The NewsWomb: Recent Episodes
Kenneth Moise and Erin Moise
Dr. Kenneth Moise and Erin Moise, PA-C aim to update patients and providers on the ever-evolving field of fetal medicine with some fun in between
SPECIAL GUEST - Dr. Saul Snowise – Part 1 of 2
This week and next week we have a two-part series with Dr. Saul Snowise as we discuss the role of selective reduction, specifically in the setting of monochorionic twins. Join us as we discuss the following this week:
- How selective reduction differs in monochorionic vs. dichorionic twins
- Most common method of selective reduction
- Potassium chloride (KCl) injection contraindicated in monochorionic twins
- Method for monochorionic pregnancy
- Cord occlusion
- Most common method of selective reduction
- Indications for selective reduction in monochorionic twins
- Selective fetal growth restriction (sIUGR)
- Discordant anomalies
- Twin-twin transfusion syndrome (TTTS)
- Twin reverse arterial perfusion (TRAP) sequence
- Failed laser
- Various methods for performing a cord occlusion selective reduction
- Microwave
- Interstitial laser
- Radiofrequency ablation (RFA)
- Bipolar cautery
- Sizes of operative instruments, energy levels used and the treatment protocols
- Gestational age thresholds for performing a selective reduction procedure
- Risks associated with a selective reduction procedure
- Membrane complications (i.e. PPROM)
- Preterm delivery
- Bleeding, infection
- Loss of co-twin
- Pre-operative counseling with patients
- Follow-up and surveillance for the remainder of the pregnancy
Tune in next week for part 2!
Welcome back "What they didn't teach you in laser school" – now onto Part 2! This week we’re going to continue talking about all our laser tips & tricks while discussing the following:
- Anterior placenta challenges
- Future of steerable operative scopes
- Current 30 degree operative Storz scope
- Using external pressure to aid in flattening the uterus
- Intraoperative amnioinfusion
- Future of steerable operative scopes
- Intraoperative complications
- Concurrent fetal bradycardia in both fetuses
- What to do when the laser won’t stop firing
- Intra-operative bleeding
- Post-operative complications
- Bleeding
- Placental abruption
- Intraperitoneal bleeding
- Amniotic fluid leakage
- PROM (premature rupture of membranes)
- Intraperitoneal amniotic fluid leakage
- Bleeding
Welcome to "What they didn't teach you in laser school"! This two-parter is going to be filled with Dr. Moise's tips and tricks (and some of Erin's too) as we share the following topics:
- Pre-operative evaluation tips
- Identifying cord insertions via ultrasound
- Following the lie of the donor twin to find the inter-twin anastomotic plane
-
Not true for “cocoon” sign
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Re-evaluate and confirm cord insertions and anticipated cannula insertion site in the OR
- Confirming renal blood flow in the donor twin
-
Renal agenesis
-
Intraoperative tips
- Anesthesia type
- Maternal drugs we use & don’t use
- Operative cannula placement
- Patients with a higher BMI or thick abdominal wall
- Using a ‘spike’ AKA ‘harpoon’ for entry
-
Spinal anesthesia for cut-down
-
Anterior placenta
- Patient positioning
-
Laparoscopic approach
-
Check uterine wall for vessels with color flow Doppler
-
Counterpressure
-
Intraoperative bleeding
- Amnioexchange / rapid infuser
- Using humidified CO2 for anterior placenta
-
Pediatric foley
-
Intraoperative septostomy
- Inadvertent vs. purposeful septostomy
- Complications
- Amniotic band syndrome
- Tangled cords
Tune in next week for part 2!
This week we’re going to be using the most recent episodes as building blocks to discuss atypical presentations of twin-twin transfusion syndrome or TTTS. Dr, Moise takes us through the following ‘unicorn’ presentations by covering the following:
- Review of the classic Quintero staging system for TTTS
- Stage I, II, III, IIID, IIIR, IIIDR, IV, V
- Alternative TTTS staging systems that have been proposed
- Cincinnati
- CHOP
- Case scenario of an atypical TTTS IIID
- TTTS with sIUGR
- Review definition of sIUGR
- Cardiac dysfunction in the setting of monochorionic twins
- Which combination of twin complications in monochorionic twins would be candidates for laser surgery
- Monoamniotic twins with TTTS
- Diagnosing TTTS with a spontaneous septostomy
SPECIAL GUEST - Dr. Ramesha Papanna – Part 2 of 2
Join us as we continue our discussions on Twin Anemia Polycythemia (TAPS).
This week Dr. Papanna walks us through the following topics on TAPS:
- Society of Maternal Fetal Medicine (SMFM) and International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guidelines and recommendations for monitoring MCA Dopplers in monochorionic twins
- Laser ablation of placental anastomoses as treatment for TAPS
- Transabdominal approach
- Role of Solomon technique / solomonization in TAPS
-
Disease severity and clinical indications for laser as treatment for TAPS
-
Intrauterine Transfusion (IUT) or exchange transfusion as treatment options for TAPS
- How gestational age affects management of TAPS
- TAPS as a complication of an incomplete laser for TTTS
- Long-term outcomes and sequelae for a pregnancy affected by TAPS
Resources for patients:
www.tapssupport.com
- SPECIAL GUEST* - Dr. Ramesha Papanna – Part 1 of 2
Join on as we head down another aisle of Twins R’ Us but this time with a very special guest who is joining us for this two-part series on Twin Anemia Polycythemia Sequence (TAPS)!
