Fetal Surgery for Placental Chorioangioma
About 19 weeks into her pregnancy, Mandi Ordonez-Buie began swelling ominously. A week later, spot bleeding concerned her enough that she went to the emergency department. There doctors discovered a placental chorioangioma that was causing excess strain on her baby Kaidinn’s heart and giving rise to polyhydramnios. Mureena Turnquest-Wells, MD, a fetal specialist in Mandi’s hometown of Evansville, IN, referred her to Timothy Crombleholme, MD, director of the Cincinnati Children's Fetal Care Center.
Large chorioangiomas (those greater than 4 cm) are rare, with an incidence rate of between one in 3,500 to one in 9,000 births, with fetal and neonatal mortality rates of 18 percent to 40 percent. Risks to the fetus include anemia, thrombocytopenia, consumptive coagulopathy, intrauterine growth restriction, prematurity, cardiac failure and hydrops fetalis.
Various interventions have been tried to prevent or treat complications of chorioangioma with varying success. Prenatal treatment by ultrasound guided interstitial laser therapy, in utero endoscopic devascularization with use of suture ligation or bipolar cautery via fetoscopy, microcoil embolization and alcohol injection have been described in the literature.
At the Fetal Care Center, an ultrasound was performed on Mandi, revealing a large (6 cm) chorioangioma arising only 2.7 cm away from the cord insertion with a dominant umbilical artery, and one large vessel feeding into the chorioangioma was seen. Fetal echocardiography revealed the combined ventricular output to be 740 ml / kilogram / minute, which confirmed the high output state. No signs of hydrops were visible.
Crombleholme and his colleagues from the Fetal Care Center determined the pregnancy was destined for severe complications if untreated and discussed treatment options with Mandi and her husband, Brandon. After extensive counseling, Mandi and Brandon elected to proceed with a fetoscopic bipolar cautery and laser coagulation to devascularize the chorioangioma.
The combined use of bipolar cautery with a diode laser proved to be an effective treatment option for symptomatic chorioangioma. With bipolar cautery, surgeons were able to reduce the blood flow to the chorioangioma by coagulating the main feeding vessel, which was too large to be safely coagulated by the laser diode. The smaller vessels could then be more safely photocoagulated with the use of laser. This combination appears to have enhanced the safety of the fetal surgeryprocedure by reducing the risk of significant hemorrhage.
After spending several days recovering from the procedure in the fetal surgery unit, Mandi returned home, where she spent the remainder of her pregnancy on bed rest. Kaidinn was delivered by C-section at 39 weeks − a healthy baby, weighing over 8 pounds.
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If you would like to request an appointment or get more information about the Cincinnati Children's Fetal Care Center, call us at 1-888-338-2559
