Intra uterine fetal surgery

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Intra uterine fetal surgery

  1. 1. Intra Uterine Fetal Surgery Dr.Sameer Dikshit
  2. 2. Dr.Sameer Dikshit <ul><li>MD,DGO,FCPS,FICOG </li></ul><ul><li>Member, Genetic & Fetal Medicine Committee </li></ul><ul><li>Past Secretary, Palghar Ob Gy Society </li></ul><ul><li>Trained at King’s College, London under Prof. Nicolaides </li></ul>AICOG 2011 [email_address] <ul><li>Hon Sonologist Wadia Hospital, Mumbai </li></ul><ul><li>Fetal Medicine Consultant BSES MG Global Hospital, Mumbai </li></ul><ul><li>Boisar Fetal Medicine Centre </li></ul><ul><li>Irla Nursing Home, Mumbai </li></ul><ul><li>Sanket Sonography, Mumbai </li></ul>
  3. 3. The allure of Fetal Surgery is the possibility of interrupting the in utero progression of an otherwise treatable condition AICOG 2011 [email_address]
  4. 4. Fetal Surgery is…….. <ul><li>Indicated in conditions which interfere with the normal development of the fetus </li></ul><ul><li>Which when corrected will allow normal development of the fetus </li></ul>AICOG 2011 [email_address]
  5. 5. <ul><li>It is contraindicated in conditions that are incompatible with life </li></ul><ul><ul><li>Severe affliction </li></ul></ul><ul><ul><li>Other associated life threatening abnormalities </li></ul></ul><ul><ul><li>Chromosomal & Genetic conditions </li></ul></ul>AICOG 2011 [email_address]
  6. 6. Father of Fetal Surgery <ul><li>Sir A.W.Liley in 1965 </li></ul><ul><li>Intra Uterine Transfusion for Hydrops due to Rh incompatibility </li></ul><ul><li>Dr.Michael Harrison in 1982 </li></ul><ul><li>First open fetal surgery for obstructive uropathy </li></ul>AICOG 2011 [email_address]
  7. 7. Types of Fetal Surgery <ul><li>Open Surgery </li></ul><ul><li>FETENDO (Fetal Endoscopic Surgery) </li></ul><ul><li>FIGS (Fetal Image Guided Surgery) </li></ul><ul><li>EXIT (Ex-Utero Intrapartum Treatment Procedure) </li></ul>AICOG 2011 [email_address]
  8. 8. FIGS (Fetal Image Guided Surgery) <ul><li>Ultrasound image guided procedure </li></ul><ul><li>Needle or a Trocar-Canula -Shunt introduced </li></ul>AICOG 2011 [email_address]
  9. 9. <ul><li>Least invasive </li></ul><ul><li>Least risk of amniotic fluid leak </li></ul><ul><li>Least risk of PT labour </li></ul>AICOG 2011 [email_address]
  10. 10. Examples <ul><li>Diagnostic </li></ul><ul><ul><li>Chorion Villus Sampling </li></ul></ul><ul><ul><li>Amniocentesis </li></ul></ul><ul><ul><li>Cordocentesis </li></ul></ul><ul><ul><li>Fetal skin Biopsy </li></ul></ul>AICOG 2011 [email_address]
  11. 11. <ul><li>Therapeutic </li></ul><ul><ul><li>RFA (Radio Frequency Ablation) of anomalous Twins </li></ul></ul><ul><ul><li>Cord cauterization in Twins </li></ul></ul><ul><ul><li>Vesical / Pleural Shunts </li></ul></ul><ul><ul><li>Balloon Dilatation of Aortic Stenosis </li></ul></ul>AICOG 2011 [email_address]
  12. 12. AICOG 2011 [email_address]
  13. 13. FETENDO (Fetal Endoscopic Surgery) <ul><li>Fetoscopic access to the Fetus </li></ul><ul><li>Real time visualisation of the Fetus </li></ul>AICOG 2011 [email_address]
  14. 14. <ul><li>The fetal visualisation is a combination of endoscopic and sonographic on two different screens </li></ul><ul><li>It is called FETENDO because the movements are like the children’s video game NINTENDO </li></ul>AICOG 2011 [email_address]
  15. 15. <ul><li>Less invasive </li></ul><ul><li>Less risk of amniotic fluid leak </li></ul><ul><li>Less risk of PT labour </li></ul>AICOG 2011 [email_address]
