fetal therapy, fetal surgery, prenatal diagnosis, congenital anomalies, EXIT procedures, fetal medicine, fetal medical therapy, RH isoimmunization, twins twins transfusion syndromes.

1. BY
MAGDY ABDELRAHMAN
2017

2.  Any intervention Aiming for correcting or
treating a fetal abnormalities.

3.  Non invasive (pharmacological).
› Preventive.
› Therapeutic.
 Invasive.

4.  Peri-conceptional folic acid supplementation.
 Antenatal steriod to enhance fetal lung
maturity.
 Anti D immunoglobulin.

5.  Congenital adrenal hyperplasia.
› Dexamethazone 20 ug/kg in three divided doses,
started at 6 W.
› Stopped when proved male fetus or unaffected
female.

6. Fetus with maternal SLE.
 Fetus at risk to develop Complete heart
block because of damage to AV bundle.
 This can be prevented by giving
Dexamethasone 4 mg per day during
pregnancy.

7. THERAPEUTIC PHARMACOTHERAPY
 Cardiac arrhythmias can be managed by
digoxin and/or amiodarone.
 Fetal thyroid goitre ….. fetal cord blood for
thyroid status then treated by either
carbimazol or levothyroxin.

8.  Termination of pregnancy.
 Fetal Image Guided procedures.
 Fetal Endoscopic Surgery (FETENDO).
 EXIT procedure (Ex-Utero Intrapartum
Treatment Procedure).
 Open fetal surgery.
 High intensity focused ultrasound (HIFU).
 Gene therapy & stem cell.

9.  1961.
› In utero transfusion (liley).
 1970s
› Embryoscopy / Fetoscopy was introduced to
visualized malformations.
› High resolution U/S take their diagnostic role.

10.  1984.
› 1st successful resection of congenital cystic
adenomatous malformation.
 1992
› 1st successful resection of sacrococcygeal
teratoma.

11.  Termination of pregnancy.
 Fetal Image Guided procedures.
 Fetal Endoscopic Surgery (FETENDO).
 EXIT procedure (Ex-Utero Intrapartum
Treatment Procedure).
 Open fetal surgery.
 High intensity focused ultrasound (HIFU).
 Gene therapy & stem cell.

12.  Ultrasound image
guided procedure
 Needle or a Trocar-
Canula -Shunt
introduced.

13.  Least invasive.
 Least risk of amniotic fluid leak.
 Least risk of preterm labour.

14.  Amniocentesis.
 Amnioinfusion.
 Septostomy.
 Selective Fetal reducion.
 Intrauterine transfusion.

15.  Acardiac twins ( twins reversed arterial
perfusion).
› Bipolar diathermy or radiofrequency ablation of
umblical cord.
 Vesico-amniotic shunt.
 Pleuro-amniotic shunt.

17.  Termination of pregnancy.
 Fetal Image Guided procedures.
 Fetal Endoscopic Surgery (FETENDO).
 EXIT procedure (Ex-Utero Intrapartum
Treatment Procedure).
 Open fetal surgery.
 High intensity focused ultrasound (HIFU).
 Gene therapy & stem cell.

18.  Fetoscopic access to the Fetus.
 The fetal visualisation is a combination of
endoscopic and sonographic on two different
screens.

19.  CDH (Congenital Diaphragmatic Hernia)-Balloon
Occlusion of trachea
 TTTS (Twin to Twin Transfusion Syndrome)- Laser
coagulation of vessels
 Laser ablation of umblical cord in cases of acardiac
Twins
 Amniotic bands division
 Posterior uretheral valve laser ablation.

21. Determine Chorionicity.

22. Amniotic Fluid Discordance
 Recipient
› Maximum vertical pocket greater than or
equal to 8.0 cm
 Donor
› Maximum vertical pocket less than or equal
to 2.0 cm

23.  Quintero Staging System
› I. Amniotic Fluid Discordance
› II. Donor Bladder Not Visible
› III. Abnormal Dopplers
› IV. Fetal Hydrops
› V. Fetal Demise

28.  Termination of pregnancy.
 Fetal Image Guided procedures.
 Fetal Endoscopic Surgery (FETENDO).
 EXIT procedure (Ex-Utero Intrapartum
Treatment Procedure).
 Open fetal surgery.
 High intensity focused ultrasound (HIFU).
 Gene therapy & stem cell.

