The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: www.tandfonline.com/journals/ijmf20

Third trimester fetoscopic laser ablation of type II

vasa previa

Ramen H. Chmait, Emiliano Chavira, Eftichia V. Kontopoulos & Rubén A.

Quintero

To cite this article: Ramen H. Chmait, Emiliano Chavira, Eftichia V. Kontopoulos & Rubén A.
Quintero (2010) Third trimester fetoscopic laser ablation of type II vasa previa, The Journal of
Maternal-Fetal & Neonatal Medicine, 23:5, 459-462, DOI: 10.3109/14767050903156718

To link to this article: https://doi.org/10.3109/14767050903156718

Published online: 20 May 2010.

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The Journal of Maternal-Fetal and Neonatal Medicine, May 2010; 23(5): 459–462

CASE REPORT

Third trimester fetoscopic laser ablation of type II vasa previa

RAMEN H. CHMAIT1, EMILIANO CHAVIRA1, EFTICHIA V. KONTOPOULOS2, & RUBÉN A. QUINTERO3

1
Department of Obstetrics and Gynecology, Keck School of Medicine, Los Angeles, University Southern California, Los Angeles,
California, USA, 2Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida,
Tampa, Florida, USA, and 3Division of Maternal–Fetal Medicine, University of Miami Miller School of Medicine, Miami, Florida,
USA
(Received 13 June 2009; revised 24 June 2009; accepted 25 June 2009)

Abstract
Objective. Vasa previa is associated with increased perinatal morbidity and mortality because of fetal exsanguination at time
of membrane rupture. We report our experience in the treatment of type II vasa previa via in utero laser ablation in the third
trimester.
Methods. Two cases of type II vasa previa were identified via endovaginal ultrasound in the second trimester and treated via
third trimester fetoscopic laser ablation.
Results. In case 1, fetoscopic laser ablation of the vasa previa was performed without complication at 28 3/7 weeks’ gestation
as a prophylactic measure. The patient delivered at 33 3/7 weeks’ gestation after rupture of membranes without sequelae with
good perinatal outcome. In case 2, expectant management of twins with a vasa previa was planned. However, significant
cervical shortening and funneling was documented at 30 5/7 weeks’, and the risk of membrane rupture was deemed relatively
high. As a therapeutic alternative to outright preterm delivery, the patient underwent uncomplicated laser ablation of the vasa
previa. Delivery occurred at 34 3/7 weeks’ after rupture of membranes, and the twins did well.
Conclusions. We suggest that type II vasa previa can be definitively treated in utero by laser photocoagulation in the third
trimester. Ablation of the vasa previa may be performed prophylactically or as a therapeutic measure to delay delivery if
symptoms of preterm labor and/or cervical shortening develop.

Keywords: Vasa previa, operative fetoscopy, fetal surgery, laser ablation

Introduction
Vasa previa is an obstetrical condition in which fetal vessels
course over the internal cervical os within the membranes
and are unsupported by underlying placenta. This condi-
tion has been classified into two types: Type I if the vasa
previa arises directly from a velamentous cord insertion
and Type II if it bridges separate lobes of a bilobed or
succenturiate placenta [1]. Diagnosis and classification of a
vasa previa is feasible by ultrasound evaluation of the lower
uterine segment [1–5].
Vasa previa has historically been associated with high
perinatal mortality rates due predominantly to fetal
exsanguination after vessel damage at time of membrane
rupture [6]. One review demonstrated that prenatal
diagnosis of vasa previa resulted in reduction of the
perinatal mortality rate from 56% to 3% [7]. This may
be attributed to intensive monitoring of the pregnancy and
subsequent preterm elective cesarean section timed to
precede rupture of membranes [8].
Quintero et al. recently reported the first case of in utero
laser ablation of a vasa previa [9]. The Type II vasa previa
was successfully laser photocoagulated at 22.5 weeks’
gestation, and the patient was subsequently delivered by
cesarean section at 27 weeks’ gestation after membrane
rupture with good perinatal outcome. Fetal exsanguination
did not occur, as the vessels had been ablated in utero. The
advantage of laser ablation of the vasa previa is that this
management approach provides definitive treatment of this
condition. In effect, the risks of vasa previa are replaced
with those of operative fetoscopy. The major concern of
operative fetoscopy is the risk of premature birth. However,
delaying the procedure until the third trimester may
mitigate this risk. We report two cases of successful in
utero laser ablation of Type II vasa previas during the third
trimester.
Materials and methods
A retrospective review of all cases of vasa previa evaluated
at the University of Southern California Fetal Therapy
Program from March 2006 to March 2009 was conducted.
Antenatal and neonatal data were obtained from medical
records and patient and physician reports.
Patients with suspected vasa previa on transabominal
ultrasound or prior fetoscopy underwent endovaginal
ultrasound. The endovaginal probe was placed in the
anterior fornix to visualize the entirety of the cervix. A vasa
previa was suspected if the following findings were
identified: a tubular structure was noted crossing over the
internal cervical os; color and pulsed Doppler confirmed

