Fetal therapy

fetal therapy - noninvasive and invasive fetal therapy

1. PERINATOLGY -
SONOGRAPHY
DR J.P.SONI M.D PEDIATRIC
ASSOCIATE PROF.
DR S.N. MEDICAL COLLEGE
JODHPUR

2. Update of Fetal therapy
DR J.P.SONI M.D PEDIATRIC
PROF.
DR S.N. MEDICAL COLLEGE
JODHPUR

3. FETAL THERAPY
fetoscopy
Intra –uterine fetal blood transfusion
Fetal surgery

4. Fetal therapy
A
therapeuticintervention
forthepurposeof
correctingortreatinga
fetal anomaly or
conditioniscalledfetal
therapy.

5. Fetal therapy
Personals required for it are –
Obstetrician
Pediatrician
Anesthetists
Ultrasonologist
Neurosurgeon
Social worker etc.

6. Fetal therapy
Tools required for it are –
Ultrasound machine
MRI
Fetoscope
laser machine etc.

7. Fetal therapy
Pharmacological fetal therapy –
(noninvasive)
•Surgical fetal therapy -
(Invasive)

8. Fetal therapy
Pharmacological fetal therapy –
Preventive pharmacotherapy
Therapeutic pharmacotherapy

9. 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

10. PREVETION OF HMD IN PRETERM NEONATES
The high riskpregnancy
associated with risk of preterm
delvaryshould be given
steroid at least 48 hours
before delivaryso as to
accelerate lung maturity as
well as renal maturity.
Dose:
Betamethasone12 mg twice
at 24 hours interval
or
• Dexona6 mg at 12
hours interval , for total 4
doses are give
•This will reduce need of
surfactant and ventilatory
therapy to baby.

11. Fetal therapy

Therapeutic pharmacotherapy

12. 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.

13. PSVT; ATRIAL FLUTTER & FIBRILLATION
Digoxin: Oral-fetus is
normal.
If fetus have feature of
hydrops
Digoxinis given either
parenteral
or
Transplacental, 0.5-1 mg
Adenosine :Per umbilical
0.05 to 0.2mg
Flecanide: oral 200-
300mg
Amiodarone: parenteral
600-800mg
Sotatlol: oral; 80-320
mg

14. COMPLETE A -V BLOCK -CAVB
Prevalence:1/15,000-1/22,000live
birth.
Path-physiology:
The fetalmortality rate of isolated CAVB may beasmuch as30-
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%.

15. Fetuswith 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 β
agonist
weekly follow up by obstetrician with
fetal
echocardiography

16. COMPLETE FETAL A –V BLOCK
AA AA A
Atthe 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 averageheart rate
declined below 55 bpm,
A ß-sympathomimeticagent
should be given
salbutamol40mg/ day for 2
weeks.

17. COMPLETE FETAL A –V BLOCK
AA AA A
In the presence of maternal
anti-Ro/La antibodies
,
there are no known markers that
will predict which fetuswill
develop an AV conductiondefect.
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.

18. Fetuswith isolated Complete
A –V block Rx
 Delivaryat tetriarycare center
Uneventful fetalcourse -LSCS at 37 wks
If fetusdevelop hydrops-Paracentesis
 LSCS
low CO out -Immediate Pacing
 Isoprenline
features of SLE -oral prednisolone
Endocardialfibroelastosis–I V IgG

19. Premature ventricular contraction
in fetus
a benign condition
either resolve spontaneously
before
Birth or after birth of baby.
If number of PVC is more, and
fetus
Develop Hydrops: -
than βblocker can be
Used orally.

20. 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

21. FETAL THYROID GOITER
Rx
FETAL CORD BLOOD FOR THYROID
STATUS
TSH,T3,T4
IF HYPERTHYRODISM
Rx -CARBIMAZOLE
METHIMAZOLE
IF HYPOTHYRODISM
BETWEEN 29-37 WEEKS
250-500 mg LEVOTHYROXIN
INTRA AMNIOTIC
WEEKLY
THIS WILL RESULT IN
REGRESSION
OF
THYROID GOITER

22. CONGENITAL ADRENAL HYPERPLASIA
Congenitaladrenalhyperplasia(CAH)isafamilydisorder
causedbyreducedactivityofenzymesrequiredforcortisol
biosynthesisintheadrenalcortex.
Themostcommon defectis21-hydroxylase(21-OH)
deficiency,whichaccountsfor>90%ofallcasesofCAH.
Classic21-hydroxylasedeficiencyisfoundinabout
1:12000to1:15000births.
Thefrequencyofnonclassicdeficiencyisunknown,althoughit
mayoccurinupto3%ofindividualsincertaingroups.

