UTHealth surgeon is among the few in the nation to treat rare disease-threatening pregnancies

About 27 weeks into her pregnancy, Marisa Resendez had a decision to make. She had been diagnosed with vasa previa, the dangerous placement of fetal blood vessels near the cervix.

“If my waters break or the baby goes through the ship, it could break,” Resendez said.

And if the blood vessel ruptured, she was told it could lead to permanent brain damage in the baby or stillbirth.

“My world was rocked,” Resendez said. “I was devastated.”

Resendez had a choice. The first option was to stay in bed, almost immediately, for the duration of her pregnancy. The delivery would be early, with a caesarean section.

She is expected to stay in the hospital in her hometown of San Antonio, where if she goes into labor, she can be rushed to the operating room immediately.

His second option was to travel to Houston to meet Dr. Ramesha Papannaassociate professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at McGovern Medical School at UTHealth.

A specialist in maternal-fetal medicine and director of research at the Fetal Center at Children’s Memorial Hermann Hospital, Papanna is at the forefront of a new surgical technique for vasa previa. Fetal laser ablation would allow a natural birth at term.

Papanna is one of the few doctors in the country to offer this option.

The surgery, however, presented its own set of issues, Resendez said. The procedure was novel – and if anything went wrong, an emergency C-section on the day of surgery would be required.

Neither scenario matched her best-laid plans for her pregnancy. She and her husband, Alberto Moravia, were still working and renovating their home.

Staying in the hospital for weeks was not appealing. And bed rest would also mean Resendez would not be able to carry her baby to term or give birth vaginally.

“Let’s talk to Dr. Papanna,” she suggested to her husband. “We are candidates or not. I would like to explore if surgery is even an option.

The couple came to Houston, consulted with Papanna, and received contact information for another patient willing to share her own surgery experience.

“We really didn’t have time to process everything because we had to act,” Resendez said. “We made a judgment call.”

By the time she and Moravia returned to San Antonio, the paperwork was signed for surgery the following week.

“We just made the choice,” Moravia said. “It felt like it was the right decision.”

A rare diagnosis

“Vasa” is Latin for ship and “previa” for previous or first comer, Papanna said.

In other words, the vessels interfere with the birth canal, obstructing the baby during delivery.

Imagine a hot air balloon like the uterus, Papanna said, and the neck like the cervix. The umbilical cord is attached to the fetus, which goes to the placenta.

The placenta is stuck to the side of the uterus.

“It’s stuck to the uterus like a painting on a wall,” Papanna said.

Almost all the time, the placenta rests at the top of the uterus. In some cases, it is lower, which places the fetal blood vessels in an exposed, unprotected position just in front of the fetal head.

As the uterus prepares for delivery in the later stages of pregnancy and the cervix pulls upward, blood vessels may tear or rupture as the mother waters are breaking.

“The baby can bleed very quickly – within minutes,” Papanna said. “By the time you get to the hospital, the baby is dead.”

He said vasa previa is rare. There are between 2,500 and 4,000 cases a year in the United States

Once diagnosed, Papanna explained, the condition needs to be closely monitored and can lead to a healthy pregnancy with a C-section and early delivery.

“The chance of being home with a normal baby is 98%,” Papanna said.

But if the condition is undiagnosed, the results differ significantly. Mothers can be injured and the probability of the baby dying is more than 60%.

In the past, when vasa previa was harder to diagnose, Papanna said women presented to hospitals bleeding and didn’t know the cause of the stillbirth until an autopsy was performed.

Things have changed over the past 10 to 15 years, Papanna said. Patients are examined during routine ultrasounds to determine if the placenta and cervix are positioned abnormally. They are also evaluated for other risk factors, including multiple births or a bilobed placenta, as Resendez had done.

A National Institutes of Health publication describes a bilobed placenta as “a placenta with two roughly equal-sized lobes separated by a membrane” and it occurs in 2% to 8% of placentas.

While diagnoses have improved, treatment has remained the same. Patients could only wait in the hospital and plan an early delivery with caesarean section.

“We would follow them very closely,” Papanna said. “And we gave birth maybe a month or two early to keep them from having emergency bleeding.”

It was only recently that he discovered another option.

A new possibility

Papanna was at a medical conference when he heard about fetal laser ablation surgery to repair vasa previa.

“It’s a completely new procedure,” Papanna said. “It’s not the standard of care.”

At the event, the doctor listened to 10 cases presented by Dr. Ramen Chmait, director of the fetal surgery program at the University of Southern California.

He had studied the technique for about a decade.

The procedure involves making a small incision in the abdomen and using a fetal scope to identify the problematic blood vessel. Then a laser is used to weld each side of the vessel so that it no longer works.

He struck up a conversation with Chmait and reviewed the results.

“I thought it was a reasonable offer for patients,” Papanna said.

And the procedure involved a technique he had experience with to correct an imbalanced vascular system in twins. Papanna has personally performed this operation about 300 times – and there are about 700 in the records of the Fetal Center at Children’s Memorial Hermann Hospital.

“We have the equipment, the surgical technique, the ultrasound skills and all the tools,” Papanna said. “We just had to apply it.”

A year and a half ago, Papanna had her first fetal laser ablation for vasa previa. He has now performed five operations.

Resendez was his third.

A saving operation

An ideal candidate for surgery would have only one or two small blood vessels on the cervix that support less than 20% of the placenta. This way, the surgeon can remove the vein without causing any harm to the baby.

During her first visit to Houston, a detailed ultrasound created a three-dimensional map of Resendez’s uterus.

Papanna uses the image to create a clear plan for the surgery.

He also asks his patients to wait until 31 or 32 weeks of pregnancy for two reasons. This gives ships a chance to migrate to the correct location on their own. And, at this point, the fetus is large enough to survive an emergency delivery.

During the procedure, the mother is awake and under local anesthesia.

Resendez was anxious the day before the operation, scheduled for August 24, 2021.

“Dr. Papanna could tell,” she recalled. “He took it upon himself to kneel down, hold my hand, breathe with me, and say, ‘It’s going to be okay. You made the right decision. It gave me a world of confidence.

Meanwhile, Moravia waited, nervously.

“I was terrified,” he recalls. “It was just very emotional.”

Papanna came out afterwards and the two talked.

“He treated my wife like family,” Moravia said. “I will owe him this forever.”

Resendez was only slightly sore the next day as the couple returned to San Antonio.

Resendez was 36 weeks pregnant when her amniotic fluid started leaking. She went to an appointment and ended up in the emergency room.

His son Luca Moravia was born on October 1.

Although she was not at full term, as she had hoped, she was able to give birth naturally and was not forced into bed rest.

Luca is now just over 5 months old and weighs around 13 pounds.

“He’s the best baby,” Resendez said. “He’s handsome with big blue eyes.”

The baby’s father is grateful that his wife’s vasa previa has been discovered.

“He’s an almost unlucky baby,” Moravia said. “I definitely feel blessed.”

Peyton is a freelance writer based in Houston.

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