Faculty Bibliography

Blood transfusion rates in obstetrics reflect critical care needs but pose risks and resource challenges. A multimodal, multidisciplinary strategy was implemented at NYU Langone Brooklyn's Labor and Delivery unit to reduce red blood cell transfusion rates through standardized care, risk assessment, and rapid escalation protocols. A retrospective study evaluated transfusion practices from 2022 to 2024. Double-unit RBC transfusion orders decreased from 32% in 2022 to 19% in 2024, while overall transfusion rates fell from 20.7 to 14.5 units per 1,000 patient days. The findings demonstrate that a multidisciplinary approach can reduce transfusion rates while optimizing resource utilization.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Cerebral amyloid angiopathy (CAA) is a common cause of intracerebral hemorrhage (ICH) in older patients. Whether CAA is associated with isolated subdural hemorrhage (SDH), without an accompanying ICH, remains unclear. We, therefore, tested this relationship in a large, heterogeneous sample of patients across the United States. METHODS:We performed a retrospective cohort study using administrative claims data from all admissions to nonfederal acute care hospitals in 11 states in the United States between 2016 and 2021. Among hospitalized patients, we included only those aged 50 years or older, a threshold necessary to meet Boston criteria v2.0 for CAA. We divided this population into 3 groups: those with a diagnosis of CAA, those with other cerebrovascular diseases (CVDs) but without CAA, and those with neither CAA nor other CVDs. The main outcome was a first-documented, isolated, nontraumatic SDH; we did not count SDH cases with a concurrent traumatic brain injury. The exposures and outcome were identified using previously validated ICD-10-CM diagnosis codes. Using Cox regression analyses, we compared the risk of incident SDH among the 3 groups after adjustment for demographics and comorbidities. In prespecified sensitivity analyses, patients with a baseline diagnosis of dementia were excluded. RESULTS:Among 8.5 million hospitalized patients aged 50 years or older, 2,335 had CAA and 600,646 had other CVDs. During a median follow-up of 2.0 years (interquartile range 1.0-3.9), incident SDH occurred in 34 patients with CAA (1.5%), 3,552 patients with other CVDs (0.6%), and 35,425 patients without CAA or other CVDs (0.4%). In adjusted Cox regression analysis, there was an increased risk of incident SDH seen with CAA (hazard ratio [HR] 3.1; 95% CI 2.2-4.4) and with prevalent CVD (HR 1.4; 95% CI 1.3-1.5). Findings were similar in sensitivity analyses excluding patients with dementia. DISCUSSION/CONCLUSIONS:In a large, heterogeneous cohort, we found that CAA was associated with a 3-fold heightened risk of SDH, higher than the increased risk seen in patients with other CVDs. These findings support the emerging hypothesis that CAA is a risk factor of isolated nontraumatic SDH.

Congenital diaphragmatic hernia (CDH) is characterized by incomplete closure of the diaphragm. Although the ensuing compression to the fetal lung causes lung hypoplasia, specific cellular phenotypes and developmental signaling defects in the alveolar epithelium in CDH are not fully understood. Employing lung samples from human CDH, a surgical lamb model, and a nitrofen rat model, we investigated whether lung compression impairs alveolar epithelial differentiation and Yes-associated protein (YAP)-mediated mechanosensing. We showed that CDH in humans and lambs caused defective alveolar epithelial differentiation manifested by more alveolar epithelial type II (ATII) cells, fewer ATI cells, and the emergence of cells coexpressing ATI and ATII markers. Associated with these alveolar epithelial defects, we found a decrease in the level and nuclear localization of YAP. Reduced YAP and abnormal distal lung development were evident as early as 21 weeks of gestation in human CDH. In addition, rat fetuses with CDH also showed diminished nuclear YAP and more abundant ATII cells. In contrast, the littermates without the hernia had no such alveolar phenotypes. Furthermore, fetal tracheal occlusion in the surgical lamb model of CDH fully normalized nuclear YAP and rescued alveolar epithelial defects in a gestational age-dependent manner. Taken together, our findings across species indicate that lung compression in CDH is sufficient to disrupt alveolar epithelial differentiation and impair YAP signaling. Tracheal occlusion can restore nuclear YAP and rescue the alveolar defects in CDH, depending on the timing and the duration of this prenatal surgical intervention.