23. CONGENITAL ADRENAL HYPERPLASIA
Clinicalconsequences of21-OH deficiency
ariseprimarilyfrom overproduction and
accumulationofprecursorsproximaltotheblocked
enzymaticstep.
Theseprecursorsareshuntedintotheandrogen
biosynthesispathway,producingvirilizationin
thefemalefetusorinfantandrapidpostnatal
growthwithacceleratedskeletalmaturation,
precociouspuberty,andshortadultstatureinboth
malesandfemales

24. CONGENITAL ADRENAL HYPERPLASIA
Treatmentshould begunasearlyasthe4
th
to6thweekof
pregnancy.
Thedoseofdexamethasone usuallyrangedbetween0.5and
2mg/dorO.3too.7mg/sqmin1to4divideddoses.
CVS11-12wks&AMNIOCENTESIS at15wksforDNAanalysisfor
CYP21B,C4&HLAclassI&IIgenes.
Thentreatmentiscontinuedtoterminfemalepositivefor
genesandstopedinmaleafterconfirmationofdiagnosisby
CVSorAmniocentesis.
Atbirth,theexternalgenitaliaisnormalintheinfantwhosemother
wasgivendexamethasone andminimallyvirilizedintheinfant
whosemotherreceivedhydrocortisone.

25. Fetus with maternal SLE
IfmotherissufferingfromSLE,then
fetusisatrisktodevelopComplete
heartblockbecauseofdamagetoAV
node.Thiscanbepreventedby
givingTabDexamethasone 4mgper
dayduringpregnancybecauseit
cannotbemetaboizedbyplacenta
andisAvailabletothefetusinan
activeform.

26. Invasivefetaltherapy
1961
Intra uterine blood transfusion

27. Invasivefetaltherapy
1961
Intra uterine blood transfusion
The fetal anemia now can be predicted by
doing middle cerebral
Artery dopplerflow study
and
intra uterine
transfusion (IUT) is done with
gamma Irradiated blood.

28. FETAL ANEMIA
-Rhallo-immunization & parvovirus B19 -Doppler
assessment of Middle cerebral artery peak velocity and
prediction of fetal anemia.

29. INTRAUTERINE FETAL TRANSFUSION
CORDOCENTESIS/ IUT if MCA peak velocity MoM=
>1.5 or MCA peak velocity in “A” zone of below
depicted graph.

30. VOLUME OF BLOOD TO BE GIVEN
TO FETUS IS CALCULATED BY
Fetoplacentalvolume X (desired Ht –Fetal Ht)
= ------------------------------------------------------
Donor hematocrit
Fetoplacental volume = USG estimated weight of
fetus X 0.14

31. .The amount of blood given
to fetusis 20,30,40 and 50
ml to the fetusat 22,26,30
and 35 weeks of gestational
age respectively.

32. Intra uterine blood transfusion

39. F
E
T
O
S
C
O
P
Y
1970

40. Fetoscopyisperformedduringthesecondtrimester(after16
weeks’gestation).
Inthistechnique,afine-caliberendoscopeisinsertedintothe
amnioticcavitythroughasmallmaternalabdominalincision,
understerileconditionsandultrasoundguidance,forthe
visualizationoftheembryotodetectthepresenceofsubtle
structuralabnormalities
Fetal visualization
Embryoscopy
Embryoscopyisperformedinthefirsttrimesterofpregnancy(up
to12weeks’gestation).
Inthistechnique,arigidendoscopeisinsertedviathecervixinthe
spacebetweentheamnionandthechorion,understerileconditions
andultrasoundguidance,tovisualizetheembryoforthediagnosis
ofstructuralmalformations.

41. ◦An injection will be given in the lower abdomen
to numb the skin where the fetoscopewill be
inserted.
◦An ultrasound will be used to determine the
position of both the fetus and the placenta.

42. 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
fetoscopeto take pictures.

44. 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

49. 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.

50. Pleural effusion
One option in the
management offetuseswith
pleural effusion is
thoracocentesis anddrainage
oftheeffusions.However,in
the majority ofcasesthe
fluidreaccumulates within
24-48 hours requiring
repeatedproceduresanditis
therefore preferable to
achievechronicdrainageby
theinsertion ofpleural-
amnioticshunts.

52. GENE THERAPY
Means replacement of missing gene by introduction of foreign
Nucleic 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 genome
To replace an abnormal, disease causing gene.
A carrier molecule called a vector (virus-lentivirus) must be
used to deliver the therapeutic gene to the patient’s target
cells

53. Therehavebeenseveralmodesofgene
deliveryusedinexperimentaleffortsatfetal
gene transfer. These include
intratracheal,intravascular,intraventricular,
intracardiac,intraperitoneal,intraplacental,
intramuscularandintra-amnioticinjection.
Intra-amnioticgenetransfer(IAGT)has
beenusedtotargetorgansexposedto
amnioticfluid,thatis,theskin,amniotic
membranes andtherespiratoryand
digestivesystems