Correspondence: Ramen Chmait, MD, Assistant Professor, Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, 1300
North Vermont Avenue, Suite 706, Los Angeles, CA 90027, USA. Tel: þ1-323-361-6074. Fax: þ1-323-361-6099. E-mail: chmait@usc.edu
ISSN 1476-7058 print/ISSN 1476-4954 online Ó 2010 Informa UK Ltd.
DOI: 10.3109/14767050903156718
460 R. H. Chmait et al.
arterial blood flow with a fetal heart rate; there was no
underlying placental tissue. The vasa previa was then
classified as Type I if the vasa previa arose directly from
a velamentous cord insertion or Type II if it brid-
ged separate lobes of a bilobed or succenturiate placenta
[2].
Patients identified with a type II vasa previa were offered
expectant management, with hospitalized bed rest between
28 and 32 weeks’ gestation and cesarean section at *35
weeks’ gestation, pregnancy termination, or operative
fetoscopic laser ablation of the vasa previa performed
between 28 and 30 weeks’ gestation. Fetoscopic laser
ablation was performed under local anesthesia with
intravenous sedation. A 3.8 mm trocar with an internal
valve (Richard Wolf, Vernon Hills, IL) was inserted
percutaneously under ultrasound guidance. The vasa
previa was identified endoscopically with a 3.3 mm 258
or 708 diagnostic endoscope (Richard Wolf, Vernon Hills,
IL). The diagnostic endoscope was then exchanged for
3.3 mm 08 operating endoscope with a 5Fr operating
channel, through which a 600 micron non-contact YAG
laser fiber (Surgical Laser Technologies, Montgomeryville,
PA) was passed. The vasa previa were lasered using 20–
40 W of energy at the placental edge of the succenturiate
lobe. Endovaginal ultrasound with Doppler interrogation
of the lower uterine segment was performed postopera-
tively to confirm the complete ablation of the vasa previa.
Approval for this case series was obtained by the
University of Southern California Institutional Review
Board and all patients gave written informed consent.
Results
We report two cases of Type II vasa previa that
were identified via endovaginal ultrasound in the second
trimester and treated via third trimester laser ablation.
Case 1
A 31-year-old, gravida 3, para 1, woman was referred for
ultrasound because of pregnancy dating discrepancy. Fetal
biometry was consistent with 19 weeks’ gestation. No
structural fetal abnormalities were identified. A left lateral
placenta whose edge was within one centimeter of the
internal cervical os was noted. The utero-placental inter-
face appeared normal and no placental lakes were seen.
The umbilical cord was centrally inserted remotely from
the cervix. Abdominal ultrasound of the lower uterine
segment incidentally identified a fetal vessel traversing the
internal cervical os unsupported by underlying placenta.
Endovaginal ultrasound with color Doppler confirmed a
fetal artery that crossed over the internal cervical os,
bridging the main anterior portion of the placenta to a
relatively smaller posterior segment of the placenta. A
corresponding fetal vein was noted in close proximity to
the internal os. The patient was advised to maintain strict
home bed rest and pelvic rest.
Follow-up ultrasounds confirmed the presence of a Type
II vasa previa with a ‘receding’ placental edge away from
the cervical region of the uterus. The fetal artery measured
0.18 cm in diameter at the level of the internal cervical os.
Management options were reviewed, and the patient opted
to proceed with operative fetoscopic laser ablation of the
vasa previa between 28 and 30 weeks’ gestation. Pre-
maturity risks were discussed with the patient by a