This week Dr. Papanna walks us through the following topics on TAPS:
- Defining TAPS
- Pathophysiology of TAPS
- Difference between spontaneous TAPS and TAPS after a laser for TTTS
- How TAPS is detected
-
Rate of occurrence of TAPS in monochorionic twin pregnancies
-
The original definition and staging of TAPS from the Leiden group in 2007
- Fetal vs. neonatal criteria
-
MCA Doppler discordance
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Staging mirror TTTS staging
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The three stages of population-based disease
- Screening – deploying a particular test on a large population to pick up on potential disease
- Diagnosis – confirmatory test
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Outcome –the effect of the diagnosis on
-
Common ultrasound findings in TAPS
- ‘Starry Liver’
- Placental thickness
-
Discordant MCAs
-
Placental vessel anastomosis types involved in TAPS
Tune in next week for Part 2!
We know many of you tuned in eager to hear a big clinical research update that we've been so excited to share! That episode will be coming down the pipeline soon but unfortunately will not be released today.
Stay tuned for an episode later today as we travel down the TAPS aisle of Twins R' Us with Dr. Ramesh Papanna!
We're heading down the Taco Aisle at Twins R' Us this week as we dive into sIUGR also known as selective intrauterine growth restriction. Join us this week as we discuss the following:
- Defining sIUGR in monochorionic twins
- Must meet at least two of the following four criteria
- Smaller twin must be less than 10th percentile for EFW by ultrasound
- And/Or the smaller twin’s AC must be less than 10th percentile for gestational age
- More than 25% difference of smaller twin and the bigger twin EFW
- UA Doppler of the smaller twin has a pulsatility index greater than 95th percentile for gestational age
- Must meet at least two of the following four criteria
- Doppler measurements and why we do them
- UA Doppler – surrogate marker for placental resistance & placental territory or how much placenta each baby has
- Pulsatility index = (systolic velocity – diastolic velocity) / mean
- AEDF – high resistance in the placenta
- REDF – if the blood ‘bounces’ off the placenta from the UA
- UA Doppler – surrogate marker for placental resistance & placental territory or how much placenta each baby has
- Defining sIUGR in dichorionic twins
- Must meet at least two of the following three criteria
- Smaller twin must be less than 10th percentile for EFW by ultrasound
- More than 25% difference of smaller twin and the bigger twin EFW
- UA Doppler of the smaller twin has a pulsatility index grea ter than 95th percentile for
- Must meet at least two of the following three criteria
- How often sIUGR occurs in monochorionic twins
- The three subtypes of sIUGR described by Dr. Eduard Gratacos & their rate of occurrence
- Type 1 – positive EDF in smaller twin
- 29% of sIUGR cases
- Type 2 – Absent or reversed EDF in smaller twin
- 22% of sIUGR cases
- Type 3 – Absent or reversed EDF in smaller twin alternating with positive diastolic flow
- 49% of sIUGR cases
- Type 1 – positive EDF in smaller twin
- The placental vessel anastomoses types & their frequency in each subtype of sIUGR
- Arterial to arterial (AA)
- Arterial to venous (AV)
- Venous to arterial (VA)
- Venous to venous (VV)
- ‘Spiders’
- Umbilical artery cord Doppler physiology differences between singleton pregnancies and monochorionic twin pregnancies
- Ductus venosus Doppler as surrogate marker for fetal cardiac function
- Defining a cotyledon
- Outcomes based on sIUGR subtypes
- Typical gestational age at delivery for each subtype
- Management, possible complications & outcomes for each subtype of sIUGR
Glossary of Abbreviations
- sIUGR – selective intrauterine growth restriction
- FGR – fetal growth restriction
- SGA – small for gestational age
- Defined as below 10th percentile
- EFW – estimated fetal weight
- AC – abdominal circumference
- UA – umbilical artery
- PI – pulsatility index
- EDF – end diastolic flow
- AEDF – absent end diastolic flow
- REDF – reversed end diastolic flow
- AA – arterial to arterial
- AV – arterial to venous
- VA – venous to arterial
- VV – venous to venous
- DV – Ductus venosus
Introducing our newest segment - Great Syndromes! Modeled after Erin's PA school course developed to prepare healthcare students for clinical rotations, this segment utilizes real case scenarios to help guide diagnostic and treatment guidelines for patients in the setting of fetal medicine.
