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Fetal or Prenatal Surgery
- 1. Prenatal Surgery Moderator Prof S.P. Sharma Presenter Katyayani K Choubey
- 2. What is PrenatalSurgery? • Fetal reconstructive surgery/ antenatal surgery/ fetal surgery/ Maternal- fetal surgery • Branch of maternal fetus medicine • Techniques- to treat birth defects in fetus while in womb • To stop the progression of congenital diseases • To protect fetus- demise and disorders by early intervention
- 3. The need 3 -11%babies - complex birth defect. Advances in post-natal therapies birth defects cause of morbidity and mortality Few ds - devastating developmental consequences benefit from fetal t/t. option other than expectant mx and termination of pregnancy.
- 4. History Sir A. W.Liley (1963) Xray BT Erythroblastosis fetalis 1995 – Ex utero Intrapartum T/t Michael Harrison, 1981 USG- PUV 1996- Fetoscopy 1998- LASER 2001- RFA
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- 6. Imaging USG Echocardiography Ultrafast MRI Others 2D 3D4D/HD Rapid 20 sec MRI is used No need for fetal immboilisation Pros • Better soft-tissue contrast • Precise volumetric measurements • Larger field of view • Better imaging of intracranial str
- 7. Ultrasonography • Development offetal Sx • Dx Px Intervention Followup • Open as well as Minimally invasive
- 8. Echocardiography 3 D echoof a heart viewed from apex Evaluate cardiac and extra cardiac ds Hemodynamic instability (Hydrops) Natural history, pathogx of dses
- 9. Criteria forin uterosx PreciseDx R/o Anomalies and chromosomal mal. Known natural history andpathogx Well studied animal modelsMinimal maternal risks Multispeciali sedwell trained team R/o Maternal Mirror Syn.
- 10. Fetal Surgery Types Open Conventional FETENDO Laparoscopic Fetal Image-guided SurgeryFor Intervention Or Therapy (FIGS-IT) Image Guided RFA LASER EXIT Intra partum Others 20-28 weeks
- 11. Open Fetal Surgery Mother-GA Incision- lower abdomen Pre/Intraop USG done Placenta visualized Uterus opened using staplers Infusion with warmed RL Seals BV, fixes mb Prevent contractions, Maintains volume Fetal Analgesia Fetal ECG, Pulse oximeter, ABG At the end of Sx- Patient still Pregnant Cons
- 12. Open Fetal Surgery Indications Prosand Cons Good visualization Less injury Maternal morbidity Preterm labour PPROM Infection • Cong. Cystic Adenoid Malformation • Sacrococcygeal Teratoma • Meningomyelocele • Lower urinary tract obs.
- 13. Minimally Invasive FetalEndosurgery (FETENDO) • See and intervene on fetus - very small endoscopes and USGs- on separate screens • Percutaneous or Mini- lap • Length-18 cm scopes diameter -1.2 to 3.5 mm • visualization angle 0-39 degrees • GA
- 14. FETENDO Indications Pros and Cons LessInvasive Less Morbidity Preterm Skill Cost Risk • Cong. Diaphrag. Hernia • Twin twin transf. syndr.- Laser/RFA • Postr. Urethral valve • Cong. High Airway Obst. Synd.
- 15. Fetal Image-guided SurgeryFor Intervention Or Therapy (FIGS-IT) • Manipulating without incision/ endoscopic view inside the uterus. real-time cross-sectional USG guide instruments. • RA/ LA/ Sedation
- 16. FIGS-IT Indications Pros and Cons LeastInvasive Less Morbidity Preterm Day care Skill Risk Not for majorprobs Catheter-shunts bladder, abdomen, or chest RFA/Laser-anomalous twins, fetal cardiac defects.
- 17. Ex Utero IntrapartumTreatment (EXIT) • Operation based On Placental Circulation (OOPS) • Controlled method of C- Section • Allows a near term fetal intervention to secure airway – prevent hypoxemia • Preservation of placental blood flow until other means of gas exchange is established Fetal relaxation Uterine relaxation Fetal anesthesia
- 18. EXIT To Airway Intrinsic CHAOS Extrinsic Teratoma,sev.Micr ognathia Iatrogenic Tracheal clipor balloon To Resection Thoracic, Pulmonary masses To Extracorporeal Mb Oxygenation Cong. Heart Ds and CDH To Separation Conjoint Twins
- 19. Laser • Fibre in3 mm sheath • Near infrared Laser/ Anode/Nd:YAG • Fired from 1cm distance 1-2cm segment (visual cessation) • Selective Fetoscopic Laser Photocoagulation (SFLP)
- 20. RFA Principle - high-frequencyalternating currents l/t temp changes local coagulation and tissue desiccation. • 40W temp 3 prongs 100°C 2-3 minutes.
