Intra Uterine Fetal Surgery Dr.Sameer Dikshit
Intra uterine fetal surgery
Aug 20, 2015
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Intra Uterine Fetal SurgeryDr.Sameer Dikshit
Dr.Sameer Dikshit MD,DGO,FCPS,FICOG
Member, Genetic & Fetal Medicine Committee
Past Secretary, Palghar Ob Gy Society
Trained at King’s College, London under Prof. Nicolaides
AICOG 2011
Hon Sonologist Wadia Hospital, Mumbai
Fetal Medicine Consultant BSES MG Global Hospital, Mumbai
Boisar Fetal Medicine Centre
Irla Nursing Home, Mumbai
Sanket Sonography, Mumbai
The allure of
Fetal Surgery is
the possibility of
interrupting the
in utero
progression of an
otherwise
treatable
condition
AICOG 2011
Fetal Surgery is…….. Indicated in conditions which
interfere with the normal development of the fetus
Which when corrected will allow normal development of the fetus
AICOG 2011
It is contraindicated in conditions that are incompatible with life Severe affliction Other associated life threatening
abnormalities Chromosomal & Genetic conditions
AICOG 2011
Father of Fetal Surgery Sir A.W.Liley in 1965 Intra Uterine Transfusion for Hydrops
due to Rh incompatibility Dr.Michael Harrison in 1982 First open fetal surgery for obstructive
uropathy
AICOG 2011
Types of Fetal Surgery Open Surgery
FETENDO (Fetal Endoscopic Surgery)
FIGS (Fetal Image Guided Surgery)
EXIT (Ex-Utero Intrapartum Treatment Procedure)
AICOG 2011
FIGS (Fetal Image Guided Surgery)
Ultrasound image guided procedure
Needle or a Trocar-Canula -Shunt introduced
AICOG 2011
Least invasive
Least risk of amniotic fluid leak
Least risk of PT labour
AICOG 2011
Examples Diagnostic
Chorion Villus Sampling
Amniocentesis
Cordocentesis
Fetal skin Biopsy
AICOG 2011
Therapeutic RFA (Radio Frequency Ablation) of
anomalous Twins
Cord cauterization in Twins
Vesical / Pleural Shunts
Balloon Dilatation of Aortic Stenosis
AICOG 2011
FETENDO (Fetal Endoscopic Surgery)
Fetoscopic access to the Fetus
Real time visualisation of the Fetus
AICOG 2011
The fetal visualisation is a combination of endoscopic and sonographic on two different screens
It is called FETENDO because the movements are like the children’s video game NINTENDO
AICOG 2011
Examples CDH (Congenital Diaphragmatic Hernia)-
Balloon Occlusion of trachea
TTTS (Twin to Twin Transfusion Syndrome)- Laser coagulation of vessels
Cord ligation in cases of acardiac Twins
Amniotic bands division
AICOG 2011
Open Surgery Mother is anaesthetised
Uterus is opened similar to LSCS
Special stapling device to prevent bleeding & amniotic fluid leak
AICOG 2011
Intra operative sonography to locate the placenta and to determine the surface anatomy of the fetus
Fetal part is exteriorized
Fetal Surgery
AICOG 2011
Examples CCAM (Congenital Cystic Adenomatoid
Malformation of Lung)- Lobectomy
SCT (Sacro-coccygeal Teratoma)- Resection
MMC (Meningo Myelocoele)- Repair
AICOG 2011
EXIT (Ex-utero Intrapartum treatment procedure)
It is the intervention that occurs at the time of delivery
It is primarily used in cases where baby’s airway requires surgical intervention
Provide the baby with patent airway that can provide O2 to the lungs after separation of placenta
AICOG 2011
It starts as a routine LSCS but under GA
Head of the baby is delivered, but the placenta is in situ
The baby gets oxygen from placenta via umbilical cord
AICOG 2011
Bronchoscopy of the fetal airway
Endotracheal intubation attempted
If unsuccessful then tracheostomy is done
O2 delivery to lungs confirmed
AICOG 2011
Examples CHAOS (Congenital High Airway
Obstruction Syndrome)
Removal of balloon after CDH
Pulmonary Sequestration
CCAM (Congenital Cystic Adenomatoid Malformation)
AICOG 2011
Challenges before the field of fetal surgery….. Ethical dilemma
Maternal & Fetal anaesthesia
Risks both to mother and fetus
Post surgical tocolysis
AICOG 2011
Ethical Dilemma Not all procedures are performed
regularly
The results are not guaranteed
Risks to mother and fetus
AICOG 2011
Should a procedure which is not guaranteed to produce results BE PERFORMED on the insistence of mother?