This week our case is a 34-year-old G10 P7 who presents at 23 weeks and 4 days with a referring diagnosis of monochorionic diamniotic twin gestation with Stage II twin-twin transfusion syndrome (TTTS). Her placenta is posterior and the maximum vertical pocket (MVP) of the 'recipient' twin sac is 22.0 cm. In this episode we'll discuss some of the following points:
- Differential diagnoses for polyhydramnios in pregnancy
- Maternal gestational diabetes
- Anatomical fetal anomalies
- Upper GI tract obstructions
- Esophageal atresia
- Duodenal atresia
- Tracheoesophageal fistula (TEF)
- Arthrogryposis multiplex
- Upper GI tract obstructions
- Twin-twin transfusion syndrome causes hypervolemia in the recipient twin and therefore increase urine output
- Post-procedure tocolytic options nifedipine vs. indomethacin
- How placental location affects surgical approach in TTTS
SPECIAL GUEST - Dr. Yves Ville – Part 2 of 2
This is an episode we recorded at the 2023 SMFM Conference back in February. Our special guest, Dr. Yves Ville, returns this week to continue our discussion about his role and contributions to the field of fetal surgery and specifically twin-twin transfusion syndrome. In part 2 we go through the following:
- Outcomes on survivors of both fetuses, one fetus or loss of both fetuses
- Laser surgery becomes accepted as evidence-based treatment as a result of the randomized controlled trial
- Intraoperative techniques:
- Selective vs. Nonselective
- Solomon
- Complications of a failed laser surgery
- Dr. Ville’s describes his contributions in research on offering laser surgery for Stage I TTTS and how he counsels these patients
- Dr. Ville’s research in short cervix and treatment options in the setting of TTTS
SPECIAL GUEST - Dr. Yves Ville – Part 1 of 2
This is an episode we recorded at the 2023 SMFM Conference back in February. Our special guest this week, Dr. Yves Ville, sat down with us to talk about his role and contributions to the field of fetal surgery and specifically twin-twin transfusion syndrome. In part 1 we go through the following:
- Dr. Ville’s training and the events that led up to him entering the field of fetal medicine
- Dr. Ville’s experience with laser surgery for twin-twin transfusion syndrome (TTTS)
- The 2004 randomized trail study comparing laser surgery to amnioreduction for TTTS
- Why the trial was stopped early
Tune in next week when we continue our conversation with Dr. Ville on the outcome studies and editorials that were published after his 2004 study.
SPECIAL GUEST - Dr. Michael Bebbington.
This week Dr. Bebbington joins us to talk about the background of twin-twin transfusion syndrome (TTTS) as he covers the following topics:
- Pathophysiology of twin-twin transfusion syndrome (TTTS) ‘Donor’ twin vs. ‘Recipient’ twin
- Types of vessel anastomoses involved in TTTS
- AA – artery to artery
- VV – vein to vein
- AV – artery to vein
- VA – vein to artery
- Pathophysiology of the polyhydramnios and oligohydramnios seen in TTTS
- Types of vessel anastomoses involved in TTTS
- Assessing Dopplers in-utero using ultrasound and the different fetal vessels Doppler is used on
- Defining the Quintero stages of TTTS (I through V)
- Stage I – “Poly” & “Oli”
- Donor DVP 8.0 cm
- Stage II – No visible bladder in donor twin
- Stage III – Doppler abnormalities in one or both twins (Stage IIID, IIIR, IIIDR, and ‘Atypical Stage III)
- Absent/reversed end diastolic flow in umbilical artery (UA)
- Absent/reversed ‘a’ wave in ductus venosus (DV)
- Umbilical vein (UV) pulsations
- Stage IV – Hydrops in one or both twins
- Stage V – Demise of one or both twins
- Stage I – “Poly” & “Oli”
- Risk of demise of both fetuses and physiological changes in the surviving twin should one twin die in-utero
- Atypical presentations of TTTS
- Why we use maximum vertical pocket (MVP) or deepest vertical pocket (DVP) to quantify fluid in twins over an amniotic fluid index (AFI)
- Adjuvant TTTS staging systems
- Frequency and rate of occurrence of TTTS in monochorionic pregnancies
- Prognosis, survival and outcomes of TTTS with and without treatment
- Frequency of surveillance for TTTS in monochorionic pregnancies
- How a laser surgery is performed for treatment of TTTS
- Solomon technique
- Recurrent TTTS and TAPS are complications of incomplete laser surgeries
- Amnioreduction at the end of the procedure to remove extra fluid from the recipient twin amniotic sac
- Pre-operative counseling for the patient and common complications that can occur during or after a laser procedure
- Gestational age at which a laser ablation of placental anastomoses typically occurs
- Follow-up after a laser surgery
- Factors associated with poorer prognosis or poorer survival rates
- Average gestational age of delivery after a laser surgery
- Training programs for learning to do laser surgery for TTTS
- The role of selective reduction in TTTS
- Implications laser surgery can have on future pregnancies for patients
- Risk of developing TTTS in a subsequent pregnancy
We’re talking through the season six premiere of The Resident, where they take on a twin-twin transfusion case. We debunk and verify all myths and truths depicted in this episode surrounding the counseling, diagnosis, management, and even laser surgery itself from this episode.
This episode is dedicated to the late Dr. Julian De Lia whom we lost in November 2022. Dr. De Lia was truly one of the greatest fetal surgery pioneers, particularly in the TTTS.
Welcome back to Twins R Us! This week we’re going to talk about the history of twin-twin transfusion syndrome (TTTS) and the history of treatment for the disease.
