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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
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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
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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
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It is contraindicated in conditions that are incompatible with life Severe affliction Other associated life threatening
abnormalities Chromosomal & Genetic conditions
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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
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Types of Fetal Surgery Open Surgery
FETENDO (Fetal Endoscopic Surgery)
FIGS (Fetal Image Guided Surgery)
EXIT (Ex-Utero Intrapartum Treatment Procedure)
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FIGS (Fetal Image Guided Surgery)
Ultrasound image guided procedure
Needle or a Trocar-Canula -Shunt introduced
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Least invasive
Least risk of amniotic fluid leak
Least risk of PT labour
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Examples Diagnostic
Chorion Villus Sampling
Amniocentesis
Cordocentesis
Fetal skin Biopsy
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Therapeutic RFA (Radio Frequency Ablation) of
anomalous Twins
Cord cauterization in Twins
Vesical / Pleural Shunts
Balloon Dilatation of Aortic Stenosis
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FETENDO (Fetal Endoscopic Surgery)
Fetoscopic access to the Fetus
Real time visualisation of the Fetus
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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
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Less invasive
Less risk of amniotic fluid leak
Less risk of PT labour
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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
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Open Surgery Mother is anaesthetised
Uterus is opened similar to LSCS
Special stapling device to prevent bleeding & amniotic fluid leak
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Intra operative sonography to locate the placenta and to determine the surface anatomy of the fetus
Fetal part is exteriorized
Fetal Surgery
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Examples CCAM (Congenital Cystic Adenomatoid
Malformation of Lung)- Lobectomy
SCT (Sacro-coccygeal Teratoma)- Resection
MMC (Meningo Myelocoele)- Repair
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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
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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
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Bronchoscopy of the fetal airway
Endotracheal intubation attempted
If unsuccessful then tracheostomy is done
O2 delivery to lungs confirmed
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Examples CHAOS (Congenital High Airway
Obstruction Syndrome)
Removal of balloon after CDH
Pulmonary Sequestration
CCAM (Congenital Cystic Adenomatoid Malformation)
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Challenges before the field of fetal surgery….. Ethical dilemma
Maternal & Fetal anaesthesia
Risks both to mother and fetus
Post surgical tocolysis
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Ethical Dilemma Not all procedures are performed
regularly
The results are not guaranteed
Risks to mother and fetus
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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?
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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
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Maternal Risks Tocolytic therapy can cause pulmonary
edema
Subsequent delivery by LSCS
Intra op blood loss
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“Maternal Mirror Syndrome” in cases of fetal Hydrops
Chorioamnionic membrane separation
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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
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Fetal Risks Prematurity
Intra Uterine Infection
Fetal vascular embolic events Intestinal atresia Renal agenesis
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Premature closure of Ductus Arteriosus
CNS injuries due to maternal hypoxia or fetal circulatory disturbance
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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
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Fetal circulating volume is low, hence little intra-operative bleeding can cause hypovolemia
Maternal anesthesia depress myocardium, circulation
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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
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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%
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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
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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
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Fetal Monitoring during surgery In case of open surgery
Fetus monitored by echocardiography and miniature pulse oxymeter
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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
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Protocol for open Fetal Surgery Assessment of the mother for fitness for
anaesthesia
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Assessment of the fetus Detailed USG to r/o other malformations
3D and 4D examination
Detailed examination of affected organ system
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Detailed Fetal Echocardiography
Amniocentesis
Localisation of placenta
Fetal MRI
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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
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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
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Incision to be taken close to the area of interest
Uterine Stapler to seal amnion and reduce blood loss
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Dr.Michael Harrison University of
California, San Francisco
Father of open fetal surgery
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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
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The fetus is monitored with Fetal
Echocardiography Pulse Oxymetry PO2 from Cord
Blood Fetal Hb from Cord
Blood
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Infusion of 50 ml aliquots of O neg Blood
Infusion of warmed Ringer Lactate to replace amniotic fluid
Fetal Surgery is performed
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At the time of closure, IV MagSulph 6g over 20 minutes
3G/hr infusion post operative
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Maternal Anaesthesia Regional Anaesthesia-Lumbar
Epidural Deep GA-(Sodium Pentothal + Scoline)
+ (Isoflurane + Fentanyl+O2 + Vecuronium)
GA with N2O- (Sodium Pentothal + Scoline) + (Isoflurane + N2O + Vecuronium)
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Fetal Pain…. “Pain” by definitive is a subjective
phenomenon
Hence it is not possible to assess “Fetal Pain” directly
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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
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Fetal administration of a narcotic inhibits cortisol and beta-endorphin release but does not inhibit “central sparing” hemodynamic changes
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Fetal pain has been said to contribute to exaggerated pain response in 8 week old infants
It is also said to stimulate preterm labour
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Future possibilities Deliver stem cells or DNA to treat sickle
cell anemia or other genetic conditions
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Inherited Genetic Diseases Treatable with Stem Cells Haemoglobinopathies
Immunodeficiency diseases
Mucopolysaccharidoses
Mucoliposes
Diamond Blackfan Syndrome
Fanconi anemia
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Prevention of graft v/s host disease
Prevents further damage to the fetus
Intra-amniotic or Intra-umbilical vein
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The key in fetal surgery is not when to operate, but to know when NOT to operate!!!
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Sacrococcygeal Teratoma (SCT) Open Surgery for excision of the
Teratoma
The tumours are benign
But can caused Fetal Hydrops due to vascular shunts
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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
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Solid SCTs have vascular shunts
High risk of Hydrops and fetal death
Hence Intra Uterine Surgery is indicated
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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
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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
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These fetuses need intra partum intervention for postpartum surgery to succeed
FETENDO with temporary tracheal occlusion
EXIT procedure to remove the balloon before birth
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Why open intra partum surgery fails????
Reduction of the liver into abdomen kinks the Ductus Venosus
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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
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Thoraco amniotic shunt
EXIT procedure for securing airway
Open Fetal Surgical Resection
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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
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Fetal Surgery is a roller coaster ride for the fetusIt is our endeavor to ensure that fetus comes through it smiling and unharmed….
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