  16. 16. Examples <ul><li>CDH (Congenital Diaphragmatic Hernia)-Balloon Occlusion of trachea </li></ul><ul><li>TTTS (Twin to Twin Transfusion Syndrome)- Laser coagulation of vessels </li></ul><ul><li>Cord ligation in cases of acardiac Twins </li></ul><ul><li>Amniotic bands division </li></ul>AICOG 2011 [email_address]
  17. 17. Open Surgery <ul><li>Mother is anaesthetised </li></ul><ul><li>Uterus is opened similar to LSCS </li></ul><ul><li>Special stapling device to prevent bleeding & amniotic fluid leak </li></ul>AICOG 2011 [email_address]
  18. 18. <ul><li>Intra operative sonography to locate the placenta and to determine the surface anatomy of the fetus </li></ul><ul><li>Fetal part is exteriorized </li></ul><ul><li>Fetal Surgery </li></ul>AICOG 2011 [email_address]
  19. 19. Examples <ul><li>CCAM (Congenital Cystic Adenomatoid Malformation of Lung)- Lobectomy </li></ul><ul><li>SCT (Sacro-coccygeal Teratoma)- Resection </li></ul><ul><li>MMC (Meningo Myelocoele)- Repair </li></ul>AICOG 2011 [email_address]
  20. 20. EXIT (Ex-utero Intrapartum treatment procedure) <ul><li>It is the intervention that occurs at the time of delivery </li></ul><ul><li>It is primarily used in cases where baby’s airway requires surgical intervention </li></ul><ul><li>Provide the baby with patent airway that can provide O 2 to the lungs after separation of placenta </li></ul>AICOG 2011 [email_address]
  21. 21. <ul><li>It starts as a routine LSCS but under GA </li></ul><ul><li>Head of the baby is delivered, but the placenta is in situ </li></ul><ul><li>The baby gets oxygen from placenta via umbilical cord </li></ul>AICOG 2011 [email_address]
  22. 22. <ul><li>Bronchoscopy of the fetal airway </li></ul><ul><li>Endotracheal intubation attempted </li></ul><ul><li>If unsuccessful then tracheostomy is done </li></ul><ul><li>O 2 delivery to lungs confirmed </li></ul>AICOG 2011 [email_address]
  23. 23. <ul><li>Cord is cut </li></ul><ul><li>Baby is delivered </li></ul>AICOG 2011 [email_address]
  24. 24. AICOG 2011 [email_address]
  25. 25. AICOG 2011 [email_address]
  26. 26. Examples <ul><li>CHAOS (Congenital High Airway Obstruction Syndrome) </li></ul><ul><li>Removal of balloon after CDH </li></ul><ul><li>Pulmonary Sequestration </li></ul><ul><li>CCAM (Congenital Cystic Adenomatoid Malformation) </li></ul>AICOG 2011 [email_address]
  27. 27. Challenges before the field of fetal surgery….. <ul><li>Ethical dilemma </li></ul><ul><li>Maternal & Fetal anaesthesia </li></ul><ul><li>Risks both to mother and fetus </li></ul><ul><li>Post surgical tocolysis </li></ul>AICOG 2011 [email_address]
  28. 28. Ethical Dilemma <ul><li>Not all procedures are performed regularly </li></ul><ul><li>The results are not guaranteed </li></ul><ul><li>Risks to mother and fetus </li></ul>AICOG 2011 [email_address]
  29. 29. <ul><li>Should a procedure which is not guaranteed to produce results BE PERFORMED on the insistence of mother? </li></ul><ul><li>Should a procedure which is guaranteed to produce results NOT BE PERFORMED on refusal of mother? </li></ul>AICOG 2011 [email_address]
  30. 30. <ul><li>Research in Fetal Surgery is ethically controversial as it poses a risk to both the fetus and the mother </li></ul><ul><li>Surgical Animal models do not always replicate in human beings </li></ul>AICOG 2011 [email_address]
  31. 31. Maternal Risks <ul><li>Tocolytic therapy can cause pulmonary edema </li></ul><ul><li>Subsequent delivery by LSCS </li></ul><ul><li>Intra op blood loss </li></ul>AICOG 2011 [email_address]
