Intrauterine Fetal Therapies

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2. INTRA UTERINE
FETAL THERAPIES
Sr. Jaisy Sebastian
II Year MSc. Nursing
Bishop Benziger College Of Nursing ,Kollam
10/29/20192

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4. INTRODUCTION
–A therapeutic intervention for the purpose
of correcting or treating a fetal anomaly or
condition is called fetal therapy. In almost
every case, the fetus is at risk of intrauterine
death from the abnormality. 10/29/2019
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5. DEFINITION
–“Fetal therapy A therapeutic intervention
for the purpose of correcting or treating a
fetal anomaly or condition is called fetal
therapy.”
–“Any intervention Aiming for correcting
or treating a fetal abnormalities.” 10/29/2019
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6. PERSONALS REQUIRED FOR
FETAL THERAPY
 Obstetrician
 Paediatrician
 Anaesthetists
 Ultrasonologist
 Neurosurgeon
 Social worker etc. 10/29/2019
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7. TOOLS REQUIRED
Ultrasound machine
MRI
Fetoscope
laser machine etc.
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8. TYPES
Pharmacological fetal therapy –
(non - invasive)
Surgical fetal therapy - (Invasive)
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9. PHARMACOLOGICAL
FETAL THERAPY
Preventive pharmacotherapy
Therapeutic pharmacotherapy
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10. PREVENTIVE PHARMACOTHERAPY
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11. Neural tube
defects
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All the women planning a
pregnancy should be given folic
acid in dose 0.4mg/day for at
least one month.
Women with a prior child with
NTD , should receive folic acid 4
mg/day for at least one month
pre - conceptually and three
months after the pregnancy.
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12. Antenatal
steroid to
enhance
fetal lung
maturity.
– The high risk pregnancy associated
with risk of preterm delivery should be
given steroid at least 48 hours before
delivery so as to accelerate lung
maturity as well as renal maturity.
– Dose:
 Betamethasone 12 mg twice at 24
hours interval
– or
 Dexona 6 mg at 12 hours interval , for
total 4 doses are given
 This will reduce need of surfactant
and ventilatory therapy to baby.
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13. Congenital
adrenal
hyperplasia.
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Stopped when proved
male fetus or unaffected
female.
Dexamethazone 20 ug/kg
in three divided doses,
started at 6 Weeks.
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14. 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.
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15. THERAPEUTIC PHARMACOTHERAPY
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16. CARDIAC16
 Cardiac arrhythmia- can be treated by giving
anti-arrhythmic drugs to mother orally or by
trans-placental route.
 PSVT
 ATRIL FLUTTER
 ATRIAL FIBRILLATION
 VENTRICULAR TACHY-CARDIA
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17. PSVT; ATRIAL FLUTTER
& FIBRILLATION17
 If fetus is normal :-
– Digoxin : Oral-
 If fetus have feature of hydrops
– Digoxin is given either parenteral or
Transplacental, 0.5- 1 mg
– Adenosine :Per umbilical 0.05 to 0.2mg
– Flecanide : oral 200- 300mg
– Amiodarone : parenteral 600-800mg
– Sotatlol : oral; 80-320 mg
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22. COMPLETE
A-V BLOCK
- CAVB
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–Prevalence: 1/15,000-
1/22,000 live birth.
–Path-physiology : The fetal
mortality rate of isolated
CAVB may be as much as 30-
50%. Patients diagnosed and
treated in the neonatal period
have a survival rate of 94%,
and patients who are
diagnosed and treated in
childhood have a survival rate
of 100%.10/29/2019

23. Fetus with isolated Complete A –
V block Rx
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HR > 55/min with normal LV function:-
• Dexamethasone - orally to mother
HR < 55/min with abnormal LV function:-
• Dexamethasone - orally with β agonist
• Weekly follow up by obstetrician with fetal
echocardiography

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COMPLETE FETALA – V BLOCK
 At the time of diagnosis of heart block in
FETUS maternal dexamethasone (4 or 8 mg/d
for 2 weeks,
 Then 4 mg/day should be initiated maintained
for the duration of the pregnancy, tapering at
times (2 mg/d) in the third trimester.
 If the average heart rate declined below 55 bpm,
A ß-sympathomimetic agent should be given
salbutamol 40mg/ day for 2 weeks. Contd….