Dr. Moise will take us through the following topics in this episode:
- The discovery of pathophysiology of TTTS
- Idea of the ‘Third Circulation’
- Berniske’s proposed phenotype
- Placental injection studies
- The fetal loss rate of TTTS without treatment
- Early treatment attempts
- Weekly amnioreductions
- Septostomy trial
- The early use of laser therapy to treat TTTS in-utero during the early 1908s by DeVore and De Lia
- Laser technique variation and development by country
- The development of the Quintero Staging system
- Initial trials and implementation of evidence-based laser therapy for TTTS
- Karl Storz endoscopy develops fetoscopes for laser surgery under HDE in the US
- Discussions and support from national & international societies
- Major changes in laser techniques since its initial introduction into fetal surgery
We’re back on scheduled wombmates! This week we’re talking about management of twin pregnancies as Dr. Moise takes us through the following topics:
- The role of ultrasound in twin pregnancies
- CRL = Crown Rump Length for dating
- Chorionicity determination
- Transvaginal cervical length measurement
- Importance of the 18-20 week anatomy scan and fetal echocardiogram
- Ultrasound monitoring based on chorionicity
- Dichorionic pregnancies should be followed every 3 to 4 weeks with a growth scan ultrasound
- Monochorionic pregnancies should begin regular ultrasound monitoring at 16 weeks gestation
- Every 2 weeks – measurements of fluid levels and fetal bladders
- Then at 20 weeks ISUOG says to start monitoring umbilical artery (UA) and middle cerebral artery (MCA) Dopplers during regular growth scans
- Discordant anomalies and their rate of occurrence in twin pregnancies
- Screening for chromosomal problems
- Cell free DNA (cffDNA) – consider vanishing twin as source of abnormal result
- Nuchal translucency with analytes
- Maternal complications in twin pregnancies & how they are managed prenatally
- Timings & method of delivery for twin pregnancies
- Treatment options for short cervix in twin pregnancies
- Antenatal testing in twin pregnancies and when to start
- Management of monoamniotic twin pregnancies
- We're kicking off a new series on all things twins! Welcome to Twin 'R' Us where we will introduce the following in this episode:
- Prevalence & rate of occurrence of twins in general and the different types
- The different types in twins in terms of zygosity
- Identical – monozygotic
- Fraternal – dizygotic
- Rare fraternal twin occurrences:
- Superfetation
- Heteropaternal superfecundation
- Factors that affect a women’s risk of twinning
- Monozygotic – chance of nature
- Dizygotic
- Genetics
- Diet
- IVF
- Ethnicity
- Zygosity vs. Chorionicity and why the difference is important
- Monochorionic vs. dichorionic and why chorionicity matters
- How embryologic age affects chorionicity
- Importance of ultrasound in twin pregnancies
- Determining chorionicity:
- ‘Lambda’ sign
- ‘T’ sign
- Dating twin pregnancy with crown-rump length (CRL)
- Measuring nuchal translucency (NT) or nuchal thickness
- Determining chorionicity:
- Possible twin complications
- Twin-twin transfusion syndrome (TTTS)
- Twin anemia polycythemia sequence (TAPS)
- Selective intrauterine growth restriction (sIUGR)
- Twin reverse arterial perfusion (TRAP) sequence
- Unusual twin cases:
- Vanishing twin
- Acardiac / Lazarus twin
- TRAP sequence
- Conjoined twins
- Parasitic twins
- Feto in feto
No new episode today wombmates! We've had a busy clinic the last couple of weeks and Erin is heading out on vacation, but stay tuned for new content to drop later in the week!
Before we enter our next series on twins, we wanted to go give some background on fetal centers and what they are. In this episode we’ll discuss some basic background on fetal centers, fetal therapies, and fetal medicine by covering the following:
- Types of cases seen at a fetal center:
- 70% anomalies with coordination of care
- 20% fetal surgery or fetal intervention
- 10% life-limiting anomalies
- As of early 2023 there are currently about 37 fetal centers in the United States
- Of which about 14 are about to provide full fetal center services
- How national organizations have defined fetal centers
- The development of NAFNET – North American Fetal Treatment Network
- Full list of fetal interventions
- IUTs – Intrauterine Transfusion
- Lasers for twin-twin transfusion syndrome
- In-utero myelomeningocele / spina bifida repair
- Tracheal occlusion for congenital diaphragmatic hernia
- Which physician specialty specialties typically serve as director or head of fetal centers
- How the MOMS trial influenced the development and definition of fetal centers
- OB center & NICU center level designations (I, II, III, IV)
- Fetal center level designations (I, II, III)
- Legislature and committees that have formed to help create guidelines for fetal centers
- Areas the committee did well in and areas for improvement
- Where does the certification of fetal centers stand today?
SPECIAL GUEST - Dr. Jacqueline Vidosh
In honor of Edwards Syndrome Awareness Day, March 18th, we're dropping Part 2 of our interview with Dr. Vidosh a little bit early.
Dr. Vidosh is a practicing OBGYN and proud Mother of a baby boy, Noah, diagnosed with Edwards Syndrome. This week she talks a bit more about Noah's early life and childhood as she continues her story.
Resources:
Support Organization For Trisomy (SOFT)
Trisomy 18 Foundation
SPECIAL GUEST - Dr. Jacqueline Vidosh
Dr. Vidosh is a practicing OBGYN and proud Mother of a baby boy, Noah, diagnosed with Edward Syndrome. She takes us through the story of her pregnancy, the arrival of Noah, and her experience with him has changed how she practices medicine and counsels patients.
Stay tuned next week for part 2 coming this Saturday, March 18th!
Resources:
Support Organization For Trisomy (SOFT)
SPECIAL GUEST - Sasha Griffith, RN, BSN, CHPPN, CPLC
We have not one but two special guests this week! Delaney Herman is back this week as my co-host to help me interview Sasha Griffith from our palliative care team.
