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Radiology
Open and Endoscopic Fetal Surgery
Built from Obstetric Imaging
What’s inside
9 sections · 148 slides
Overview
- Scope of open and endoscopic fetal surgery
Fetal Surgery as a Field
Where it came from, who does it, and the rules that govern it
- Definition of fetal surgery
- Origins of fetal surgery
- Conditions targeted in the first two decades
- Shift from survival to quality of life
- Organisation of the field today
- Anticipated developments in fetal therapy
- The multidisciplinary fetal team
- Specialists who may be involved in a fetal case
- Assessment before any fetal intervention
- Shared decision-making
- Quality of evidence across fetal interventions
- Criteria a case must satisfy before fetal surgery
- Requirements for Fetal Surgery
Myelomeningocele
The condition that turned fetal surgery from a rescue into a treatment
- Myelomeningocele: what the defect is
- Ultrasound appearance of a lumbosacral spine defect
- Unified theory of spina bifida
- Consequences described by the unified theory
- Functional deficits in children born with myelomeningocele
- Hydrocephalus and its management
- Tethered cord and repeat neurosurgery
- Lifelong multidisciplinary care after birth
- Two-hit hypothesis
- Evidence leading to prenatal repair
- Management of Myelomeningocele Study
- 50%
- Durability of the MOMS benefits at school age
- Maternal and pregnancy risks of open repair
- Uterine rupture in subsequent pregnancies
- What to notice in the open repair photographs
- Open fetal surgery for myelomeningocele
- Fetoscopic approaches to myelomeningocele repair
- Outcomes reported after fetoscopic repair
- Open versus fetoscopic repair
- Unanswered questions in fetoscopic repair
- What to notice in the fetoscopic repair images
- Fetoscopic surgery for myelomeningocele
- Work-up before myelomeningocele repair
- What the imaging must define
- Amniotic fluid testing for an open lesion
- What to notice in the three-dimensional reconstruction
- Three-dimensional ultrasound reconstruction of a spine defect
- Three-dimensional rendering of the open spine defect
- Eligibility criteria used in MOMS
- Exclusions applied in MOMS
- How eligibility has been relaxed since MOMS
- Timing of myelomeningocele repair
- Choosing between open and fetoscopic repair
- Steps of open myelomeningocele repair
- Procedure for Open Management of Myelomeningocele Repair
- Procedure for Open Management of Myelomeningocele Repair (continued)
- Steps of fetoscopic myelomeningocele repair
- Procedure for Fetoscopic Management of Myelomeningocele Repair
- Procedure for Fetoscopic Management of Myelomeningocele Repair (continued)
Congenital Diaphragmatic Hernia
From open repair, to a balloon in the fetal windpipe
- Congenital diaphragmatic hernia: what it is
- Types of diaphragmatic hernia treated before birth
- Effect of herniated viscera on the fetal lung
- How a diaphragmatic hernia damages the lung
- Dual-hit phenomenon in diaphragmatic hernia
- Associated anomalies and candidate selection
- Severe diaphragmatic hernia on fetal MRI
- First attempts at prenatal repair of the diaphragm
- Why open prenatal repair was abandoned
- Rationale for fetal tracheal occlusion
- The plug-unplug sequence
- From tracheal clip to endoluminal balloon
- First randomised trial of endoluminal tracheal occlusion
- Defining severity in later series
- Design of the TOTAL trial
- Timing and balloon removal in the TOTAL trial
- 40% vs 15%
- Results of the TOTAL trial
- Reanalysis and meta-analysis of the TOTAL data
- North American concerns about FETO
- Methodological criticisms of the TOTAL trial
- Current status of FETO
- Candidates for fetoscopic endoluminal tracheal occlusion
- Living with the balloon in place
- What to notice in the fetoscopic balloon images
- Fetoscopic endoluminal tracheal occlusion
- Steps of balloon insertion for tracheal occlusion
- Procedure for Fetoscopic Endoluminal Tracheal Occlusion Balloon Insertion
- Procedure for Fetoscopic Endoluminal Tracheal Occlusion Balloon Insertion (continued)
- Procedure for Fetoscopic Endoluminal Tracheal Occlusion Balloon Insertion (continued)
Fetal Lung Masses
Congenital pulmonary airway malformation and bronchopulmonary sequestration
- Fetal lung masses that may need prenatal intervention
- Ultrasound appearance and classification of a CPAM
- Classification of fetal lung masses
- Macrocystic versus microcystic CPAM
- Bronchopulmonary sequestration and hybrid lesions
- Large macrocystic lung lesion on ultrasound
- Predicting which lung lesions need intervention
- CPAM volume ratio and the risk of hydrops
- Natural history of fetal lung lesions
- Open fetal resection of lung masses
- Complications of open fetal lung resection
- Betamethasone for large fetal lung masses
- How betamethasone is given
- Limits of betamethasone and the role of shunting
- Minimally invasive options for fetal lung masses
Sacrococcygeal Teratoma
A tumour that steals the fetal circulation
- Sacrococcygeal teratoma: what it is
- Prognosis before and after birth
- How a teratoma causes high-output cardiac failure
- Vascular steal and the fetal heart
- Other complications of a fetal teratoma
- Features linked with a less favourable prognosis
- Echocardiographic signs of the high-output state
- Limits of surveillance in sacrococcygeal teratoma
- Options for intervention
- Preemptive delivery and immediate resection
- Open fetal resection before 27 weeks
- Technical cautions in open resection
- What to notice in the teratoma images
- Fetal MRI of a large sacrococcygeal teratoma
- Sacrococcygeal teratoma on MRI and at open resection
- Minimally invasive treatment of sacrococcygeal teratoma
Tocolysis, Anaesthesia and Fetal Monitoring
The care around the operation that every fetal procedure depends on
- Why tocolysis matters in open fetal surgery
- Evidence base for tocolysis
- Tocolytic regimen used by the authors
- Maternal pulmonary oedema after aggressive tocolysis
- Anaesthetic preparation and patient positioning
- Inhaled anaesthetic and uterine relaxation
- Management of acute fetal bradycardia
- Maternal circulation and drugs for fetal resuscitation
- Continuous fetal monitoring during surgery
- Thresholds for fetal resuscitation
- Preparing for fetal haemorrhage
Summary
What to carry away from this topic
- Key points on fetal surgery as a field
- Key points on myelomeningocele
- Key points on congenital diaphragmatic hernia
- Key points on lung masses and sacrococcygeal teratoma
- Key points on perioperative care
References
Sources cited in this topic
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- References (continued)
- Obstetric Imaging: Fetal Diagnosis and Care, 2nd Edition