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 In the presence of maternal anti-Ro/La
antibodies , there are no known markers that
will predict which fetus will develop an AV
conduction defect.
 Little evidence suggests that the administration
of steroids, immunoglobulins or plasmapheresis
in the mother can reverse third-degree AV block.
 However, these therapies are helpful if given in
early to Rx first-degree and second-degree heart
block.

27. Fetus with
isolated
Complete A
–V block
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Treatment:-
• Delivery at tertiary care centre.
• Uneventful fetal course - LSCS at
37 weeks.
• If fetus develop hydrops-
Paracentesis , LSCS
• Low CO out - Immediate Pacing -
Isoprenline
• Features of SLE - oral
prednisolone
• Endocardial fibroelastosis – I V
IgG

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29. PREMATURE
VENTRICULAR
CONTRACTION
IN FETUS
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A benign condition either
resolve spontaneously
before Birth or after birth
of baby.
If number of PVC is more,
and fetus Develop
Hydrops: - than β blocker
can be Used orally.

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31. VENTRICULAR
TACHYCARDIA
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Fetal therapy for
VT is
administration of
β – blocker
Flecanide = 200-
300mg/Day orally
Amiodarone = 600-
800mg/day I.V. to
mother

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33. FETAL THYROID GOITER33
–Treatment
–Fetal cord blood for thyroid status TSH,T3,T4
–If Hyperthyroidism :- Treatment - Carbimazole
methimazole
–If hypothyroidism between 29-37 weeks 250-500
mg levothyroxin intra amniotic weekly this will
result in regression of thyroid goitre
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35. 10/29/2019
35 CONGENITAL ADRENAL
HYPERPLASIA

36. Congenital
adrenal
hyperplasia
(CAH)
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Congenital adrenal
hyperplasia (CAH) is a
family disorder caused
by reduced activity of
enzymes required for
cortisol biosynthesis
in the adrenal cortex.
The most common
defect is 21-
hydroxylase (21-OH)
deficiency, which
accounts for >90% of
all cases of CAH.
Classic 21-hydroxylase
deficiency is found in
about 1:12 000 to
1:15 000 births.
The frequency of
nonclassic deficiency
is unknown, although
it may occur in up to
3% of individuals in
certain groups.

37. CONGENITALADRENAL
HYPERPLASIA
 Clinical consequences of 21-OH deficiency arise primarily from
overproduction and accumulation of precursors proximal to the blocked
enzymatic step.
 These precursors are shunted into the androgen biosynthesis pathway,
producing virilization in the female fetus or infant and rapid postnatal
growth with accelerated skeletal maturation, precocious puberty, and
short adult stature in both males and females
 Treatment should begin as early as the 4th to 6th week of pregnancy.
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38. CONGENITAL ADRENAL
HYPERPLASIA
 The dose of dexamethasone usually ranged between 0.5 and 2 mg/d or O.3 to o.7 mg/sq
m in 1 to 4 divided doses.
 CVS 11-12 wks
 AMNIOCENTESIS at 15 wks for DNA analysis for CYP21B,C4 & HLA class I & II
genes.
 Then treatment is continued to term in female positive for genes and stopped in male
after confirmation of diagnosis by CVS or Amniocentesis.
 At birth, the external genitalia is normal in the infant whose mother was given
dexamethasone and minimally virilized in the infant whose mother received
hydrocortisone. 10/29/2019
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39. FETUS WITH
MATERNAL SLE
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40. FETUS WITH MATERNAL
SLE
 If mother is suffering from SLE, then fetus is at risk to
develop Complete heart block because of damage to AV
node.
 This can be prevented by giving Tab Dexamethasone 4 mg
per day during pregnancy because it cannot be metabolized
by placenta and is Available to the fetus in an active form.
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41. INVASIVE FETAL
THERAPY
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42. INVASIVE FETAL THERAPY
 Intra uterine blood transfusion.
 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.
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43. HISTORY43
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In utero transfusion (liley).
1961
Embryoscopy / Fetoscopy was
introduced to visualized
malformations. › High resolution U/S
take their diagnostic role.
1970s
1st successful resection of
congenital cystic adenomatous
malformation.
1984
1st successful resection of
sacrococcygeal teratoma.
1992

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45. INTRA UTERINE BLOOD
TRANSFUSION
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 The fetal anaemia now can be predicted by
doing middle cerebral Artery doppler flow
study and intra uterine transfusion (IUT) is
done with gamma Irradiated blood.
 VOLUME OF BLOOD TO BE GIVEN TO
FETUS IS CALCULATED BY:-
– Fetoplacental volume X (desired Ht – Fetal
Ht) ÷ Donor hematocrit
 Feto placental volume = USG estimated
weight of fetus X 0.14
 The amount of blood given to fetus is 20,30,40
and 50 ml to the fetus at 22,26,30 and 35
weeks of gestational age respectively.
– 10/29/2019

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47. FETAL IMAGE GUIDED
PROCEDURES
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ULTRASOUND IMAGE GUIDED
PROCEDURE
NEEDLE OR A TROCAR- CANULA
-SHUNT INTRODUCED.