neonatology consultant. The case was reviewed at our
multidisciplinary fetal care conference, and unanimous
approval for the procedure was obtained. Consent for laser
ablation of the vasa previa and possible emergency cesarean
section was obtained.
Following a course of corticosteroids for fetal organ
maturation therapy, the patient underwent operative
fetoscopy at 28 3/7 weeks’ gestation. Intravenous sedation
and local anesthesia was used. An amnioinfusion through
the trocar of 700 milliliters of normal saline was performed
to enhance the visualization by increasing intra-amniotic
volume. Fetoscopic evaluation of the lower uterine
segment revealed a fetal artery and vein without underlying
placental tissue traversing the lower uterine segment and
crossing the cervical area in the sagittal plane. The two
vessels were photocoagulated at the anterior edge of the
placenta with 30 W of Nd:Yag laser energy without
complication. Color Doppler ultrasound confirmed suc-
cessful ablation of the vasa previa. Operative time was
30 min, of which 18 min were spent photocoagulating the
vessels. Postoperative fetal heart rate tracing showed
normal baseline and reactivity without decelerations. The
patient was discharged home on postoperative day 1. All
subsequent ultrasounds revealed no measurable Doppler
flow through the ablated vessels. Fetal growth, amniotic
fluid volume, and umbilical artery Dopplers were normal
throughout the postoperative period.
The patient presented to labor and delivery at 33 1/7
weeks’ gestation because of leaking of fluid per vagina.
Sterile speculum examination was negative for membrane
rupture. She returned 2 days later for persistent watery
discharge, and membrane rupture was confirmed at that
time. A repeat cesarean section was performed at 33 3/7
weeks’ gestation. The birth weight was 1924 g, and the
Apgars were 8 at 1 min and 8 at 5 min. Placental
pathological evaluation was significant for a marginal
placental infarction of 5% of the placenta. The neonate
was discharged from the hospital at 25 days of life without
complications. The child is well at 15 months of age.
Case 2
A 26-year-old woman, gravida 1, para 0, was referred at 22
weeks and 2 days with the diagnosis of twin–twin
transfusion syndrome (TTTS). Ultrasound findings were
consistent with monochorionic diamniotic twins compli-
cated by Quintero stage II TTTS. The placenta was
located along the right lateral aspect of the uterus.
Endovaginal ultrasound performed without color Doppler
showed a cervical length of 3.2 cm without funnel of the
internal cervical os. After management options were
reviewed with the patient, she elected to proceed with
selective laser photocoagulation of the communicating
vessels, which was performed at 22 3/7 weeks’ gestation
without complication. During surgery, several vessels that
belonged exclusively to the recipient twin were noted to
traverse off the placental disk along the fetal membranes.
In keeping with the selective technique, these non-
communicating vessels were not laser ablated.
Ultrasound performed on postoperative day number one
revealed normal heart rates for both fetuses. Endovaginal
ultrasound showed a stable cervical length of 3.2 cm.
Endovaginal ultrasound with color Doppler identified a
fetal vessel with an arterial waveform that crossed the
internal cervical os and was unsupported by underlying
placenta. The diagnosis of type II vasa previa was
established. Management options were reviewed with the
patient, and she opted for expectant management with

