KARL-STORZ SEMI-RIGID TTTS FETOSCOPY INSTRUMENT SET 26008AA

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed with the FDA on 2013-05-31 for KARL-STORZ SEMI-RIGID TTTS FETOSCOPY INSTRUMENT SET 26008AA manufactured by Karl Storz Endoscopy America, Inc.

Event Text Entries

[3497457] On (b)(6) 2013, pt as presented to the office for an ultrasound eval of her pregnancy. She was given the diagnosis of a dichorionic-diamniotic triplet pregnancy. This type of pregnancy consists of a singleton fetus in its own amniotic sac with its own placenta and a pair of identical twins within the same amniotic sac that share a placenta. The pt was referred to me by a colleague in (b)(6) for consultation and eval of this rare high risk pregnancy on (b)(6) 2013. The above findings were confirmed and a detailed consultation in regards to this unique triplet pregnancy, specifically with a monochorionic-monoamniotic twin pair, was performed. Management options for this pregnancy were reviewed during the initial consultation and on 2 subsequent visits, (b)(6). The ultrasound eval on (b)(6) identified that triplet (b)(6) had an anomaly to the left hand. Discordant congenital anomalies in these types of twins are not uncommon. During the visit on the (b)(6), the pt and her family indicated that they had elected to proceed with fetoscopic umbilical vessel coagulation and cutting in an attempt to decrease the risk of a twin demise due to umbilical cord entanglement and decrease the risk of neurological injury to the surviving twin if one of them should die as a result of umbilical cord accident. They had elected to coagulate the umbilical vessels of triplet (b)(6), unless at the time of fetoscopy it was noted that triplet (b)(6) had a more severe anomaly. As was counseled extensively about the risks of such a procedure to include the loss of one or both twins, wrong cord coagulation and possibly the loss of all three fetuses due to complications of the procedure. The procedure was performed on (b)(6) 2013, without any known complications. Ultrasound eval at the end of the procedure demonstrated 2 normal fetal heart rates, triplet (b)(6) and what was thought to be triplet (b)(6) at the time. The presumed triplet (b)(6) demonstrated a terminal heart rate as expected from the procedure. The pt tolerated the procedure without any problems and had a follow-up ultrasound eval by my associate the following day. This ultrasound demonstrated 2 viable fetuses and no known complication related to the procedure (rupture of membranes, maternal bleeding, shortened cervical length or chorioamniotic separation). The pt was discharged to home on post-operative day one. On post-operative day number six, she presented to (b)(6) for eval. During an ultrasound performed by myself, i had identified that the surviving monochorionic twin was in fact twin (b)(6) and that twin (b)(6) was the demised fetus. While the intention of the procedure was the cord coagulation of triplet (b)(6), this unforeseen outcome was not as a direct result of the hud device (hud 03120) or any malfunction or misuse of such device. The loss of triplet (b)(6) in this case, is unfortunately a known potential complication of this procedure and is being reported to the fda as an adverse outcome related to the use of a medical device.
Patient Sequence No: 1, Text Type: D, B5


MAUDE Entry Details

Report NumberMW5030396
MDR Report Key3148670
Date Received2013-05-31
Date of Report2013-05-30
Date of Event2013-03-28
Date Added to Maude2013-06-06
Event Key0
Report Source CodeVoluntary report
Manufacturer LinkN
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA0
Event Location0
Single Use0
Previous Use Code0
Event Type3
Type of Report3

Device Details

Brand NameKARL-STORZ SEMI-RIGID TTTS FETOSCOPY INSTRUMENT SET
Generic NameFETOSCOPE
Product CodeHGK
Date Received2013-05-31
Model Number26008AA
OperatorHEALTH PROFESSIONAL
Device AvailabilityY
Device Sequence No1
Device Event Key0
ManufacturerKARL STORZ ENDOSCOPY AMERICA, INC
Manufacturer Address600 CORPORATE POINTE CULVER CITY CA 90230 US 90230


Patients

Patient NumberTreatmentOutcomeDate
101. Other 2013-05-31

© 2024 FDA.report
This site is not affiliated with or endorsed by the FDA.