48. Advantages48
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Least invasive.
Least risk of amniotic fluid leak.
Least risk of preterm labour.

49. Procedures49
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Amniocentesis. Amnioinfusion. Septostomy.
Selective Fetal
reduction.
Intrauterine
transfusion.

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51. AMNIOCENTESIS.51
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Amniocentesis is a procedure in
which amniotic fluid is removed
from the uterus for testing or
treatment. Amniotic fluid is the fluid
that surrounds and protects a baby
during pregnancy. This fluid contains
fetal cells and various proteins.
Although amniocentesis can provide
valuable information about the
baby's health, it's important to
understand the risks of
amniocentesis — and be prepared
for the results.

52. AMNIOINFUSION
– An amnioinfusion is a technique of instilling an
isotonic fluid, such as a normal saline or lactated
ringer’s solution, into the amniotic cavity with the
purpose of thinning out a thick meconium that has
been found to pass into the amniotic fluid.
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54. SEPTOSTOMY
It is the creation of a small hole in the membrane between the
babies using a fine, hollow needle.
This allows the amniotic fluid to move from one baby to the
other, so both babies have a more equal amount of amniotic
fluid.
The surgeon may also remove some of the amniotic fluid
through the needle. 10/29/2019
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56. SELECTIVE FETAL
REDUCTION
Selective reduction is the practice of reducing the
number of fetuses in a multiple pregnancy, say
quadruplets, to a twin or singleton pregnancy.
The procedure is also called multifetal pregnancy
reduction.
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57. SELECTIVE FETAL
REDUCTION
 The procedure is most commonly done to reduce the
number of fetuses in a multiple pregnancy to a safe
number, when the multiple pregnancy is the result of use of
assisted reproductive technology; outcomes for both the
mother and the babies are generally worse, the higher the
number of fetuses.
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58. SELECTIVE FETAL
REDUCTION
 The procedure is also used in multiple pregnancies when one of the
fetuses has a serious and incurable disease, or in the case where one of
the fetuses is outside the uterus, in which case it is called selective
termination.
 The procedure generally takes two days; the first day for testing in order
to select which fetuses to reduce, and the second day for the procedure
itself, in which potassium chloride is injected into the heart of each
selected fetus under the guidance of ultrasound imaging.
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59. SELECTIVE FETAL
REDUCTION
 Risks of the procedure include bleeding requiring transfusion,
rupture of the uterus, retained placenta, infection, a miscarriage,
and prelabor rupture of membranes. Each of these appears to be
rare.
 Selective reduction was developed in the mid-1980s, as people in
the field of assisted reproductive technology became aware of the
risks that multiple pregnancies carried for the mother and for the
fetuses. 10/29/2019
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61. FETAL ENDOSCOPIC
SURGERY (FETENDO)
Fetoscopic access to the Fetus:- The
fetal visualisation is a combination of
endoscopic and sonographic on two
different screens.
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62. EMBRYOSCOPY:-
– is performed in the first trimester of pregnancy (up to 12
weeks’ gestation).
 In this technique, a rigid endoscope is inserted via the
cervix in the space between the amnion and the chorion,
under sterile conditions and ultrasound guidance, to
visualize the embryo for the diagnosis of structural
malformations.
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65. FETOSCOPY:-
It is performed during the second trimester (after 16 weeks’
gestation).
In this technique, a fine-caliber endoscope is inserted into
the amniotic cavity through a small maternal abdominal
incision, under sterile conditions and ultrasound guidance,
for the visualization of the embryo to detect the presence of
subtle structural abnormalities.
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66. FETOSCOPY:-
– An injection will be given in the lower abdomen to numb
the skin where the fetoscope will be inserted.
– An ultrasound will be used to determine the position of
both the fetus and the placenta.
– The fetus is seen through a small incision made in the
belly, and a fetal ultrasound guides the placement of the
fetoscope.
– A camera is attached to the fetoscope to take pictures.10/29/2019
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67. TTTS (TWIN TO TWIN TRANSFUSION
SYNDROME)
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68. TTTS (TWIN TO TWIN
TRANSFUSION SYNDROME)
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Occurs only in monozygotic, monochorionic, diamniotic
Laser coagulation of vessels
Laser ablation of umbilical cord in cases of acardiac Twins
Amniotic bands division
Posterior urethral valve laser ablation.

