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Fetoscopic surgery enables normal delivery in vasa previa Type 2 case

Written By: Karen Kephart | Updated: March 4, 2024
The Collins family with their daughter after a healthy birth despite vasa previa

The Collins family is thankful for early diagnosis and a successful procedure to deliver their healthy baby girl, Charlotte. (Photo by Jane McNeill)

A serious pregnancy complication, vasa previa occurs when unprotected fetal blood vessels from the placenta or umbilical cord cross the entrance to the birth canal in the fetal membranes underneath the baby. The condition can result in rapid fetal hemorrhage if the blood vessels tear when the cervix dilates or the membranes of the amniotic sac rupture.

Twenty-six-year-old Samantha Collins’ obstetrician suspected she had vasa previa when he reviewed the results of her second trimester anatomy scan. He suggested an in-depth ultrasound study with Clara E. Ward, MD, maternal-fetal medicine specialist with UT Physicians and associate professor at McGovern Medical School at UTHealth Houston. Ward reviewed the results of her ultrasound and sent them to her colleague to validate her diagnosis.         

Ramesha Papanna, MD who performed a fetoscopic surgery on a woman with a vasa previa pregnancy
Ramesha Papanna, MD

“When I saw Samantha at 29 weeks and four days, the main part of her placenta was on the back wall of the uterus and a small part was on the front wall. The vein connecting the two parts was traveling over the cervix through the fetal membranes,” said Ramesha Papanna, MD, co-director of UTHealth Houston Fetal Center and professor in the Division of Maternal-Fetal Medicine at McGovern Medical School at UTHealth Houston. “If the vein were to rupture, her baby would bleed out in minutes.”

Understanding vasa previa

Vasa previa occurs in 1 in 2,500 births, with a fetal mortality rate estimated as high as 95% for cases not diagnosed prenatally. There is no known cause; the complication is an anomaly of placental attachment that can occur in any pregnancy.

 “When we found out, we were obviously very scared and didn’t have much knowledge about how to proceed,” Collins said. “Dr. Papanna did multiple scans to ensure the accuracy of his diagnosis before we discussed our options. The standard of care is bed rest and delivery by C-section. But because of the type of vasa previa I had, he talked with us about a new fetoscopic surgery. This could potentially mean a later delivery and perhaps even a vaginal birth. We talked about the risks of both options, and he didn’t sugar coat any of it. Because of his knowledge and demeanor, we had 100% confidence in him and decided to go ahead with the fetoscopic surgery.”

Collins had vasa previa Type 2, in which the placenta has two lobes. The larger lobe had an umbilical cord connection and the smaller lobe, called a succenturiate lobe, was attached to the main lobe through smaller vessels that traveled over the cervical canal. The exposed blood vessels traveling between the lobes and over the cervix carried a risk of bursting and bleeding when labor begins. Mothers diagnosed with vasa previa Type 1, in which the umbilical cord is inserted into the membranes rather than the placenta, are admitted to the hospital for bed rest with delivery planned at 34 to 36 weeks by C-section.

Dangers of stress

Patients with a diagnosis of either type of vasa previa suffer a significant amount of stress. “If the mother ruptures and bleeds at home, the baby will die in 95% or more of cases,” said Papanna, who is internationally recognized for his research on improving outcomes following fetal intervention and investigating methods for the prevention of preterm delivery. “If the mother’s membranes rupture while she is hospitalized on bed rest and close to the operating room, the chance of fetal death is still about 50%. For mothers with Type 2 who are eligible for the surgery and have a successful outcome, it removes the anxiety associated with rupture during pregnancy and allows them to sleep well at night.”

Collins said that lowering the level of stress was a major factor in her decision to move forward with the surgery. “I could play the waiting game on bed rest, and there would still be a chance that our baby wouldn’t make it,” she said. “I asked Dr. Papanna about the probability of success because there are risks to the procedure. If the vein ruptured during the fetoscopic procedure, he would be prepared to do a C-section and deliver her immediately. If he thought he couldn’t get to the vein, he wouldn’t proceed and I would still have the bed rest option. We felt the surgery gave us the biggest chance that she would be alive at the end of it all. We didn’t want to play a waiting game and then potentially lose her.”

A delicate fetal procedure

Papanna performed the fetoscopic surgery on Sept. 22, 2022, when Collins was just a day beyond 31 weeks of pregnancy. “We gave her two steroid shots immediately before the surgery to help ensure that her baby’s lungs were developed fully in case we had to deliver. We entered the uterus through a tiny port and used a laser to burn the vessel up and down to stop the blood flow. The procedure went very well,” he said.

Collins returned home and stayed close to the hospital until she went into labor. At 35 weeks – three days before she was due to deliver – she experienced some bleeding. The following day her water broke. Charlotte Reese Collins was delivered vaginally on Oct. 20, 2022, five weeks early but without the need for a stay in the Neonatal Intensive Care Unit. She went home with her family after a typical, three-day hospital stay.

Thankful for the team

“I could not be more thankful for every doctor, nurse, medical assistant, and ultrasound tech. They were all so calming, and being with them always relieved my stress,” Collins said. “They weren’t afraid to answer my questions, and they were honest and reassuring every step of the way. After I went home, they called and texted me to make sure we were doing okay.

“When I was pregnant and talked with people about vasa previa, they said they would be freaking out if they were in the same situation, and I said, ‘I’m okay,’” she added. “Freaking out wouldn’t have helped. All I could do was make the best decision and move forward. I did that, and now we have a healthy baby, and that’s all that matters.”

As the clinical practice of McGovern Medical School at UTHealth Houston, UT Physicians has locations across the Greater Houston area to serve the community. To schedule an appointment, call 888-4UT-DOCS.