  32. 32. <ul><li>Amniotic fluid leak </li></ul><ul><li>Wound infection </li></ul><ul><li>Intra uterine infection </li></ul>AICOG 2011 [email_address]
  33. 33. <ul><li>“ Maternal Mirror Syndrome” in cases of fetal Hydrops </li></ul><ul><li>Chorioamnionic membrane separation </li></ul>AICOG 2011 [email_address]
  34. 34. <ul><li>Deep anaesthesia is required to provide with adequate uterine relaxation for fetal manipulation and to prevent PT labour </li></ul><ul><li>This depth can cause fetal and maternal myocardial depression also can affect placental perfusion </li></ul>AICOG 2011 [email_address]
  35. 35. Fetal Risks <ul><li>Prematurity </li></ul><ul><li>Intra Uterine Infection </li></ul><ul><li>Fetal vascular embolic events </li></ul><ul><ul><li>Intestinal atresia </li></ul></ul><ul><ul><li>Renal agenesis </li></ul></ul>AICOG 2011 [email_address]
  36. 36. <ul><li>Premature closure of Ductus Arteriosus </li></ul><ul><li>CNS injuries due to maternal hypoxia or fetal circulatory disturbance </li></ul>AICOG 2011 [email_address]
  37. 37. Fetal response to maternal anaesthesia <ul><li>Fetal organs system is immature </li></ul><ul><li>Fetal Cardiac Output is sensitive to heart rate changes </li></ul><ul><li>Fetus has high vagal tone and hence responds to stress with precipitous bradycardia </li></ul>AICOG 2011 [email_address]
  38. 38. <ul><li>Fetal circulating volume is low, hence little intra-operative bleeding can cause hypovolemia </li></ul><ul><li>Maternal anesthesia depress myocardium, circulation </li></ul>AICOG 2011 [email_address]
  39. 39. <ul><li>Fetus tends to lose heat much easily from the exposed skin resulting in hypothermia </li></ul><ul><li>Immature coagulation system predispose the fetus to bleeding and difficulty in hemostasis </li></ul>AICOG 2011 [email_address]
  40. 40. <ul><li>Maternal anesthesia reduces placental blood flow, this reduces the amount of O 2 delivered to the fetus </li></ul><ul><li>Normal Fetal oxygen saturation is 60-70% and the aim is to maintain it above 40% </li></ul>AICOG 2011 [email_address]
  41. 41. <ul><li>Intra-operative fetal distress is manifested by bradycardia, decreased fetal oxygen saturation and reduced stroke output </li></ul><ul><li>During prolonged surgery, fetus may be transfused O neg blood </li></ul>AICOG 2011 [email_address]
  42. 42. <ul><li>Top up fetal anaesthesia may be needed to augment the maternal anaesthesia </li></ul><ul><li>When fetus is hydropic, it is very sensitive to fluctuating maternal hemodynamics </li></ul><ul><li>Maternal hyperventilation is avoided as maternal hypocapnia causes fetal placental vasoconstriction and fetal hypoxia </li></ul>AICOG 2011 [email_address]
  43. 43. Fetal Monitoring during surgery <ul><li>In case of open surgery </li></ul><ul><li>Fetus monitored by echocardiography and miniature pulse oxymeter </li></ul>AICOG 2011 [email_address]
  44. 44. Post op care <ul><li>High risk of Pre term labour </li></ul><ul><li>Mag Sulph is the tocolytic of choice and maintained for 2-3 days </li></ul><ul><li>Maternal analgesia is important because maternal pain can cause PT labour and Fetal distress </li></ul>AICOG 2011 [email_address]
  45. 45. <ul><li>Epidural analgesia for 24-48 hours is recommended </li></ul>AICOG 2011 [email_address]
  46. 46. Protocol for open Fetal Surgery <ul><li>Assessment of the mother for fitness for anaesthesia </li></ul>AICOG 2011 [email_address]
  47. 47. <ul><li>Assessment of the fetus </li></ul><ul><ul><li>Detailed USG to r/o other malformations </li></ul></ul><ul><ul><li>3D and 4D examination </li></ul></ul><ul><ul><li>Detailed examination of affected organ system </li></ul></ul>AICOG 2011 [email_address]