hospitalized surveillance. Subsequent serial ultrasounds
revealed normalization of amniotic fluid on either side of
the dividing membranes and appropriate interval fetal
growth.
The patient was readmitted to the hospital at 29 weeks’
gestation for fetal surveillance, at which time continuous
fetal heart rate monitoring ensued. Endovaginal ultrasound
showed a cervical length of 2.1 cm without cervical funnel
and the presence of the arterial vasa previa. Because of the
catastrophic risk of fetal exsanguination should membrane
rupture occur, she was placed in close proximity to
the operating room. At 30 5/7 weeks’, the patient reported
increased vaginal discharge. A repeat endovaginal ultra-
sound showed a cervical length of 1.1 cm with significant
funnel of the internal cervical os. The vasa previa was noted
to cross over the funnel, bridging one end to the other.
There was separation of the membrane and vasa previa
from the underlying cervix (Figure 1). Doppler interroga-
tion of the vasa previa confirmed an arterial waveform
(Figure 2) with a fetal heart rate. In view of the significant
cervical change and relatively increased risk of membrane
rupture and possible fetal vessel laceration, the patient was
given the following options: (1) proceed with cesarean
section; (2) attempt fetoscopic laser ablation of the vasa
previa. After risks versus benefits of each option were
Figure 1. Endovaginal ultrasound with color Doppler showing a
vasa previa overlying a shortened and funneled cervix prior to laser
ablation.
Figure 2. Doppler interrogation of the vasa previa revealed an
arterial waveform with a fetal heart rate.
Laser ablation of vasa previa 461
reviewed in detail, the patient decided to proceed with laser
surgery.
The patient was taken to the operating room at 30 6/7
weeks’ gestation. After epidural anesthesia was provided,
an 18-gauge needle was inserted into the amniotic sac of
Twin A under direct ultrasound guidance. An amnioinfu-
sion of 960 mL of normal saline was performed to expand
the amniotic sac to facilitate trocar insertion and endo-
scopic visualization. A 3.8 mm trocar was percutaneously
inserted under ultrasound guidance into Twin A’s sac.
Visualization of the lower uterine segment with the 258
diagnostic endoscope identified the vasa previa. The
relatively large caliber vasa previa was laser photocoagu-
lated with 30 W of Nd:Yag laser energy, followed by 40 W
of laser energy. An incidental septostomy of the dividing
membrane occurred. Operative time was 30 min, of which
20 min were utilized to photocoagulate the vessel.
Subsequent color Doppler ultrasound interrogation of
the lower uterine segment confirmed the successful
ablation of the vasa previa (Figure 3). Fetal surveillance,
as assessed by growth scans, amniotic fluid volume
assessments, umbilical artery Dopplers, and heart rate
monitoring, remained reassuring for the duration of the
pregnancy. Preterm premature rupture of membranes was
diagnosed at 34 3/7 weeks’ gestation, after which she went
into preterm labor. A cesarean section was performed.
Twin A, the former recipient, had 1 and 5 min Apgars of 7
and 9, respectively, and her birth weight was 2656 g. Twin
B, the former donor, had 1 and 5 min Apgars of 7 and 8,
and her birth weight was 2224 g. Placental pathology
revealed a diamniotic, monochorionic twin placenta with a
small succenturiate lobe with minimal infarctions. There
were no patent anastomoses identified on water injection
studies. Both infants were alive and well at age 6 months.
Discussion
In this report, we described our experiences with two cases
that underwent laser photocoagulation of Type II vasa
previas in the third trimester. In the first case, laser ablation
Figure 3. Doppler interrogation of the vasa previa post laser
ablation revealed the absence of documentable blood flow through
the portion of the vessel over the cervix.
462 R. H. Chmait et al.
of the vasa previa was done as a prophylactic procedure to
prevent subsequent fetal exsanguination because of vessel
laceration should preterm rupture of membranes occur. In
the second case, laser ablation was performed as a
therapeutic alternative to preterm delivery after significant
cervical shortening was documented. In this latter case, the
laser ablation of the vasa previa allowed for prolongation of
the pregnancy for almost 4 weeks.
In utero laser ablation of Type II vasa previa offers the
potential benefit of definitive treatment, thereby alleviating
concern of subsequent fetal exsanguinations. Prolonged
maternal hospitalization may be avoided, and there is the
possibility of vaginal delivery at term. However, the risks of
the vasa previa are substituted for that of operative