Should a procedure which is guaranteed to produce results NOT BE NOT BE PERFORMED PERFORMED on refusal of mother?
AICOG 2011
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
AICOG 2011
Maternal Risks Tocolytic therapy can cause pulmonary
edema
Subsequent delivery by LSCS
Intra op blood loss
AICOG 2011
“Maternal Mirror Syndrome” in cases of fetal Hydrops
Chorioamnionic membrane separation
AICOG 2011
Deep anaesthesia is required to provide with adequate uterine relaxation for fetal manipulation and to prevent PT labour
This depth can cause fetal and maternal myocardial depression also can affect placental perfusion
AICOG 2011
Fetal Risks Prematurity
Intra Uterine Infection
Fetal vascular embolic events Intestinal atresia Renal agenesis
AICOG 2011
Premature closure of Ductus Arteriosus
CNS injuries due to maternal hypoxia or fetal circulatory disturbance
AICOG 2011
Fetal response to maternal anaesthesia Fetal organs system is immature
Fetal Cardiac Output is sensitive to heart rate changes
Fetus has high vagal tone and hence responds to stress with precipitous bradycardia
AICOG 2011
Fetal circulating volume is low, hence little intra-operative bleeding can cause hypovolemia
Maternal anesthesia depress myocardium, circulation
AICOG 2011
Fetus tends to lose heat much easily from the exposed skin resulting in hypothermia
Immature coagulation system predispose the fetus to bleeding and difficulty in hemostasis
AICOG 2011
Maternal anesthesia reduces placental blood flow, this reduces the amount of O2 delivered to the fetus
Normal Fetal oxygen saturation is 60-70% and the aim is to maintain it above 40%
AICOG 2011
Intra-operative fetal distress is manifested by bradycardia, decreased fetal oxygen saturation and reduced stroke output
During prolonged surgery, fetus may be transfused Oneg blood
AICOG 2011
Top up fetal anaesthesia may be needed to augment the maternal anaesthesia
When fetus is hydropic, it is very sensitive to fluctuating maternal hemodynamics
Maternal hyperventilation is avoided as maternal hypocapnia causes fetal placental vasoconstriction and fetal hypoxia
AICOG 2011
Fetal Monitoring during surgery In case of open surgery
Fetus monitored by echocardiography and miniature pulse oxymeter
AICOG 2011
Post op care High risk of Pre term labour
Mag Sulph is the tocolytic of choice and maintained for 2-3 days
Maternal analgesia is important because maternal pain can cause PT labour and Fetal distress
AICOG 2011
Protocol for open Fetal Surgery Assessment of the mother for fitness for
anaesthesia
AICOG 2011
Assessment of the fetus Detailed USG to r/o other malformations
3D and 4D examination
Detailed examination of affected organ system
AICOG 2011
Detailed Fetal Echocardiography
Amniocentesis
Localisation of placenta
Fetal MRI
AICOG 2011
Maternal blood cross matched
Mother given GA with intubation as the uterus has to be relaxed to allow manipulation of the uterus
Indomethacin rectal suppository
AICOG 2011
O neg blood for fetus kept ready
Abdomen opened as in LSCS
Intra operative USG to localise placenta and to assess the surface anatomy of the fetus
AICOG 2011
Incision to be taken close to the area of interest
Uterine Stapler to seal amnion and reduce blood loss
AICOG 2011
Dr.Michael Harrison University of
California, San Francisco
Father of open fetal surgery
AICOG 2011
Fetus is given Inj Atropine 0.02 mg/kg Inj Epinephrine 1 μg/kg Inj Vecuronium 0.2 mg/kg Inj Fentanyl 1-2 μg/kg
AICOG 2011
The fetus is monitored with Fetal