OBJECTIVE:The objective of this study was to describe the technical aspects and postnatal neurosurgical outcomes of a prenatal, 3-miniport fetoscopic myelomeningocele (MMC) repair technique providing a multilayered closure using cryopreserved decellularized human umbilical cord (HUC) matrix allograft for duraplasty. METHODS:The authors conducted a subanalysis of an ongoing prospective cohort study analyzing the neurosurgical outcomes of 57 of 92 consecutive patients who underwent multilayered fetoscopic surgical MMC repair using HUC matrix allograft for duraplasty at their institution from December 2016 to March 2022, including more than 24 months of postnatal follow-up. RESULTS:Of 92 patients who underwent fetoscopic MMC repair, 88 had duraplasty using cryopreserved HUC matrix allograft. Fifty-seven patients had at least 24 months of follow-up data. The mean gestational age at the time of surgical repair was 24.8 ± 0.7 weeks. The average operative time from skin incision to closure was 260 ± 43.4 minutes, in which 79% of this time was used for the fetoscopic portion. No patient required intraoperative emergency delivery. At birth, there were no cases of CSF leak or complete wound dehiscence. Six (11.5%) of 52 patients experienced superficial wound dehiscence, and only 2 (3.5%) required surgical revision. At 30 months, 54.8% of patients were noted to be independent ambulators, 35.5% were therapeutic ambulators, and 9.7% remained wheelchair users in this subset of patients. The rate of hydrocephalus requiring CSF diversion was 35.3%, and 84.3% of patients had complete reversal of hindbrain herniation at birth. Eight (15.7%) of 51 patients had spinal inclusion cysts noted on routine follow-up spinal imaging, but only 2 (3.9%) required surgical intervention due to radiological progression without neurological symptoms. CONCLUSIONS:A laparotomy-assisted, 3-miniport fetoscopic approach for prenatal MMC multilayered repair offers excellent access and visualization for an effective watertight closure. The use of HUC matrix allograft as a dural substitute was shown to be effective with a low rate of neurosurgical postnatal complications.

INTRODUCTION/BACKGROUND:This study evaluated whether comorbidities such as genetic conditions, other congenital anomalies, infection, and other exposures impact the mortality rate and/or neurologic outcomes of patients with congenital ventriculomegaly. METHODS:This was a retrospective cohort study that assessed the mortality rate and developmental delay of 91 patients diagnosed with congenital ventriculomegaly followed at Cincinnati Children's Hospital Medical Center between January 1, 2010, and December 31, 2020. RESULTS:Of the 91 patients included in the study, 20 (22.0%) had a genetic diagnosis. The mortality rate was higher for patients with a genetic diagnosis compared to those without a genetic diagnosis (p = 0.022), as was the rate of developmental delay (p = 0.026). The presence of comorbidities (confirmed genetic condition, confirmed maternal exposures or infections, and/or additional anomalies) was not associated with an increased risk of mortality nor developmental delay. CONCLUSIONS:Patients diagnosed with congenital ventriculomegaly and a genetic condition have a significantly higher risk of early mortality and developmental delay compared to those without a genetic diagnosis. Therefore, diagnostic genetic testing should be considered after identification of congenital ventriculomegaly to facilitate counseling about prognosis and care management.

INTRODUCTION/BACKGROUND:Perinatal management of gastroschisis remains a subject of substantial research. Current models, including teratogenic, genetic, and surgical approaches, often fail to accurately replicate gastroschisis, exhibiting limitations such as inaccurate phenotyping, low success rates, high mortality, lack of scientific validation, and significant technical challenges. Refined disease models are essential for improving the understanding of GS. This study seeks to develop and validate a minimally invasive transuterine experimental model of GS that overcomes these existing constraints to advance gastroschisis research. METHODS:A gastroschisis model was surgically created in rat fetuses at E17 (n = 51 fetuses from n = 13 dams). Intestines were harvested at term and divided into herniated gastroschisis (GS-H), intra-abdominal gastroschisis (GS-I), and control (Co) groups. Morphometric analysis, histopathological examination, immunohistochemistry for interstitial cells of Cajal (ICC), double immunofluorescence for ICC and mast cells, TUNEL assay for apoptotic cells, and multiplex cytokine assay were performed to assess intestinal architecture, inflammation, ICC network, apoptosis, and cytokine levels across studied groups. RESULTS:Histology from GS intestines revealed subchronic inflammation, peel formation, and architectural disruption. Herniated intestines exhibited a significantly increased weight/length ratio and thicker outer layers (p < 0.001) compared with control intestines. Herniated intestines had elevated inflammatory cytokine levels (GS-H vs GS-I and Co, p < 0.05 for G-CSF, GM-CSF, IL-12p70, IL-1beta) and increased apoptotic activity. CONCLUSIONS:We developed and validated a new surgical model of GS that offers improved survival and feasibility. The key morphological changes and molecular markers observed in this experimental model resemble human gastroschisis.