29.  It is the intervention that occurs at the time of
delivery.
 It is primarily used in cases where baby’s
airway requires surgical intervention as:
› CHAOS (Congenital High Airway Obstruction
Syndrome)
› Removal of balloon after treatment of
diaphragmatic hernia.

31.  Termination of pregnancy.
 Fetal Image Guided procedures.
 Fetal Endoscopic Surgery (FETENDO).
 EXIT procedure (Ex-Utero Intrapartum
Treatment Procedure).
 Open fetal surgery.
 High intensity focused ultrasound (HIFU).
 Gene therapy & stem cell.

32.  Congenital cystic adenomatous
malformation.
› Progressive increase in the size.
› Mediastinal shift.
› Hydrops.
› Polyhydramnios.
 Sacrococcygeal teratoma.
› Fetal Hydrops due to vascular shunts. ( high
output heart failure)
 Open spina bifida ???

33.  Dr.Michael Harrison
(California)
 Father of open fetal
surgery

36.  Ethical dilemma.
 Maternal & Fetal anaesthesia.
 Risks both to mother and fetus.
 Post surgical tocolysis.

37.  Not all procedures are performed regularly.
 The results are not guaranteed.
 Research in Fetal Surgery is ethically
controversial as it poses a risk to both the fetus
and the mother.
 Surgical Animal models do not always replicate
in human beings.

38.  Tocolytic therapy can cause pulmonary
edema.
 Subsequent delivery by LSCS.
 Intraoperative blood loss.
 Intra uterine infection.
 Deep anaesthesia can cause maternal
myocardial depression.

40.  Prematurity & PROM.
 Intra Uterine Infection.
 Fetal vascular embolic events.
› Intestinal atresia.
› Renal agenesis.

41.  Fetal circulating volume is low, hence little
intra-operative bleeding can cause
hypovolemia.
 During prolonged surgery, fetus may be
transfused Oneg blood
 Premature closure of Ductus Arteriosus
 CNS injuries due to maternal hypoxia or fetal
circulatory disturbance.

42.  Assessment of the mother for fitness for
anaesthesia & cross matched blood.
 Assessment of the fetus
› Detailed U/S to exclude other malformations.
› O neg blood for fetus kept ready.
› Detailed Fetal Echocardiography.
› Localization of placenta.
› Fetal MRI.

43.  Mother given GA with intubation as the
uterus has to be relaxed to allow
manipulation of the uterus.
 Intra operative U/S to localise placenta and
to assess the surface anatomy of the fetus
 Incision to be taken close to the area of
interest
 Uterine Stapler to reduce blood loss

44.  The fetus is
monitored with
› Fetal
Echocardiography
› Pulse Oxymetry
 Continous Infusion of
warmed Ringer
Lactate to replace
amniotic fluid

48.  Termination of pregnancy.
 Fetal Image Guided procedures.
 Fetal Endoscopic Surgery (FETENDO).
 EXIT procedure (Ex-Utero Intrapartum
Treatment Procedure).
 Open fetal surgery.
 High intensity focused ultrasound (HIFU).
 Gene therapy & stem cell.

49.  (HIFU) is a non-invasive alternative method
of vessel occlusion which may avoid
complications inherent to surgery.
 Still under research in animal study for
treating TTTs, A cardiac twin &
sacrococcygeal teratoma.
 Only one case report in human. It was used
to occlude umblical cord vessel in A cardiac
twin (Okai T, et al., 2013)

50.  Termination of pregnancy.
 Fetal Image Guided procedures.
 Fetal Endoscopic Surgery (FETENDO).
 EXIT procedure (Ex-Utero Intrapartum
Treatment Procedure).
 Open fetal surgery.
 High intensity focused ultrasound (HIFU).
 Gene therapy & stem cell.

51.  It means replacement of missing gene by
introduction of foreign Nucleic acid
sequence.
 It is divided into two categories, classic gene
therapy and stem cell gene therapy.
 A carrier molecule called a vector (virus-
lentivirus) must be used to deliver the
therapeutic gene to the patient’s target cells.

52.  Hematopoeitic stem cells can give rise to
complete blood system.
 Potential for treatment or even cure of many
hematopoeitic diseases ( ex. alph thalassemia,
1ry immunodeficiency syndrome).
 Theoretically, rejection should not be a problem
of “fetal tolerance”.
 Fetus remains in a sterile environment, so post-
transfusion isolation after transplant is
automatic.