Current state of antenatal in utero surgical interventions
- C Kimbera,
- L Spitzb,
- A Cuschieric
- aDepartment of Surgery, Oxford University, Oxford, bInstitute of Child Health, Great Ormond Street London, cDepartment of Surgery, University of Dundee
- Dr C Kimber.
Antenatal ultrasound scanning has facilitated the prenatal diagnosis of many fetal anomalies. The improved understanding of fetal pathophysiology, combined with increased accuracy of fetal diagnosis and knowledge of the clinical postnatal outcome, have culminated in the development of fetal treatment. This is usually considered when a potentially life threatening and/or disabling, but correctable, condition is diagnosed antenatally. The decision for fetal surgical intervention carries with it the potential of dual mortality (mother and fetus).1-5
Fetal anomalies can adversely affect the mother by causing hypertension, oedema, and pulmonary failure. The condition, known as the maternal mirror syndrome, may prove fatal but appropriate fetal intervention can save the life of the mother. This syndrome has been reported in cases of antenatally diagnosed sacrococcygeal teratoma and cystadenomatoid malformation of the lung.
The decision to undertake fetal intervention must be the prerogative of the mother. A clear explanation of the risk of survival and quality of life of the fetus with and without surgical intervention is essential.5 Maternal informed consent includes the risk of fetal intervention to the mother, although there have been no reported maternal deaths from open fetal surgery.7-9
Fetal interventions
NEEDLE ASPIRATION
Ultrasound guided percutaneous sampling of blood, urine, pleural effusion and hydrocephalus have been established since 1983.10-13 Exchange transfusion via the umbilical cord is the standard treatment for haemolytic disease caused by Rhesus incompatibility. Diagnostic bladder aspiration and fetal urinalysis are undertaken to determine the severity of renal damage in obstructive uropathy. Fluid collections can be identified and aspirated under fetal ultrasound guidance. Ovarian cysts have been needled, perhaps unnecessarily, and large exophytic sacrococcygeal teratomas have been aspirated to facilitate delivery.13-15 The rate of fetal loss after these aspirations has not been determined, but is probably similar to that following amniocentesis—around 0.5%.15
FETO-AMNIOTIC SHUNTING
Insertion of double J stents under …