Sasha walks us through the complexities of palliative care covering the following:
- The difference between palliative care & hospice care
- What it looks like for a patient to be discharged home on hospice care
- What kinds of providers & healthcare professionals form a palliative care team
- The role of palliative care in the hospital/inpatient setting
- Counseling patients and families on how to talk about their baby's diagnosis with other young children in the family and also adult family members and friends
- The process of developing a care plan or delivery plan for a family in need of palliative care
SPECIAL GUEST – Dr. Amy Coffey
Pediatric pathologist & Hematopathologist
Dr. Coffey leads our discussion on the role of autopsy after a stillbirth or infant loss covering the following topics:
- Process/procedure of an autopsy
- Types of autopsies
- Non-invasive autopsy testing
- The ‘four hour’ guideline to get the fetus/neonate to the morgue
- Estimating time of death for an IUFD based on physiologic changes using autopsy
- Conditions or diseases where autopsy can be helpful in guiding future pregnancy treatment
- Funeral service options after an autopsy
- Genetic testing options after an infant or neonatal loss
- Role and significant of placental pathology
- Placental pathological findings including funicitis and fibrin deposition in the placenta
- Placenta reserve capacity
- What pathologists look for to rule out a placental abruption
- Who pays for the autopsy?
- How long results take to return on an autopsy
SPECIAL GUEST - Delaney Herman, LCSW
This week continues our discussion on stillbirth, infant loss, and neonatal loss. Delaney starts out by telling us a bit about her background, how she came to be a social worker, and what the role of social worker is in our particular clinical setting.
In this episode with discuss the following:
· The spectrum of loss we see in our practice including miscarriages, fetal loss, and infant/neonatal loss
· Is there a correct way to grieve?
· What grief may look like shortly after a loss
· How grief can differ, fluctuate, and change throughout the grieving process
· Differences between social workers, licensed professional counselors, psychologists, and psychiatrists
· Warning signs/symptoms that family members and loved ones of those who have lost a baby should look out for to seek emergency help
· Memory making after a loss
· Resources:
o Post-partum support international
o Beads of courage
TRIGGER WARNING this episode discusses stillbirth, infant loss, and fetal loss and may be distressing or trigger for some listeners. Listener discretion is advised.
We’re continuing our discussion on stillbirth this week getting into a bit more of the nuchal cord aspect of the House of the Dragon – The Black Queen episode. This week we talk about the following topics:
· Umbilical cord issues including nuchal cord (single, double, triple) and their prevalence
· Work-up for a stillbirth
o Maternal labs
o Amniocentesis vs. fetal tissue for chromosome analysis
o Placental culture/pathology evaluation
o Introduction to neonatal/fetal autopsy
· Incidence of unknown cause of stillbirth
Note: this episode will cover broad strokes of neonatal/fetal autopsy but tune in for Part 4 when we’ll dive into a bit more detail on autopsies when we interview pediatric pathologist, Dr. Amy Coffey.
Part 3 drops next week featuring our amazing social worker, Delaney Herman!
TRIGGER WARNING this episode discusses stillbirth, infant loss, and fetal loss and may be distressing or trigger for some listeners. Listener discretion is advised.
In this episode of Debunking Dramatizations we’re going to talk briefly about House of the Dragon Season 1 Episode 10 – The Black Queen. This is the fourth. Yes, the FOURTH obstetrical delivery depicted in just this one season of House of the Dragon. This is also Raenyra’s 4th child, which appears to be stillborn with a nuchal cord, and a possible placental abruption?
In this episode we start by talking about what a nuchal cord is and also explain what happens in a placental abruption. Then we talk a bit more about stillbirth covering the following topics:
- How stillbirth is defined
- The prevalence of stillbirth
- Maternal and fetal risk factors for stillbirth
- Preventing stillbirth utilizing antenatal testing such a growth scans, biophysical profiles (BPP), non-stress test (NST), and the modified BPP
- Kick counts
- Method of delivery for a pregnancy resulting in stillbirth
- Future pregnancy deliveries and surveillance after experiencing a stillbirth
Stay tuned for Part 2 next week! Then we have our wonderful social worker, Delaney Herman, that will give us some perspective and resources for the psychosocial aspect after experiencing a neonatal or infant loss.
The cherry on top of our season on HDFN and alloimmunization. This week we're talking about the future potential medical therapies for this disease including nipocalimab. See below for the episode outline and topics Dr. Moise discusses this week!