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73. CONGENITAL
DIAPHRAGMATIC
HERNIA (CHD)
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Initial approach to treat CDH
was - tracheal occlusion by
clips on the trachea.
It is now performed with
intra-tracheal inflatable
balloon.
The balloon is inserted at 26
to 28 weeks and removed at
34 weeks.

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77. PLEURAL
EFFUSION
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One option in the management of
foetuses with pleural effusion is
thoracentesis and drainage of the
effusions.
However, in the majority of cases
the fluid reaccumulates within 24-48
hours requiring repeated procedures
and it is therefore preferable to
achieve chronic drainage by the
insertion of pleural- amniotic shunt

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EXIT PROCEDURE
(EX-UTERO
INTRAPARTUM
TREATMENT
PROCEDURE)

80. EXIT PROCEDURE (EX-UTERO
INTRAPARTUM TREATMENT
PROCEDURE)
80
 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.
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81. OPEN
FETAL
SURGERY
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82. OPEN
FETAL
SURGERY
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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

83. OPEN FETAL
SURGERY
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84. OPEN FETAL
SURGERY
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95. HIGH INTENSITY
FOCUSED
ULTRASOUND (HIFU)
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97. HIGH
INTENSITY
FOCUSED
ULTRASOUND
(HIFU)
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Only one case report in human. It was
used to occlude umbilical cord vessel in
Acardiac twin.
Still under research in animal study for
treating TTTs, Acardiac twin &
sacrococcygeal teratoma.
HIFU is a non-invasive alternative
method of vessel occlusion which may
avoid complications inherent to surgery.

98. GENE
THERAPY
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GENE THERAPY
 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.
 In most gene therapy a normal gene is inserted into
genome to replace an abnormal, disease causing gene.

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 There have been several modes of gene delivery
used in experimental efforts at fetal gene transfer.
 These include intratracheal, intravascular,
intraventricular, intracardiac, intraperitoneal,
intraplacental, intramuscular and intra-amniotic
injection.
 Intra-amniotic gene transfer (IAGT) has been
used to target organs exposed to amniotic fluid,
that is, the skin, amniotic membranes and the
respiratory and digestive systems

101. Stem cell
therapy
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102. Stem cell therapy102
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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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103 NURSING MANAGEMENT OF
HIGH RISK PREGNANCIES

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NURSING MANAGEMENT OF
HIGH RISK PREGNANCIES
Steps to promote healthy pregnancy
Schedule preconception appointment
Eat healthy
Gain weight
Avoid risky substance

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NURSING MANAGEMENT
Assess the condition of the mother during
pregnancy
Screen out the high risk mothers
Advice to do the regular follow up
Provide the information regarding warning
signs of pregnancy and signs of pregnancy and
any signs are noted report to the hospital

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106Detail history collection and physical examination
Collect the laboratory findings
Abdominal examination – obstetrical examination
Monitor the vital signs
Provide bed rest
Assist in screening of fetal wellbeing diagnosis of
fetal such as amniocentesis, chorionic villi
sampling

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Assist in fetal therapy procedure
Discuss the fetal risk associated with
pregnancy
Instruct the client on use of prescribed
medication for particular disease condition
Motivate for life style modifications

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 Instruct about self-care techniques
 Report any deviation from normal fetal or maternal
conditions immediately
 Encourage in expression of feelings
 Determine the demographic and social factors in the
poor outcome of pregnancy
 Review obstetrical history for pregnancy risk
 Anticipatory guidance participation
 Refer to high risk support group of the mother
 Monitor physical psychological status throughout the
pregnancy.

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110 CONCLUSION
A high risk pregnancy is one of greater
risk to the mother or her fetus than an
uncomplicated pregnancy.
 Pregnancy places additional physical
and emotional stress on a woman’s body.
 Health problems that occur before a
woman becomes pregnant or during
pregnancy may also increase the
likelihood for a high risk pregnancy.

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