  48. 48. <ul><ul><li>Detailed Fetal Echocardiography </li></ul></ul><ul><ul><li>Amniocentesis </li></ul></ul><ul><ul><li>Localisation of placenta </li></ul></ul><ul><li>Fetal MRI </li></ul>AICOG 2011 [email_address]
  49. 49. <ul><li>Maternal blood cross matched </li></ul><ul><li>Mother given GA with intubation as the uterus has to be relaxed to allow manipulation of the uterus </li></ul><ul><li>Indomethacin rectal suppository </li></ul>AICOG 2011 [email_address]
  50. 50. <ul><li>O neg blood for fetus kept ready </li></ul><ul><li>Abdomen opened as in LSCS </li></ul><ul><li>Intra operative USG to localise placenta and to assess the surface anatomy of the fetus </li></ul>AICOG 2011 [email_address]
  51. 51. <ul><li>Incision to be taken close to the area of interest </li></ul><ul><li>Uterine Stapler to seal amnion and reduce blood loss </li></ul>AICOG 2011 [email_address]
  52. 52. Dr.Michael Harrison <ul><li>University of California, San Francisco </li></ul><ul><li>Father of open fetal surgery </li></ul>AICOG 2011 [email_address]
  53. 53. Uterine Stapler AICOG 2011 [email_address]
  54. 54. <ul><li>Fetus is given </li></ul><ul><ul><li>Inj Atropine 0.02 mg/kg </li></ul></ul><ul><ul><li>Inj Epinephrine 1 μ g/kg </li></ul></ul><ul><ul><li>Inj Vecuronium 0.2 mg/kg </li></ul></ul><ul><ul><li>Inj Fentanyl 1-2 μ g/kg </li></ul></ul>AICOG 2011 [email_address]
  55. 55. The fetus is monitored with <ul><li>Fetal Echocardiography </li></ul><ul><li>Pulse Oxymetry </li></ul><ul><li>PO 2 from Cord Blood </li></ul><ul><li>Fetal Hb from Cord Blood </li></ul>AICOG 2011 [email_address]
  56. 56. <ul><li>Infusion of 50 ml aliquots of O neg Blood </li></ul><ul><li>Infusion of warmed Ringer Lactate to replace amniotic fluid </li></ul><ul><li>Fetal Surgery is performed </li></ul>AICOG 2011 [email_address]
  57. 57. <ul><li>At the time of closure, IV MagSulph 6g over 20 minutes </li></ul><ul><li>3G/hr infusion post operative </li></ul>AICOG 2011 [email_address]
  58. 58. Maternal Anaesthesia <ul><li>Regional Anaesthesia -Lumbar Epidural </li></ul><ul><li>Deep GA -(Sodium Pentothal + Scoline) + (Isoflurane + Fentanyl+O 2 + Vecuronium) </li></ul><ul><li>GA with N 2 O - (Sodium Pentothal + Scoline) + (Isoflurane + N 2 O + Vecuronium) </li></ul>AICOG 2011 [email_address]
  59. 59. Fetal Pain…. <ul><li>“ Pain” by definitive is a subjective phenomenon </li></ul><ul><li>Hence it is not possible to assess “Fetal Pain” directly </li></ul>AICOG 2011 [email_address]
  60. 60. <ul><li>It is assessed indirectly by the ability of the fetus to mount a stress response to a noxious stimulus </li></ul><ul><li>Increased fetal cortisol, beta-endorphins and “central sparing” hemodynamic changes </li></ul>AICOG 2011 [email_address]
  61. 61. <ul><li>Fetal administration of a narcotic inhibits cortisol and beta-endorphin release but does not inhibit “central sparing” hemodynamic changes </li></ul>AICOG 2011 [email_address]
  62. 62. <ul><li>Fetal pain has been said to contribute to exaggerated pain response in 8 week old infants </li></ul><ul><li>It is also said to stimulate preterm labour </li></ul>AICOG 2011 [email_address]
  63. 63. Future possibilities <ul><li>Deliver stem cells or DNA to treat sickle cell anemia or other genetic conditions </li></ul>AICOG 2011 [email_address]
  64. 64. Inherited Genetic Diseases Treatable with Stem Cells AICOG 2011 [email_address]
