-1102
CrossRef35
Roman M. Sydorak, Craig T. Albanese. (2001) Minimal Access Surgery in the Fetus. Problems in General Surgery 18:1, 33-44
CrossRef36
Michael R Harrison. (2000) Surgically correctable fetal disease. The American Journal of Surgery 180:5, 335-342
CrossRef37
C. Mohanty, O.P. Mishra, C.P. Singh, B.K. Das, P.N. Singla. (2000) Acardiac anomaly spectrum. Teratology 62:5, 356-359
CrossRef38
Norwitz, Errol R., Hoyte, Lennox P.J., Jenkins, Kathy J., van der Velde, Mary E., Ratiu, Peter, Rodriguez-Thompson, Diana, Wilkins-Haug, Louise, Tempany, Clare M.C., Fishman, Steven J., . (2000) Separation of Conjoined Twins with the Twin Reversed-Arterial-Perfusion Sequence after Prenatal Planning with Three-Dimensional Modeling. New England Journal of Medicine 343:6, 399-402
Full Text39
Perry Osborn, Thomas L. Gross, J. J. Shah, Lindsey Ma. (2000) Prenatal diagnosis of fetal heart failure in twin reversed arterial perfusion syndrome. Prenatal Diagnosis 20:8, 615-617
CrossRef40
M TAYLOR, N FISK. (2000) Prenatal diagnosis in multiple pregnancy. Best Practice & Research Clinical Obstetrics & Gynaecology 14:4, 663-675
CrossRef41
Ross Milner, Timothy M. Crombleholme. (1999) Troubles with twins: Fetoscopic therapy. Seminars in Perinatology 23:6, 474-483
CrossRef42
Mark I. Evans, James D. Goldberg, Janet Horenstein, Ronald J. Wapner, Melissa A. Ayoub, Joanne Stone, Shlomo Lipitz, Rueven Achiron, Wolfgang Holzgreve, Bruno Brambati, Anthony Johnson, Mark P. Johnson, Alex Shalhoub, Richard L. Berkowitz. (1999) Selective termination for structural, chromosomal, and mendelian anomalies: International experience. American Journal of Obstetrics and Gynecology 181:4, 893-897
CrossRef43
E. Albert Reece. (1999) First trimester prenatal diagnosis: Embryoscopy and fetoscopy. Seminars in Perinatology 23:5, 424-433
CrossRef44
Rubén A. Quintero, Walter J. Morales, Mary Allen, Patricia W. Bornick, Jorge Arroyo, German LeParc. (1999) Treatment of iatrogenic previable premature rupture of membranes with intra-amniotic injection of platelets and cryoprecipitate (amniopatch): Preliminary experience. American Journal of Obstetrics and Gynecology 181:3, 744-749
CrossRef45
M. L. Denbow, T. G. Overton, K. R. Duncan, P. M. Cox, N. M. Fisk. (1999) High failure rate of umbilical vessel occlusion by ultrasound-guided injection of absolute alcohol or enbucrilate gel. Prenatal Diagnosis 19:6, 527-532
CrossRef46
Shlomo Wientroub, David Keret, Moshe Bronshtein. (1999) Prenatal Sonographic Diagnosis of Musculoskeletal Disorders. Journal of Pediatric Orthopaedics 19:1, 1-4
CrossRef47
Shlomo Wientroub, David Keret, Moshe Bronshtein. (1999) Journal of Pediatric Orthopedics 19:1, 1-4
CrossRef48
Rodeck, Charles, Deans, Anne, Jauniaux, Eric, . (1998) Thermocoagulation for the Early Treatment of Pregnancy with an Acardiac Twin. New England Journal of Medicine 339:18, 1293-1295
Full Text49
Rubén A. Quintero, Walter J. Morales, Craig S. Kalter, Mary Allen, Gustavo Mendoza, Jeffrey L. Angel, Roberto Romero. (1998) Transabdominal intra-amniotic endoscopic assessment of previable premature rupture of membranes. American Journal of Obstetrics and Gynecology 179:1, 71-76
CrossRef50
Nikolaos A. Papadopulos, Paul P. Van Ballaer, Jose L. Ordoñez, Ivan J. Laermans, Kamiel Vandenberghe, Toni E. Lerut, Jan A. Deprest. (1998) Fetal membrane closure techniques after hysteroamniotomy in the midgestational rabbit model. American Journal of Obstetrics and Gynecology 178:5, 938-942
CrossRef51