- The neonatal Fc receptor is the FcRN (Neonatal crystallizable fragrant receptor)
- Where FcRN receptors are located in the human body
- Endothelial cells of blood vessels in the skin & muscle
- Placenta
- Function of FcRN receptors
- Definition an FcRN blocker
- Monoclonal antibody or fragment that blocks the FcRN by connecting to it
- How monoclonal antibodies are made
- Human applications for FcRN blockers
- Vvygart made by Argenx for myasthenia gravis
- Warm autoimmune hemolytic anemia
- Idiopathic thrombocytopenia purpura (ITP)
- Chronic demyelinating polyneuropathy
- Pemphigus vulgaris
- Grave’s exophthalmos
- Autoimmune disease, the inflammatory pathway and the FcRN blockers role in the bigger picture
- How FcRN blocker medications are administered
- How an FcRN blocker could be used in pregnancy
- Diseases in pregnancy that could potentially be treated with an FcRN blocker:
- Hemolytic Disease of the Fetus & Newborn (HDFN)
- Fetal Neonatal Alloimmune Thrombocytopenia (FNAIT)
- Gestational Alloimmune Liver Disease (GALD)
- Congenital Heart Block / Neonatal Lupus
- Current drug trials for FcRN blockers in pregnancy
- FDA drug trial process – pre-clinical, phase I, phase II, phase III, and phase IV for drug trials
- Potential risks of FcRN blockers
- How FcRN blockers may affect vaccines in pregnancy
- Other clinical conditions where FcRN blockers have been successfully used
Send us your questions on HDFN & alloimmunization for a Q&A episode! Email us at newswombpodcast@gmail.com
In this episode we’re going to discuss future pregnancy & conception options after alloimmunization sensitization. Dr. Moise starts by briefly touching on Bethany Weathersby’s story after her loss to HDFN and her pregnancies that followed. Bethany is the mother of five living children, the CEO and founder of The Allo Hope Foundation, and one of the hosts of The Allo Podcast. about her pregnancies affected by alloimmunization and after a loss from alloimmunization. Dr. Moise takes us through the future pregnancy options for alloimmunized mothers including:
- Adoption
- Surrogacy also known as a gestational carrier
- IVF pre-implantation testing (heterozygous Dad’s only)
- Confirm paternal zygosity first – refer to our Episode 8 ‘Who’s yo Daddy’
- ‘Snowflake’ babies – donor embryos
- Although rarely have any DNA testing for blood type prior to freezing
- Donor insemination
- Chorionic Villus Sampling (CVS) and the effects on an alloimmunized pregnancy
- Future medical therapies and potential noninvasive treatment options
Send us your suggestions for future episodes or questions for us to cover!
Instagram: @newswomb
Email: newswombpodcast@gmail.com
Bili is back and so is Dr. Lopriore!
Last week we talked about Phase 1 of neonatal management of HDFN and alloimmunization. This week we’re moving into Phase 2 while we discuss the following:
- Phase 1: intensive phototherapy – usually lasts about 1-2 weeks
- Phase 2: monitoring neonatal hemoglobin & hematocrit
- Outpatient neonatal monitoring – measuring hemoglobin, hematocrit, and reticulocyte counts
- Neonatal red blood cell production
- Why HDFN babies do NOT need supplemental iron
- The role of erythropoietin (EPO) in HDFN and the latest studies on it
- How HDFN treatment varies in different countries
- Other rare neonatal diseases related to HDFN
- Inspissated bile syndrome or “bronze babies” – elevated direct bilirubin as a complicated or cholestasis
- Neonatal hemochromatosis – elevated ferritin levels
- Difference between a ‘top-up’ or ‘simple’ transfusion vs. exchange transfusion
- Anecdotal evidence on the role of maternal phenobarbital prior to delivery
- Breastfeeding, hyperbilirubinemia, and phototherapy
- Reticulocyte count of 2% for two consecutive weeks to ‘graduate’ from pediatric hematology (in the US)
- Long term outcome & developmental expectations for children with HDFN
Articles:
- Antenatal maternal phenobarbital
- doi: 10.1016/j.ajog.2004.08.016
- The LOTUS study: neurodevelopmental outcome after intrauterine transfusion for hemolytic disease of the fetus/newborn
- doi: 10.1016/j.ajog.2011.09.024
- Updated AAP Neonatal Hyperbilirubinemia Management
A special thank you again to Dr. Lopriore for his time and all his contributions to this field!
Special guest on our episode this week and next, Dr. Enrico Lopriore from Leiden University. He sat down with us at IFMSS in November to do a special episode on the neonatal portion of alloimmunization and HDFN.
This week we start by discussing Dr. Lopriore's background and training and then cover treatment and management of HDFN in the neonatal phase. See below for more details!
- Hyperbilirubinemia – why is matters
- How to measure it – direct bilirubin vs. total bilirubin
- Complications of untreated elevated indirect bilirubin
- Treatment options in the neonatal course of HDFN
- Phototherapy
- Single vs. Double vs. Triple phototherapy
- Biliblankets
- Factors that affect efficacy of phototherapy
- Exchange Transfusions
- How they’re performed
- Risks & complications associated with them
- Intravenous Immune Globulin (IVIG)
- Literature and research review on efficacy and its role in the neonatal phase of HDFN
- Updated AAP Neonatal Hyperbilirubinemia Management
- Phototherapy
More to follow next week in Part 2!
This week we're going to summarize all the tools we've discussed for alloimmunization and HDFN. We’re going to use case scenarios to walk through the individual diagnosis, management, surveillance, and treatment, followed by delivery and the neonatal course for each. Dr. Moise takes us through three different case scenarios - mild, moderate, and severe. See below for timestamps and some reference information!
2:57 Case 1 - 'Mild' Disease - First affected pregnancy with a low titer
14:45 Case 2 – ‘Moderate’ Disease – Subsequent pregnancy with a moderate titer
32:47 Case 3 – ‘Severe’ Disease – Subsequent pregnancy with high titer or early need for IUTs
MCA MoM Score Calculators:
- Barcelona calculator: https://medicinafetalbarcelona.org/calc/
- Select “Anemia” then “Cerebral Doppler”
- Perinatology: https://perinatology.com/calculators/MCA.htm
IUT Blood Volume Formulas
- IVT = volume of donor blood (78-80% hct) to raise the fetal hct 10 points = 0.02 x EFW (in grams)
- IPT = (GA (in weeks)) – 20 x 10
Bring the caffeine as we wrap up IUTs this week with our detailed step by step on the procedure itself. In this episode we talk about:
- The pre-operative process including consenting and lab studies
- Using the MCV value on a CBC to determine fetal vs. maternal sample (only works for the 1st IUT)
- Fetal sample= 105-110
-
Maternal sample = 80s-90s
-
How much blood to order from the blood bank for a transfusion
Grab your coffee and eat your Wheaties wombmates! We’ve finally made it to our favorite topic – Intrauterine Transfusions! We love this topic so much we had to split it into two parts to cover everything we wanted to. This week we'll cover the background and leading up the procedure itself, then next week we'll go into more detail about the procedure itself. See the topic list below for part 1 and stay tuned next week for part 2!
