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Advancements in

Fetal SurgeryService with a Heart:

The tiniest of lives

Thomas Cunningham, RN

Fetal Intervention Fetal Surgery

Fetal Surgery

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Fetal surgery

•The treatment of fetal

abnormalities that might

otherwise cause fetal

demise or significant

problems if permitted to

persist.

• http://www.surgeryencyclopedia.com/Ce-Fi/Fetal-Surgery.html

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FETAL SURGERY

•Fetal Surgery improves

outcomes from

congenital

malformations and

improves postnatal

outcomes.

• Johnson MD et al, f etal surgery update 2011

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FETAL SURGERY

•Lung mass (CCAM-congenital cystic adenomal malformation)

•Sacrococcygeal teratoma

•Giant neck masses/obstructions

•Congenital diaphragmatic hernia

•Spina bifida

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Fetal Surgery

•Risks to the mother

•Two lives at risk

•Long term morbidity to mother

•PRE-TERM LABOR

• Recent Adv ances In Fetal Surgery

• Amy J. Wagner, Diana L. FarmerThe Fetal Treatment Center, University of California, San Francisco

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The Fetal Surgery Team

•Pediatric surgery (fetal surgery)

•Maternal fetal medicine (OB)

•Anesthesia (maternal/fetal)

•Cardiology

•ENT

•Neurosurgery

•Nursing

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EXIT Procedure

• Giant neck masses

• Lung lesions

•CHAOS (Congenital

High Airway

Obstruction

Syndrome)

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FETAL SURGERY

•Congenital Lung mass (CCAM-

congenital cystic adenomatoid

malformation)

•Entire lobe of lung is replaced by a

non-working cystic piece

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In utero spina bifida repair

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Spina Bifida(Myelomeningocele)

•Second most common birth defect

•One out of every one thousand pregnancies

•Myelomeningocele – most severe

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In utero spina bifida repair

•MOMs Trial

http://www.spinabifidamoms.co

m/english/index.html

•Surgery between 19 and 25

weeks

•Benefits

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Minimally Invasive Fetal

Intervention

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Minimally Invasive Fetal Intervention

• Twin twin transfusion syndrome

• Fetal bladder obstructions

• Fetal chest tube placement

• Cardiac intervention (HLHS)

• FETO (Fetal Tracheal Balloon Occlusion)

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Brief History of Fetal Intervention

•1961 Fetal peritoneal transfusion

•1970’s Diagnostic embryo-fetoscopy

•1970’s Introduction of ultrasound

•1983 Ultrasound guided cordocentesis

•1988 Placental laser ablation for twin to twin transfusion syndrome (DeLia MD)

•Dr. Micheal Harrison (UCSF)

• A short History of Amniocentesis, Fetoscopy and Chorionic Villus Sampling Dr. Joseph Woo 1998-2002

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Twin to Twin Transfusion Syndrome

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Twin to Twin Transfusion Syndrome

•A complication of disproportionate blood supply between monochorionic (one placenta) diamniotic (2 amniotic cavities) monozygotic (identical) twins.

•Blood vessels in the placenta are shared by the twins.

•Complicates approximately 9% of identical twin pregnancies.

•Usually begins in the 2nd trimester of pregnancy.

• Improving survival in twin to twin transfusion syndrome, Johnon, Moise December 2006 Contemporary OB/GYN

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Twin to Twin Transfusion Syndrome

•DONOR TWIN

• Intra-uterine growth retardation

•Chronic hypoxia and anemia

•Hypovolemia

•Hypotension

•Decreased urine production

•Oligohydramnios

• Twin to twin transfusion: An Update, Skupski, 2000

•RECIPIENT TWIN

•Increased urine production

•Polyhydramnios

•Heart failure

•Hypertension

•Hydrops

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TTTS Staging System• Stage I: The fetal bladder of the donor twin remains visable

• Stage II: The bladder of the donor twin is collapsed and not visible by ultrasound.

• Stage III: Critically abnormal fetal doppler studies.

• Stage IV: Fetal hydrops present.

• Stage V: Demise of one or both twins.

• Improving survival in twin to twin transfusion syndrome, Johnson, Moise December 2006 Contemporary OB/GYN

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Consequences of No Treatment

•90% to 100% mortality

w/o treatment of one or

both fetuses.

•30% chance of a

neurological compromise

in surviving singleton.

•Pre-term labor.

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Amnioreduction & Septostomy

•50% survivability of a

singleton.

•Septostomy/amnio-reduction

only treats the

polyhydramnios and not the

TTTS.

• http://fetus.ucsfmedicalcenter.org/twin/twin_twin_transfusion.asp, 2/7/2011

• Mari et al. Am J Obstet Gynecol 2001;185:708-15

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Placental Laser Ablation

• Ultrasound guidance for entry to uterus.

• Percutaneous entry into the womb.

• Introduction of a fetoscope into the uterus.

• Laser photocoagulation of conjoined placental vessels.

• Amnioreduction post laser ablation without septostomy

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Twin to Twin Transfusion Syndrome

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Outcomes of Laser Ablation•75% for one live twin

•35% two live twins

•25% chance of neither

twin surviving

•7% chance of

complications to a

surviving twin after a fetal

demise

• http://fetus.ucsfmedicalcenter.org/twin/twin_twin_transfusion.asp, 2/7/2011

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RISKS

•Bleeding

•Premature rupture of

membranes

•Pre-term labor

•Infection

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Other Fetal Procedures

•Intra-uterine fetal blood transfusion

•Fetal Anemia

•Thoracic shunt placement

•CCAM (congenital adenomatoid cystic malformation)

•Tracheal balloon occlusion (FETO)

•Congenital diaphragmatic hernia

•Posterior urethral valve ablation – fetal cystoscopy-shunt placement

•Fetal cardiac intervention

• Hypoplastic left heart syndrome

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A chance at Life

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HOPE

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