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Fetal therapy and surgery

Fetal therapy includes all treatment that could be given to the fetus. Some treatments are non-invasive, such as a medical treatment given orally to the mother, passing through the placenta to be delivered to the fetus. Other treatments are invasive, from fetal surgery involving cameras (fetoscopy) to open fetal surgery.

Fetal surgery could be proposed in specific cases of fetal abnormalities. Fetal surgery offered in our center is performed through a small 3 mm hole into the mother’s abdomen. Such a surgery is performed using cameras and could be compared to laparoscopic techniques in adults. Fetoscopy is a minimal invasive technique, with minimal complications to the mother.

Here is an overview of various fetal therapies performed nowadays:

Fetal anemia and in-utero transfusion

Fetal anemia is a relatively rare complication, with the most common etiology being maternal –fetal alloimmunisation, particularly anti-RhD. Other etiologies are maternal-fetal infection with parvovirus B19 and cytomegalovirus. Finally, very rarely, fetal anemia can be caused by feto-maternal hemorraghe and some fetal hemoglobinopathies.

Intravascular fetal transfusion has transformed the prognosis of fetal anemia and nowadays is considered as a relatively safe procedure. Lethal complications related to such a procedure is about 1,5 to 3 %, which is relatively high in case of early onset fetal anemia necessitating repeated transfusions, up to 5 to 6 times during the same pregnancy.

Prognosis depends also in many cases on how early the diagnosis as well the treatment was instituted. Risks for fetal death and neurological complications are higher when the diagnosis is made at the stage of fetal hydrops rather than of simple isolated anemia.

Congenital diaphragmatic hernia and fetal surgery

Antenatal evaluation of fetuses with congenital diaphragmatic hernia (CDH) involves measurement of lung volume at ultrasound and/or magnetic resonance imaging, from 22 weeks of gestation onwards.

Fetal surgery in case of severe CDH involves fetoscopic placement of an intratracheal balloon, which allows fetal lung growth.

Twin-to-twin transfusion syndrome

There is a benefit in early diagnosis of twin-to-twin transfusion syndrome (TTS) following bimensual ultrasound, as this has been recommended for monochorionic-biamniotic twin pregnancies. Follow-up of such pregnancies is complex and needs to be done in specialised units. Treatment of TTS involves laser separation of the communicating vessels at the level of the placenta and is performed using fetoscopy.

Fetal valvulopathies

Fetal surgery could be offered in specific types of cardiac abnormalities such as hypoplastic left or right ventricle. Treatment consists of in utero valvuloplasty. Such intervention is performed through an ultrasound guided needle, introduced into the heart of the baby.

Fetal goiter

Thyroid hormones have a fondamental role in fetal brain development. A goiter could be associated with fetal hyper- or hypothyroidy. Cordocentesis is not systematic. Depending on the clinical or ultrasound context and when doubt persists on the origin of the goiter, cordocentesis could be indicated.

In case of fetal hypothyroïdy, a treatment should be instaured after reducing of stopping the antithyroïdiens de synthèse (ATS). Fetal hyperthyroïdism can be treated with ATS. Perinatal treatment needs an experienced multidisciplinary team.

Fetal therapy in myelomeningocele

Myelomeningocele (MMC) corresponds to the non-closure of the neural tube which leads to the exposure of the spinal cord. Part of post-natal sequellas could be secondary to in utero exposure of the spinal cord and to the cerebral repercussion of the leakage of cerebral fluid from the defect itself.

A number of animal experiments have shown that surgical repair of the defect at mid-gestation is associated with reduction of post-natal sequellas.

These results have been confirmed in humans following the Management of Myelomeningocele Study (MOMS). However, open fetal surgical repair (with maternal laparotomy and hysterotomy) is associated with significant maternal and fetal morbidity.

All these in-utero treatments are offered at the University Hospital Brugmann. For more information, please call the fetal medicine unit at the number 02 4772958.