- The 4 types of IUTs: intravascular (IVT), intraperitoneal (IPT), combined, and intracardiac
- When does a patient need an IUT?
- Timing of IUTs – when we start, the latest we’ll do them, and how often
- Common complications such as fetal bradycardia and options for treating it
- Donor blood preparation – extended maternal crossmatch, CMV negative, irradiated, leukocyte reduced, and washed
- How long the procedure lasts and where it takes place
- What type of anesthesia we use for Mom in IUTs (conscious sedation)
- Why we don’t use fetal Lasix (furosemide) for fetal hydrops in the setting of HDFN
- Formulas!
- IVT = volume of donor blood (78-80% hct) to raise the fetal hct 10 points = 0.02 x EFW (in grams)
- IPT = (GA (in weeks) – 20) x 10
- Fetal vecuronium dose = EFW x 0.1 mg/kg
- Fetal fentanyl dose = EFW x 2 mcg/kg
- Fetal atropine dose = EFW x 0.02 mg/kg
- Abbreviations Key:
- EFW = estimated fetal weight
- GA = gestational age
- IUT = intrauterine transfusion
- IVT = intravascular transfusion
- IPT = intraperitoneal transfusion
- Hct = hematocrit
- HDFN = hemolytic disease of the fetus & newborn
- MCA = middle cerebral artery
- MoM = multiples of the median
Breaking into our toolbox this week! Dr. Moise takes us through immune therapy options in the treatment and management of HDFN and alloimmunization.
This week we cover the following topics:
- Alloimmunized patients that qualify for immune therapy as management for HDFN
- Options available for immune therapy
- Intravenous immunoglobulin (IVIG)
- Plasmapheresis
- Timing, dosing, frequency, and administration of IVIG
- Common complications of IVIG
- IgA deficiency
- Headache
- Fatigue
- FDA Black Box Warning
- And our tricks for treating them!
- Imitrex (sumatriptan) + Zofran (ondansetron)
- Reglan (metoclopramide)
- IVIG pre-meds and post-meds
- IVIG rate adjustment
A brief little bonus episode of Erin's interview with Dr. Michael Harrison while at the 40th annual IFMSS conference in Los Cabos in early November 2022.
Many consider Dr. Michael Harrison to be the Father of Fetal Surgery. He paved the way for many of the advancements we know today in fetal medicine and has continued his work as a professor of pediatric surgery and director emeritus of the Fetal Treatment Center at the University of California in San Francisco. Dr. Harrison was gracious enough to take some time to sit down and allow us to interview him - so please enjoy!
*Please excuse our audio quality and the echo!
This week we're going into a deep dive on MCA Doppler as Dr. Moise discusses the following:
- The initial role & importance of ultrasound in pregnancy – determining crown rump length (CRL) to then calculate the estimated date of delivery (EDD)
- How MCA Doppler was first discovered – thanks to Dr. Gian Carlo Mari
-
How viscosity and cardiac output are affected in an anemic fetus
-
MCA Doppler peak systolic velocity (PSV) vs. multiples of the median (MoM)
- Factors that can affect an accurate MCA Doppler reading (here’s where the cop analogy comes in)
- Angle
- Fetal movement
- Software and ultrasound equipment
- Expertise and experience
-
Rescue steroids (betamethasone)
-
When to start MCA surveillance and how often
- Definition of fetal hydrops
- Using MCA Dopplers vs. empiric intervals for timing IUTs
- Other fetal conditions that utilize MCA Doppler to detect fetal anemia:
- Non-immune fetal hydrops
- Parvovirus
- TAPS in twins
MCA MoM Score Calculators:
- Barcelona calculator: https://medicinafetalbarcelona.org/calc/
- Select “Anemia” then “Cerebral Doppler”
- Perinatology: https://perinatology.com/calculators/MCA.htm
Editorial by Dr. Kenneth Moise: “ Diagnosing Hemolytic Disease of the Fetus — Time to Put the Needles Away?”
DOI: 10.1056/NEJMe068071
Earlier this month we jetted off to Los Cabo, Mexico to attend the 40th annual the International Fetal Medicine and Surgery Society (IFMSS) conference. This is the first time the society has been able to meet since COVID-19 and with that came a lot of new research and exciting advancements in the field of fetal medicine.
Dr. Moise takes us through his top 11 topics from this jampacked conference. (Seriously. The detailed scientific program scheduled was 13 pages). See below for the episode timestamps and abstract details!
8:44 – Fetal Enzyme Replacement: “A Fetal First: In Utero Enzyme Replacement Therapy in a Fetus with Infantile-Onset Pompe Disease”. Presented by Dr. Tippie MacKenzie from University of California, San Francisco
13:28 – Stem Cell Therapy for Spina Bifida: “From the Barn to the Bedside: The Cure Trial Story”. Presented by Dr. Abd-Elrahman Hassan from University of California, Davis. “Safety Reports of First 3 CURE Trial Patients”. Presented by Dr. Su Yeon Lee from University of California, Davis.