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- 22. Congenital conditions treatedin utero Disorder Natural History Benefits Recommended t/t CDH Lung Hypoplasia Normal anatomy Reverse Open/FETO LUTO VUR HNOligohy Lung Hypoplasia Removal of uropathy avoids irreversible changes Vesicostomy/VAS/ Valve ablation CCAM Lung Hypoplasia Hydrops Resection Open/Fetoscopic/ Aspirate/ Laser ablation SCT Vascular Insufficiency Hydrops Resection Open/laser/fetos. Placenta Circulation anomalies Blood Steal Destroy anastomosis Laser/RFA CHAOS Lung inflation cardiac insufficiency Hydrops Normal airway Fetscopic Tracheostomy /Valveplasty/ EXIT MMC Spinal cord lesion, hydroceph, ACM, myeloplegia Amniotic fluid destructive effect on exposed nerves Open or Fetoscopic Lesion coverage ABS Amputation/ cord constriction Amniotic band dissection
- 23. Congenital Diaphragmatic Hernia Embryonic phase abdominal organs herniate interfere with lung growth developmental arrest- airways & vasculature. At birth pulmonary hypoplasia, hypertension, immaturity Lung head circumference ratio (LHR) < 1
- 24. 2 techniques Open FETO Fetoscopicendoluminal tracheal occlusion • Liver up - Kinking of umblical veins Abandoned “Plug the lung until it grows” 34 weeks/ EXIT TOTAL (Tracheal Occlusion To Accelerate Lung Growth) Trial FETO vs Expectant
- 25. Congenital Cystic AdenomatoidMalformation (CCAM) • Overgrowth of terminal bronchioles Macrocystic –>5mm, Fluid Microcystic – < 5 mm, Solid, Bulky Large size Mediastinal shift Pulmonary hypoplasia Polyhydroamnios Nonimmune hydrops CVR = (Length X Height X Width X 0.52 )/ HC CCAM volume ratio(CVR) > 1.6/ Dominant cyst – hydrops
- 26. Lobectomy/ Segmetectomy Thoracoamniotic shunt (TAS) Two 12-mgim doses are given 24 hours apart Fetal Sx
- 27. Lower urinary tractobstructions (LUTO) • Urethral atresia (UA) • Posterior Urethral valve (PUV) • Triad syndrome • An enlarged fetal bladder + normal amniotic fluid incomplete obstruction. USG • APRPD • Oligohydramnios • Loss of CMD • Renal cortical cysts Fetal Urine • Calcium > 8mg/L • Na+>100meq/L • Cl- >90meq/L • β- 2 μglobulin >4 mg/L, • Urine osmolality >200 mosm/L Prognosis
- 28. Open Sx The goal– To obtain sufficient amniotic fluid - lung growth and increase chance of fetal adaptation Vesicostomy- abdandoned Vesicoamniotic shunt Fetoscopic Laser Fulgration In utero Treatment of LUTO Harrison’s Catheter
- 29. CHAOS Complete glottic weband interarytenoid fusion • Laryngeal atresia • Subglottic stenosis • Laryngeal/ tracheal -rings or agenesis Trapping of pulmonary secretions hyperinflation of the lungs increased intrathoracic pressure compromised venous return cardiac output hydrops
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- 31. Sacrococcygeal Teratoma High outputHF Tumor at sacrum- coccyx USG: cystic or solid or mixed • Cystic asymptomatic • Solid lot of blood flow double work done by heart high output failure hydrops Dx No High output HF <32 wks >32 wks In utero Tx Sx Emergency C- sec FU with USG Term C- sec
- 32. Treatment Options Open TxResection RFA LASER
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- 34. Treatment Options Repair OfMeningomyelocele
- 35. Twin- Twin TransfusionSyndrome MCDA twins - unbalanced flow Donor • Low flow • Oligohydramnios • High output HF • Brain ischemia • Small Recipient • Fluid overload • Polyhydramnios • Congestive HF • Hydrops fetalis • Large Treatment • Fetoscopic laser ablation - Stage II or greater • Amnioreduction- limited role QUINTERO
- 36. Only those vesselsthat go from one twin to the other are coagulated by the laser beam. Fetoscopic laser ablation
- 37. Twin Reversed ArterialPerfusion(TRAP) One twin normal other with anencephaly Normal twin acts as pump for other via A-A anastomosis Normal- High output failure and Hydrops Options • Fetoscopic ligation • Bipolar cautery/harmonic scalpel division • Thermal/laser coagualation • RFA of acardiac/acephalic cord insertion
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- 39. Others • Plastic Sx-cleft lip and palate • Neck Masses
- 40. Ethics • Two patients,mother and the fetal patient. • Balancing risks vs potential benefit. • Fetal reduction- concern
- 41. Current Scenario • InternationalFetal Medicine and Surgical Society (IFMSS) • North American Fetal Therapy Network (NAFTNet)
- 42. India Dr. Mohan Abraham,21-week – PUV- Laser Fulgration
- 43. What lies infuture? Stem cell transplant • Genetic diseases • Metabolic disorders • Hemoglobinopathies, • Meningomyelocele • Alpha thalassemia Future Fix- tissue engineering Gene Therapy
- 44. Conclusions • Rapidly evolvingfield • More experiments and trials to look for safer techniques • Premature labour remains a challenge • Rarity of dses, collaborative studies • Long-term outcomes –unknown.
- 45. First fetal surgerysurvivor finally meets his doctor / 24 years ago, UCSF surgeon saved his life in mom's womb Dr. Michael Harrison (R) listens to Michael Skinner's lungs during an exam May 10, 1981, at UCSF Medical Center. Harrison’s catheter • Magnetic mini mover • Magnap • Magnamosis
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