Echocardiography Pulse Oxymetry PO2 from Cord
Blood Fetal Hb from Cord
Blood
AICOG 2011
Infusion of 50 ml aliquots of O neg Blood
Infusion of warmed Ringer Lactate to replace amniotic fluid
Fetal Surgery is performed
AICOG 2011
At the time of closure, IV MagSulph 6g over 20 minutes
3G/hr infusion post operative
AICOG 2011
Maternal Anaesthesia Regional Anaesthesia-Lumbar
Epidural Deep GA-(Sodium Pentothal + Scoline)
+ (Isoflurane + Fentanyl+O2 + Vecuronium)
GA with N2O- (Sodium Pentothal + Scoline) + (Isoflurane + N2O + Vecuronium)
AICOG 2011
Fetal Pain…. “Pain” by definitive is a subjective
phenomenon
Hence it is not possible to assess “Fetal Pain” directly
AICOG 2011
It is assessed indirectly by the ability of the fetus to mount a stress response to a noxious stimulus
Increased fetal cortisol, beta-endorphins and “central sparing” hemodynamic changes
AICOG 2011
Fetal administration of a narcotic inhibits cortisol and beta-endorphin release but does not inhibit “central sparing” hemodynamic changes
AICOG 2011
Fetal pain has been said to contribute to exaggerated pain response in 8 week old infants
It is also said to stimulate preterm labour
AICOG 2011
Future possibilities Deliver stem cells or DNA to treat sickle
cell anemia or other genetic conditions
AICOG 2011
Inherited Genetic Diseases Treatable with Stem Cells Haemoglobinopathies
Immunodeficiency diseases
Mucopolysaccharidoses
Mucoliposes
Diamond Blackfan Syndrome
Fanconi anemia
AICOG 2011
Prevention of graft v/s host disease
Prevents further damage to the fetus
Intra-amniotic or Intra-umbilical vein
AICOG 2011
The key in fetal surgery is not when to operate, but to know when NOT to operate!!!
AICOG 2011
Sacrococcygeal Teratoma (SCT) Open Surgery for excision of the
Teratoma
The tumours are benign
But can caused Fetal Hydrops due to vascular shunts
AICOG 2011
Cystic SCTs do not have vascular shunts
Hence the fetus does not land up with Hydrops
Hence, there is NO INDICATION for Intra Uterine Surgery in these cases
AICOG 2011
Solid SCTs have vascular shunts
High risk of Hydrops and fetal death
Hence Intra Uterine Surgery is indicated
AICOG 2011
Congenital Diaphragmatic Hernia (CDH) The key to the successful management
is to have a fetus with competent lungs after birth
If the lungs are collapsed, then post natal surgery fails
AICOG 2011
The status of the lungs can be predicted by- Presence of liver in the thorax (presence
of liver more severe disease)
LHR (Lung to Head ratio) less than 1.0
AICOG 2011
These fetuses need intra partum intervention for postpartum surgery to succeed
FETENDO with temporary tracheal occlusion
EXIT procedure to remove the balloon before birth
AICOG 2011
Why open intra partum surgery fails????
Reduction of the liver into abdomen kinks the Ductus Venosus
AICOG 2011
Congenital Cystic Adenomatoid Malformation of the lungs (CCAM) Most fetuses do well in utero
Indications for intra uterine surgery are:- Progressive increase in the size Mediastinal shift Hydrops Polyhydramnios
AICOG 2011
Thoraco amniotic shunt
EXIT procedure for securing airway
Open Fetal Surgical Resection
AICOG 2011
CCAM Prenatal Steroid Trial University of California, San Francisco
Cases with large CCAM who would otherwise need intra uterine surgery
2 doses of Betamethasone 12 mg IM, 24 hours apart
AICOG 2011
Fetal Surgery is a roller coaster ride for the fetusIt is our endeavor to ensure that fetus comes through it smiling and unharmed….
AICOG 2011
Related Documents