Christine Louis-Sylvestre, Jacob H. Rand, Ronald E. Gordon, Carolyn M. Salafia, Richard L. Berkowitz. (1998) In vitro studies of the interactions between platelets and amniotic membranes: A potential treatment for preterm premature rupture of the membranes. American Journal of Obstetrics and Gynecology 178:2, 287-293
CrossRef52
G. R. HOWARTH L. R. PISTORUIS W. COMBR. (1998) Exteriorisation, ligation and replacement of the umbilical cord in the management of early onset severe twin-twin transfusion syndrome. Journal of Obstetrics & Gynaecology 18:3, 278-278
CrossRef53
Keith R. Duncan, Mark L. Denbow, Nicholas M. Fisk. (1997) The aetiology and management of twin–twin transfusion syndrome. Prenatal Diagnosis 17:13, 1227-1236
CrossRef54
Larry G. Dennis, Carey L. Winkler. (1997) Twin-to-twin transfusion syndrome: Aggressive therapeutic amniocentesis. American Journal of Obstetrics and Gynecology 177:2, 342-349
CrossRef55
Ash Hanafy, C. Matthew Peterson. (1997) Twin-Reversed Arterial Perfusion (TRAP) Sequence: Case Reports and Review of Literature. The Australian and New Zealand Journal of Obstetrics and Gynaecology 37:2, 187-191
CrossRef56
E REECE. (1997) EMBRYOSCOPY AND EARLY PRENATAL DIAGNOSIS. Obstetrics and Gynecology Clinics of North America 24:1, 111-121
CrossRef57
T QUINN, N ADZICK. (1997) FETAL SURGERY. Obstetrics and Gynecology Clinics of North America 24:1, 143-157
CrossRef58
(1997) Short communication. Journal of Perinatal Medicine 25:1, 119-124
CrossRef59
Erik D Skarsgard, Martin Meuli, Karen J VanderWall, John F Bealer, N.Scott Adzick, Michael R Harrison. (1996) Fetal endoscopic tracheal occlusion (‘Fetendo-PLUG’) for congenital diaphragmatic hernia. Journal of Pediatric Surgery 31:10, 1335-1338
CrossRef60
RubénA. Quintero, Roberto Romero, Jeff Dzieczkowski, Eberhard Mammen, MarkI. Evans. (1996) Sealing of ruptured amniotic membranes with intra-amniotic platelet-cryoprecipitate plug. The Lancet 347:9008, 1117
CrossRef61
Rubén A Quintero, Mark I Evans. (1995) Bringing surgery to the fetus. The Lancet 346, S18
CrossRef62
Joanne Stone, Richard L. Berkowitz. (1995) Multifetal pregnancy reduction and selective termination. Seminars in Perinatology 19:5, 363-374
CrossRef63
Mary E. D'Alton, Lynn L. Simpson. (1995) Syndromes in twins. Seminars in Perinatology 19:5, 375-386
CrossRef64
Jan A. Deprest, François I. Luks, Koen H.E. Peers, Kamiel Vandenberghe, Toni E. Lerut, Ivo A. Brosens, F.André Van Assche. (1995) Intrauterine endoscopic creation of urinary tract obstruction in the fetal lamb: A model for fetal surgery. American Journal of Obstetrics and Gynecology 172:5, 1422-1426
CrossRef65
Richard P. Porreco, Jack H.T. Chang, Barbara J. Quissell. (1995) Reply. American Journal of Obstetrics and Gynecology 172:2, 716-717
CrossRef66
Kenneth J. Moise, Michael Belfort, George Saade. (1995) Iatrogenic gastroschisis in the treatment of diaphragmatic hernia. American Journal of Obstetrics and Gynecology 172:2, 715
CrossRef67
Michael R. Foley, William H. Clewell, Harris J. Finberg, Marlin D. Mills. (1995) Use of the Foley Cordostat grasping device for selective ligation of the umbilical cord of an acardiac twin: A case report. American Journal of Obstetrics and Gynecology 172:1, 212-214
CrossRef68
(1994) A Simpler Technique for Umbilical-Cord Blockade of an Acardiac Twin. New England Journal of Medicine 331:1, 56-57
Full Text69
N.S. Adzick, M.R. Harrison. (1994) Fetal surgical therapy. The Lancet 343:8902, 897-902
CrossRef
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