OBJECTIVE:Membrane damage at or near the uterine entry site is a prevalent complication of fetal surgery and may result in chorioamniotic separation (CAS), preterm prelabor rupture of membranes (PPROM) and preterm birth. Transamniotic transuterine suturing approaches offer the potential to reduce the prevalence of CAS and PPROM accompanying fetoscopy, with the overarching aim of reducing preterm birth. This study aimed to explore the feasibility and potential efficacy of employing a novel vascular closure device for transamniotic transuterine suturing in a sheep model of fetoscopic surgery. METHODS:This study employed a pregnant sheep model to simulate fetal surgery and was conducted between December 2023 and February 2025. We used multiple methodologies to evaluate the Abbott Perclose™ vascular closure device for suturing membranes at the uterine entry site before or after the insertion of a 12-French outer diameter cannula. Feasibility was defined as successful suture placement by two independent surgical teams at two different gestational ages. Potential efficacy was demonstrated by the watertight closure of the entry site during in-vivo gross examination, along with organizing fibrosis and healing of membranes and myometrium, as assessed by postdelivery histopathological evaluation. The procedures were conducted in two phases during the sheep's gestation. Three approaches were used for abdominal entry to access the uterus: midline laparotomy and direct uterine entry; 2-cm mini laparotomy allowing access to the uterus; and a percutaneous approach. Histopathological examination of samples from the entry sites was conducted using routine microscopy, trichrome staining and immunohistochemistry for Connexin 43 (Cx43). This study was approved by the Institutional Animal Care and Use Committee (AN-2010). RESULTS:Ten pregnant sheep were included in this study, four of which had a twin pregnancy. The median gestational age at the occurrence of the first and second rounds of intervention was 85.5 and 104 days, respectively. Overall, 32 Perclose devices were used, and 75% (24/32) were placed successfully. Watertight closure of all sutures was observed during the first and second rounds of intervention, at Cesarean delivery and in situ. Histopathological examination confirmed organizing fibrosis surrounding the device entry site, in addition to overexpression of Cx43. CONCLUSIONS:Employing multiple orthogonal approaches, we have shown for the first time that the Perclose device is both feasible and potentially efficacious as a novel means of uterine port closure in our preclinical sheep model of fetoscopic surgery. Inspired by our success in this preclinical model, we anticipate that clinical validation studies will provide translational data and a direct means of measuring efficacy in the reduction of CAS, PPROM and preterm birth. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

OBJECTIVE/UNASSIGNED:Prior clinical findings have demonstrated that maternal laparotomy with trans-amniotic trans-uterine suturing of the fetoscopic port site during in utero myelomeningocele repair reduces the risk of membrane rupture. However, due to laparotomy-associated morbidity, we aimed to explore the feasibility of using a vascular closure device for percutaneous trans-amniotic trans-uterine suturing. METHODS/UNASSIGNED:cannula over the same guidewire. Samples of the sutured uterine wall were sent to pathology and H&E staining was performed to assess uterine hole closure and amnion-to-uterus fixation. RESULTS/UNASSIGNED:device effectively sutured the amnion to the uterus in both the pre- and post-close approach. The pre-close technique achieved better amnion-to-uterus approximation and more appropriate uterine hole closure. H&E staining revealed that without suturing, amnion separation from the chorion layer occurred, and the uterine hole persisted. The post-close technique showed partial connection between the amnion and chorion, but inadequate uterine hole closure with amnion shift into the defect. Optimal closure, with secure amnion-to-chorion fixation and uterine closure, was achieved through the pre-close technique. CONCLUSION/UNASSIGNED:Device seems to be a feasible device for use of uterine port closure in maternal-fetal surgery, larger animal studies with mid-pregnancy application are needed to further validate or refute these findings.