16:42 – Artificial Placenta: “Toward Clinical Application: An Update on the Extra-Uterine Environment for Neonatal Developed (EXTEND)”. Presented by Dr. Alan Flake from Children’s Hospital of Philadelphia.
22:41 – Robotic Fetoscopy: “Twin-Twin-Transfusion-Syndrome: Robotic Surgery Using Magnetic Navigation”. Presented by Dr. Ueli Moehrlen from University of Children’s Hospital Zurich
25:49 – IUTs: “Natural Course of Hemolytic Disease of the Fetus and Newborn after Pregnancy with Intrauterine Transfusion”. Presented by Dr. Joanne Verweij from Leiden University Medical Center.
27:50 – TAPS: “Low Risk for Co-Twin Death and Severe Cerebral Injury after Single Fetal Demise in Twin Anemia Polycythemia Sequence (TAPS)”. Presented by Dr. Enrico Lopriore from Leiden University Medical Center.
31:11 – Vasa Previa: “Fetoscopic Laser Ablation of Type 2 Vasa Previa”. Presented by Dr. Ramesha Papanna from University of Texas Health Science Center at Houston.
35:30 – Heart Block: “Results from First 218 Anti-Ro/SSA Antibody Positive Pregnancies Enrolled in STOP BLOQ”. Presented by Dr. Lisa Howley from Midwest Fetal Care Center.
38:56 – MMC Repair: “Open Maternal-Fetal Surgery for Myelomeningocele Closure: Outcomes from the fMMC Consortium Registry Sponsored by NAFTNet.” Presented by Dr. Julie Moldenhauer from Children’s Hospital of Philadelphia.
41:58 – Amnioport: “Use of an Amnioport to Maintain Amniotic Fluid Volume in Fetuses with Oligohydramnios Secondary to Lower Urinary Tract Obstruction or Fetal Renal Anomalies”.
43:49 – Trepostinil: “Prenatal Trepostinil Reduces Pulmonary Arterioles Media Thickness in Fetal Rabbits”. Presented by Dr. Felix De Bie from KU Leuven in Belgium.
Financial Disclosure: Dr. Moise receives fees paid on his behalf to Dell Medical School - UT Austin for consultation with the genetics company BillionToOne, Inc.
This week we're trekking on through more details about alloimmunization and HDFN in the setting of lab studies and specific testing. Dr. Moise discusses the timing intervals for maternal antibody screenings, defines a critical titer, and then we get into the juicy part.....who's the daddy?! We talk about the paternal zygosity as it applies to alloimmunization as well as cffDNA to find out baby's antigen status.
We're kicking off the holiday season early this year courtesy of the mneumonic 'DEcK' that stands for the major HDFN red blood cell antigens 'bad players' - D, big E, little c, and Kell.
This week Dr. Moise talks about some of the more common red cell antigens and also the not so common. We wrap up our discussion on antigens using a dalmation analogy to help describe weak D.
Happy Halloween wombmates! Our special spooky gift to you is another segment of "Debunking Dramatizations". Dr. Moise is a diehard Game of Thrones fan and so naturally has closely followed the new House of the Dragon series on HBOMax. In this episode, Dr. Moise walks us through the series premiere episode, "The Heirs of the Dragon", in which Queen Aemma's attempts to delivery a male heir via Cesarean section. We talk about the history of anesthesia, Cesarean deliveries, and how delivery forceps were developed.
Dr. Moise teaches us about rhesus immune globulin, how it's made, when to administer it, and how it played in a role in university mens' income.
Part 2 of 2 continues our discussion on the history of Rh disease. Dr. Moise talks about how the diagnosis and treatment of this disease have changed over the years. We discuss the major contributions to this disease by Sir William Liley, Dr. Giancarlo Mari, Dr. Dennis Lo, Dr. Charles Rodeck, and others.
Giancarlo M., et al. Noninvasive Diagnosis by Doppler Ultrasonography of Fetal Anemia Due to Maternal Red-Cell Alloimmunization. NEJM. Jan 2000; 342:9-1.
DOI: 10.1056/NEJM200001063420102
Sources for this episode:
"Rh: The Intimate History of a Disease and Its Conquest" by David R. Zimmerman. Library of Congress Catalog Number 72-90280.
Part 1 of 2 covering the history of Rh disease. Dr. Moise talks about the history of the disease itself and the history of prevention. We discuss how the Rh antigen was first discovered. And then we cover how RhoGAM (AKA rhesus immune globulin) was first developed and the experiments designed to determine the intervals to administer the medication in a patient's prenatal and delivery course.
Sources for this episode:
"Rh: The Intimate History of a Disease and Its Conquest" by David R. Zimmerman. Library of Congress Catalog Number 72-90280.
Remember that comedic relief we promised?
In this episode, Dr. Moise and Erin discuss a fetal surgery case from NBC's series New Amsterdam Season 4 Episode 20 "Rise".
We start every fetal surgery in the operating room with a timeout. Dr. Moise always asks we begin with introductions starting at the head of the bed. This episode we'll be introducing ourselves and how we got to where we are today.
The first half tells Erin's story and background.
21:36 begins Dr. Moise's story and background.
Each week, Dr. Kenneth Moise and his daughter, Erin Moise, bring the latest in the field of fetal medicine by delving into the history, background, diagnosis, and treatment of complex fetal conditions.