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PERINATOLGY -SONOGRAPHY
DR J.P.SONI M.D PEDIATRIC ASSOCIATE PROF.
DR S.N. MEDICAL COLLEGEJODHPUR
Update of Fetal therapy
DR J.P.SONI M.D PEDIATRIC PROF.
DR S.N. MEDICAL COLLEGEJODHPUR
FETAL THERAPY
fetoscopy
Intra – uterine fetal blood transfusion
Fetal surgery
Fetal therapy
Atherapeutic interventionfor the purpose ofcorrecting or treating afetal anomaly orcondition is called fetaltherapy.
Fetal therapy
Personals required for it are –
ObstetricianPediatricianAnesthetists
UltrasonologistNeurosurgeon
Social worker etc.
Fetal therapy
Tools required for it are –
Ultrasound machine
MRI
Fetoscope
laser machine etc.
Fetal therapy
Pharmacological fetal therapy –
(noninvasive)
• Surgical fetal therapy -
(Invasive)
Fetal therapy
Pharmacological fetal therapy –
Preventive pharmacotherapy
Therapeutic pharmacotherapy
Preventive pharmacotherapy
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 preconceptually and three months after the
pregnancy.
Neural tube defects
PREVETION OF HMD IN PRETERM NEONATES
The high riskpregnancyassociated with risk of preterm
delvary should be given steroid at least 48 hours before delivary 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 give
• This will reduce need of surfactant and ventilatory
therapy to baby.
Fetal therapy
Therapeutic pharmacotherapy
CARDIAC
Cardiac arrhythmia-
PSVT
ATRIL FLUTTER
ATRIAL FIBRILLATION
AND VENTRICULAR TACHY-CARDIA
can be treated by giving anti-arrhythmic drugs to mother orally or
by trans-placental route.
PSVT; ATRIAL FLUTTER & FIBRILLATION
Digoxin : Oral- fetus is normal.
If fetus have feature of hydrops
Digoxin is given either parenteral
orTransplacental, 0.5- 1 mg
Adenosine :Per umbilical0.05 to 0.2mg
Flecanide : oral 200-300mg
Amiodarone : parenteral600-800mg
Sotatlol : oral; 80-320 mg
COMPLETE A-V BLOCK - CAVB
Prevalence: 1/15,000- 1/22,000 livebirth.
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%.
Fetus with isolated Complete A –V block Rx
HR > 55/min with normal LV function Rx
Dexamethasone - orally to mother
• HR < 55/min with abnormal LV function• Rx
Dexamethasone - orally with βagonist
weekly follow up by obstetrician with fetal
echocardiography
COMPLETE FETAL A – V BLOCK
AA A A A
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.
COMPLETE FETAL A – V BLOCK
AA A A A
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.
Fetus with isolated Complete A –V block Rx
Delivary at tetriary care center
Uneventful fetal course - LSCS at 37 wks
If fetus develop hydrops- Paracentesis
LSCS
low CO out - Immediate Pacing
Isoprenline
features of SLE - oral prednisolone
Endocardial fibroelastosis – I V IgG
Premature ventricular contraction in fetus
a benign condition either resolve spontaneously
beforeBirth or after birth of baby.
If number of PVC is more, and fetus
Develop Hydrops: -than β blocker can be
Used orally.
Ventricular tachycadrdia
Fetal therapy for VT is administration of
β – blocker
Flecanide = 200-300mg/Day orally
And
Amiodarone = 600-800mg/day I.V. to
mother
FETAL THYROID GOITERRxFETAL CORD BLOOD FOR THYROID STATUSTSH,T3,T4
IF HYPERTHYRODISMRx - CARBIMAZOLE
METHIMAZOLE
IF HYPOTHYRODISM
BETWEEN 29-37 WEEKS 250-500 mg LEVOTHYROXININTRA AMNIOTIC WEEKLYTHIS WILL RESULT INREGRESSIONOF THYROID GOITER
CONGENITAL ADRENAL HYPERPLASIA
Congenital adrenal hyperplasia (CAH) is a family disordercaused by reduced activity of enzymes required for cortisolbiosynthesis 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 itmay occur in up to 3% of individuals in certain groups.
