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Fetal therapy

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

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Fetal therapy

  1. 1. BY MAGDY ABDELRAHMAN 2017
  2. 2.  Any intervention Aiming for correcting or treating a fetal abnormalities.
  3. 3.  Non invasive (pharmacological). › Preventive. › Therapeutic.  Invasive.
  4. 4.  Peri-conceptional folic acid supplementation.  Antenatal steriod to enhance fetal lung maturity.  Anti D immunoglobulin.
  5. 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. 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. 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. 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. 9.  1961. › In utero transfusion (liley).  1970s › Embryoscopy / Fetoscopy was introduced to visualized malformations. › High resolution U/S take their diagnostic role.
  10. 10.  1984. › 1st successful resection of congenital cystic adenomatous malformation.  1992 › 1st successful resection of sacrococcygeal teratoma.
  11. 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. 12.  Ultrasound image guided procedure  Needle or a Trocar- Canula -Shunt introduced.
  13. 13.  Least invasive.  Least risk of amniotic fluid leak.  Least risk of preterm labour.
  14. 14.  Amniocentesis.  Amnioinfusion.  Septostomy.  Selective Fetal reducion.  Intrauterine transfusion.
  15. 15.  Acardiac twins ( twins reversed arterial perfusion). › Bipolar diathermy or radiofrequency ablation of umblical cord.  Vesico-amniotic shunt.  Pleuro-amniotic shunt.
  16. 16.  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.
  17. 17.  Fetoscopic access to the Fetus.  The fetal visualisation is a combination of endoscopic and sonographic on two different screens.
  18. 18.  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.
  19. 19. Determine Chorionicity.
  20. 20. 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
  21. 21.  Quintero Staging System › I. Amniotic Fluid Discordance › II. Donor Bladder Not Visible › III. Abnormal Dopplers › IV. Fetal Hydrops › V. Fetal Demise
  22. 22.  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.
  23. 23.  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.
  24. 24.  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.
  25. 25.  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 ???
  26. 26.  Dr.Michael Harrison (California)  Father of open fetal surgery
  27. 27.  Ethical dilemma.  Maternal & Fetal anaesthesia.  Risks both to mother and fetus.  Post surgical tocolysis.
  28. 28.  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.
  29. 29.  Tocolytic therapy can cause pulmonary edema.  Subsequent delivery by LSCS.  Intraoperative blood loss.  Intra uterine infection.  Deep anaesthesia can cause maternal myocardial depression.
  30. 30.  Prematurity & PROM.  Intra Uterine Infection.  Fetal vascular embolic events. › Intestinal atresia. › Renal agenesis.
  31. 31.  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.
  32. 32.  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.
  33. 33.  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
  34. 34.  The fetus is monitored with › Fetal Echocardiography › Pulse Oxymetry  Continous Infusion of warmed Ringer Lactate to replace amniotic fluid
  35. 35.  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.
  36. 36.  (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)
  37. 37.  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.
  38. 38.  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.
  39. 39.  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.

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