  65. 65. Inherited Genetic Diseases Treatable with Stem Cells <ul><li>Haemoglobinopathies </li></ul><ul><li>Immunodeficiency diseases </li></ul><ul><li>Mucopolysaccharidoses </li></ul><ul><li>Mucoliposes </li></ul><ul><li>Diamond Blackfan Syndrome </li></ul><ul><li>Fanconi anemia </li></ul>AICOG 2011 [email_address]  
  66. 66. <ul><li>Prevention of graft v/s host disease </li></ul><ul><li>Prevents further damage to the fetus </li></ul><ul><li>Intra-amniotic or Intra-umbilical vein </li></ul>AICOG 2011 [email_address]
  67. 67. The key in fetal surgery is not when to operate, but to know when NOT to operate!!! AICOG 2011 [email_address]
  68. 68. Sacrococcygeal Teratoma (SCT) <ul><li>Open Surgery for excision of the Teratoma </li></ul><ul><li>The tumours are benign </li></ul><ul><li>But can caused Fetal Hydrops due to vascular shunts </li></ul>AICOG 2011 [email_address]
  69. 69. Cystic SCTs AICOG 2011 [email_address]
  70. 70. <ul><li>Cystic SCTs do not have vascular shunts </li></ul><ul><li>Hence the fetus does not land up with Hydrops </li></ul><ul><li>Hence, there is NO INDICATION for Intra Uterine Surgery in these cases </li></ul>AICOG 2011 [email_address]
  71. 71. Solid SCT AICOG 2011 [email_address]
  72. 72. <ul><li>Solid SCTs have vascular shunts </li></ul><ul><li>High risk of Hydrops and fetal death </li></ul><ul><li>Hence Intra Uterine Surgery is indicated </li></ul>AICOG 2011 [email_address]
  73. 73. Congenital Diaphragmatic Hernia (CDH) <ul><li>The key to the successful management is to have a fetus with competent lungs after birth </li></ul><ul><li>If the lungs are collapsed, then post natal surgery fails </li></ul>AICOG 2011 [email_address]
  74. 74. <ul><li>The status of the lungs can be predicted by- </li></ul><ul><ul><li>Presence of liver in the thorax (presence of liver  more severe disease) </li></ul></ul><ul><ul><li>LHR (Lung to Head ratio) less than 1.0 </li></ul></ul>AICOG 2011 [email_address]
  75. 75. These fetuses need intra partum intervention for postpartum surgery to succeed <ul><li>FETENDO with temporary tracheal occlusion </li></ul><ul><li>EXIT procedure to remove the balloon before birth </li></ul>AICOG 2011 [email_address]
  76. 76. <ul><li>Why open intra partum surgery fails???? </li></ul><ul><li>Reduction of the liver into abdomen kinks the Ductus Venosus </li></ul>AICOG 2011 [email_address]
  77. 77. Congenital Cystic Adenomatoid Malformation of the lungs (CCAM) <ul><li>Most fetuses do well in utero </li></ul><ul><li>Indications for intra uterine surgery are:- </li></ul><ul><ul><li>Progressive increase in the size </li></ul></ul><ul><ul><li>Mediastinal shift </li></ul></ul><ul><ul><li>Hydrops </li></ul></ul><ul><ul><li>Polyhydramnios </li></ul></ul>AICOG 2011 [email_address]
  78. 78. <ul><li>Thoraco amniotic shunt </li></ul><ul><li>EXIT procedure for securing airway </li></ul><ul><li>Open Fetal Surgical Resection </li></ul>AICOG 2011 [email_address]
  79. 79. CCAM Prenatal Steroid Trial <ul><li>University of California, San Francisco </li></ul><ul><li>Cases with large CCAM who would otherwise need intra uterine surgery </li></ul><ul><li>2 doses of Betamethasone 12 mg IM, 24 hours apart </li></ul>AICOG 2011 [email_address]
  80. 80. Fetal Surgery is a roller coaster for the fetus…. AICOG 2011 [email_address]
  81. 81. Fetal Surgery is a roller coaster ride for the fetus <ul><li>It is our endeavor to ensure that fetus comes through it smiling and unharmed…. </li></ul>AICOG 2011 [email_address]
  82. 82. AICOG 2011 [email_address]
  83. 83. Thank you AICOG 2011 [email_address]
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