fetoscopy. The most worrisome risk of fetoscopy is that
of preterm delivery. In case 1, we attempted to mitigate this
prematurity risk by delaying the laser ablation until 28
weeks’ gestation. In case 2, we believe that the surgical
procedure lengthened the gestation of the pregnancy from
30 weeks’ to 34 weeks’ gestation. Other risks of fetoscopy
include membrane rupture at the site of laser occlusion of
the vasa previa. This risk was decreased by targeting the
fetal vessels at their origins along the placental edge,
thereby avoiding potential weakening of the fetal mem-
branes or damage to the underlying decidua. Also, there is
concern that the relatively large caliber fetal vessels may be
inadvertently punctured at time of laser photocoagulation,
thereby causing fetal exsanguination. This was avoided by
targeting the vessel along the lateral edges first using brief
bursts of energy, and moving toward the midline of the
vessel once the edges were photocoagulated.
Another potential concern of vasa previa ablation is the
risk of placental insufficiency. In cases with Type II vasa
previa in which the offending vessels course to a relatively
small segment of the placenta, we suspect that this risk is
small because of the inherent redundancy of the placenta.
Our patients were counseled of the risk of fetal compro-
mise due to acute placental insufficiency and the possibility
of emergent cesarean section. In our two cases, we noted
reassuring fetal heart rate patterns after the ablation, and
fetal growth and birth weights were appropriate. Indeed,
placental pathology confirmed infarction of only minute
portions of the placentas. We believe that the candidacy for
vasa previa ablation should be assessed on an individual
basis, and that an important factor that needs to be taken
into account is the relative amount of placental tissue
supported by the aberrant vessel(s).
The standard management strategy employed for pre-
natally diagnosed vasa previa is hospitalized fetal surveil-
lance with subsequent preterm elective cesarean section
timed to proceed membranes rupture [7,8]. Although
perinatal morbidity and mortality has dropped significantly
using this approach, there remains approximately a 3%
perinatal mortality rate [7]. Is this perinatal outcome
sufficiently favorable such that invasive therapy need not be
considered? At this time there is insufficient evidence to
answer this question. The risks of fetal hemorrhage from
expectant management must be weighed against the
prematurity related risks of operative fetoscopy associated
with laser ablation.
To the best of our knowledge, this is the first report of
fetoscopic laser ablation of vasa previa in the third
trimester. Further study will be required to ascertain if
vasa previa ablation is justified as a prophylactic procedure,
as was done in the first case, or as a treatment to prolong
gestation in a patient with increased risk of preterm
delivery or preterm rupture of membranes, as occurred in
the second case of this report.
Declaration of interest: The authors alone are respon-
sible for the content and writing of the paper.
References
1. Clerici G, Burnelli L, Lauro V, Pilu GL, Di Renzo GC.
Prenatal diagnosis of vasa previa presenting as amniotic band.
‘A not so innocent amniotic band’. Ultrasound Obstet Gynecol
1996;7:61–63.
2. Catanzarite V, Maida C, Thomas W, Mendoza A, Stanco L,
Piacquadio KM. Prenatal sonographic diagnosis of vasa previa:
ultrasound findings and obstetric outcome in ten cases.
Ultrasound Obstet Gynecol 2001;18:109–115.
3. Nomiyama M, Toyota Y, Kawano H. Antenatal diagnosis of
velamentous umbilical cord insertion and vasa previa with
color Doppler imaging. Ultrasound Obstet Gynecol 1998;12:
426–429.
4. Baulies S, Maiz N, Munoz A, Torrents M, Echevarria M, Serra
B. Prenatal ultrasound diagnosis of vasa praevia and analysis of
risk factors. Prenat Diagn 2007;27:595–599.
5. Lee W, Lee VL, Kirk JS, Sloan CT, Smith RS, Comstock CH.
Vasa previa: prenatal diagnosis, natural evolution, and clinical
outcome. Obstet Gynecol 2000;95:572–576.
6. Fung TY, Lau TK. Poor perinatal outcome associated
with vasa previa: is it preventable? A report of three cases and
review of the literature. Ultrasound Obstet Gynecol 1998;12:
4430–433.
7. Oyelese Y, Catanzarite V, Prefumo F, Lashley S, Schachter
M, Tovbin Y, et al. Vasa previa: the impact of prenatal
diagnosis on outcomes. Obstet Gynecol 2004;103(5 Part 1):
937–942.
8. Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and
vasa previa. Obstet Gynecol 2006;107:927–941.
9. Quintero RA, Kontopoulos EV, Bornick PW, Allen MH. In
utero laser treatment of type II vasa previa. J Matern Fetal
Neonatal Med 2007;20:847–851.