CONGENITAL ADRENAL HYPERPLASIA
Clinical consequences of 21-OH deficiencyarise primarily from overproduction andaccumulation of precursors proximal to the blockedenzymatic step.
These precursors are shunted into the androgenbiosynthesis pathway, producing virilization inthe female fetus or infant and rapid postnatalgrowth with accelerated skeletal maturation,precocious puberty, and short adult stature in bothmales and females
CONGENITAL ADRENAL HYPERPLASIA
Treatment should begun as early as the 4th to 6th week ofpregnancy.
The dose of dexamethasone usually ranged between 0.5 and2 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 forCYP21B,C4 & HLA class I & II genes.
Then treatment is continued to term in female positive forgenes and stoped in male after confirmation of diagnosis byCVS or Amniocentesis.
At birth, the external genitalia is normal in the infant whose motherwas given dexamethasone and minimally virilized in the infantwhose mother received hydrocortisone.
Fetus with maternal SLE
If mother is suffering from SLE, thenfetus is at risk to develop Completeheart block because of damage to AVnode. This can be prevented bygiving Tab Dexamethasone 4 mg perday during pregnancy because itcannot be metaboized by placentaand is Available to the fetus in anactive form.
Invasive fetal therapy
1961Intra uterine blood transfusion
Invasive fetal therapy
1961Intra uterine blood transfusion
The fetal anemia now can be predicted bydoing middle cerebral
Artery doppler flow study and
intra uterinetransfusion (IUT) is done with
gamma Irradiated blood.
FETAL ANEMIA -Rh allo-immunization & parvovirus B19 - Doppler
assessment of Middle cerebral artery peak velocity and prediction of fetal anemia.
INTRAUTERINE FETAL TRANSFUSION
CORDOCENTESIS/ IUT if MCA peak velocity MoM = >1.5 or MCA peak velocity in “A” zone of below depicted graph.
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.
Intra uterine blood transfusion
FETOSCOPY
1970
Fetoscopy is performed during the second trimester (after 16weeks’ gestation).
In this technique, a fine-caliber endoscope is inserted into theamniotic cavity through a small maternal abdominal incision,under sterile conditions and ultrasound guidance, for thevisualization of the embryo to detect the presence of subtlestructural abnormalities
Fetal visualization Embryoscopy
Embryoscopy is performed in the first trimester of pregnancy (upto 12 weeks’ gestation).In this technique, a rigid endoscope is inserted via the cervix in thespace between the amnion and the chorion, under sterile conditionsand ultrasound guidance, to visualize the embryo for the diagnosisof structural malformations.
◦ 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.
TWIN TO TWIN TRANSFUSION IN MONOCHORIONIC TWIN
Rx INDOMETHACIN LASER COAGULATION OF A-V
ANASTOMOSES
Laser coagulation of A –V malformation in case of twin to twin transfusion
Congenital diaphragmatic hernia
Rx
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.
Pleural effusion
One option in themanagement of fetuses withpleural effusion isthoracocentesis and drainageof the effusions. However, inthe majority of cases thefluid reaccumulates within24-48 hours requiringrepeated procedures and it istherefore preferable toachieve chronic drainage bythe insertion of pleural-amniotic shunts.
GENE THERAPY
Means replacement of missing gene by introduction of foreignNucleic acid sequence. It is divided into two categories, classic gene therapy and stem cell gene therapy.
In most gene therapy a normal gene is inserted into genomeTo replace an abnormal, disease causing gene.
A carrier molecule called a vector (virus- lenti virus) must beused to deliver the therapeutic gene to the patient’s target cells
There have been several modes of genedelivery used in experimental efforts at fetalgene transfer. These includeintratracheal, intravascular, intraventricular,intracardiac, intraperitoneal, intraplacental,intramuscular and intra-amniotic injection.Intra-amniotic gene transfer (IAGT) hasbeen used to target organs exposed toamniotic fluid, that is, the skin, amnioticmembranes and the respiratory anddigestive systems